Blackwater fever

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Blackwater fever
Conjunctival jaundice found in affected individuals
SpecialtyInfectious disease

Blackwater fever is a complication of malaria infection in which red blood cells burst in the bloodstream (hemolysis), releasing hemoglobin directly into the blood vessels and into the urine, frequently leading to kidney failure. The disease was first linked to malaria by the Sierra Leone Creole physician John Farrell Easmon in his 1884 pamphlet entitled The Nature and Treatment of Blackwater Fever. Easmon coined the name "blackwater fever" and was the first to successfully treat such cases following the publication of his pamphlet.

Signs and symptoms

Within a few days of onset there are chills, with rigor, high fever, jaundice, vomiting, rapidly progressive anemia, and dark red or black urine.


The cause of hemolytic crises in this disease is unknown (mainly due to intravascular haemolysis). There is rapid and massive destruction of red blood cells resulting in hemoglobinemia (hemoglobin in the blood, but outside the red blood cells), hemoglobinuria (hemoglobin in urine), intense jaundice, anuria (passing less than 50 milliliters of urine in a day), and finally death in the majority of cases.[citation needed]

The most probable explanation for blackwater fever is an autoimmune reaction apparently caused by the interaction of the malaria parasite and the use of quinine. Blackwater fever is caused by heavy parasitization of red blood cells with Plasmodium falciparum. However, there have been other cases attributed to Plasmodium vivax,[1] Plasmodium malariae,[2] Plasmodium knowlesi.[3]

Blackwater fever is a serious complication of malaria, but cerebral malaria has a higher mortality rate. Blackwater fever is much less common today than it was before 1950.[4] It may be that quinine plays a role in triggering the condition,[5] and this drug is no longer commonly used for malaria prophylaxis. Quinine remains important for treatment of malaria.[6]


The diagnosis of Blackwater fever can be done via a rapid diagnostic test for malaria and the symptoms consistent with this complication[7]


The treatment is antimalarial chemotherapy, intravenous fluid and sometimes supportive care such as intensive care and dialysis.[citation needed]

Society and culture

Prominent victims

  • Prior to his photography career, Henri Cartier-Bresson[8] contracted blackwater fever while hunting in Western Africa. Expecting to die, he sent instructions to his family on his wishes for a funeral. He made a full recovery.
  • Zoologist John Samuel Budgett died from the disease in 1904, after returning from a collecting trip to West Africa, in search of specimens of the fish Polypterus.[9]
  • Missionary and explorer George Grenfell died after a bad attack of blackwater fever at Basoko on 1 July 1906.[citation needed]
  • Jesse Brand, a missionary to the Chat Mountains in India, died of blackwater fever in 1928.[citation needed]
  • Actor Don Adams, best known as Maxwell Smart from the popular sitcom Get Smart and as the title character in Inspector Gadget, contracted blackwater fever after being shot in combat at Guadalcanal during World War II. Adams was evacuated from his United States Marine Corps unit to a hospital in New Zealand where he ultimately made a full recovery.[10]
  • Humanitarian and MMA fighter Justin Wren contracted malaria, which devolved into blackwater fever, while drilling water-wells for Congo Pygmies in 2013. The affliction nearly claimed Wren's life. He was misdiagnosed four times and required airlift to Uganda, where he narrowly recovered from severe symptoms.[11]
  • Aeneas, Jeannie Gunn's husband, is described as having died from Blackwater Fever or Malarial Dysentry at Elsey Station in the Northern Territory in 1903.[citation needed] She later authored the classic account We of the Never Never.
  • Bernard Deacon
  • Peter Cameron Scott, a Scottish-American missionary and founder of Africa Inland Mission, died from the disease in December 1896.
  • Henry Stricker, South African cricketer

Cultural references

See also


  1. Katongole-Mbidde E, Banura C, Kizito A (1988-03-19). "Blackwater fever caused by Plasmodium vivax infection in the acquired immune deficiency syndrome". Br Med J (Clin Res Ed). 296 (6625): 827. doi:10.1136/bmj.296.6625.827. PMC 2545111. PMID 3130932.
  2. Madhuri, M. S.; Elavarasan, K.; Benjamin, V. P.; Sridhar, M. S.; Natarajan, S.; Chiranjeevi, V. (2018-10-01). "Falciparum malaria complicated by black water fever". Journal of Clinical and Scientific Research. 7 (4): 187. doi:10.4103/JCSR.JCSR_14_19. ISSN 2277-5706. S2CID 189946053. Archived from the original on 2021-11-29. Retrieved 2023-02-10.
  3. Barber, Bridget E.; Grigg, Matthew J.; William, Timothy; Yeo, Tsin W.; Anstey, Nicholas M. (2016-09-09). "Intravascular haemolysis with haemoglobinuria in a splenectomized patient with severe Plasmodium knowlesi malaria". Malaria Journal. 15 (1): 462. doi:10.1186/s12936-016-1514-0. ISSN 1475-2875. PMC 5017000. PMID 27613607.
  4. Bruneel, F.; B. Gacho; M. Wolff; et al. (2002). "Blackwater fever". Presse Médicale (in français). 31 (28): 1329–34. PMID 12355996.
  5. Brunee, Fabrice; Gachot, Bertrand; Wolff, Michel; Régnier, Bernard; Danis, Martin; Vachon, François (2001-04-15). "Resurgence of Blackwater Fever in Long-Term European Expatriates in Africa: Report of 21 Cases and Review". Clinical Infectious Diseases. 32 (8): 1133–1140. doi:10.1086/319743. ISSN 1058-4838. PMID 11283802. Archived from the original on 2022-10-06. Retrieved 2023-02-10.
  6. World Health Organization (2021). World Health Organization model list of essential medicines: 22nd list (2021). Geneva: World Health Organization. p. 22. hdl:10665/345533. WHO/MHP/HPS/EML/2021.02.
  7. Biase, Anna Rita Di; Buonfrate, Dora; Stefanelli, Francesca; Zavarise, Giorgio; Franceschini, Erica; Mussini, Cristina; Iughetti, Lorenzo; Gobbi, Federico. "Blackwater Fever Treated with Steroids in Nonimmune Patient, Italy - Volume 29, Number 4—April 2023 - Emerging Infectious Diseases journal - CDC". doi:10.3201/eid2904.221267. Archived from the original on 8 May 2023. Retrieved 2 June 2023.
  8. "10 things to know about HenriCartier-Bresson | Christie's'". Archived from the original on 2017-09-17. Retrieved 2017-09-16.
  9. "John Samuel Budgett (1872–1904): In Pursuit of Polypterus" BioScience May 2001 / Vol. 51 No. 5
  10. Martin, Douglas (September 27, 2005). "Don Adams, Television's Maxwell Smart, Dies at 82". The New York Times. Archived from the original on April 24, 2009. Retrieved February 10, 2023. Don Adams, who played Maxwell Smart in the 1960s sitcom "Get Smart", combining clipped, decisive diction with appalling, hilarious ineptitude, died on Sunday at a Los Angeles hospital. He was 82.
  11. "Wren back in MMA to 'Fight for the Forgotten'". 27 August 2015. Archived from the original on 23 May 2022. Retrieved 10 February 2023.
  12. Brunner, John (1969). Stand on Zanzibar. New York: Ballantine. ISBN 978-0345027580."Stand on Zanzibar, a 1968 science-fiction novel by John Brunner quotes a line from the sea chanty "The Bight of Benin": "The bight of Benin, the bight of Benin! Blackwater fever and pounds of quinine!""