Fatal delayed diagnosis in a patient with Falciparum malaria.

A 55-year old italian, male, was referred to our hospital for the evaluation of fever of unknown origin (F.U.O.) associated with jaundice and a severe multiorgan failure. This expatriate worker had returned from Nigeria three days earlier with some prodromal symptoms: malaise, headache myalgia, anorexia; he developed a very high temperature at once ranging between 40 to 41°C (105 to 106°F) associated with progressive cerebral and pulmonary complications. This clinical picture was misinterpreted as a viral infection and only when, 48 hours later, the patient developed a severe dyspnea and a deep unrousable coma he was referred to our department. His complete blood count showed Hb 5.1 g/dL, white cell count 25.1×10/L, and platelet count 50×10/L. Serum haptoglobins were undetectable, blood urea 240 mg/dL, serum creatinine 4.6 mg/dL, unconjugated plasma bilirubin concentrations 62.1 mg/dL, glycaemia 32 mg/dL. Thin blood smears showed ring stages of P. falciparum with multiple infections of some cells (Figure 1). Two hours after recovery the patient died from a pulmonary edema. This is a classical case of blackwater fever which is one of the most serious hematologic complications of falciparum malaria. The clinical manifestations of this acute intravascular hemolityc anemia are fulminating and delayed diagnosis is an important cause of mortality.