Skip to main content

Intravascular haemolysis with haemoglobinuria in a splenectomized patient with severe Plasmodium knowlesi malaria



Haemoglobinuria is an uncommon complication of severe malaria, reflecting acute intravascular haemolysis and potentially leading to acute kidney injury. It can occur early in the course of infection as a consequence of a high parasite burden, or may occur following commencement of anti-malarial treatment. Treatment with quinine has been described as a risk factor; however the syndrome may also occur following treatment with intravenous artesunate. In Malaysia, Plasmodium knowlesi is the most common cause of severe malaria, often associated with high parasitaemia. Asplenic patients may be at additional increased risk of intravascular haemolysis.

Case presentation

A 61 years old asplenic man was admitted to a tertiary referral hospital in Sabah, Malaysia, with severe knowlesi malaria characterized by hyperparasitaemia (7.9 %), jaundice, respiratory distress, metabolic acidosis, and acute kidney injury. He was commenced on intravenous artesunate, but1 day later developed haemoglobinuria, associated with a 22 % reduction in admission haemoglobin. Additional investigations, including a cell-free haemoglobin of 10.2 × 105 ng/mL and an undetectable haptoglobin, confirmed intravascular haemolysis. The patient continued on intravenous artesunate for a total of 48 h prior to substitution with artemether–lumefantrine, and made a good recovery with resolution of his haemoglobinuria and improvement of his kidney function by day 3.


An asplenic patient with hyperparasitaemic severe knowlesi malaria developed haemoglobinuria after treatment with intravenous artesunate. There are plausible mechanisms for increased haemolysis with hyperparasitaemia, and following both splenectomy and artesunate. Although in this case the patient made a rapid recovery, knowlesi malaria patients with this unusual complication should be closely monitored for potential deterioration.


Haemoglobinuria reflects acute intravascular haemolysis, and can occur as a complication of severe malaria, potentially leading to acute kidney injury. While it can occur early in the course of infection as a direct consequence of a high parasite burden and rupture of parasitized and unparasitized cells, it may also occur as a complication of anti-malarial treatment. In previous reports, haemoglobinuria occurring in patients with malaria has been referred to as blackwater fever. While definitions vary, the term was historically used to describe a clinical syndrome of haemoglobinuria, fever and jaundice that typically involved non- or partially immune European expatriates who had been residing in malaria-endemic areas and who had received, often intermittently, treatment with quinine. More recent reports however, have described blackwater fever or haemoglobinuria in Southeast Asian adults [1] and in African children [25], including in those treated with artesunate [1, 68]. The syndrome is most commonly associated with falciparum malaria, although has also been reported with Plasmodium vivax [9] and with mixed species infections [1, 3], and in severe knowlesi malaria [10, 11].

The comparative risk of intravascular haemolysis in splenectomized patients with malaria has not been evaluated. Splenectomized patients are thought to be at increased risk of developing complications from malaria, and in patients with thalassaemia, asplenic patients experience more severe intravascular haemolysis [12]. Plasmodium knowlesi is the most common cause of malaria in Malaysia and is associated with high parasitaemia infections [13]. In rhesus macaques with high parasitaemia P. knowlesi infections, haemoglobinuria was commonly a pre-terminal event [14, 15]. This report describes a case of haemoglobinuria that occurred in a splenectomized patient with severe knowlesi malaria, following treatment with intravenous artesunate.

Case presentation

A 61 years old farmer presented to Kudat District Hospital in northeastern Sabah with a 3-day history of fever, rigours, cough, headache, arthralgia, and myalgia. He lived in a village near Kudat town and had recently travelled to Banggi Island off the coast of Sabah, at the time highly endemic for malaria, where he had stayed overnight in forested areas, and had seen monkeys. His past history was significant for having undergone a splenectomy 5 years previously following a motor vehicle accident, hypertension, and self-reported malaria 10 years previously. His medications included life-long prophylactic penicillin and perindopril. He denied having taken any anti-malarial medications prior to presentation.

On examination his temperature was 38.9 °C, heart rate 93 beats per minute, blood pressure 114/79 mm Hg, respiratory rate 36 breaths/minute and oxygen saturation 88 % on room air. He was notably jaundiced and had a scar on his abdomen, but examination was otherwise unremarkable. His urine was of normal colour. Blood film was reported as P. knowlesi, with a parasite count of 7.9 %. His haemoglobin was 15.2 g/dL, white cell count 8.7 × 103/μL, platelets 24 × 103/μL, and creatinine 145 µmol/L (Table 1). He was commenced on intravenous artesunate in addition to ceftriaxone, and transferred to a tertiary referral hospital. An arterial blood gas taken the following morning on 35 % oxygen via a Venturi mask revealed metabolic acidosis with a pH of 7.31 and bicarbonate of 11 mmol/L. His chest X-ray was unremarkable. One day later, after two doses of intravenous artesunate given on admission and at 12 h, he was noted to have “coca-cola” coloured urine (Fig. 1), with urinalysis positive for haemoglobin with no intact red blood cells. Additional blood investigations revealed a bilirubin of 181 µmol/L and elevated liver transaminases (Table 1). Glucose-6 phosphate dehydrogenase (G6PD) activity was normal, thalassemia screen was negative, and dengue NS1 antigen was negative. Testing for leptospirosis was not performed. The patient received two further doses of artesunate (at 24 and 48 h) before changing to artemether–lumefantrine. He made a good clinical recovery, with improvement of his oxygen saturation, jaundice, thrombocytopaenia, and renal function (creatinine 86 µmol/L on day 3; Table 1). By day 3 he was afebrile with no malaria parasites seen on blood film, and his haemoglobinuria had largely resolved. PCR confirmed P. knowlesi mono-infection. No pathogens were isolated from blood cultures taken after commencement of antibiotics. The patient received ceftriaxone for a total of 7 days.

Table 1 Laboratory values
Fig. 1
figure 1

Urine sample on day 1, after completion of two doses of intravenous artesunate

As the patient was enrolled in a prospective pathophysiology study, venous blood was collected (14.5 h after commencement of intravenous artesunate) in lithium heparin and citrate tubes and centrifuged within 30 min, with plasma stored at −80 °C. Cell-free haemoglobin and haptoglobin were measured by enzyme-linked immunosorbent assay (ELISA), revealing markedly elevated cell-free haemoglobin (10.2 × 105 ng/mL) and undetectable haptoglobin.


This report describes a case of knowlesi malaria in a splenectomized patient, with WHO-defined criteria for severe disease, including hyperparasitaemia, respiratory distress, metabolic acidosis, and jaundice [16], who developed haemoglobinuria (sometimes referred to as blackwater fever) following treatment with artesunate. This is the second reported case of haemoglobinuria in a patient with severe knowlesi malaria treated with artesunate [10], and, given the potential for association with acute kidney injury, highlights the importance of monitoring for this complication in such patients, particularly in those who are splenectomized.

The haemoglobinuria in this patient developed on the day following admission, and laboratory investigations, including a 22 % drop in haemoglobin, undetectable haptoglobin and massively elevated cell-free haemoglobin, all confirmed intravascular haemolysis. The cause of this haemolysis is likely multifactorial. In the setting of hyperparasitaemia, rupture of parasitized red blood cells (RBCs) alone can be expected to cause substantial haemolysis; however the degree of anaemia in this case implies additional loss of unparasitized RBCs. In falciparum malaria, factors that may contribute to lysis of non-parasitized RBCs include the direct effects of parasite products [17], inflammatory cytokines [18], complement activation [17, 19], and membrane lipid peroxidation [18]. However, in the current case the haemoglobinuria occurred only after the patient received two doses of intravenous artesunate, and it is therefore possible that artesunate may have contributed to the haemolysis.

While haemoglobinuria is well documented as a complication of quinine and other arylamino alcohol drugs, the link with artesunate is less well described. However, recent studies suggest that rates may be similar to those seen with quinine. In the AQUAMAT study involving African children with severe falciparum malaria, blackwater fever was reported in 18/2597 (0.7 %) patients following treatment with intravenous artesunate compared to 30/2591 (1.2 %) following treatment with intravenous quinine [6]. Blackwater fever was more common in the SEAQUAMAT study involving Southeast Asian adults and children with severe falciparum malaria, being reported in 49/730 (7 %) and 33/731 (5 %) following treatment with artesunate and quinine, respectively [8]. In a smaller study, haemoglobinuria occurred in 3/76 (3.9 %) Ugandan children receiving intravenous artesunate for severe falciparum malaria [7].

In addition to these reports of haemoglobinuria occurring following treatment with artesunate, there are numerous reports of artesunate-associated haemolytic anaemia occurring without haemoglobinuria [2022]. Jaureguiberry et al. described three patterns of haemolytic anaemia occurring in patients with falciparum malaria treated with artesunate: (1) a ‘rising’ pattern, in which the nadir haemoglobin and peak of haemolysis occur before day 8; (2) a delayed pattern (post-artesunate delayed haemolysis; PADH), defined by a >10 % drop in haemoglobin or a >10 % rise in lactate dehydrogenase (LDH) occurring after day 8; and, (3) a ‘persistent pattern’, in which anaemia and haemolysis occur before and after day 8 [22]. In a study of 60 non-transfused travellers with falciparum malaria treated with intravenous artesunate, these patterns of post-artesunate haemolytic anaemia occurred in 32, 17 and 22 % of patients, respectively, with the rising pattern (as occurred in the current case) associated with a mean 21 % decline in haemoglobin and marked haemolysis until day 4 [22]. The association between these patterns of artesunate-associated haemolytic anaemia and the occurrence of haemoglobinuria however remains uncertain.

The mechanisms of acute artesunate-related haemolysis are unclear. One mechanism contributing to PADH is the splenic removal of parasites from RBCs, with these ‘pitted’ once-infected RBCs then returned to the circulation but with reduced lifespan [22]. This mechanism however is less likely to explain acute haemolysis. In addition, the degree of anaemia in this case, and in previous reports of PADH [23], suggests that artesunate may also contribute to haemolysis of non-parasitized RBCs. Artesunate contains a highly active endoperoxide bridge that, cleaved in the presence of haem, generates reactive oxygen species and other free radicals [2427]; it is possible that this oxidative stress may contribute to haemolysis of RBCs. Artesunate has also been shown to induce phosphatidylserine (PS) translocation at the RBC membrane [27]. PS is a membrane phospholipid which is normally located on the internal leaflet of the lipid bilayer, however may become exposed when cells undergo oxidative stress, or during parasite maturation [28, 29]. PS-RBCs have been shown to play a role in inflammation [30], coagulation [31], platelet activation [32], and adhesion to vascular endothelial cells [33], and may increase susceptibility to haemolysis [12].

In this case, ceftriaxone was another possible cause of drug-induced haemolysis; haemolysis attributed to ceftriaxone has been previously reported in a patient with severe falciparum malaria [34]. However, in the current case, the patient’s haemoglobinuria resolved despite continuation of ceftriaxone for a total of 7 days, making this unlikely. G6PD deficiency is a known risk factor for blackwater fever [1]; however, was not present in this case.

In the current case, the lack of a spleen likely contributed to the severity of intravascular haemolysis, and may have increased the risk of haemoglobinuria. In patients with haemoglobin E/β-thalassaemia disease, splenectomy has been shown to be associated with increased intravascular haemolysis, possibly due to an absence of splenic filtering of aged and/or defective RBCs [12]. In addition, PS-RBCs have been shown to be increased in splenectomized individuals [30, 31]. Blackwater fever in a splenectomized patient with falciparum malaria has been reported [35]. However, whether risk of haemolysis is increased in splenectomized patients with malaria has not been evaluated.

This is the sixth report of knowlesi malaria to occur in a splenectomized patient. Previous reports include two cases of uncomplicated malaria [10] and three cases of severe malaria [10, 36, 37], one of which occurred in a patient with β-thalassaemia and was transfusion-acquired [37]. Of the four severe cases (including the current case), all had jaundice, respiratory distress and metabolic acidosis, with two also complicated by acute kidney injury requiring dialysis [10, 36]. Not unexpectedly, in two cases parasite clearance was markedly delayed [10, 36]. In the two uncomplicated cases there was an absence of thrombocytopaenia [10], with this finding being notable due to the near-universal finding of thrombocytopaenia with knowlesi malaria in patients with intact spleens [10, 13]. An increase in platelet counts has also been reported in thalassaemic patients who are splenectomized; while the mechanisms are unclear, an increase in PS-RBCs may be contributory [12].

In this case, although stage 1 AKI [by Kidney Disease Improving Global Outcomes (KDIGO)] criteria [38] was present on admission, the patient made a rapid recovery with anti-malarial treatment. In previous series, AKI has been a common complication of haemoglobinuria/blackwater fever. In Vietnamese adults 42 % of cases had acute renal failure [1], while renal failure was seen in 16 % of Congolese children with blackwater fever [3]. In European expatriates, renal failure occurred in 70 % of cases with blackwater fever [39]. Haemoglobinuria has also been associated with AKI in other diseases, including babesiosis [40], paroxysmal nocturnal haemoglobinuria [4143], and post-cardiopulmonary bypass [44]. While the mechanisms of haemolysis-induced AKI remain uncertain, direct tubular cell injury from free haem likely contributes [23, 45]. In addition, free haem has been shown to cause oxidative damage by lipid peroxidation, leading to renal injury through vasoconstriction [46, 47]. Finally, cell-free haemoglobin is a scavenger of nitric oxide (NO) and in severe falciparum malaria has been shown to be associated with reduced NO-dependent endothelial function and impaired tissue perfusion [48], possibly also contributing to renal injury.


This report describes a case of a splenectomized patient with severe knowlesi malaria who developed haemoglobinuria following commencement of treatment with artesunate. The AKI in this case was not severe, antedated the artesunate and the patient made a rapid recovery despite continuation of artemisinins. Artesunate reduces mortality in severe falciparum malaria [6, 8] and is associated with lower case-fatality than quinine in severe knowlesi malaria [10, 11, 49], making it the clear treatment of choice for severe disease in knowlesi malaria [16]. Clinicians should however be aware of the possibility of this rare complication in knowlesi malaria with high parasitaemia so that patients can be adequately monitored for potential deterioration.



acute kidney injury


enzyme-linked immunosorbent assay


glucose-6 phosphate dehydrogenase


lactate dehydrogenase


post-artesunate delayed haemolysis


polymerase chain reaction


red blood cell




Kidney Disease Improving Global Outcomes


nitric oxide


  1. Chau TTH, Day NP, Van Chuong L, Mai NTH, Loc PP, Phu NH, et al. Blackwater fever in southern Vietnam: a prospective descriptive study of 50 cases. Clin Infect Dis. 1996;23:1274–81.

    Article  Google Scholar 

  2. Bodi JM, Nsibu CN, Aloni MN, Lukute GN, Kunuanuna TS, Tshibassu PM, et al. Black water fever associated with acute renal failure among Congolese children in Kinshasa. Saudi J Kidney Dis Transpl. 2014;25:1352.

    Article  PubMed  Google Scholar 

  3. Bodi JM, Nsibu CN, Longenge RL, Aloni MN, Akilimali PZ, Tshibassu PM, et al. Blackwater fever in Congolese children: a report of clinical, laboratory features and risk factors. Malar J. 2013;12:205.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Rogier C, Imbert P, Tall A, Sokhna C, Spiegel A, Trape J-F. Epidemiological and clinical aspects of blackwater fever among African children suffering frequent malaria attacks. Trans R Soc Trop Med Hyg. 2003;97:193–7.

    Article  PubMed  Google Scholar 

  5. Gobbi F, Audagnotto S, Trentini L, Nkurunziza I, Corachan M, Di Perri G. Blackwater fever in children, Burundi. Emerg Infect Dis. 2005;11:1118–20.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Dondorp AM, Fanello CI, Hendriksen IC, Gomes E, Seni A, Chhaganlal KD, et al. Artesunate versus quinine in the treatment of severe falciparum malaria in African children (AQUAMAT): an open-label, randomised trial. Lancet. 2010;376:1647–57.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  7. Hawkes MT, Conroy AL, Opoka RO, Hermann L, Thorpe KE, McDonald C, et al. Inhaled nitric oxide as adjunctive therapy for severe malaria: a randomized controlled trial. Malar J. 2015;14:421.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Dondorp A, Nosten F, Stepniewska K, Day N, White N. South East Asian Quinine Artesunate Malaria Trial (SEAQUAMAT) group. Artesunate versus quinine for treatment of severe falciparum malaria: a randomised trial. Lancet. 2005;366:717–25.

    Article  PubMed  Google Scholar 

  9. Katongole-Mbidde E, Banura C, Kizito A. Blackwater fever caused by Plasmodium vivax infection in the acquired immune deficiency syndrome. Br Med J. 1988;296:827.

    Article  CAS  Google Scholar 

  10. Barber BE, William T, Grigg MJ, Menon J, Auburn S, Marfurt J, et al. A prospective comparative study of knowlesi, falciparum and vivax malaria in Sabah, Malaysia: high proportion with severe disease from Plasmodium knowlesi and P. vivax but no mortality with early referral and artesunate therapy. Clin Infect Dis. 2013;56:383–97.

    Article  CAS  PubMed  Google Scholar 

  11. William T, Menon J, Rajahram G, Chan L, Ma G, Donaldson S, et al. Severe Plasmodium knowlesi malaria in a tertiary hospital, Sabah, Malaysia. Emerg Infect Dis. 2011;17:1248–55.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Atichartakarn V, Chuncharunee S, Archararit N, Udomsubpayakul U, Aryurachai K. Intravascular hemolysis, vascular endothelial cell activation and thrombophilia in splenectomized patients with hemoglobin E/β-thalassemia disease. Acta Haematol. 2014;132:100–7.

    Article  CAS  PubMed  Google Scholar 

  13. Daneshvar C, Davis TM, Cox-Singh J, Rafa’ee M, Zakaria S, Divis P, et al. Clinical and laboratory features of human Plasmodium knowlesi infection. Clin Infect Dis. 2009;49:852–60.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Knowles R. Das Gupta, B.M. A study of monkey-malaria and its experimental transmission to man. Indian Med Gaz. 1932;67:246–9.

    Google Scholar 

  15. Rigdon R. Hemoglobinuria (blackwater fever) in monkeys: a consideration of the disease in man. Am J Pathol. 1949;25:195.

    CAS  PubMed  PubMed Central  Google Scholar 

  16. World Health Organization. Severe malaria. Trop Med Int Health. 2014;19:7–131.

    Article  Google Scholar 

  17. Omodeo-Salè F, Motti A, Dondorp A, White NJ, Taramelli D. Destabilisation and subsequent lysis of human erythrocytes induced by Plasmodium falciparum haem products. Eur J Haematol. 2005;74:324–32.

    Article  PubMed  Google Scholar 

  18. Mohan K, Dubey M, Ganguly N, Mahajan R. Plasmodium falciparum: role of activated blood monocytes in erythrocyte membrane damage and red cell loss during malaria. Exp Parasitol. 1995;80:54–63.

    Article  CAS  PubMed  Google Scholar 

  19. Layez C, Nogueira P, Combes V, Costa FT, Juhan-Vague I, da Silva LHP, et al. Plasmodium falciparum rhoptry protein RSP2 triggers destruction of the erythroid lineage. Blood. 2005;106:3632–8.

    Article  CAS  PubMed  Google Scholar 

  20. Kreeftmeijer-Vegter AR, van Genderen PJ, Visser LG, Bierman W, Clerinx J, van Veldhuizen C, et al. Treatment outcome of intravenous artesunate in patients with severe malaria in the Netherlands and Belgium. Malar J. 2012;11:102.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. Zoller T, Junghanss T, Kapaun A, Gjorup I, Richter J, Hugo-Persson M, et al. Intravenous artesunate for severe malaria in travelers, Europe. Emerg Infect Dis. 2011;17:771–7.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Jauréguiberry S, Ndour PA, Roussel C, Ader F, Safeukui I, Nguyen M, et al. Postartesunate delayed hemolysis is a predictable event related to the lifesaving effect of artemisinins. Blood. 2014;124:167–75.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Plewes K, Haider MS, Kingston HW, Yeo TW, Ghose A, Hossain MA, et al. Severe falciparum malaria treated with artesunate complicated by delayed onset haemolysis and acute kidney injury. Malar J. 2015;14:246.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Gopalakrishnan AM, Kumar N. Antimalarial action of artesunate involves DNA damage mediated by reactive oxygen species. Antimicrob Agents Chemother. 2015;59:317–25.

    Article  PubMed  Google Scholar 

  25. Meshnick SR, Yang Y, Lima V, Kuypers F, Kamchonwongpaisan S, Yuthavong Y. Iron-dependent free radical generation from the antimalarial agent artemisinin (qinghaosu). Antimicrob Agents Chemother. 1993;37:1108–14.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  26. Berman PA, Adams PA. Artemisinin enhances heme-catalysed oxidation of lipid membranes. Free Radic Biol Med. 1997;22:1283–8.

    Article  CAS  PubMed  Google Scholar 

  27. Alzoubi K, Calabrò S, Bissinger R, Abed M, Faggio C, Lang F. Stimulation of suicidal erythrocyte death by artesunate. Cell Physiol Biochem. 2014;34:2232–44.

    Article  CAS  PubMed  Google Scholar 

  28. Maguire P, Prudhomme J, Sherman I. Alterations in erythrocyte membrane phospholipid organization due to the intracellular growth of the human malaria parasite, Plasmodium falciparum. Parasitology. 1991;102:179–86.

    Article  PubMed  Google Scholar 

  29. Sherman IW, Prudhomme J, Tait JF. Altered membrane phospholipid asymmetry in Plasmodium falciparum-infected erythrocytes. Parasitol Today. 1997;13:242–3.

    Article  CAS  PubMed  Google Scholar 

  30. Banyatsuppasin W, Butthep P, Atichartakarn V, Thakkinstian A, Archararit N, Pattanapanyasat K, et al. Activation of mononuclear phagocytes and its relationship to asplenia and phosphatidylserine exposing red blood cells in hemoglobin E/β-thalassemia patients. Am J Hematol. 2011;86:89–92.

    Article  CAS  PubMed  Google Scholar 

  31. Atichartakarn V, Angchaisuksiri P, Aryurachai K, Onpun S, Chuncharunee S, Thakkinstian A, et al. Relationship between hypercoagulable state and erythrocyte phosphatidylserine exposure in splenectomized haemoglobin E/β-thalassaemic patients. Br J Haematol. 2002;118:893–8.

    Article  CAS  PubMed  Google Scholar 

  32. Ruf A, Pick M, Deutsch V, Patscheke H, Goldfarb A, Rachmilewitz EA, et al. In-vivo platelet activation correlates with red cell anionic phospholipid exposure in patients with β-thalassaemia major. Br J Haematol. 1997;98:51–6.

    Article  CAS  PubMed  Google Scholar 

  33. Closse C, Dachary-Prigent J, Boisseau MR. Phosphatidylserine-related adhesion of human erythrocytes to vascular endothelium. Br J Haematol. 1999;107:300–2.

    Article  CAS  PubMed  Google Scholar 

  34. Plewes K, Maude RJ, Ghose A, Dondorp AM. Severe falciparum malaria complicated by prolonged haemolysis and rhinomaxillary mucormycosis after parasite clearance: a case report. BMC Infect Dis. 2015;15:1.

    Article  Google Scholar 

  35. Maharaj D, McDonald G, Dobbie J. Splenectomy and blackwater fever. Br J Haematol. 1982;51:663–4.

    Article  CAS  PubMed  Google Scholar 

  36. Boo YL, Lim HT, Chin PW, Lim SY, Hoo FK. A case of severe Plasmodium knowlesi in a splenectomized patient. Parasitol Int. 2016;65:55–7.

    Article  PubMed  Google Scholar 

  37. Bird E, Paramaswaran U, William T, Khoo TM, Grigg MJ, Aziz A, et al. Transfusion-transmitted severe Plasmodium knowlesi malaria in a splenectomized patient with beta-thalassemia major in Sabah, Malaysia: a case report. Malar J. 2016;15:357.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Khwaja A. KDIGO clinical practice guidelines for acute kidney injury. Nephron Clin Prac. 2012;120:c179–84.

    Article  Google Scholar 

  39. Bruneel F, Gachot B, Wolff M, Régnier B, Danis M, Vachon F. Resurgence of blackwater fever in long-term European expatriates in Africa: report of 21 cases and review. Clin Infect Dis. 2001;32:1133–40.

    Article  CAS  PubMed  Google Scholar 

  40. Blum S, Gattringer R, Haschke E, Walochnik J, Tschurtschenthaler G, Lang F, et al. The Case: hemolysis and acute renal failure. Kidney Int. 2011;80:681.

    Article  PubMed  Google Scholar 

  41. Jose M, Lynn K. Acute renal failure in a patient with paroxysmal nocturnal hemoglobinuria. Clin Nephrol. 2001;56:172–4.

    CAS  PubMed  Google Scholar 

  42. Clark DA, Butler SA, Braren V, Hartmann RC, Jenkins DJ. The kidneys in paroxysmal nocturnal hemoglobinuria. Blood. 1981;57:83–9.

    CAS  PubMed  Google Scholar 

  43. Rubin H. Paroxysmal nocturnal hemoglobinuria with renal failure. JAMA. 1971;215:433–6.

    Article  CAS  PubMed  Google Scholar 

  44. Windsant ICV, Snoeijs MG, Hanssen SJ, Altintas S, Heijmans JH, Koeppel TA, et al. Hemolysis is associated with acute kidney injury during major aortic surgery. Kidney Int. 2010;77:913–20.

    Article  Google Scholar 

  45. Sitprija V. Nephropathy in falciparum malaria. Kidney Int. 1988;34:867–77.

    Article  CAS  PubMed  Google Scholar 

  46. Billings FT, Ball SK, Roberts LJ, Pretorius M. Postoperative acute kidney injury is associated with hemoglobinemia and an enhanced oxidative stress response. Free Radic Biol Med. 2011;50:1480–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  47. Moore KP, Holt SG, Patel RP, Svistunenko DA, Zackert W, Goodier D, et al. A causative role for redox cycling of myoglobin and its inhibition by alkalinization in the pathogenesis and treatment of rhabdomyolysis-induced renal failure. J Biol Chem. 1998;273:31731–7.

    Article  CAS  PubMed  Google Scholar 

  48. Yeo TW, Lampah DA, Tjitra E, Gitawati R, Kenangalem E, Piera K, et al. Relationship of cell-free haemoglobin to impaired nitric oxide bioavailability and perfusion in severe falciparum malaria. J Infect Dis. 2009;200:1522–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  49. Rajahram G, Barber BE, William T, Grigg MJ, Menon J, Yeo TW, et al. Falling Plasmodium knowlesi malaria death rate among adults despite rising incidence, Sabah, Malaysia, 2010–2014. Emerg Infect Dis. 2016;22:41–8.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Authors’ contributions

BEB managed the patient and wrote the first draft of the manuscript. All authors read and approved the final manuscript.


We thank the patient for allowing publication of this case review; medical and nursing staff at Queen Elizabeth Hospital for their care of this patient; research staff Rita Wong, Ann Wei and Beatrice Wong for clinical and laboratory assistance; Kim Piera for measuring the haptoglobin and cell-free haemoglobin at Menzies School of Health Research, Darwin, Australia; and the Director General of Health, Ministry of Health Malaysia, for permission to publish this report.

Competing interests

The authors declare that they have no competing interests.

Availability of data and materials

All relevant data are included in this report.

Consent for publication

Written informed consent was obtained from the patient for publication of this case report.

Ethics approval

Ethics approval was obtained from the ethics committees of the Malaysian Ministry of Health and the Menzies School of Health Research.


This study was supported by the National Health Medical Research Council of Australia (Grant Numbers 10451516 and 496600; Fellowships to NMA, TWY and BEB; and scholarship to MJG).

Author information

Authors and Affiliations


Corresponding author

Correspondence to Bridget E. Barber.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Barber, B.E., Grigg, M.J., William, T. et al. Intravascular haemolysis with haemoglobinuria in a splenectomized patient with severe Plasmodium knowlesi malaria. Malar J 15, 462 (2016).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: