we report a case of a patient visiting africa for the first time presenting with malaria and arf .
malaria is an italian word composed of  mala  and  aria  , derived from malus ( bad ) and aeris ( air ) .
it is a disease caused by a protozoan parasite of the genus plasmodium , namely , p. falciparum , p. vivax , p. malariae , and p. ovale , while p. knowles commonly affects nonhuman primates .
the disease remains to be the major cause of morbidity and mortality in many tropical developing countries where it is mostly caused by plasmodium falciparum .
it is estimated that the latter causes around 600,000 deaths annually and the vast majority of such deaths occur in sub - saharan african countries .
the high mortality rates caused by p. falciparum are to a great extent attributed to the parasite 's ability to induce severe malaria associated with life - threatening complications such as cerebral malaria ( cm ) , acute renal failure ( arf ) , severe anemia , acidosis , respiratory distress , jaundice , and acute respiratory distress syndrome ( ards ) .
plasmodium falciparum malaria presenting symptoms and mortality pattern vary considerably according to geographical distribution , parasite 's transmission intensity , and host 's immunity to the parasite . in areas with high and stable malaria transmission , for instance ,
severe malaria is common in children under 5 years of age and commonly presents as severe anemia , while adults with acquired immunity to the parasite do not usually suffer severe malaria . in areas with moderate malaria transmission intensity
likewise , in low unstable malaria transmission intensity , severe malaria occurs in all age groups and can manifest as , cm , renal failure , severe jaundice , and/or pulmonary edema .
however , arf has been reported to be one of the most common complications of falciparum malaria in nonimmune adults .
malarial acute renal failure ( marf ) can occur as an isolated complication or as a component of multiorgan involvement . indeed , an association of arf and cm has been reported and found to cause relatively higher mortality rates than cm alone .
marf should be suspected when urine output falls to less than 400 ml/24 h or 20 ml / h despite adequate rehydration and the diagnosis is confirmed when serum creatinine exceeds 3 mg / dl ( 260 mol / l ) . the availability and provision of renal replacement therapy ( rrt ) as well as appropriate antimalarial chemotherapy has been shown to reduce marf associated mortalities and enhance the restoration of renal function .
we are reporting a case of a 55-year - old male caucasian referred from morogoro regional referral hospital to the university of dodoma haemodialysis unit , with a 3-days history of acute onset of high - grade fever associated with episodes of nonprojectile vomiting with the vomitus being mostly comprised of recently eaten food .
the fever was also associated with chills , myalgia , and loss of consciousness , with episodes of generalized tonic 
few hours following the fever onset , the patient developed shortness of breath with no cough . on the second day , while in the ward , he developed anuria ( decrease in urine output ) , with 50 ml collected over 24 h that was soon followed by hiccups .
the patient was visiting morogoro , tanzania for the first time and he had never been to any malaria endemic area before .
he denied having chest pain , palpitations , diarrhea , bleeding from any site , and declared that he had not been exposed to sick contacts . at the morogoro regional referral hospital ,
he was given two doses of 600 mg quinine in 600 ml of 5% dextrose infusion .
he was referred to the university of dodoma haemodialysis unit due to his nonimproving renal functioning ( anuria ) .
he had smoked one pack of cigarette per day for 30 years and he drank alcohol occasionally .
however , he denied illicit or any kind of drug use , and he had no known allergies .
physical examination revealed that he was obtunded ( gcs = 9/15 ) , jaundiced , dyspneic , pale .
vitals : his blood pressure was 90/60 mm hg with no postural hypotension , his heart rate was 102 beats per minute .
pertinent findings on chest examination included fine crackles at the lung bases , with decreased vocal fremitus .
his cardiovascular examination showed normal first and second heart sounds , with no jugular venous distention , murmurs , rubs , or gallops .
abdominal examination revealed normal bowel sounds without distension , tenderness to palpation , or organomegaly .
rectal examination showed normal rectal tone , heme - negative stool , and no masses .
additionally , an electrocardiogram was performed and results were remarkable for sinus tachycardia . furthermore , laboratory analyses including complete blood cell count ( cbc ) with differential , complete metabolic panel , finger - stick blood glucose , blood slide ( bs ) for malaria parasites ( mps ) , malaria rapid diagnostic test ( mrdt ) , bilirubin levels , urine analysis , and lumbar puncture for cerebral spinal fluid ( csf ) were carried out .
the cbc revealed a normal white blood cell ( wbc ) count without a left shift .
he was found to be anemic , with a hemoglobin level of 11.9 g / dl , mean corpuscular volume of 87 fl , and an elevated erythrocyte sedimentation rate ( esr ) of 35 mm / h .
the initial renal workup revealed serum creatinine of 1.33 mg / dl ( 117.24 mol / l ) , high serum urea of 30.66 mmol / l , serum potassium of 5.1 meq / l , and serum sodium of 140 meq / l .
mol / l , while direct bilirubin was 30 mol / l and random blood glucose was 8.8
. microscopic examination of bs for mps showed 1200 trophozoites/200 wbc ( 4800 mps per l ) and mrdt was positive for p.falciparum . regarding urine analysis , sedimentation revealed muddy brown granular casts , specific gravity of 1.010 , and sodium content of 42 ( mmol / d ) .
csf analysis revealed normal findings and abdominal ultrasound showed normal - sized kidneys with no features of chronic kidney disease .
on the basis of the foregoing findings , the case was diagnosed as complicated malaria with arf , pulmonary edema , cm and anemia , and the patient was scheduled for emergency dialysis .
double lumen catheter was inserted on the right femoral vein of the patient and hemodialysis was started and ran for 4 h on day one .
the process was facilitated by pump pressure of 100 and no fluid removal from the body was allowed .
the patient was also subjected to intramuscular ( i / m ) injection of artemether 160 mg bolus then 80 mg od  4/7 , i / v frusemide 80 mg bid  3/7 , i / v normal saline alternating with ringers lactate 6 l/12 h , and po paracetamol 1 g tid  5/7 .
after three sessions of consecutive hemodialysis of 4 h per day , the patient was conscious , able to sit upright without support , and had urine output of 2400 ml/24 h. his serum creatinine , urea , and potassium were 0.43 mg / dl ( 37.8 mol / l ) , 4.72 mmol / l , and 3.5 meq / l , respectively .
he was closely followed up after 2 weeks and 1 month and found to have normal and stable renal function .
marf is almost always caused by p.falciparum infection although renal involvement has also been reported in p. malariae , and recently in p. vivax infections .
p. malariae has been associated with chronic progressive renal failure , while p. falciparum is usually associated with arf as in our patient .
the incidence of marf worldwide is 14% and may be as high as 60% among nonimmune adults from nonendemic regions visiting endemic regions of the world   as it is the case in our patient . in severe malaria , arf has been shown to be an important cause of mortality . in most cases
, marf manifests clinically and pathologically as acute tubular necrosis as is reported in this case .
the jaundice is usually  biphasic  with both conjugated and nonconjugated bilirubin elevated due to cholestasis and hemolysis , respectively .
it has been shown elsewhere that early initiation of hemodialysis speeds recovery of renal function in the management of a patient with marf , .
hemodialysis has been shown to be more effective than peritoneal dialysis which is often readily available in sub - saharan africa .
hemodialysis is considered adequate when there is postdialysis decrease of blood urea nitrogen ( bun ) and serum creatinine by 50% from baseline .
our patient underwent three consecutive cycles and demonstrated complete recovery of renal function and postdialysis bun and serum creatinine more than 50% less than baseline values .
the foregoing report conclusively outlines the importance of rapid recognition , proper case assessment , and early initiation of repeated sessions of hemodialysis in addition to fluid replacement and appropriate antimalarial therapy for early recovery of renal function in marf .
a copy of the written consent is available for review by the editor - in - chief of this journal .
 key clinical messageacute renal failure ( arf ) secondary to severe malaria is uncommon . 
 we report a case of a patient visiting africa for the first time presenting with malaria and arf . 
 there was complete recovery after hemodialysis . 
 early initiation of hemodialysis proves to be useful in restoration of renal function . 