Acute acalculous cholecystitis and blackwater fever with acute kidney injury in children with malaria: case series and literature review

Abstract Background Acute acalculous cholecystitis (AAC) is an inflammatory gallbladder disease occurring in the absence of gallstones. It typically presents with right upper quadrant (RUQ) pain, fever and gastrointestinal symptoms, and is diagnosed by ultrasound evidence of cholecystitis without gallstones. AAC can have multiple causes, including infections, with malaria only rarely reported. Case presentations We describe four Ugandan children who developed malaria-associated AAC. They were all referred from other centers and presented at a more advanced stage of disease. Apart from AAC, they also presented blackwater fever (BWF) and severe acute kidney injury (AKI), complications increasingly recognized in malaria. AAC was managed conservatively, while two patients required dialysis for kidney failure. All patients ultimately recovered both gallbladder and renal function. Conclusions We provide a review of the literature on malaria-associated AAC, which identified 28 previously reported cases, only 7 in children. Most reported patients contracted the infection in malaria-endemic regions but were then managed in high-income countries. The majority were managed conservatively and had favorable outcomes. Including our series, 32 cases (11 pediatric) have now been reported. Our findings suggest that AAC, which can often occur in association with BWF and AKI, is likely underrecognized in malaria-endemic regions. Heightened clinical awareness and early assessment are important, and practical management recommendations are provided.