Bindu Mudduluru

Dikshya Sharma

Elias Moussaly

Matthew Hurford

Neville Mobarakai

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Case Report
Babesia in a Nonsplenectomized Patient Requiring
Exchange Transfusion
Dikshya Sharma, Bindu Mudduluru, Elias Moussaly,
Neville Mobarakai, and Matthew Hurford
Staten Island University Hospital, Staten Island, NY, USA
Correspondence should be addressed to Dikshya Sharma; dsharma2@nshs.edu
Received 14 September 2015; Revised 12 November 2015; Accepted 15 November 2015
Academic Editor: Gernot Walder
Copyright © 2015 Dikshya Sharma et al.This is an open access article distributed under theCreativeCommonsAttribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Babesiosis is a tick born zoonosis caused by red blood cell parasites of the genus Babesia. It is caused predominantly by B. microti
and B. divergens, microti being more common in the US. The parasites are transmitted by Ixodes tick to their host but infection
can also spread by blood transfusion and perinatally. Clinical manifestations vary from subclinical infection to fulminating disease
depending upon the immune status of the patient. About half of patients, hospitalized with babesiosis, develop complication with
fatality rates of 6 to 9% which increase up to 21% among those with immunosuppression. A case of 58-year-old previously healthy
man, infected by B. microti, was reported on 2000 who presented with severe disease characterized by severe anemia, DIC, and
renal and respiratory failure. First case of overwhelming septic shock without respiratory involvement due to babesiosis in a healthy
patient with an intact spleen was published in a case report on 2011. Since our patient here is an immunocompetent healthy male
with intact spleen presentingwith severe babesiosis requiring exchange transfusion, this presentation ofBabesia is rare andwarrants
further study.
1. Introduction
Babesia is among the most ubiquitous blood parasites and
maintains their life cycle via exchange between Ixodes ticks
and various mammals. Since its recognition on Nantucket
Island and Cape Cod, Massachusetts, USA, during the 1970s,
human babesiosis from B. microti infection has become a
public health threat in several states.
2. Case
A 53-year-old male with no significant past medical history
presented with 3-day history of fever, generalized weakness,
cold sweats, nausea, and headache. He resides in Staten
Island, New York, and is a wedding photographer by profes-
sion which requires him to travel around woods of upstate
New York. He also admits working in his backyard for 2
weeks. He has two dogs and recalls no sick contact in the
family, no insect or tick bite, or no recent travel outside
United States. He is an occasional drinker and neither reports
drug abuse nor has any history suggestive of functional or
anatomical asplenia. In his primary doctor’s office, he was
found to be hypotensive and tachycardic with blood pressure
of 90/60 and pulse of 101. Labs revealed platelet count of
41, total bilirubin of 3.2, and AST/ALT of 115 and 106 IU/L,
respectively. He had a normal white and red blood cell count.
A blood smearwas positive forB.microti. His PMD requested
him to report to emergency room.
In ER, physical examination showed a well-built healthy
man in no acute distress. His vitals were stable. Physical
examination was pertinent for jaundiced sclera and a retic-
ular rash on his left arm consitent with livedo reticularis.
A repeated blood work was sent that showed hemoglobin
of 13.2 g/dL, platelet counts of 45 L, AST of 148 IU/L, ALT
of 124 IU/L, and total billirubi of 3.4mg/dL. High lactate
dehydrogenase of 699 IU/L and decreased haptoglobulin
of <3 were suggestive of intravascular hemolysis. He had
negative hepatitis panel and HIV status.
A peripheral smear was done that showed red blood cells
contain ring and tetrad forms consistent with B. microti with
Hindawi Publishing Corporation
Case Reports in Infectious Diseases
Volume 2015, Article ID 405263, 3 pages
http://dx.doi.org/10.1155/2015/405263
2 Case Reports in Infectious Diseases
Figure 1: Red blood cells contain ring forms of B. microti (arrow)
and tetrad (Maltese cross, arrow head), 1000x.
Figure 2: Red blood cells contain ring forms of B. microti (arrow)
and tetrad (Maltese cross, arrow head), 1000x.
9.8% parasitemia (Figures 1 and 2). PCR for B. microti was
positive in serum giving us definite species identification.
He was started on azithromycin 500mg/d orally on day one
and then 250mg/d from next day and atovaqoune 750mg
orally every 12 hours. Over the next day, he continued
spiking temperature. His hemoglobin decreased further from
13.2 gm/dL on admission to 9.3 gm/dL on day four and
he continued being symptomatic with high temperatures,
chills, and sweating. A repeated parasite count revealed
16% parasitemia. Due to ongoing hemolysis and increasing
parasite count, he was upgraded to the intensive care unit
for red blood cell exchange therapy while his antibiotics were
changed to IV clindamycin 600mg orally every 8 hours and
oral quinine 650mg orally every 8 hours. After one session of
exchange therapy, he reported feeling better. His hemoglobin
stabilized around 9.3 over the following two days. His LDH
decreased to 436 IU/L, his bilirubin normalized, and parasites
were not detected at the end of fifth day. He was discharged
on 8th day of admission on total of 10 days of oral antibiotic
with close outpatient infectious disease follow-up.
3. Discussion
Human babesiosis is a disease caused by protozoa that invade
mammalian red blood cells and reproduce within them.
In 2013, the CDC was notified of 1.762 cases of babesiosis
among the 27 states in USA. Severity of babesiosis depends
on its host’s characteristic. Age and immunocompetence are
probably among the main determining factors. The most
severe infections occurmainly in the elderly, splenectomized,
or immunocompromised hosts.
Cases of severe B. microti are rare in patient with intact
spleen and hence it was not clear why this patient had
such an aggressive clinical course. Spleen destroys RBCs
containing the parasites from blood. Therefore, asplenic
individuals have increased risk for overwhelming infection
and sepsis. Both humoral immunity and cellular immu-
nity are required to fight against babesiosis. It is proposed
that humoral immunity prevents infection by binding and
neutralizing parasites before they invade target cells. Innate
immune system is involved in controlling the growth rate
and the extent of parasitemia while resolution requires T
lymphocytes, specifically the CD4+IFN-𝛾 producers which
degrade intraerythrocytic parasite. The role of immunity
againstB.microtiwas studied inmicewhich showed necessity
for CD4+ T cells and IFN-𝛾 in conferring immunity against
infection [1]. Unlike immunocompetent mice, SCID mice
(severe combined immunodeficient mice), which lack the
lymphocytes necessary for adaptive immunity, developed
high degree of parasitemia which was markedly reduced
by transfer of naive splenocytes. This study explains the
importance of spleen in clearing the parasite.
Few cases have been reported in the literature where
patient with intact spleen and no evidence of immunosup-
pression developed severe babesiosis.Three reported cases (2
in France and one in Spain) presented with severe flu like
symptoms in immunocompetent hosts and respond to oral
antibiotic. In all cases, Babesia divergens was identified [2, 3].
Some rare cases are seen in theUnited States, mostly confined
to healthy individuals aged ≥50 years. One case was reported
on a 59-year-old immunocompetent male presenting with
ARDS-like picture in US. The patient was treated with ato-
vaquone and azithromycin for seven days and was extubated
successfully [4]. Dorman et al. reported a case 58-year-old
previously healthy man, infected by B. microti, presenting
with severe disease characterized by severe anemia, DIC,
and renal and respiratory failure. No clinical improvement
was seen despite him being on dual antibiotic therapy with
clindamycin and quinine.Whole-blood exchange transfusion
was performed on second day to lower the parasite load and
replace the patient’s plasma. He showedmarked resolution of
parasitemia and slow, general improvement [5]. Dacey et al.
reported the first case of overwhelming septic shock without
respiratory involvement due to babesiosis in a healthy patient
with an intact spleen [6]. As in our case, why these patients
developed such fulminant course is not clear and hence
other host factors that affect the course of Babesia need
further study. Many studies have shown age as clear risk
factor for severe B. microti infection in humans. 139 patients
hospitalized with babesiosis in New York State were found
to have mean age of 62.5 at first hospitalization [7]. To
determine the relation between age and severity, a study was
done in mice using clinical isolate of B. microti. The study
concluded that there is age associated decline in immune
Case Reports in Infectious Diseases 3
protection conferred by spleen cells. This may contribute
to the loss of resistance to the parasite as we age. Also the
study found that there was clear difference in susceptibility
in different genetic strains of mice of same age. And it
concluded that age-associated decline in resistance to B.
microti is genetically determined [8]. Thus, further study was
required to understand relation between genes and resistance
or susceptibility to B. microti. This was also shown in a study
done in inbred mouse strains that showed genetic influence
on the severity of infection. Certain strain ofmice as C57BL/6
were found to be highly resistant to babesiosis, in contrast to
the susceptibility demonstrated byA/J, C3H, 129, and BALB/c
strains [9]. This possibility of genetic susceptibility is yet to
be studied in humans as this may explain why some people
with intact immune system develop severe infection while
others get away with mild forms. A detailed immunological
study is however not required neither recommended in any
immunocompetent patients presenting with severe parasitic
infection including Babesia.
Other factors that may determine the severity of Babesia
infection were also studied in various studies. In a chart
review of patients admitted with babesiosis in a hospital in
long island over the period of 13 years, it was found that
about 94% of patients had some comorbid conditions; among
them about 34% had splenectomy. Severe anemia defined
as a hemoglobin level less than 10 g/dL was the only factor
associatedwith the presence of complicated babesiosis. 20.6%
underwent exchange transfusion and only high parasitemia
of more than 10% was significantly associated with the
likelihood of undergoing the transfusion [10]. This study
corelates with our case as both hemoglobin less than 10% and
high parasitemia of more than 10% were seen in this patient.
186 cases of Babesia were reported in New York State over a
decade in the years 1982 to 1993. Among them 77.4% were
hospitalized. Demographic characteristics of the hospitalized
patients showed that majority of them were old male patients
with history of chronic disease [7].
As referenced above, our case of severe babesiosis in
an immunocompetent host could be secondary to number
of other underlying factors. Age related loss on immune
system and possible genetic susceptibility probably play role
in determining the severity of infection.
Conflict of Interests
The authors declare that there in no conflict of interests
regarding the publication of this paper.
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Case Report Babesia in a Nonsplenectomized Patient Requiring Exchange Transfusion

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Case Report Babesia in a Nonsplenectomized Patient Requiring Exchange Transfusion

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