Templer, Suzanne J, DO

Zukas, Jeanne L, DO

English

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health NetworkLVHN Scholarly WorksDepartment of MedicineIn Our Own BackyardJeanne L. Zukas DOLehigh Valley Health Network, Jeanne_L.Zukas@lvhn.orgSuzanne J. Templer DOLehigh Valley Health Network, Suzanne_J.Templer@lvhn.orgFollow this and additional works at: http://scholarlyworks.lvhn.org/medicinePart of the Medical Sciences CommonsThis Poster is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by anauthorized administrator. For more information, please contact LibraryServices@lvhn.org.Published In/Presented AtZukas, J., & Templer, S. (2011). In our own backyard. Poster presentation.Lehigh Valley Health Network, Allentown, PennsylvaniaIn Our Own BackyardJeanne Zukas, DO; Suzanne Templer, DOTransmission•		Asymptomatic•		Mild/Moderate:	 	 -	 	Fever/chills	-	most	common	presenting	symptoms	 	 -	 Nausea/	vomiting	 	 -	 Fatigue	 	 -	 Headaches	 	 -	 Anorexia	 	 -	 Myalgias/	arthralgias	 	 -	 	Lab	findings:	Anemia/	thrombocytopeniaA	77	year	old	female	from	eastern	Pennsylvania	presented	with	one	month	of	progressive	fatigue,	anorexia,	dark	colored	urine,	and	increasing	weakness,	prompting	her	to	seek	medical	attention.		On	presentation,	the	patient	had	slowed	mental	acuity,	but	was	appropriate.		She	denied	other	symptoms.		Her	exam	was	completely	non-focal,	with	the	exception	of	a	tick	on	her	right	calf.Labs	revealed	a	new	macrocytic	anemia	(hemoglobin	7.1	g/dl)	and	thrombocytopenia	(92K	platelets).		CT	imaging	of	her	abdomen	and	pelvis	was	normal	with	the	exception	of	a	new	splenic	infarct.		A	peripheral	blood	smear	demonstrated	intra-erythrocytic	ringed	forms.		Slides	were	then	sent	to	the	State	DOH	and	the	CDC	for	confirmation	of	the	diagnosis.		The	percent	parasitemia	was	reported	by	the	CDC	as	>10.		A	diagnosis	of	babesiosis	was	made.		Treatment	was	initiated	with	Quinine	and	Clindamycin.		Given	her	advanced	age	and	her	other	lab	findings,	RBC	exchange	transfusion	was	performed.		Afterwards,	her	mental	status,	weakness,	and	appetite	improved.		Her	hemoglobin	improved	to	10.2	g/dl;	and,	her	repeat	blood	smears	showed	clearance	of	the	parasite.		Further	testing	revealed	co-infections	with	Borrelia burgdorferi and	Anaplasma phagocytophilum.		She	completed	a	full	course	of	therapy	for	all	three	infections.		She	did	experience	some	hypoglycemia	as	a	result	of	her	Quinine	therapy,	but	this	resolved	after	cessation	of	treatment.	CaseBabesiosis	is	an	emerging	infectious	disease,	newly	reportable	to	the	CDC	this	year.	No	rapid	test	for	exposure	to	B.	microti	exists,	and	blood	transfusion	related	infections	have	occurred.	Cases	of	babesiosis	are	on	the	rise	in	Eastern	Pennsylvania.		Our	patient	presented	with	a	rare	case	of	co-infection	with	B. microti, B. burgdorferi and A. phagocytophilum.	In	patients	living	in	tick	infested	areas	presenting	with	fevers,	new	onset	of	macrocytic	anemia,	and/or	history	of	tick	exposure,	this	diagnosis	should	be	strongly	considered.		Prompt	recognition	can	prevent	complications	of	this	potentially	fatal	infection.	Summary•		Vector: Ixodes scapularis	tick•		Incubation period:		1	-	9	weeks•		Peak prevalence:	May	to	October•	 Location: New	England/	northeastern	United	StatesSigns/Symptoms•	Severe	 	 -	 	Acute	respiratory	failure/	pulmonary	edema/	ARDS	 	 -	 Change	in	mental	state	 	 -	 Sepsis/	DIC	 	 -	 Acute	renal	failure	 	 -	 Acuate	hepatic	failure	 	 -	 Anorexia	 	 -	 Myalgias/	arthralgias	 	 -	 	Lab	findings:	marked	thrombocytopenia•		Physical	exam	findings:	hepatomegaly/	splenomegaly/	jaundiceDiagnosis•		PCR	•		Blood	smear	visualization	of	intra-erythrocytic	inclusions•		Antibody	serologyTreatment•		Mild	to	moderate	disease	-	Atovaquone	750	mg	orally	twice	a	day	&	Azithromycin	on	day	1	give	500-1000	mg	orally;	on	subsequent	days,	give	a	total	daily	dose	in	the	range	of	250-1000	mg•		Severe	disease	-	Clindamycin	600	mg	orally	3	times	a	day	&	Quinine	650	mg	orally	3	times	a	day	 	 	 -	 	RBC	exchange	transfusion-	indicated	when	the	level	of	parasitemia	is	greater	than	10%,	renal	or	hepatic	dysfunction	occur,	substantial	hemolysis	is	present,	or	the	patient	experiences	respiratory	distress.	Blood	smear	monitoring	is	performed	until	the	level	of	parasitemia	is	<5%.			 	 	 -	 	Risk	factors	for	severe	disease:	asplenia,	immunocompromised	state,	&	age	>50	 	 	 -	 	Mortality	rate:	5%	in	immunocompetent	patients	&	21%	in	immunocompromised	populations•	Duration	of	therapy:	7-10	daysReferences:1.		Vannier,	Edouard,	and	Krause,	Peter.		Update	on	Babesiosis.		Interdisciplinary	Perpective	on	Infectious	Diseases.Vol	2009.	3/2009.2.		Wormser,	Gary,	Dattwyler,	Raymond,	Etal.		The	Clinical	Assessment,	Treatment,	and	Prevention	of	Lyme	Disease,	Human	Granulocytic	Anaplasmosis	and	Babesiosis:		Clinical	Practice	Guidelines	by	the	Infectious	Diseases	Society	of	America.		Clinical	Infectious	Diseases.2006;	43:	1089-134.3.		Parasites	–	Babesiosis.	Center	for	Disease	Control	and	Prevention.	www.cdc.gov/parasites/babesiosis/4.		Peripheral	Blood	Smear	Slides:	James	R.	Lute,	Ph.D.			Director	Division	of	Clinical	Microbiology	Bureau	of	Laboratories,	Pennsylvania	Department	of	Health.

In Our Own Backyard

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In Our Own Backyard

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