A case of severe babesiosis treated successfully with exchange transfusion
Esra Tanyel a,*, Nil Guler b, Murat Hokelek c, Fatma Ulger d, Mustafa Sunbul a
a Department of Infectious Disease and Clinical Microbiology, Faculty of Medicine, Ondokuz Mayıs University, Samsun 55139, Turkey
b Department of Hematology, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkey
c Department of Clinical Microbiology, Cerrahpas¸ a Medical Faculty, Istanbul University, Istanbul, Turkey
d Department of Anesthesiology and Reanimation, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkey
Received 22 April 2015
Received in revised form 13 July 2015
Accepted 21 July 2015
Babesiosis is a zoonotic disease that may be asymptomatic or result in severe clinical conditions, with severe hemolysis, hepatic, and renal failure, in humans. Clinical symptoms depend on the species and immune status of the host. The disease is especially severe in those of advanced age, those with an immune deficiency, and the splenectomized. A severe case of babesiosis that developed in a splenectomy patient is presented here; the patient was admitted from a rural region with severe anemia and a deterioration in her general condition, with an initial diagnosis of malaria. In such situations, an exchange transfusion (ET), in addition to antimicrobial treatment, could be lifesaving.
2015 Published by Elsevier Ltd on behalf of International Society for Infectious Diseases. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Babesiosis is a zoonotic disease that is caused by an intraerythrocytic protozoan; it is frequently transmitted through deer ticks (Ixodes scapularis).1–3 Although human babesiosis is often transmitted through tick bites, it can also be transmitted through transfusions or transplacentally or perinatally. Humans are an accidental host in babesiosis.4,5 The main Babesia species that produce the disease in humans are Babesia microti, Babesia divergens, and Babesia bovis.1 In a study conducted in Turkey, the IgG antibody seropositivity for B. microti with the indirect fluorescence antibody method was found to be 6.23% (17/273) in people living in rural areas of Sinop.6 A severe clinical picture including hemolysis, HIV-derived immunosuppression, renal–hepatic failure, and hypotension can develop, particularly in patients who have undergone a splenectomy.4,5,7–9 Clindamycin + quinine or atovaquone + azithromycin are the preferred antimicrobial treatments.
A case of severe babesiosis that developed in a woman living in the countryside is presented here. The patient had undergone a splenectomy 15 years previously due to a firearm injury.
2. Case report
In August 2014, a 28-year-old housewife was admitted to health center in Ordu province with complaints of malaise, jaundice, and general impairment. She had severe anemia (hemoglobin 5.5 g/dl), and so was referred to the hematology department. A large number of signet ring forms were observed within the erythrocytes in the peripheral smear. Consequently she was hospitalized in the infectious diseases clinic with an initial diagnosis of malaria.
The patient had a tendency to sleep, so her medical history was obtained from her relatives. It was learned that she had been experiencing her complaints for approximately 1 month and that she was living in a rural area. She had not traveled to any other cities or countries. Fifteen years earlier she had undergone a splenectomy due to a firearm injury. Upon physical examination, the patient’s body temperature was 37.8 8C, her blood pressure was 110/70 mmHg, her respiratory rate was 24 breaths/min, her pulse was 110 beats/min, her sclera and skin were icteric, and her liver was palpable. In terms of laboratory findings, the white blood cell count was 17.6 109/l (neutrophils 72%, lymphocytes 11%), hemoglobin was 5.5 g/dl, hematocrit was 13.2%, platelet count was 114 109/l, aspartate aminotransferase (AST) was 469 U/l (normal range 8–46 U/l), alanine aminotransferase (ALT) was 89 U/l (normal range 0–35 U/l), total/direct bilirubin was 10.6/2.9 mg/dl, lactate dehydrogenase (LDH) was 4053 U/l (normal range 0–480 U/l), creatine phosphokinase (CPK) was 1576 U/l (normal range 35–195 U/l), and creatinine was 2.5 mg/dl (normal range 0.4–1.4 mg/dl). Tests for hepatitis B surface antigen (HBsAg), antibody to hepatitis C virus (anti-HCV), and antibody to HIV (anti-HIV) were all negative, as was a Brucella tube agglutination test. In the peripheral blood samples, a large number of ring-shaped parasites (>50%) were observed within the erythrocytes on Giemsa staining (Figure 1).
The patient was diagnosed with babesiosis according to the history and the evaluation of the preparations. Treatment with quinine (3 650 mg, orally) + clindamycin (4 600 mg, intravenous) was initiated. Patient blood samples were sent to Cerrahpas¸ a University and the causative agent was identified as Babesia divergens by PCR.
All active babesiosis cases should be treated.5 A combination of either atovaquone + azithromycin or quinine + clindamycin for 7–10 days is the preferred treatment.4,5 It has been reported that a more successful outcome could be obtained from clindamycin + quinine therapy in >10% of the cases with organ failure or parasitemia.9 In the current case, the combination quinine + clindamycin was preferred in the first instance, due to the presence of high parasitemia and the deterioration in the patient’s general condition.
In conclusion, babesiosis is a disease that can be diagnosed with a detailed epidemiological history and an examination of thin and/or thick smear preparations, which is a simple and rapid method. Treatment should be initiated promptly, as the disease may become progressively more severe in immunocompromised and asplenic individuals. ET can be lifesaving in patients with extreme cases of the disease and a high parasite load; therefore, it could be performed in addition to medical therapy.
Medical topics with questions, information and discussion related to Lyme disease and other tick-borne diseases.
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