Human babesiosis in Japan: isolation of Babesia microti-like parasites from an asymptomatic transfusion donor and from a rodent from an area where babesiosis is endemic

Importance of nonenteric protozoan infections in immunocompromised people

There are many neglected nonenteric protozoa able to cause serious morbidity and mortality in humans, particularly in the developing world. Diseases caused by certain protozoa are often more severe in the presence of HIV. While information regarding neglected tropical diseases caused by trypanosomatids and Plasmodium is abundant, these protozoa are often not a first consideration in Western countries where they are not endemic. As such, diagnostics may not be available in these regions. Due to global travel and immigration, this has become an increasing problem. Inversely, in certain parts of the world (particularly sub-Saharan Africa), the HIV problem is so severe that diseases like microsporidiosis and toxoplasmosis are common. In Western countries, due to the availability of highly active antiretroviral therapy (HAART), these diseases are infrequently encountered. While free-living amoebae are rarely encountered in a clinical setting, when infections do occur, they are often fatal. Rapid diagnosis and treatment are essential to the survival of patients infected with these organisms. This paper reviews information on the diagnosis and treatment of nonenteric protozoal diseases in immunocompromised people, with a focus on patients infected with HIV. The nonenteric microsporidia, some trypanosomatids, Toxoplasma spp., Neospora spp., some free-living amoebae, Plasmodium spp., and Babesia spp. are discussed.

Update on babesiosis

Human babesiosis is an emerging tick-borne infectious disease caused by intraerythrocytic protozoan species of the genus Babesia with many clinical features similar to those of malaria. Over the last 50 years, the epidemiology of human babesiosis has changed from a few isolated cases to the establishment of endemic areas in the northeastern and midwestern United States. Episodic cases are reported in Europe, Asia, Africa, and South America. The severity of infection ranges from asymptomatic infection to fulminant disease resulting in death, although the majority of healthy adults experience a mild-to-moderate illness. People over the age of 50 years and immunocompromised individuals are at the highest risk of severe disease, including those with malignancy, HIV, lacking a spleen, or receiving immunosuppressive drugs. Asymptomatic carriers present a blood safety risk when they donate blood. Definitive diagnosis of babesial infection generally is made by microscopic identification of the organism on thin blood smear, amplification of Babesia DNA using PCR, and detection of Babesia antibody in acute and convalescent sera. Specific antimicrobial therapy consists of atovaquone and azithromycin or clindamycin and quinine. Exchange transfusion is used in severe cases. The use of multiple prevention strategies is recommended and consists of personal, residential, and community approaches.

Babesia microti-group parasites compared phylogenetically by complete sequencing of the CCTeta gene in 36 isolates

Babesia microti, the erythroparasitic cause of human babesiosis, has long been taken to be a single species because classification by parasite morphology and host spectrum blurred distinctions between the parasites. Phylogenetic analyses of the 18S ribosomal RNA gene (18S rDNA) and, more recently, the beta-tubulin gene have suggested inter-group heterogeneity. Intra-group relationships, however, remain unknown. This study was conducted to clarify the intra- and inter-group phylogenetic features of the B. microti-group parasites with the eta subunit of the chaperonin-containing t-complex polypeptide l (CCTeta) gene as a candidate genetic marker for defining the B. microti group. We prepared complete sequences of the CCTeta gene from 36 piroplasms and compared the phylogenetic trees. The B. microti-group parasites clustered in a monophyletic assemblage separate from the Babesia sensu stricto and Theileria genera and subdivided predominantly into 4 clades (U.S., Kobe, Hobetsu, Munich) with highly significant evolutionary distances between the clades. B. rodhaini branched at the base of the B. microti-group parasites. In addition, a unique intron presence/absence matrix not observable in 18S rDNA or beta-tubulin set the B. microti group entirely apart from either Babesia sensu stricto or Theileria. These results have strong implications for public health, suggesting that the B. microti-group parasites are a full-fledged genus comprising, for now, four core species, i.e., U.S., Kobe, Hobetsu, and Munich species nova. Furthermore, the CCTeta gene is an instructive and definitive genetic marker for analyzing B. microti and related parasites.

Human babesiosis

Human babesiosis is an emerging intraerythrocytic infection caused by protozoal parasites transmitted by ixodid ticks. Babesiosis is endemic in the northeastern and upper midwestern regions of the United States and is found sporadically in other parts of the United States, Europe, Asia, Africa, and South America. Babesial infections range from asymptomatic to severe and occasionally are fatal. Specific laboratory diagnosis of babesial infection is made by morphologic examination of Giemsa-stained blood smears, serology, and amplification of babesial DNA using polymerase chain reaction. The combination of atovaquone and azithromycin is the treatment of choice for mild-to-moderate illness, whereas clindamycin and quinine and exchange transfusion are indicated for severe disease.

Detection of Kobe-type Babesia microti associated with Japanese human babesiosis in field rodents in central Taiwan and southeastern mainland China

Field rodent surveys for Babesia infection were performed from 2002 to 2005 in the vicinities of human babesiosis occurrences in Taiwan and mainland China. Babesia microti was identified by microscopical examination and/or PCR in 1 Rattus coxinga and 1 Crocidura horsfieldii in central Taiwan and in 13 Niviventer confucianus and 1 Apodemus agrarius in Zhejiang and Fujian Provinces of southeastern China. Of 15 B. microti samples detected by PCR, all except 1 were shown to be the Kobe-type, the aetiological small subunit rRNA gene-type of the first Japanese patient; the exception was also a Kobe-related type. The Kobe-type had been found in rodents only in a few places including the human infection occurrence place in Japan. The internal transcribed spacer 1 to 2 sequences of the Taiwanese and Chinese Kobe-types were very similar to each other but considerably different (approx. 94% pairwise identities) from that of the Japanese Kobe-type. A Taiwanese Kobe-type strain was serologically differentiated from the Kobe strain originating from the Japanese first patient. The distribution of the Kobe-type in the vicinities of human babesiosis occurrences in Taiwan and China as well as in Japan is suggestive of involvement of the Kobe-type in Asian human babesiosis.

Persistent and relapsing babesiosis in immunocompromised patients

BACKGROUND

Human babesiosis is a tickborne malaria-like illness that generally resolves without complication after administration of atovaquone and azithromycin or clindamycin and quinine. Although patients experiencing babesiosis that is unresponsive to standard antimicrobial therapy have been described, the pathogenesis, clinical course, and optimal treatment regimen of such cases remain uncertain.

METHODS

We compared the immunologic status, clinical course, and treatment of 14 case patients who experienced morbidity or death after persistence of Babesia microti infection, despite repeated courses of antibabesial treatment, with those of 46 control subjects whose infection resolved after a single course of standard therapy. This retrospective case-control study was performed in southern New England, New York, and Wisconsin.

RESULTS

All case patients were immunosuppressed at the time of acute babesiosis, compared with <10% of the control subjects. Most case patients experienced B cell lymphoma and were asplenic or had received rituximab before babesial illness. The case patients were more likely than control subjects to experience complications, and 3 died. Resolution of persistent infection occurred in 11 patients after 2-10 courses of therapy, including administration of a final antimicrobial regimen for at least 2 weeks after babesia were no longer seen on blood smear.

CONCLUSIONS

Immunocompromised people who are infected by B. microti are at risk of persistent relapsing illness. Such patients generally require antibabesial treatment for >or=6 weeks to achieve cure, including 2 weeks after parasites are no longer detected on blood smear.

Molecular survey of Babesia microti, Ehrlichia species and Candidatus neoehrlichia mikurensis in wild rodents from Shimane Prefecture, Japan

A significant number of patients are diagnosed with "fevers of unknown origin" (FUO) in Shimane Prefecture in Japan where tick-borne diseases are endemic. We conducted molecular surveys for Babesia microti, Ehrlichia species, and Candidatus Neoehrlichia mikurensis in 62 FUO cases and 62 wild rodents from Shimane Prefecture, Japan. PCR using primers specific for the Babesia 18S small-subunit rRNA (rDNA) gene and Anaplasmataceae groESL amplified products from 45% (28/62) and 25.8% (16/62) of captured mice, respectively. Of the 28 18S rDNA PCR positives, 23 and five samples were positive for Hobetsu- and Kobe-type B. microti, respectively. In contrast, of the 16 groESL PCR positives, eight, one and seven samples were positive for Ehrlichia muris, Ehrlichia sp. HF565 and Candidatus N. mikurensis, respectively. Inoculation of selected blood samples into Golden Syrian hamsters indicated the presence of Hobetsu- and Kobe-type B. microti in four and one sample, respectively. Isolation of the latter strain was considered important as previous studies suggested that the distribution of this type was so far confined to Awaji Island in Hyogo Prefecture, where the first case of transfusion-associated human babesiosis originated. DNA samples from 62 FUO human cases tested negative for B. microti 18S rDNA gene, Anaplasmataceae groESL gene, Rickettsia japonica 17K genus-common antigen gene and Orientia tsutsugamushi 56K antigen gene by PCRs. We also conducted seroepidemiological surveys on 62 human sera collected in Shimane Prefecture from the FUO patients who were suspected of carrying tick-borne diseases. However, indirect immunofluorescent antibody tests using B. microti- and E. muris-infected cells detected IgG against E. muris in only a single positive sample. This study demonstrates the presence of several potentially important tick-borne pathogens in Shimane Prefecture and suggests the need for further study on the causative agents of FUOs.

First case of human babesiosis in Korea: detection and characterization of a novel type of Babesia sp. (KO1) similar to ovine babesia

We report on the first case of human babesiosis in Korea. The intraerythrocytic parasite (KO1) in the patient's blood mainly appeared as paired pyriforms and ring forms; but Maltese cross forms were not seen, and the parasite showed morphological features consistent with those of the genus Babesia sensu stricto. The sequence of the 18S rRNA gene of KO1 was closely related to that of Babesia spp. isolated from sheep in China (similarity, 98%). The present study provides the first evidence of the presence of a hitherto unidentified, new type of Babesia parasite capable of infecting humans.

The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America

Evidence-based guidelines for the management of patients with Lyme disease, human granulocytic anaplasmosis (formerly known as human granulocytic ehrlichiosis), and babesiosis were prepared by an expert panel of the Infectious Diseases Society of America. These updated guidelines replace the previous treatment guidelines published in 2000 (Clin Infect Dis 2000; 31[Suppl 1]:1-14). The guidelines are intended for use by health care providers who care for patients who either have these infections or may be at risk for them. For each of these Ixodes tickborne infections, information is provided about prevention, epidemiology, clinical manifestations, diagnosis, and treatment. Tables list the doses and durations of antimicrobial therapy recommended for treatment and prevention of Lyme disease and provide a partial list of therapies to be avoided. A definition of post-Lyme disease syndrome is proposed.

Babesia microti-like parasites detected in Eurasian red squirrels (Sciurus vulgaris orientis) in Hokkaido, Japan

Six Eurasian red squirrels (Sciurus vulgaris orientis), victims of road traffic found during 2002 and 2004 near the Noppro Forest Park in Ebetsu, Hokkaido, Japan, were examined for the presence of Babesia parasites. Three of the six squirrels exhibited positive signals by nested PCRs targeting both the 18S rRNA and beta-tubulin genes. Three squirrels proved to be infected with a B. microti-like parasite as evidenced by sequencing the amplified DNAs and by the morphology of the intraerythrocytic parasites. Genotypically, however, the parasite appeared to be of a new type, as it was clearly distinguishable from any of the known types that have previously been reported in various wild animals. This is the first report showing molecular evidence for the presence of B. microti-like parasites in Sciuridae.

Babesiaparasites develop and are transmitted by the non-vector soft tickOrnithodoros moubata(Acari: Argasidae)

Ornithodoros moubataticks were fed on blood infected withBabesia equi. However, the parasites were quickly cleared as evidenced by the disappearance ofB. equi-specific ribosomal RNA from the ticks. We hypothesized that if theBabesiaparasite can escape midgut-associated barriers a non-vector tick can become infected withBabesia. To test this hypothesis,B. equiparasite-infected blood fromin vitroculture was injected into the haemocoel of ticks.B. equi-specific rRNA was surprisingly detected 45 days after injection even in the eggs.Babesia-free dogs were infested withO. moubataticks that were infected by inoculation withB. gibsoni-infected red blood cells. Parasitaemia and antibody production against Bg-TRAP ofB. gibsoniincreased gradually. These results indicate thatO. moubatamay be a useful vector model forBabesiaparasites and also a very important tool for studies on tick immunity againstBabesiaparasites and tick-Babesiainteractions.

Epizootiologic survey for Babesia microti among small wild mammals in northeastern Eurasia and a geographic diversity in the beta-tubulin gene sequences

We previously reported that small wild rodents in Japan harbor two types of novel Babesia microti-like parasites (designated as Hobetsu and Kobe types), but not the type commonly found in the northeastern United States (U.S. type) where human babesiosis is endemic. To determine whether these new types of parasites are distributed in places surrounding Japan, an epizootiologic survey was undertaken in three geographically distant areas in northeastern Eurasia; South Korea, Vladivostok in Russia, and Xinjiang in China. Blood samples were collected from a total of 387 animals comprising 24 species. DNAs extracted from the samples were tested by nested PCR targeting babesial nuclear small-subunit rRNA gene (rDNA), which revealed that small rodents harboring B. microti exist in all three survey areas. Sequence analysis showed that all PCR-positive samples had rDNA sequences virtually identical to that of U.S.-type B. microti. However, when beta-tubulin gene sequences were compared, evident geographic variations were seen. By use of primers specific for each of the beta-tubulin genes of Kobe-, Hobetsu-, and U.S.-type parasites, a type-specific PCR was developed. Parasite with Hobetsu- or Kobe-type sequence was not detected from any of the three survey areas. These findings suggest that U.S.-type B. microti is widely distributed among small wild mammals in temperate zones of not only North America, but also Eurasia, whereas that Hobetsu- and Kobe-type parasites may be uniquely distributed in Japan.

Survey of rodents and ticks in human babesiosis emergence area in Japan: first detection of Babesia microti-like parasites in Ixodes ovatus

Babesia microti-like parasites were detected for the first time in Ixodes ovatus in Hyogo Prefecture, Japan, where two reported types of B. microti-like parasites were recognized in many rodents. Of 80 adult I. ovatus ticks collected, 5 possessed the reported type and 1 possessed a new type of B. microti-like parasite.

Risk and prevention of transfusion-transmitted babesiosis and other tick-borne diseases

PURPOSE OF REVIEW

Tick-borne diseases have increasingly been recognized in the United States as public health problems. The importance of tick-borne diseases has been accelerated by increases in animal populations, as well as increased human recreation in wooded environments that are conducive to tick bites. Babesiosis, usually caused by the intraerythrocytic parasite, Babesia microti and transmitted by the same tick as Lyme disease, has important transfusion implications. Although Lyme disease has not been reported from blood transfusion, newly identified tick-borne diseases such as ehrlichiosis raise additional questions about the role of the tick in transfusion-transmitted diseases.

RECENT FINDINGS

The risk of transfusion-transmitted babesiosis is higher than usually appreciated and in endemic areas represents a major threat to the blood supply. Furthermore, the geographic range of B. microti is expanding, other Babesia spp. have been implicated in transfusion transmission in the western United States, and the movement of blood donors and donated blood components may result in the appearance of transfusion babesiosis in areas less familiar with these parasites. Consequently, a higher degree of clinical suspicion will allow early recognition and treatment of this important transfusion complication.

SUMMARY

In endemic areas transfusion-transmitted babesiosis is more prevalent than usually believed. The extension of the geographic range of various Babesia spp. and the movement of donors and blood products around the United States has resulted in the risk extending to non-endemic areas. Clinicians should maintain a high degree of clinical suspicion for transfusion-transmitted babesiosis.

Inactivation of protozoan parasites in red blood cells using INACTINE PEN110 chemistry

BACKGROUND

The transmission of parasites, including Babesia, plasmodia, and Trypanosoma cruzi, via transfusions is an important public health concern. INACTINE technology is a pathogen-reduction process that utilizes PEN110, an electrophilic agent that inac-tivates a wide range of pathogens by disrupting nucleic acid replication. The present study investigated the effect of PEN110 treatment on the viability of protozoa in RBCs.

STUDY DESIGN AND METHODS

B. microti-parasitized RBCs from infected hamsters were treated with PEN110 and inoculated to naïve animals. Parasitemia was detected by blood smears and PCR. Human RBCs infected with P. falciparum were treated with PEN110 and incubated with fresh RBCs. P. falciparum multiplication was detected by blood smears. Human RBCs spiked with T. cruzi and treated with PEN110 were analyzed for the presence of live parasites using in-vitro infectivity assay or by inoculating susceptible mice.

RESULTS

Treatment of RBCs infected with B. microti or P. falciparum with 0.01 to 0.1 percent (vol/vol) PEN110 resulted in parasite inactivation to below the limit of detection during 24 hours. T. cruzi inoculated into human RBCs was inactivated below the limit of detection by 0.1 percent PEN110 after 3 hours.

CONCLUSION

The study demonstrates that treatment of blood with PEN110 is highly effective in eradicating transfusion-transmitted protozoan parasites.

U.S.-Type Babesia microti Isolated from Small Wild Mammals in Eastern Hokkaido, Japan

Our previous report demonstrated that small wild rodents in Japan harbored two types of novel Babesia microti-like parasites (Kobe and Hobetsu types), but not the type widely distributed throughout the temperate zones of North American and Eurasian Continents (U.S. type). In this study, we surveyed small wild mammals collected at various places in the northern part of Japan, seeking for U.S.-type B. microti. A total of 197 small mammals comprising 10 species, Apodemus speciosus, A. argenteus, Clethrionomys rufocanus, C. rutilus, Eothenomys andersoni, Microtus montebelli, Tamias sibiricus, Sorex unguiculatus, S. caecutiens, and Urotrichus talpoides, were examined. Babesia parasites were detected in A. speciosus, C. rufocanus, C. rutilus, M. montebelli, S. unguiculatus, and S. caecutiens by microscopy of blood smears and by PCR targeting babesial nuclear small-subunit rRNA (rDNA) and beta-tubulin genes. Inoculation of their bloods into experimental animals gave rise to 23 parasite isolates, which included 16 from A. speciosus, 4 from C. rufocanus, and 1 each from C. rutilus, M. montebelli and S. unguiculatus. Sequencing analyses of their rDNA and beta-tubulin genes revealed that, of the 23 isolates, 20 and 3 were of Hobetsu and U.S. types, respectively. The U.S.-type B. microti strains isolated in Japan, however, were distinguishable from the isolates in the United States when their beta-tubulin gene sequences and antigen profiles in Western blots were compared. We conclude that U.S.-type B. microti exists in Japan although it has been genetically and antigenically diversified from that distributed in the United States. The results also suggest that not only rodents, but also some insectivores may serve as reservoirs for the agent of human babesiosis.

Human babesiosis – an unrecorded reality

Human babesiosis, caused by parasitic protozoa of erythrocytes, has escaped usual associates--lower mammals. Thriving in tick guts, it has spread inland from the coasts of America, adopting mankind as a host. Babesia spp. threaten life quality of unsuspecting humans in quickly expanding territories worldwide, including the state of Pennsylvania, USA. The causative spirochetes of Lyme disease often similarly co-exist in ticks. Singly or together they may, by causing persistent and chronic infections, duplicate any symptom in the medical literature--including depression and hypochondriasis. Physicians practicing throughout Pennsylvania have identified patients with symptomatic babesiosis, but without governmental surveillance or health registries that require doctors to consider and report babesiosis, these cases have not prompted epidemiological concern. Misunderstandings such as, "Isn't that an obscure tropical disease?" are usual responses when doctors are asked about babesiosis, inadvertently trivializing patients and disease. Mandatory reporting of babesiosis should now be considered a medical necessity.

Babesiosis diagnosis and treatment

Human babesiosis due to Babesia microti is an emerging malaria-like infection that is endemic in parts of the northeastern and northcentral United States. The clinical manifestations of babesiosis range from subclinical illness to fulminant disease resulting in death. Prompt and accurate diagnosis is difficult because the signs and symptoms are non-specific. A CBC is a useful screening test since anemia and thrombocytopenia are commonly observed and parasites may be visualized on blood smear. Conclusive diagnosis of this disease generally depends upon microscopic examination of thin blood smears. Babesia frequently are overlooked, however, because parasitemia tends to be sparse, often infecting fewer than 1% of erythrocytes early in the course of the illness. Identification of amplifiable babesial DNA by polymerase chain reaction (PCR) has comparable sensitivity and specificity to microscopic analysis of thin blood smear for detection of babesia in blood. Serologic testing provides useful supplementary evidence of infection because a robust antibody response characterizes human babesial infection, even at the time that parasitemia first becomes detectable. The currently recommended therapy for babesiosis is a 7-10-day course of clindamycin (600 mg every 6 h) and quinine (650 mg every 8 h). Recently, azithromycin (500-600 mg on day 1, and 250-600 mg on subsequent days) and atovaquone (750 mg every 12 h) was found to be equally effective in treating adults experiencing babesiosis. This combination also was associated with fewer adverse reactions than clindamycin and quinine. Exchange transfusion is a potentially life-saving therapy for patients suffering from severe disease with high parasitemia (>5%), significant hemolysis, or renal or pulmonary compromise. Babesiosis may be prevented by avoiding areas such as tall grass and brush where ticks, deer, and mice are known to thrive.

Erythrocyte-replaced mouse model for Haemoparasite studies: comparison of NOD/shi-scid and C.B-17/Jcl-scid mouse upon acceptability of human erythrocytes

The erythrocyte-exchanged chimera mouse model has become to be a significant tool for studying animal and human (hu) protozoan haemoparasites, though the usefulness of this model varies depending primarily on the acceptability of xenogeneic red blood cells (RBC). To find a superior recipient in comparison with C.B-17/Jcl mouse with severe combined immuno-deficiency (scid) mutation, we examined in this report the non-obese diabetes (NOD)/shi-scid mouse, a recently available strain of SCID. When 2.5 x 10(8) of fluorescent dye-labeled hu-RBCs were transfused, C.B-17scid mouse eliminated them logarithmically by a simple linear regression, while NOD-scid mouse eradicated hu-RBCs by a unique two-step fashion, i.e., a potent but only briefly functioning RBC eradication followed by a weak steadily functioning step. The means of regression line constance +/- their standard deviations (SD) of 205 C.B-17scid and of 213 NOD-scid mice for their short- and long-lasting steps were -0.73 +/- 0.63, -0.53 +/- 0.25 and -0.16 +/- 0.10, respectively. Hu-RBC half-lives determined from these means of C.B-17scid mice and of NOD-scid mice for the short- and long-living steps were 3.6, 4.9 and 16.3 hr, respectively. Higher hu-RBC acceptability of NOD-scid mouse, especially at their long-lasting step, was also demonstrated under at an activated state of mouse innate immunity. Treatment with 1.0 mg heat-killed Candida cells caused an acceleration of hu-RBC elimination in both mouse strains but the magnitudes for the short- and long-living steps of NOD-scid mice evaluated by "stimulation index" were only 1/2.6 and 1/7.6 of C.B-17scid mice, respectively.

Epidemiological survey of Babesia species in Japan performed with specimens from ticks collected from dogs and detection of new Babesia DNA closely related to Babesia odocoilei and Babesia divergens DNA

Detection and analysis of Babesia species from ticks recovered from dogs in Japan were attempted by PCR and nucleotide sequence analysis based on the 18S rRNA gene, respectively. A total of 1136 ticks were examined for Babesia DNA by 18S rRNA-based PCR and nucleotide sequencing. Partial sequences of Babesia canis vogeli DNA were detected from six ticks in Aomori, Nara, Hiroshima, Oita, and Okinawa Prefectures; and Babesia gibsoni Asia-1 DNA was also detected in four ticks in Osaka, Hiroshima, Miyazaki, and Okinawa Prefectures. Unique sequences of 1678 bp were also obtained from Ixodes ovatus ticks in Akita and Fukui Prefectures. The sequences were similar to those of Babesia odocoilei (97.7%) and Babesia divergens (97.6%). This is the first report of the detection of DNA belonging to this group in Japan.

Retrospective seroepidemiological survey for human babesiosis in an area in Japan where a tick-borne disease is endemic

A total of 1,335 archived human sera collected in 1985 from an area in Japan where a tick-borne disease is endemic were examined by indirect immunofluorescence antibody test (IFAT) to estimate seroprevalence against three serologically distinct types of Babesia microti-like parasites; namely, Hobetsu, Kobe, and U.S. types. Eighteen sera (1.3%) were found to be IFAT-positive (titer 1:100-1:6,400), of which 14 and three were ascertained by Western blot analysis to be positive against the Hobetsu and Kobe types, respectively. In addition, four sera showed an IFAT titer of 1:100 against the U.S. type, but they appeared to be false-positive because they were cross-reactive against the Hobetsu and Kobe types, and also because a U.S.-type parasite has not been found in Japan. Our results suggest that human babesiosis in Japan occurred prior to the discovery of the index case in 1999 and that the infections were caused mainly by Hobetsu-type parasites.

Identification and characterization of putative secreted antigens from Babesia microti

The need for improved diagnostic reagents to identify human long-term carriers of the zoonotic parasite Babesia microti is evidenced by numerous reported cases of transfusion-acquired infections. This report describes the identification and initial characterization of 27 clones representing seven genes or gene families that were isolated through serological expression cloning by using a technique that we specifically designed to screen for shed antigens. In this screen, sera from B. microti-infected SCID mice, putatively containing secreted or shed antigens from the parasites, were harvested and used to immunize syngeneic immunocompetent mice (BALB/c). After boosting, the sera from the BALB/c mice, containing antibodies against the immunodominant secreted antigens, were used to screen a B. microti genomic expression library. Analyses of the putative peptides encoded by the novel DNA sequences revealed characteristics indicating that these peptides might be secreted. Initial serological data obtained with recombinant proteins and a patient serum panel demonstrated that several of the proteins could be useful in developing diagnostic tests for detection of B. microti antibodies and antigens in serum.

Identification of Babesia microti-specific immunodominant epitopes and development of a peptide EIA for detection of antibodies in serum

BACKGROUND

Babesia microti is a tick-borne agent that is increasingly implicated in transfusion-acquired infection, especially in immunocompromised and elderly recipients. To develop a test that can detect antibody responses to B. microti, peptide epitopes identified in two serocomplementary B. microti-specific antigens were used in a prototype EIA.

STUDY DESIGN AND METHODS

A prototype peptide EIA was used to detect B. microti-specific antibodies in 15 sera taken before infection and 107 taken after infection from 59 individuals with known tick-borne infections previously confirmed by other methods. Three additional groups of samples were also tested: a proficiency panel of 18 sera positive for B. microti by IFA, 38 sera from blood donors confirmed positive by IFA, and 30 sera from random blood donors.

RESULTS

The combination peptide detected 98 out of 107 sera taken after infection that were IgG blot positive (4 equivocal). This included all 12 samples that were PCR positive and six sera from smear-negative patients that were confirmed positive by PCR, immunoblot, or IFA. Of the IgG blot-positive specimens that were equivocal (four specimens) or did not react (nine specimens) by EIA, most had low IFA titers consistent with previous exposure. In a second evaluation, 15 out of 15 Babesia IFA-positive sera and 3 out of 3 Babesia-Ehrlichia IFA-positive sera were positive, whereas sera from 30 random donors were negative. Finally, of 38 IFA-positive blood-donor samples, 35 were positive by peptide EIA. The three EIA-negative sera were Western blot negative.

CONCLUSION

Reactivity of the B. microti-specific peptide EIA shows a high correlation with IFA, PCR, and B. microti immunoblot in confirmed B. microti cases. The peptide EIA may be the most suitable B. microti infection test for adaptation to the blood bank environment if testing for B. microti is required in the future.

Cultivation of Babesia and Babesia-like blood parasites: agents of an emerging zoonotic disease

Babesia and its close relatives are members of a group of organisms called piroplasms, a name which comes from their pear-shaped outlines. Long associated with blood diseases of cattle and other mammals, members of the genus Babesia have been recognized since the 1950s as infectious agents in humans. Species of this protozoan blood parasite that have routinely been isolated from mice (B. microti) or cattle (B. divergens) have also been isolated from humans. In addition to these familiar species, new isolates that resist being placed in existing taxonomic categories are the basis for rethinking their phylogenetic relationships based on sequencing data. The parasite represents a threat to the safety of the blood supply in that blood from asymptomatic humans can transmit Babesia to blood recipients. Such transmissions have occurred. The development of methods for cultivation of these organisms represents a significant opportunity to study their biology and disease potential. In addition, in vitro cultivation has provided a basis for studying immune responses of mammals to these infectious agents, with the hope of ultimately producing attenuated strains that could be used for immunizing of cattle and, perhaps, humans who live in areas of endemicity. The microaerophilous stationary phase culture technique, which uses a tissue culture medium base supplemented with appropriate serum and erythrocytes, has made it possible to obtain large numbers of parasitized erythrocytes for studying the biology of this parasite.

Transmission studies of Babesia microti in Ixodes ricinus ticks and gerbils

In order to investigate the possible role of Ixodes ricinus as a vector of zoonotic Babesia microti infection in Europe, a European rodent isolate (HK) and a zoonotic American isolate (GI) were studied in transmission experiments. PCR detected B. microti in the blood and spleens of infected gerbils (Meriones unguiculatus) and also in laboratory-induced infections of I. ricinus ticks. B. microti DNA was detected by PCR in all pooled samples of nymphs and the majority of adults that had fed as larvae and nymphs, respectively, on gerbils with acute infection of the European isolate, confirming that I. ricinus could serve as a vector in Europe. The American isolate, GI, proved to be equally infective for larval and nymphal I. ricinus as the HK strain, despite a very different appearance in gerbil erythrocytes. Nymphs infected with the HK and GI strains readily infected gerbils. In contrast to the finding in acute infections, ticks that fed on gerbils with chronic infections of HK and GI did not become infected. It was also found that the HK strain was not transmitted transovarially. The finding that a B. microti strain (GI) from a distant geographical region (United States) can infect and be transmitted by I. ricinus suggests that other European B. microti strains, in addition to the HK strain used here, are probably infective for I. ricinus, supporting the view that infection of humans with European B. microti may be a regular occurrence.

Babesiosis

Babesiosis is an emerging infection caused by protozoal parasites and transmitted by the same tick that transmits Lyme disease. Babesiosis is found throughout the world, but most cases have been described from the northeastern and northern midwestern United States. Patients experience a flulike illness that usually lasts for 1 or 2 weeks but may require hospital admission. Those at greatest risk of fatal disease include individuals older than age 50 years; asplenic individuals; and immunocompromised individuals as a result of immunosuppressive drugs, malignancy, or HIV infection. Specific diagnosis is made through examination of a Giemsa-stained thin blood smear, DNA amplification using polymerase chain reaction, or detection of specific antibody. Treatment consists of clindamycin and quinine or atovaquone and azithromycin and, in severe cases, exchange transfusion.

Human babesiosis in Japan: epizootiologic survey of rodent reservoir and isolation of new type of Babesia microti-like parasite

We have carried out epizootiologic surveys at various sites in Japan to investigate wild animals that serve as reservoirs for the agents of human babesiosis in the country. Small mammals comprising six species, Apodemus speciosus, Apodemus argenteus, Clethrionomys rufocanus, Eothenomys smithii, Crocidura dsinezumi, and Sorex unguiculatus, were trapped at various places, including Hokkaido, Chiba, Shiga, Hyogo, Shimane, and Tokushima Prefectures. Animals harboring Babesia microti-like parasites were detected in all six prefectures. Inoculation of their blood samples into hamsters gave rise to a total of 20 parasite isolates; 19 were from A. speciosus, and the other 1 was from C. rufocanus. Sequencing of the parasite small-subunit rRNA gene (rDNA) sequence revealed that 2 of the 20 isolates were classified as Kobe type because their rDNAs were identical to that of the Kobe strain (the strain from the Japanese index case). The other 18 isolates were classified as a new type, designated the Hobetsu type, because they all shared an identical rDNA sequence which differed significantly from both that of Kobe-type isolates and that of northeastern United States B. microti (U.S. type). The parasites with Kobe-, Hobetsu- and U.S.-type rDNAs were phylogenetically closely related to each other but clearly different from each other antigenically. The isolates from rodents were demonstrated to be infective for human erythrocytes by inoculation into SCID mice whose erythrocytes had been replaced with human erythrocytes. The results suggest that a new type of B. microti-like parasite, namely, the Hobetsu type, is the major one which is prevalent among Japanese wild rodents, that A. speciosus serves as a major reservoir for both Kobe- and Hobetsu-type B. microti-like parasites, and that C. rufocanus may also be an additional reservoir on Hokkaido Island.