Spontaneous Splenic Rupture Secondary to Babesia microti Infection: Treatment with Splenic Artery Embolization

Human Babesiosis

Babesiosis is caused by intraerythrocytic parasites that are transmitted primarily by ticks, infrequently through blood transfusion, and rarely through transplacental transmission or organ transplantation. Human babesiosis is found throughout the world, but the incidence is highest in the Northeast and upper Midwestern United States. Babesiosis has clinical features that resemble malaria and can be fatal in immunocompromised and older patients. Diagnosis is confirmed by identification of Babesia parasites on blood smear or Babesia DNA with polymerase chain reaction. Standard treatment consists of atovaquone and azithromycin or clindamycin and quinine for 7 to 10 days.

Splenic artery embolization for spontaneous splenic rupture due to Babesiosis: a case report

Babesiosis incidence in the United States has been increasing with an 11% rise between 2018 and 2019 based on the latest CDC annual summary, reaching its highest ever reported incidence. This primarily tick-borne disease is particularly prevalent in New England. Despite predominantly nonspecific and at times subtle symptoms, life-threatening complications do occur. One such complication is splenic rupture which has been suggested to be more common in younger and otherwise healthy individuals. This is a report on a successful splenic artery embolization in a 65-year-old male from upstate New York who, unlike most prior studies, showed splenic rupture after he was discharged with negative parasitemia and general improvement following several days of targeted antibiotic therapy. Increased incidence and various presentations of Babesiosis call for an attempt to promote clinical awareness for radiologists among other specialties.

Splenic Artery Embolization and Splenectomy for Spontaneous Rupture of Splenic Hemangioma and Its Imaging Features

Background

Spontaneous splenic rupture (SSR) is a rare, often life-threatening, acute abdominal injury that requires immediate diagnosis and early treatment. SSR is mainly treated surgically or conservatively. A few cases of interventional embolization for SSRs have been reported.

Case Presentation

A 30-year-old male patient complaining mainly of left upper abdominal pain underwent emergency abdominal computed tomography (CT) and showed enlargement of the spleen with a massive mixed-density shadow approximately 10.0 × 8.0 × 12.5 cm in size. The boundary was unclear and showed obvious progressive enhancement. Considering the intrasplenic tumor lesions with rupture and hemorrhage, the possibility of vascular tumors was high, with intraperitoneal blood and fluid accumulation. Digital subtraction angiography of the splenic arteriography and embolization of the ruptured splenic artery branches were performed. Postoperative hemoglobin progressively decreased, inflammatory indicators, such as white blood cell counts, procalcitonin (PCT), and C-reactive protein (CRP) were significantly increased, and 2 days after embolization, the patient developed severe hypoxemia, shock, pulmonary edema, and acute respiratory distress syndrome. CT re-examination 9 days after embolization showed reduced lesion absorption. After stabilization of the condition, splenectomy was performed, and postoperative platelet count increase, anticoagulant improvement, and discharge were observed. Postoperative pathological examination revealed extensive hemorrhage and necrosis, vascular tissue with abnormal hyperplasia in the surrounding area, vascular tissue in the bleeding area and outer wall (elastic fiber staining +), and local myofibroblast hyperplasia. Immunohistochemistry showed actin (SM +) and Ki67 (10% +).

Conclusion

SSR caused by splenic hemangioma is rare, and the choice between surgical treatment or splenic artery embolization remains dependent on the patient's hemodynamic stability and imaging findings.

Babesiosis-associated Splenic Rupture: Case Series From a Hyperendemic Region

BACKGROUND

Spontaneous splenic rupture is an increasingly reported complication of babesiosis and has been described as a severe complication.

METHODS

We performed a retrospective chart review in a high-prevalence area to identify 7 cases of babesiosis-related splenic rupture between 2014 and 2016.

RESULTS

Splenic rupture occurred in approximately 1% of babesiosis cases. Compared to cases without splenic rupture, these patients were younger (by >10 years), healthier (most with ≤1 comorbidity), had a lower degree of parasitemia (<10%), and were less likely to have end-organ dysfunction other than their splenic involvement.

CONCLUSIONS

Younger, healthier patients may be more prone to develop splenic rupture, as splenic histiocytes engage in more robust erythrophagocytosis, leading to pathological mechanical strain and rupture.

Splenic Complications of Babesia microti Infection in Humans: A Systematic Review

Splenic complications of acute Babesia microti infection include splenomegaly, splenic infarct, and splenic rupture. These complications are relatively rarely reported, and the aim of this research was to synthetize data on this topic according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using the PubMed database. In this review, we find that unlike other severe complications of babesiosis, splenic infarct and rupture occur in younger and immunocompetent patients, and they do not correlate with parasitemia level. Furthermore, admission hemoglobin of 10 mg/dl or less, platelet count of 50 × 10⁹/L or less, presence of hemodynamic instability, and splenic rupture were associated independently with an increased risk of requiring splenectomy. As babesiosis is an emerging tick-borne zoonosis, we hope that this review will help to raise awareness among clinicians regarding this rare but potentially life-threatening complication.

Splenic rupture from babesiosis, an emerging concern? A systematic review of current literature

Babesiosis is a relatively common tick-borne parasitic infection of erythrocytes primarily affecting the northeastern United States. Babesiosis' prevalence and presentation have earned it the monikers "malaria of the northeast" and "Nantucket fever". Clinical presentation ranges from asymptomatic infection to severe infection including acute respiratory distress syndrome (ARDS) and disseminated intravascular coagulopathy (DIC) or death. Since 2008, there have been a number of reports of splenic rupture in patients with the disease. We seek to provide a further understanding of this process, with the report of a case of splenic rupture followed by a systematic review of the current literature. We found that 87% of splenic rupture secondary to babesiosis occurred in male patients who are otherwise healthy, with an average of 56 years. Computed tomography is a reliable mode of diagnosis, and hemoperitoneum is the most common imaging finding. Patients with splenic rupture due to human babesiosis were successfully treated by various management strategies, such as conservative non-operative approach, splenic artery embolization, and splenectomy. The modality of treatment depends on patient's clinical course and hemodynamic stability, although spleen conserving strategy should be considered first whenever possible.

Splenic Rupture as the First Manifestation of Babesia Microti Infection: Report of a Case and Review of Literature

Patient: Female, 79

Final Diagnosis: Splenic rupture due to babesia microti infection

Symptoms: Abdominal discomfort • chest pain • fever • tachycardia

Medication: —

Clinical Procedure: Splenectomy

Specialty: Infectious Diseases

Hematologic manifestations of babesiosis

BACKGROUND

Babesiosis, a zoonotic parasitic infection transmitted by the Ixodes tick, has become an emerging health problem in humans that is attracting attention worldwide. Most cases of human babesiosis are reported in the United States and Europe. The disease is caused by the protozoa of the genus Babesia, which invade human erythrocytes and lyse them causing a febrile hemolytic anemia. The infection is usually asymptomatic or self-limited in the immunocompetent host, or follows a persistent, relapsing, and/or life threatening course with multi-organ failure, mainly in the splenectomized or immunosuppressed patients. Hematologic manifestations of the disease are common. They can range from mild anemia, to severe pancytopenia, splenic rupture, disseminated intravascular coagulopathy (DIC), or even hemophagocytic lymphohistiocytosis (HLH).

CASE PRESENTATION

A 70 year old immunocompetent female patient living in New York City presented with a persistent fever, night sweats, and fatigue of 5 days duration. Full evaluation showed a febrile hemolytic anemia along with neutropenia and thrombocytopenia. Blood smear revealed intraerythrocytic Babesia, which was confirmed by PCR. Bone marrow biopsy was remarkable for dyserythropoiesis, suggesting possible HLH, supported by other blood workup meeting HLH-2004 trial criteria.

CONCLUSION

Human babesiosis is an increasing healthcare problem in the United States that is being diagnosed more often nowadays. We presented a case of HLH triggered by Babesia microti that was treated successfully. Also, we presented the hematologic manifestations of this disease along with their pathophysiologies.