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Hajiabbasi M, Shah N, Bhatt N, Malik MS. Atypical haemolytic uremic syndrome in a patient with severe Babesiosis. BMJ Case Rep 2024; 17:e260735. [PMID: 38890115 DOI: 10.1136/bcr-2024-260735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2024] Open
Abstract
Babesiosis is a tick-borne parasitic infection that can result in various haematological complications. This case report discusses a patient with severe Babesiosis complicated by an unorthodox presentation of Babesiosis-associated haemolytic uremic syndrome. Discussed here is the patient's clinical course and the management strategies employed, with an emphasis on early recognition and treatment of renal failure in the context of severe Babesiosis. Haematologic manifestations of Babesia are common and the severity of disease is dependent on parasite load. While treatment options such as red blood cell exchange have been proposed for severe cases, their impact on clinical outcomes is limited and they may not be readily available in resource-limited settings. Traditional management using antimicrobials has been proposed but there is limited discussion about managing unique presentations such as renal failure in Babesiosis. Hence, understanding the pathophysiology, early recognition and aggressive treatment strategies can optimise clinical outcomes and reduce mortality.
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Affiliation(s)
- Maryam Hajiabbasi
- Department of Medicine, NYC Health + Hospitals / Elmhurst, Icahn School of Medicine at Mount Sinai, Elmhurst, New York, USA
| | - Nagma Shah
- Department of Medicine, NYC Health + Hospitals / Elmhurst, Icahn School of Medicine at Mount Sinai, Elmhurst, New York, USA
| | - Navin Bhatt
- Department of Medicine, NYC Health + Hospitals / Elmhurst, Icahn School of Medicine at Mount Sinai, Elmhurst, New York, USA
| | - Muhammad Saad Malik
- Department of Medicine, NYC Health + Hospitals / Elmhurst, Icahn School of Medicine at Mount Sinai, Elmhurst, New York, USA
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Muench JR, Jha P, Wojtkowski A. Babesiosis: An Atypical Cause of Respiratory Failure. Cureus 2023; 15:e39028. [PMID: 37323362 PMCID: PMC10265922 DOI: 10.7759/cureus.39028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2023] [Indexed: 06/17/2023] Open
Abstract
Babesiosis is a parasitic infection of the Babesia protozoa, which has been increasing in incidence in endemic areas of the United States. Symptoms of babesiosis can occur on a wide spectrum, from a mild flu-like illness to a fulminant disease course. Known complications of severe cases include intravascular hemolytic anemia and may involve the coagulation system, heart, spleen, kidneys, and in some cases, the lungs. This case report describes an 81-year-old, asplenic female in northern Wisconsin who presented to a hospital with shortness of breath and a non-productive cough. Definitive diagnosis of babesiosis, which was made through both a nucleic acid panel and blood smear, was initially delayed given the rare pulmonary manifestation of babesiosis. When the lungs are involved in the disease course, non-cardiogenic pulmonary edema leading to acute respiratory distress syndrome is among the most commonly seen complications. The pathophysiology of pulmonary involvement has not been made entirely clear but is most likely multifactorial, including the sequelae of changes to both the patient's red blood cells and pulmonary vasculature. This report highlights that atypical tick-borne illnesses like babesiosis should be considered as a cause of acute respiratory failure, particularly in the setting of sepsis and fever. The threshold for parasitic testing should be low in patients in endemic regions with risk factors, including increased age and history of asplenia, as babesiosis frequently has no localizing symptoms to suggest a protozoan infection. As babesiosis incidence continues to rise, prompt diagnosis and proper treatment can prevent severe complications and death in patients.
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Affiliation(s)
- Jared R Muench
- Internal Medicine, Medical College of Wisconsin, Milwaukee, USA
| | - Pinky Jha
- Internal Medicine, Medical College of Wisconsin, Milwaukee, USA
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Marcos LA, Vorkas CK, Mann I, Garry E, Lamba P, Pham SK, Spector R, Papamanoli A, Krivacsy S, Lum M, Zahra A, Hou W, Spitzer ED. Reduced Cholesterol Levels during Acute Human Babesiosis. Pathogens 2023; 12:pathogens12040613. [PMID: 37111499 PMCID: PMC10144092 DOI: 10.3390/pathogens12040613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/10/2023] [Accepted: 04/14/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Babesiosis, an intra-erythrocytic protozoan disease, is an emerging zoonotic parasitic disease worldwide. Cholesterol levels are correlated with severe infections, such as sepsis and COVID-19, and anecdotal reports suggest that high-density lipoprotein (HDL) cholesterol declines during acute babesiosis. Our aim was to describe the cholesterol levels in patients with acute babesiosis diagnosed in an endemic area in New York, hypothesizing that HDL levels correlate with the severity of infection. METHODS We reviewed the medical records of adult patients with babesiosis diagnosed by identification of Babesia parasites on a thin blood smear and confirmed by polymerase chain reaction from 2013 to 2018, who also had available a lipid profile drawn at the time of clinical presentation. Additional lipid profile levels were considered as "baseline" if they were drawn within 2 months before or after the infection as part of routine care. RESULTS A total of 39 patients with babesiosis had a lipid profile drawn on presentation. The patients were divided into two groups for comparison based on the treating physician's clinical decision: 33 patients who were admitted to the hospital and 8 patients who were evaluated as outpatients. A history of hypertension was more common in admitted patients (37% vs. 17%, p = 0.02). The median levels of low-density lipoprotein (LDL) and HDL were significantly reduced in admitted patients compared to non-admitted patients (46 vs. 76 mg/dL, p = 0.04; and 9 vs. 28.5 mg/dL, p = 0.03, respectively). In addition, LDL and HDL levels returned to baseline values following resolution of acute babesiosis. CONCLUSION LDL and HDL levels are significantly reduced during acute babesiosis, suggesting that cholesterol depletion may predict disease severity. Pathogen and host factors may contribute to a reduction in serum cholesterol levels during acute babesiosis.
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Affiliation(s)
- Luis A Marcos
- Division of Infectious Diseases, Department of Internal Medicine, Stony Brook University, Stony Brook, NY 11794, USA
- Department of Microbiology and Immunology, Stony Brook University, Stony Brook, NY 11794, USA
| | - Charles Kyriakos Vorkas
- Division of Infectious Diseases, Department of Internal Medicine, Stony Brook University, Stony Brook, NY 11794, USA
- Department of Microbiology and Immunology, Stony Brook University, Stony Brook, NY 11794, USA
| | - Inderjit Mann
- Division of Infectious Diseases, Department of Internal Medicine, Stony Brook University, Stony Brook, NY 11794, USA
| | - Evan Garry
- Division of Infectious Diseases, Department of Internal Medicine, Stony Brook University, Stony Brook, NY 11794, USA
| | - Pooja Lamba
- Division of Infectious Diseases, Department of Internal Medicine, Stony Brook University, Stony Brook, NY 11794, USA
| | - Sophia K Pham
- Stony Brook Southampton Hospital, Southampton, NY 11968, USA
| | - Rachel Spector
- Division of Infectious Diseases, Department of Internal Medicine, Stony Brook University, Stony Brook, NY 11794, USA
| | - Aikaterini Papamanoli
- Division of Infectious Diseases, Department of Internal Medicine, Stony Brook University, Stony Brook, NY 11794, USA
| | - Sara Krivacsy
- Division of Infectious Diseases, Department of Internal Medicine, Stony Brook University, Stony Brook, NY 11794, USA
| | - Michael Lum
- Division of Infectious Diseases, Department of Internal Medicine, Stony Brook University, Stony Brook, NY 11794, USA
| | - Aleena Zahra
- Division of Infectious Diseases, Department of Internal Medicine, Stony Brook University, Stony Brook, NY 11794, USA
| | - Wei Hou
- Division of Epidemiology and Biostatistics, Department of Family, Population and Preventive Medicine, Stony Brook University, Stony Brook, NY 11794, USA
| | - Eric D Spitzer
- Department of Pathology, Stony Brook University, Stony Brook, NY 11794, USA
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A Case Report and Literature Review of Babesiosis-Induced Acute Respiratory Distress Syndrome. Case Rep Infect Dis 2022; 2022:4318731. [DOI: 10.1155/2022/4318731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/04/2022] [Accepted: 11/05/2022] [Indexed: 11/13/2022] Open
Abstract
Babesiosis, a tick-borne protozoan disease, has been increasing in frequency in recent years. Familiarity with presentations of babesiosis is important for clinicians. Acute respiratory distress syndrome (ARDS) is a rarely seen complication of severe babesiosis. In most cases, the patients with babesiosis developed ARDS several days after initiation of antibabesia therapy. We present a unique case of babesiosis without any respiratory symptoms on presentation who developed ARDS within 24 hours of babesiosis treatment initiation. Furthermore, we reviewed published cases of ARDS in babesiosis.
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Tannous T, Cheves TA, Sweeney JD. Red Cell Exchange as Adjunctive Therapy for Babesiosis: Is it Really Effective? Transfus Med Rev 2021; 35:16-21. [PMID: 34334285 DOI: 10.1016/j.tmrv.2021.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 06/28/2021] [Accepted: 06/30/2021] [Indexed: 11/30/2022]
Abstract
Human babesiosis is a parasitic disease prevalent in the Northeastern and Midwestern United States (US). Treatment with antibiotics is the standard of care but red cell exchange (RCE) has been used as an adjunctive treatment in more severe disease. Data for the efficacy of RCE in the treatment of babesiosis has been based on case reports and case series. An English language literature search was conducted for cases of babesiosis treated with RCE since 1980 and relevant laboratory and clinical outcome data were extracted. Similar data were obtained on severe cases of babesiosis referred for RCE in our hospitals in the time period 2000 to 2020. Fifty reports including forty-one individual case reports and nine case series were retrieved. There were 108 patients that underwent RCE with an overall mortality rate of 20%. Some patients had more than one RCE. The patients varied in the level of anemia and evidence of compromise of renal or pulmonary function. The pre-RCE level of parasitemia varied between 1.7% to 85% with the vast majority >10%. The post-RCE level of parasitemia varied between 1% to 10%. Since 2000, 32 patients were referred for RCE in our hospitals and RCE was performed on 23 of 32. There were more patients treated with RCE in the second decade as compared to the first decade, 19 versus 4 respectively. The overall mortality was 22% similar to the national data. Comparing the cohort treated with RCE to the 9 patients who were treated only with antibiotics, there were similar levels of parasitemia and laboratory parameters. The overall number of days needed to achieve a parasite count <1% was similar between the two cohorts and mortality for the antibiotics only cohort was 0%. More than 40 years after the first reported case of RCE in severe babesiosis it cannot be concluded that this adjunctive therapy favorably influences the clinical outcome. Since there is largely equipoise, a registry of severe patients treated with or without RCE could identify a benefit or otherwise.
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Affiliation(s)
- Toufic Tannous
- Roger Williams Medical Center, Providence, RI, USA; Boston University School of Medicine, Boston, MA, USA
| | - Tracey A Cheves
- Rhode Island Hospital and Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Joseph D Sweeney
- Roger Williams Medical Center, Providence, RI, USA; Rhode Island Hospital and Warren Alpert Medical School of Brown University, Providence, RI, USA.
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Abstract
Babesiosis is an emerging infection in the state of Pennsylvania, and clinicians need to be made aware of its clinical manifestations as well as the risk factors associated with severe disease. Before 2010, our tertiary academic center in central Pennsylvania previously saw zero cases of babesiosis. We saw our first confirmed case of Babesia infection acquired in Pennsylvania in 2011; we recorded 2 confirmed cases in 2017 and 4 confirmed cases in 2018. All 4 cases from 2018 were thought to be acquired in southcentral Pennsylvania counties, whereas prior reports of cases were predominately in the southeast and northeast counties of the state.
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Krause PJ, Auwaerter PG, Bannuru RR, Branda JA, Falck-Ytter YT, Lantos PM, Lavergne V, Meissner HC, Osani MC, Rips JG, Sood SK, Vannier E, Vaysbrot EE, Wormser GP. Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA): 2020 Guideline on Diagnosis and Management of Babesiosis. Clin Infect Dis 2021; 72:e49-e64. [PMID: 33252652 DOI: 10.1093/cid/ciaa1216] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Indexed: 11/12/2022] Open
Abstract
The purpose of this guideline is to provide evidence-based guidance for the most effective strategies for the diagnosis and management of babesiosis. The diagnosis and treatment of co-infection with babesiosis and Lyme disease will be addressed in a separate Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR) guideline [1]. Recommendations for the diagnosis and treatment of human granulocytic anaplasmosis can be found in the recent rickettsial disease guideline developed by the Centers for Disease Control and Prevention [2]. The target audience for the babesiosis guideline includes primary care physicians and specialists caring for this condition, such as infectious diseases specialists, emergency physicians, intensivists, internists, pediatricians, hematologists, and transfusion medicine specialists.
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Affiliation(s)
- Peter J Krause
- Yale School of Public Health and Yale School of Medicine, New Haven, Connecticut, USA
| | - Paul G Auwaerter
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Raveendhara R Bannuru
- Center for Treatment Comparison and Integrative Analysis (CTCIA), Division of Rheumatology, Tufts Medical Center, Boston, Massachusetts, USA
| | - John A Branda
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Yngve T Falck-Ytter
- Case Western Reserve University and VA Northeast Ohio Healthcare System, Cleveland, Ohio, USA
| | - Paul M Lantos
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Valéry Lavergne
- Research Center CIUSSS NIM, University of Montreal, Quebec, Canada
| | - H Cody Meissner
- Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Mikala C Osani
- Center for Treatment Comparison and Integrative Analysis (CTCIA), Division of Rheumatology, Tufts Medical Center, Boston, Massachusetts, USA
| | | | - Sunil K Sood
- Zucker School of Medicine and Cohen Children's Medical Center, Northwell Health, New York, USA
| | - Edouard Vannier
- Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Elizaveta E Vaysbrot
- Center for Treatment Comparison and Integrative Analysis (CTCIA), Division of Rheumatology, Tufts Medical Center, Boston, Massachusetts, USA
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O'Bryan J, Gokhale A, Hendrickson JE, Krause PJ. Parasite burden and red blood cell exchange transfusion for babesiosis. J Clin Apher 2020; 36:127-134. [PMID: 33179803 DOI: 10.1002/jca.21853] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 10/20/2020] [Accepted: 10/29/2020] [Indexed: 11/12/2022]
Abstract
BACKGROUND The association between parasite burden and end-organ dysfunction in subjects with Babesia microti infection has not been extensively studied, nor has the optimal role of red blood cell exchange (RCE) transfusion in babesiosis treatment. This retrospective chart review evaluates the associations between parasitemia, end-organ dysfunction, and outcomes in babesiosis patients treated with antimicrobial agents and RCE compared to those treated with antimicrobial agents alone. MATERIALS AND METHODS We evaluated adults (≥18 years of age) with laboratory-confirmed babesiosis who were admitted between 2011 and 2017 to Yale New Haven Hospital, located in a Babesia-endemic region of the Northeastern United States. Patient demographics, parasitemia levels, clinical and laboratory indicators of end-organ dysfunction, and outcomes were examined. RESULTS Ninety-one subjects (mean age 65.1 years, 69.2% male) were studied. Subjects were stratified according to peak parasitemia: <1% (n = 34), 1-5% (n = 24), 5-10% (n = 15), and >10% (n = 18). Laboratory measures indicating degrees of hemolysis, coagulopathy, and pulmonary, renal and hepatic dysfunction differed significantly across peak parasitemia levels. Median length of hospital stay increased with each successive peak parasitemia level (P < .001). These results indicate a strong association between peak parasitemia level and disease severity. Nineteen subjects underwent RCE, all with peak parasitemia ≥9% and some degree of end-organ dysfunction. CONCLUSIONS Babesia microti parasitemia is closely associated with disease severity, though not all subjects with end-organ dysfunction had high-grade parasitemia. Our data suggest that the use of parasitemia >10%, coupled with clinical status, is a reasonable indicator for RCE in babesiosis patients.
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Affiliation(s)
- Jane O'Bryan
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Amit Gokhale
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jeanne E Hendrickson
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut, USA.,Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Peter J Krause
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA.,Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, USA.,Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
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Abstract
INTRODUCTION Human babesiosis is reported throughout the world and is endemic in the northeastern and northern Midwestern United States and northeastern China. Transmission is primarily through hard bodied ticks. Most cases of severe disease occur in immunocompromised individuals and may result in prolonged relapsing disease or death. AREAS COVERED We provide a summary of evidence supporting current treatment recommendations for immunocompetent and immunocompromised individuals experiencing babesiosis. EXPERT OPINION Most cases of human babesiosis are successfully treated with atovaquone and azithromycin or clindamycin and quinine. Severe disease may require prolonged treatment.
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Affiliation(s)
- Robert P Smith
- Division of Infectious Diseases, Maine Medical Center, Portland, Maine; Tufts University School of Medicine , Boston, MA, USA
| | - Klaus-Peter Hunfeld
- Institute for Laboratory Medicine, Microbiology & Infection Control, Northwest Medical Centre, Medical Faculty, Goethe University , Frankfurt/Main, Germany
| | - Peter J Krause
- Yale School of Public Health and Yale School of Medicine , New Haven, CT, USA
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Stussi G, Buser A, Holbro A. Red Blood Cells: Exchange, Transfuse, or Deplete. Transfus Med Hemother 2019; 46:407-416. [PMID: 31933570 DOI: 10.1159/000504144] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 10/15/2019] [Indexed: 12/11/2022] Open
Abstract
Erythrocytapheresis, red blood cell (RBC) depletion, and RBC exchange transfusions are apheresis techniques used to rapidly lower the circulating RBC mass or to exchange the patient erythrocyte mass with donor RBC. Automated RBC exchange is performed using an apheresis device, while manual RBC exchange is based on sequential phlebotomies and isovolemic replacement. Compared to simple RBC transfusions, RBC exchange offers several advantages, e.g., a lower risk for iron accumulation and efficient control of pathological erythrocyte populations. Disadvantages are the higher costs of the procedure, the increased use of donor RBC, and the requirement of apheresis devices and trained hospital staff. The most frequent indication for RBC exchange is sickle cell disease (SCD). RBC exchange transfusions are standard treatment in SCD patients with a history of or a risk for acute stroke and are clinical options for other acute complications of SCD. The most common indication for RBC depletion is the removal of donor RBC from the bone marrow grafts in major ABO-incompatible allogeneic hematopoietic stem cell transplantation to avoid immediate hemolysis. Rare indications for RBC exchange are severe infections with intraerythrocytic pathogens such as malaria or babesiosis and severe erythrocytosis or hereditary hemochromatosis where the aim is to rapidly decrease RBC populations or the iron content. However, only few high-quality studies are available looking at the efficacy of RBC exchange in the different disease entities, and treatment is often based on low levels of evidence and should therefore be decided in close collaboration with a transfusion medicine specialist.
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Affiliation(s)
- Georg Stussi
- Division of Hematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Andreas Buser
- Regional Transfusion Service, Swiss Red Cross, Basel, Switzerland.,Division of Hematology, University Hospital Basel, Basel, Switzerland
| | - Andreas Holbro
- Regional Transfusion Service, Swiss Red Cross, Basel, Switzerland.,Division of Hematology, University Hospital Basel, Basel, Switzerland
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