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Conti J, Gagliardi T, Arnaboldi PM, Hale SJ, Skariah S, Sultan AA, Mordue DG. Immune Mediators Important for a Protective Secondary Response to Babesia microti. Pathogens 2024; 13:123. [PMID: 38392861 PMCID: PMC10892757 DOI: 10.3390/pathogens13020123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 01/17/2024] [Accepted: 01/26/2024] [Indexed: 02/25/2024] Open
Abstract
Babesia microti (B. microti) is a tick-transmitted protozoan parasite that invades red blood cells. It is the primary cause of human babesiosis in the US. The severity of babesiosis caused by B. microti infection can range from asymptomatic to fatal. Risk factors for severe disease include general immune suppression, advanced age (>50) and lack of a spleen. However, severe disease can occur in the absence of any known risk factors. The degree to which tick-transmitted B. microti infection confers protection from subsequent exposure is largely unexplored. This is an important question as both the prevalence and geographic range of tick-transmitted B. microti infection continues to increase and individuals in endemic regions may have multiple exposures over their lifetime. In the current study we used a mouse model to evaluate the degree to which primary infection with B. microti protected against secondary challenge with the same parasite strain. We show that CD4 T cells, and to a lesser extent B cells, contribute to protection. However, mice exhibited significant protection from secondary parasite challenge even in the absence of either CD4 T cells or B cells. The protection mediated by CD4 T cells did not depend on their production of IFN-γ as mice with a targeted gene deletion for the IFN-γ receptor remained fully protected against secondary challenge. Other factors including inducible nitric oxide synthase (iNOS) and the adaptor protein MyD88, important for toll-like receptors, IL-18 and IL-1 signaling, were not important for protection against primary or secondary challenge with B. microti. Thus, our study shows that resolution of primary infection with B. microti results in robust protection against secondary challenge with parasites, at least in the short term. Further studies are needed to evaluate the length of protection and the degree to which protection is impacted by parasite heterogeneity. Although we show an important role for CD4 T cells in protection against secondary challenge, our results suggest that no single aspect of the immune system is solely responsible for adequate protection against secondary challenge with B. microti.
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Affiliation(s)
- Joseph Conti
- Department of Pathology, Microbiology and Immunology, New York Medical College, Valhalla, NY 10595, USA; (J.C.); (T.G.); (P.M.A.); (S.J.H.)
| | - Thomas Gagliardi
- Department of Pathology, Microbiology and Immunology, New York Medical College, Valhalla, NY 10595, USA; (J.C.); (T.G.); (P.M.A.); (S.J.H.)
| | - Paul M. Arnaboldi
- Department of Pathology, Microbiology and Immunology, New York Medical College, Valhalla, NY 10595, USA; (J.C.); (T.G.); (P.M.A.); (S.J.H.)
| | - Synthia J. Hale
- Department of Pathology, Microbiology and Immunology, New York Medical College, Valhalla, NY 10595, USA; (J.C.); (T.G.); (P.M.A.); (S.J.H.)
| | - Sini Skariah
- Department of Microbiology and Immunology, Weill Cornell Medicine-Qatar, Doha 2713, Qatar; (S.S.); (A.A.S.)
| | - Ali A. Sultan
- Department of Microbiology and Immunology, Weill Cornell Medicine-Qatar, Doha 2713, Qatar; (S.S.); (A.A.S.)
| | - Dana G. Mordue
- Department of Pathology, Microbiology and Immunology, New York Medical College, Valhalla, NY 10595, USA; (J.C.); (T.G.); (P.M.A.); (S.J.H.)
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Meredith S, Oakley M, Kumar S. Technologies for Detection of Babesia microti: Advances and Challenges. Pathogens 2021; 10:pathogens10121563. [PMID: 34959518 PMCID: PMC8703551 DOI: 10.3390/pathogens10121563] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 11/24/2021] [Accepted: 11/29/2021] [Indexed: 12/26/2022] Open
Abstract
The biology of intraerythrocytic Babesia parasites presents unique challenges for the diagnosis of human babesiosis. Antibody-based assays are highly sensitive but fail to detect early stage Babesia infections prior to seroconversion (window period) and cannot distinguish between an active infection and a previously resolved infection. On the other hand, nucleic acid-based tests (NAT) may lack the sensitivity to detect window cases when parasite burden is below detection limits and asymptomatic low-grade infections. Recent technological advances have improved the sensitivity, specificity and high throughput of NAT and the antibody-based detection of Babesia. Some of these advances include genomics approaches for the identification of novel high-copy-number targets for NAT and immunodominant antigens for superior antigen and antibody-based assays for Babesia. Future advances would also rely on next generation sequencing and CRISPR technology to improve Babesia detection. This review article will discuss the historical perspective and current status of technologies for the detection of Babesia microti, the most common Babesia species causing human babesiosis in the United States, and their implications for early diagnosis of acute babesiosis, blood safety and surveillance studies to monitor areas of expansion and emergence and spread of Babesia species and their genetic variants in the United States and globally.
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Puri A, Bajpai S, Meredith S, Aravind L, Krause PJ, Kumar S. Babesia microti: Pathogen Genomics, Genetic Variability, Immunodominant Antigens, and Pathogenesis. Front Microbiol 2021; 12:697669. [PMID: 34539601 PMCID: PMC8446681 DOI: 10.3389/fmicb.2021.697669] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 07/30/2021] [Indexed: 12/30/2022] Open
Abstract
More than 100 Babesia spp. tick-borne parasites are known to infect mammalian and avian hosts. Babesia belong to Order Piroplasmid ranked in the Phylum Apicomplexa. Recent phylogenetic studies have revealed that of the three genera that constitute Piroplasmida, Babesia and Theileria are polyphyletic while Cytauxzoon is nested within a clade of Theileria. Several Babesia spp. and sub-types have been found to cause human disease. Babesia microti, the most common species that infects humans, is endemic in the Northeastern and upper Midwestern United States and is sporadically reported elsewhere in the world. Most infections are transmitted by Ixodid (hard-bodied) ticks, although they occasionally can be spread through blood transfusion and rarely via perinatal transmission and organ transplantation. Babesiosis most often presents as a mild to moderate disease, however infection severity ranges from asymptomatic to lethal. Diagnosis is usually confirmed by blood smear or polymerase chain reaction (PCR). Treatment consists of atovaquone and azithromycin or clindamycin and quinine and usually is effective but may be problematic in immunocompromised hosts. There is no human Babesia vaccine. B. microti genomics studies have only recently been initiated, however they already have yielded important new insights regarding the pathogen, population structure, and pathogenesis. Continued genomic research holds great promise for improving the diagnosis, management, and prevention of human babesiosis, and in particular, the identification of lineage-specific families of cell-surface proteins with potential roles in cytoadherence, immune evasion and pathogenesis.
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Affiliation(s)
- Ankit Puri
- Laboratory of Emerging Pathogens, Division of Emerging and Transfusion Transmitted Diseases, Office of Blood Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD, United States
| | - Surabhi Bajpai
- Department of Bioscience and Biotechnology, Banasthali Vidyapith, Banasthali, India
| | - Scott Meredith
- Laboratory of Emerging Pathogens, Division of Emerging and Transfusion Transmitted Diseases, Office of Blood Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD, United States
| | - L Aravind
- National Center for Biotechnology Information, National Library of Medicine, National Institutes of Health, Bethesda, MD, United States
| | - Peter J Krause
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health and Yale School of Medicine, New Haven, CT, United States
| | - Sanjai Kumar
- Laboratory of Emerging Pathogens, Division of Emerging and Transfusion Transmitted Diseases, Office of Blood Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD, United States
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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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Emerging Human Babesiosis with "Ground Zero" in North America. Microorganisms 2021; 9:microorganisms9020440. [PMID: 33672522 PMCID: PMC7923768 DOI: 10.3390/microorganisms9020440] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 02/15/2021] [Accepted: 02/16/2021] [Indexed: 12/15/2022] Open
Abstract
The first case of human babesiosis was reported in the literature in 1957. The clinical disease has sporadically occurred as rare case reports in North America and Europe in the subsequent decades. Since the new millennium, especially in the last decade, many more cases have apparently appeared not only in these regions but also in Asia, South America, and Africa. More than 20,000 cases of human babesiosis have been reported in North America alone. In several cross-sectional surveys, exposure to Babesia spp. has been demonstrated within urban and rural human populations with clinical babesiosis reported in both immunocompromised and immunocompetent humans. This review serves to highlight the widespread distribution of these tick-borne pathogens in humans, their tick vectors in readily accessible environments such as parks and recreational areas, and their phylogenetic relationships.
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Menis M, Whitaker BI, Wernecke M, Jiao Y, Eder A, Kumar S, Xu W, Liao J, Wei Y, MaCurdy TE, Kelman JA, Anderson SA, Forshee RA. Babesiosis Occurrence Among United States Medicare Beneficiaries, Ages 65 and Older, During 2006-2017: Overall and by State and County of Residence. Open Forum Infect Dis 2020; 8:ofaa608. [PMID: 33598501 DOI: 10.1093/ofid/ofaa608] [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: 09/08/2020] [Accepted: 12/09/2020] [Indexed: 12/29/2022] Open
Abstract
Background Human babesiosis is a mild-to-severe parasitic infection that poses health concerns especially in older and other at-risk populations. The study objective was to assess babesiosis occurrence among US Medicare beneficiaries, ages 65 and older, during 2006-2017. Methods Our retrospective claims-based study used Medicare databases. Babesiosis cases were identified using recorded diagnosis codes. The study estimated rates (per 100 000 beneficiary-years) overall, by year, diagnosis month, demographics, and state and county of residence. Results Nationwide, 19 469 beneficiaries had babesiosis recorded, at a rate of 6 per 100 000 person-years, ranging from 4 in 2006 to 9 in 2017 (P < .05). The highest babesiosis rates by state were in the following: Massachusetts (62), Rhode Island (61), Connecticut (51), New York (30), and New Jersey (19). The highest rates by county were in the following: Nantucket, Massachusetts (1089); Dukes, Massachusetts (236); Barnstable, Massachusetts (213); and Dutchess, New York (205). Increasing rates, from 2006 through 2017 (P < .05), were identified in multiple states, including states previously considered nonendemic. New Hampshire, Maine, Vermont, Pennsylvania, and Delaware saw rates increase by several times. Conclusions Our 12-year study shows substantially increasing babesiosis diagnosis trends, with highest rates in well established endemic states. It also suggests expansion of babesiosis infections in other states and highlights the utility of real-world evidence.
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Affiliation(s)
- Mikhail Menis
- Food and Drug Administration, Silver Spring, Maryland, USA
| | | | | | | | - Anne Eder
- Food and Drug Administration, Silver Spring, Maryland, USA
| | - Sanjai Kumar
- Food and Drug Administration, Silver Spring, Maryland, USA
| | - Wenjie Xu
- Acumen LLC, Burlingame, California, USA
| | | | - Yuqin Wei
- Acumen LLC, Burlingame, California, USA
| | - Thomas E MaCurdy
- Acumen LLC, Burlingame, California, USA.,Stanford University, Stanford, California, USA
| | - Jeffrey A Kelman
- Centers for Medicare & Medicaid Services, Baltimore, Maryland, USA
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Miller MJ, McVoy L, Rapkiewicz A. Educational Case: Babesiosis and Transfusion-Transmitted Infections. Acad Pathol 2020; 7:2374289520935591. [PMID: 32733991 PMCID: PMC7370331 DOI: 10.1177/2374289520935591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 02/14/2020] [Accepted: 05/09/2020] [Indexed: 11/16/2022] Open
Abstract
The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. These are divided into three basic competencies: Disease Mechanisms and Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology. For additional information, and a full list of learning objectives for all three competencies, seehttp://journals.sagepub.com/doi/10.1177/2374289517715040.1
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Affiliation(s)
- Maureen J Miller
- Department of Pathology & Laboratory Medicine, Center for Transfusion & Cellular Therapies, Emory School of Medicine, Atlanta, GA, USA
| | - Lauren McVoy
- Department of Pathology, NYU Langone Health, New York, NY, USA
| | - Amy Rapkiewicz
- Department of Pathology, NYU Winthrop Hospital, Mineola, NY, USA
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Verma N, Puri A, Essuman E, Skelton R, Anantharaman V, Zheng H, White S, Gunalan K, Takeda K, Bajpai S, Lepore TJ, Krause PJ, Aravind L, Kumar S. Antigen Discovery, Bioinformatics and Biological Characterization of Novel Immunodominant Babesia microti Antigens. Sci Rep 2020; 10:9598. [PMID: 32533024 PMCID: PMC7293334 DOI: 10.1038/s41598-020-66273-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 05/11/2020] [Indexed: 12/20/2022] Open
Abstract
Babesia microti is an intraerythrocytic parasite and the primary causative agent of human babesiosis. It is transmitted by Ixodes ticks, transfusion of blood and blood products, organ donation, and perinatally. Despite its global public health impact, limited progress has been made to identify and characterize immunodominant B. microti antigens for diagnostic and vaccine use. Using genome-wide immunoscreening, we identified 56 B. microti antigens, including some previously uncharacterized antigens. Thirty of the most immunodominant B. microti antigens were expressed as recombinant proteins in E. coli. Among these, the combined use of two novel antigens and one previously described antigen provided 96% sensitivity and 100% specificity in identifying B. microti antibody containing sera in an ELISA. Using extensive computational sequence and bioinformatics analyses and cellular localization studies, we have clarified the domain architectures, potential biological functions, and evolutionary relationships of the most immunodominant B. microti antigens. Notably, we found that the BMN-family antigens are not monophyletic as currently annotated, but rather can be categorized into two evolutionary unrelated groups of BMN proteins respectively defined by two structurally distinct classes of extracellular domains. Our studies have enhanced the repertoire of immunodominant B. microti antigens, and assigned potential biological function to these antigens, which can be evaluated to develop novel assays and candidate vaccines.
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Affiliation(s)
- Nitin Verma
- Laboratory of Emerging Pathogens, Division of Emerging and Transfusion Transmitted Diseases, Office of Blood Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD, 20993, USA
| | - Ankit Puri
- Laboratory of Emerging Pathogens, Division of Emerging and Transfusion Transmitted Diseases, Office of Blood Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD, 20993, USA
| | - Edward Essuman
- Laboratory of Emerging Pathogens, Division of Emerging and Transfusion Transmitted Diseases, Office of Blood Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD, 20993, USA
| | - Richard Skelton
- Laboratory of Emerging Pathogens, Division of Emerging and Transfusion Transmitted Diseases, Office of Blood Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD, 20993, USA
| | - Vivek Anantharaman
- National Center for Biotechnology Information, National Library of Medicine, National Institutes of Health, Bethesda, MD, 20894, USA
| | - Hong Zheng
- Laboratory of Emerging Pathogens, Division of Emerging and Transfusion Transmitted Diseases, Office of Blood Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD, 20993, USA
| | - Siera White
- Laboratory of Emerging Pathogens, Division of Emerging and Transfusion Transmitted Diseases, Office of Blood Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD, 20993, USA
| | - Karthigayan Gunalan
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, 20852, USA
| | - Kazuyo Takeda
- Lab Of Method Development, Office of Vaccine Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD, 20993, USA
| | - Surabhi Bajpai
- Department of Bioscience and Biotechnology, Banasthali Vidyapith, Banasthali, 304022, India
| | | | - Peter J Krause
- Yale School of Public Health and Yale School of Medicine, New Haven, CT, 06520, USA
| | - L Aravind
- National Center for Biotechnology Information, National Library of Medicine, National Institutes of Health, Bethesda, MD, 20894, USA
| | - Sanjai Kumar
- Laboratory of Emerging Pathogens, Division of Emerging and Transfusion Transmitted Diseases, Office of Blood Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD, 20993, 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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11
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Little EA, Molaei G. Passive Tick Surveillance: Exploring Spatiotemporal Associations of Borrelia burgdorferi (Spirochaetales: Spirochaetaceae), Babesia microti (Piroplasmida: Babesiidae), and Anaplasma phagocytophilum (Rickettsiales: Anaplasmataceae) Infection in Ixodes scapularis (Acari: Ixodidae). Vector Borne Zoonotic Dis 2020; 20:177-186. [DOI: 10.1089/vbz.2019.2509] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Affiliation(s)
- Eliza A.H. Little
- Department of Entomology, The Connecticut Agricultural Experiment Station, New Haven, Connecticut
- Center for Vector Biology & Zoonotic Diseases, The Connecticut Agricultural Experiment Station, New Haven, Connecticut
| | - Goudarz Molaei
- Center for Vector Biology & Zoonotic Diseases, The Connecticut Agricultural Experiment Station, New Haven, Connecticut
- Department of Environmental Sciences, The Connecticut Agricultural Experiment Station, New Haven, Connecticut
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut
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12
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A Bayesian Study of the Dynamic Effect of Comorbidities on Hospital Outcomes of Care for Congestive Heart Failure Patients. TECHNOLOGIES 2019. [DOI: 10.3390/technologies7030066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Comorbidities can have a cumulative effect on hospital outcomes of care, such as the length of stay (LOS), and hospital mortality. This study examines patients hospitalized with congestive heart failure (CHF), a life-threatening condition, which, when it coexists with a burdened disease profile, the risk for negative hospital outcomes increases. Since coexisting conditions co-interact, with a variable effect on outcomes, clinicians should be able to recognize these joint effects. In order to study CHF comorbidities, we used medical claims data from the Centers for Medicare and Medicaid Services (CMS). After extracting the most frequent cluster of CHF comorbidities, we: (i) Calculated, step-by-step, the conditional probabilities for each disease combination inside this cluster; (ii) estimated the cumulative effect of each comorbidity combination on the LOS and hospital mortality; and (iii) constructed (a) Bayesian, scenario-based graphs, and (b) Bayes-networks to visualize results. Results show that, for CHF patients, different comorbidity constructs have a variable effect on the LOS and hospital mortality. Therefore, dynamic comorbidity risk assessment methods should be implemented for informed clinical decision making in an ongoing effort for quality of care improvements.
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Parveen N, Bhanot P. Babesia microti- Borrelia Burgdorferi Coinfection. Pathogens 2019; 8:E117. [PMID: 31370180 PMCID: PMC6789475 DOI: 10.3390/pathogens8030117] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 07/25/2019] [Accepted: 07/26/2019] [Indexed: 12/31/2022] Open
Abstract
The incidence and geographic distribution of human babesiosis is growing in the U.S. Its major causative agent is the protozoan parasite, Babesia microti. B. microti is transmitted to humans primarily through the bite of Ixodes scapularis ticks, which are vectors for a number of other pathogens. Other routes of B. microti transmission are blood transfusion and in rare cases of mother-to-foetus transmission, through the placenta. This review discusses the current literature on mammalian coinfection with B. microti and Borrelia burgdorferi, the causative agent Lyme disease.
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Affiliation(s)
- Nikhat Parveen
- Rutgers New Jersey Medical School, Department of Microbiology, Biochemistry and Molecular Genetics, Newark, NJ 07103, USA.
| | - Purnima Bhanot
- Rutgers New Jersey Medical School, Department of Microbiology, Biochemistry and Molecular Genetics, Newark, NJ 07103, USA.
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14
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Krause PJ. Human babesiosis. Int J Parasitol 2019; 49:165-174. [PMID: 30690090 DOI: 10.1016/j.ijpara.2018.11.007] [Citation(s) in RCA: 129] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 10/31/2018] [Accepted: 11/13/2018] [Indexed: 10/27/2022]
Abstract
Babesiosis is a worldwide emerging tick-borne disease that is increasing in frequency and geographic range. It imposes a significant health burden, especially on those who are immunocompromised and those who acquire the infection through blood transfusion. Death from babesiosis occurs in up to 20 percent of these groups. Diagnosis is confirmed with identification of typical intraerythrocytic parasites on a thin blood smear or Babesia DNA using PCR. Treatment consists of atovaquone and azithromycin or clindamycin and quinine, and exchange transfusion in severe cases. Personal and communal protective measures can limit the burden of infection but it is important to recognize that none of these measures are likely to prevent the continued expansion of Babesia into non-endemic areas.
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Affiliation(s)
- Peter J Krause
- Yale School of Public Health and Yale School of Medicine, New Haven, CT, USA.
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15
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Investigating disease severity in an animal model of concurrent babesiosis and Lyme disease. Int J Parasitol 2018; 49:145-151. [PMID: 30367867 DOI: 10.1016/j.ijpara.2018.06.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 06/11/2018] [Accepted: 06/19/2018] [Indexed: 02/04/2023]
Abstract
The incidence of babesiosis, Lyme disease and other tick-borne diseases has increased steadily in Europe and North America during the last five decades. Babesia microti is transmitted by species of Ixodes, the same ticks that transmit the Lyme disease-causing spirochete, Borrelia burgdorferi. B. microti can also be transmitted through transfusion of blood products and is the most common transfusion-transmitted infection in the U.S.A. Ixodes ticks are commonly infected with both B. microti and B. burgdorferi, and are competent vectors for transmitting them together into hosts. Few studies have examined the effects of coinfections on humans and they had somewhat contradictory results. One study linked coinfection with B. microti to a greater number of symptoms of overall disease in patients, while another report indicated that B. burgdorferi infection either did not affect babesiosis symptoms or decreased its severity. Mouse models of infection that manifest pathological effects similar to those observed in human babesiosis and Lyme disease offer a unique opportunity to thoroughly investigate the effects of coinfection on the host. Lyme disease has been studied using the susceptible C3H mouse infection model, which can also be used to examine B. microti infection to understand pathological mechanisms of human diseases, both during a single infection and during coinfections. We observed that high B. microti parasitaemia leads to low haemoglobin levels in infected mice, reflecting the anaemia observed in human babesiosis. Similar to humans, B. microti coinfection appears to enhance the severity of Lyme disease-like symptoms in mice. Coinfected mice have lower peak B. microti parasitaemia compared to mice infected with B. microti alone, which may reflect attenuation of babesiosis symptoms reported in some human coinfections. These findings suggest that B. burgdorferi coinfection attenuates parasite growth while B. microti presence exacerbates Lyme disease-like symptoms in mice.
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16
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Klevens RM, Cumming MA, Caten E, Stramer SL, Townsend RL, Tonnetti L, Rios J, Young CT, Soliva S, DeMaria A. Transfusion-transmitted babesiosis: one state's experience. Transfusion 2018; 58:2611-2616. [PMID: 30260481 DOI: 10.1111/trf.14943] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 07/25/2018] [Accepted: 07/25/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND The risk for tickborne exposure to Babesia microti infection exists statewide in Massachusetts. Broad exposure complicates investigations of transfusion-transmitted babesiosis (TTB). We summarize 8 years of the epidemiology of TTB and highlight the role of public health in prevention and control. STUDY DESIGN AND METHODS Cases of babesiosis are routinely reported to the Massachusetts Department of Public Health. These are investigated to determine whether they meet the surveillance case definition and to identify whether they were potentially transfusion transmitted. Frequencies from 2009 to 2016 are described and incidence rates calculated using population denominators from the US census. Changes over time were analyzed using simple linear regression. RESULTS From 2009 to 2016, there were 2578 cases of babesiosis reported; of these, 45 (1.7%) were transfusion transmitted. Of the 45 cases of TTB, 15 (33%) received blood products from two or more suppliers. In 11 TTB cases, the Department of Public Health was notified first, who in turn notified the appropriate blood provider. In 2009, the crude rate of reported babesiosis was 1.2 per 100,000 population and increased significantly through 2016 to 7.8 per 100,000 population (p = 0.006). The number of blood donors reported with laboratory evidence of B. microti infection increased from 19 in 2012 to 78 in 2016; at the same time, the number of TTB cases decreased from six to three. CONCLUSION TTB remains a major challenge, and blood donor screening strategies are currently in the process of implementation. While population and environmental changes facilitate increases in babesiosis, donor screening has the potential to eliminate TTB.
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Affiliation(s)
- R Monina Klevens
- Massachusetts Department of Public Health, Bureau of Infectious Disease and Laboratory Sciences, Boston, Massachusetts
| | - Melissa A Cumming
- Massachusetts Department of Public Health, Bureau of Infectious Disease and Laboratory Sciences, Boston, Massachusetts
| | - Evan Caten
- Massachusetts Department of Public Health, Bureau of Infectious Disease and Laboratory Sciences, Boston, Massachusetts
| | - Susan L Stramer
- Scientific Affairs Department, American Red Cross, Gaithersburg, Maryland
| | - Rebecca L Townsend
- Scientific Affairs Department, American Red Cross, Gaithersburg, Maryland
| | - Laura Tonnetti
- Scientific Affairs Department, American Red Cross, Gaithersburg, Maryland
| | - Jorge Rios
- Biomedical Services, American Red Cross, Massachusetts Region, Dedham, Massachusetts
| | | | - Susan Soliva
- Massachusetts Department of Public Health, Bureau of Infectious Disease and Laboratory Sciences, Boston, Massachusetts
| | - Alfred DeMaria
- Massachusetts Department of Public Health, Bureau of Infectious Disease and Laboratory Sciences, Boston, Massachusetts
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17
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Djokic V, Akoolo L, Parveen N. Babesia microti Infection Changes Host Spleen Architecture and Is Cleared by a Th1 Immune Response. Front Microbiol 2018; 9:85. [PMID: 29445365 PMCID: PMC5797759 DOI: 10.3389/fmicb.2018.00085] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 01/12/2018] [Indexed: 12/11/2022] Open
Abstract
Babesia microti is a malaria-like parasite, which infects ∼2000 people annually, such that babesiosis is now a notifiable disease in the United States. Immunocompetent individuals often remain asymptomatic and are tested only after they feel ill. Susceptible C3H/HeJ mice show several human-like disease manifestations and are ideal to study pathogenesis of Babesia species. In this study, we examined parasitemia of B. microti at different time points and assessed its impact on hemoglobin levels in blood, on spleen pathology and overall immune response in C3H/HeJ mice. Peak parasitemia of 42.5% was immediately followed by diminished hemoglobin level. Parasitemia at 21 days of infection was barely detectable by microscopy presented 5.7 × 108 to 5.9 × 109B. microti DNA copies confirming the sensitivity of our qPCR. We hypothesize that qPCR detects DNA released from recently lysed parasites or from extracellular B. microti in blood, which are not easily detected in blood smears and might result in under-diagnosis of babesiosis in patients. Splenectomized patients have been reported to show increased babesiosis severity and result in high morbidity and mortality. These results emphasize the importance of splenic immunity in resolution of B. microti infection. Splenomegaly in infected mice associated with destruction of marginal zone with lysed erythrocytes and released B. microti life forms in our experiments support this premise. At conclusion of the experiment at 21 days post-infection, significant splenic B and T cells depletion and increase in macrophages levels were observed in B. microti infected mice suggesting a role of macrophage in disease resolution. Infected mice also showed significantly higher plasmatic concentration of CD4 Th1 cells secreted cytokines such as IL-2 and IFN-γ while cytokines such as IL-4, IL-5, and IL-13 secreted by Th2 cells increase was not always significant. Thus, Th1 cells-mediated immunity appears to be important in clearance of this intracellular pathogen. Significant increase in IL-6 that promotes differentiation of Th17 cells was observed but it resulted in only moderate change in IL-17A, IL-17F, IL-21, and IL-22, all secreted by Th17 cells. A similar immune response to Trypanosoma infection has been reported to influence the clearance of this protozoan, and co-infecting pathogen(s).
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Affiliation(s)
- Vitomir Djokic
- Department of Microbiology, Biochemistry and Molecular Genetics, Rutgers New Jersey Medical School, Newark, NJ, United States
| | - Lavoisier Akoolo
- Department of Microbiology, Biochemistry and Molecular Genetics, Rutgers New Jersey Medical School, Newark, NJ, United States
| | - Nikhat Parveen
- Department of Microbiology, Biochemistry and Molecular Genetics, Rutgers New Jersey Medical School, Newark, NJ, United States
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18
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Mareedu N, Schotthoefer AM, Tompkins J, Hall MC, Fritsche TR, Frost HM. Risk Factors for Severe Infection, Hospitalization, and Prolonged Antimicrobial Therapy in Patients with Babesiosis. Am J Trop Med Hyg 2017; 97:1218-1225. [PMID: 28722598 DOI: 10.4269/ajtmh.17-0146] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Babesiosis is an emerging tick-borne disease transmitted by the hard tick Ixodes scapularis, which also transmits Lyme disease. Better gradation of prognostic indicators are needed to determine which patients may develop serious complications requiring hospitalization, and to provide early guidance on appropriate therapy. In this study, we evaluated 128 patients with smear or real time polymerase chain reaction-confirmed Babesia microti infections over a period of 16 years. Patients with asplenia or immunocompromising conditions were more likely to have severe infection (P < 0.01), require hospitalization (P < 0.01), or receive prolonged courses of antimicrobials (P < 0.01). Nausea or vomiting (P < 0.01) and diarrhea (P < 0.01) along with hyperbilirubinemia (P < 0.01) were predictive of severe infection, hospitalization, and prolonged antimicrobial therapy. Patients with concurrent Lyme disease were less likely to require hospitalization and had similar severity of disease and length of antibiotic treatment compared with those without Lyme disease.
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Affiliation(s)
| | | | | | | | - Thomas R Fritsche
- University of Wisconsin, La Crosse, Wisconsin.,Marshfield Clinic Health System, Marshfield, Wisconsin
| | - Holly M Frost
- Marshfield Clinic Health System, Minocqua, Wisconsin.,Marshfield Clinic Research Institute, Marshfield, Wisconsin
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19
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Lemieux JE, Tran AD, Freimark L, Schaffner SF, Goethert H, Andersen KG, Bazner S, Li A, McGrath G, Sloan L, Vannier E, Milner D, Pritt B, Rosenberg E, Telford S, Bailey JA, Sabeti PC. A global map of genetic diversity in Babesia microti reveals strong population structure and identifies variants associated with clinical relapse. Nat Microbiol 2016; 1:16079. [PMID: 27572973 DOI: 10.1038/nmicrobiol.2016.79] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 04/28/2016] [Indexed: 11/09/2022]
Abstract
Human babesiosis caused by Babesia microti is an emerging tick-borne zoonosis of increasing importance due to its rising incidence and expanding geographic range(1). Infection with this organism, an intraerythrocytic parasite of the phylum Apicomplexa, causes a febrile syndrome similar to malaria(2). Relapsing disease is common among immunocompromised and asplenic individuals(3,4) and drug resistance has recently been reported(5). To investigate the origin and genetic diversity of this parasite, we sequenced the complete genomes of 42 B. microti samples from around the world, including deep coverage of clinical infections at endemic sites in the continental USA. Samples from the continental USA segregate into a Northeast lineage and a Midwest lineage, with subsequent divergence of subpopulations along geographic lines. We identify parasite variants that associate with relapsing disease, including amino acid substitutions in the atovaquone-binding regions of cytochrome b (cytb) and the azithromycin-binding region of ribosomal protein subunit L4 (rpl4). Our results shed light on the origin, diversity and evolution of B. microti, suggest possible mechanisms for clinical relapse, and create the foundation for further research on this emerging pathogen.
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Affiliation(s)
- Jacob E Lemieux
- The Broad Institute of MIT Division of Health Sciences and and MIT, Cambridge 02142, Massachusetts, USA.,Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts 02114, USA
| | - Alice D Tran
- Program in Bioinformatics and Integrative Biology, University of Massachusetts Medical School, Worcester, Massachusetts 01605, USA
| | - Lisa Freimark
- The Broad Institute of MIT Division of Health Sciences and and MIT, Cambridge 02142, Massachusetts, USA
| | - Stephen F Schaffner
- The Broad Institute of MIT Division of Health Sciences and and MIT, Cambridge 02142, Massachusetts, USA
| | - Heidi Goethert
- Tufts School of Veterinary Medicine, North Grafton, Massachusetts 01536, USA
| | - Kristian G Andersen
- The Broad Institute of MIT Division of Health Sciences and and MIT, Cambridge 02142, Massachusetts, USA.,The Scripps Research Institute, La Jolla, California 92037, USA
| | - Suzane Bazner
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts 02114, USA
| | - Amy Li
- Koch Institute for Integrative Cancer Research at MIT, Cambridge, Massachusetts 02142, USA
| | - Graham McGrath
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts 02114, USA
| | - Lynne Sloan
- Department of Pathology, The Mayo Clinic, Rochester, Minnesota 55905, USA
| | - Edouard Vannier
- Division of Geographic Medicine and Infectious Disease, Tufts Medical Center, Boston, Massachusetts 02111, USA
| | - Dan Milner
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA
| | - Bobbi Pritt
- Department of Pathology, The Mayo Clinic, Rochester, Minnesota 55905, USA
| | - Eric Rosenberg
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts 02114, USA.,Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts 02114, USA
| | - Sam Telford
- Tufts School of Veterinary Medicine, North Grafton, Massachusetts 01536, USA
| | - Jeffrey A Bailey
- Program in Bioinformatics and Integrative Biology, University of Massachusetts Medical School, Worcester, Massachusetts 01605, USA.,Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts 01655, USA
| | - Pardis C Sabeti
- The Broad Institute of MIT Division of Health Sciences and and MIT, Cambridge 02142, Massachusetts, USA.,Department of Evolutionary and Organismic Biology, MIT Division of Health Sciences and University, Cambridge, Massachusetts 02138, USA
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20
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Diuk-Wasser MA, Vannier E, Krause PJ. Coinfection by Ixodes Tick-Borne Pathogens: Ecological, Epidemiological, and Clinical Consequences. Trends Parasitol 2015; 32:30-42. [PMID: 26613664 DOI: 10.1016/j.pt.2015.09.008] [Citation(s) in RCA: 209] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2015] [Revised: 09/25/2015] [Accepted: 09/28/2015] [Indexed: 12/13/2022]
Abstract
Ixodes ticks maintain a large and diverse array of human pathogens in the enzootic cycle, including Borrelia burgdorferi and Babesia microti. Despite the poor ecological fitness of B. microti, babesiosis has recently emerged in areas endemic for Lyme disease. Studies in ticks, reservoir hosts, and humans indicate that coinfection with B. burgdorferi and B. microti is common, promotes transmission and emergence of B. microti in the enzootic cycle, and causes greater disease severity and duration in humans. These interdisciplinary studies may serve as a paradigm for the study of other vector-borne coinfections. Identifying ecological drivers of pathogen emergence and host factors that fuel disease severity in coinfected individuals will help guide the design of effective preventative and therapeutic strategies.
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Affiliation(s)
| | - Edouard Vannier
- Tufts Medical Center and Tufts University School of Medicine, Boston, MA, USA
| | - Peter J Krause
- Yale School of Public Health and Yale School of Medicine, New Haven, CT, USA.
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