Unravelling the cellular and molecular pathogenesis of bovine babesiosis: is the sky the limit?

The global impact of bovine babesiosis caused by the tick-borne apicomplexan parasites Babesia bovis, Babesia bigemina and Babesia divergens is vastly underappreciated. These parasites invade and multiply asexually in bovine red blood cells (RBCs), undergo sexual reproduction in their tick vectors (Rhipicephalus spp. for B. bovis and B. bigemina, and Ixodes ricinus for B. divergens) and have a trans-ovarial mode of transmission. Babesia parasites can cause acute and persistent infections to adult naïve cattle that can occur without evident clinical signs, but infections caused by B. bovis are associated with more severe disease and increased mortality, and are considered to be the most virulent agent of bovine babesiosis. In addition, babesiosis caused by B. divergens has an important zoonotic potential. The disease caused by B. bovis and B. bigemina can be controlled, at least in part, using therapeutic agents or vaccines comprising live-attenuated parasites, but these methods are limited in terms of their safety, ease of deployability and long-term efficacy, and improved control measures are urgently needed. In addition, expansion of tick habitats due to climate change and other rapidly changing environmental factors complicate efficient control of these parasites. While the ability to cause persistent infections facilitates transmission and persistence of the parasite in endemic regions, it also highlights their capacity to evade the host immune responses. Currently, the mechanisms of immune responses used by infected bovines to survive acute and chronic infections remain poorly understood, warranting further research. Similarly, molecular details on the processes leading to sexual reproduction and the development of tick-stage parasites are lacking, and such tick-specific molecules can be targets for control using alternative transmission blocking vaccines. In this review, we identify and examine key phases in the life-cycle of Babesia parasites, including dependence on a tick vector for transmission, sexual reproduction of the parasite in the midgut of the tick, parasite-dependent invasion and egression of bovine RBCs, the role of the spleen in the clearance of infected RBCs (IRBCs), and age-related disease resistance in cattle, as opportunities for developing improved control measures. The availability of integrated novel research approaches including "omics" (such as genomics, transcriptomics, and proteomics), gene modification, cytoadhesion assays, RBC invasion assays and methods for in vitro induction of sexual-stage parasites will accelerate our understanding of parasite vulnerabilities. Further, producing new knowledge on these vulnerabilities, as well as taking full advantage of existing knowledge, by filling important research gaps should result in the development of next-generation vaccines to control acute disease and parasite transmission. Creative and effective use of current and future technical and computational resources are needed, in the face of the numerous challenges imposed by these highly evolved parasites, for improving the control of this disease. Overall, bovine babesiosis is recognised as a global disease that imposes a serious burden on livestock production and human livelihood, but it largely remains a poorly controlled disease in many areas of the world. Recently, important progress has been made in our understanding of the basic biology and host-parasite interactions of Babesia parasites, yet a good deal of basic and translational research is still needed to achieve effective control of this important disease and to improve animal and human health.

Genetic Analysis of Babesia Isolates from Cattle with Clinical Babesiosis in Sri Lanka

Bovine babesiosis is a serious threat to the cattle industry. We prepared blood DNA samples from 13 cattle with clinical babesiosis from the Badulla (n = 8), Jaffna (n = 3), and Kilinochchi (n = 2) districts in Sri Lanka. These DNA samples tested positive in PCR assays specific for Babesiabovis (n = 9), Babesia bigemina (n = 9), and Babesiaovata (n = 1). Twelve cattle were positive for B. bovis and/or B. bigemina One cow was negative for the tested Babesia species but was positive for Babesia on microscopic examination; the phylogenetic positions of 18S rRNA and cytochrome oxidase subunit III gene sequences suggested that the cow was infected with Babesia sp. Mymensingh, which was recently reported from a healthy cow in Bangladesh. We then developed a novel Babesia sp. Mymensingh-specific PCR assay and obtained positive results for one other sample. Analysis of gene sequences from the cow with positive B. ovata-specific PCR results demonstrated that the animal was infected not with B. ovata but with Babesia sp. Hue-1, which was recently reported from asymptomatic cattle in Vietnam. The virulence of Babesia sp. Hue-1 is unclear, as the cow was coinfected with B. bovis and B. bigemina However, Babesia sp. Mymensingh probably causes severe clinical babesiosis, as it was the sole Babesia species detected in a clinical case. The present study revealed the presence of two bovine Babesia species not previously reported in Sri Lanka, plus the first case of severe bovine babesiosis caused by a Babesia species other than B. bovis, B. bigemina, and Babesiadivergens.

What's eating you? Ixodes tick and related diseases, part 1: life cycle, local reactions, and lyme disease

The Ixodes tick is an important arthropod vector in the transmission of human disease. This 3-part review highlights the biology of the Ixodes tick and manifestations of related diseases. Part 1 addresses the Ixodes tick biology and life cycle; local reactions; and Lyme disease, the most prevalent of associated diseases. Part 2 will address human granulocytic anaplasmosis, babesiosis, Powassan virus infection, Borrelia miyamotoi disease, tick-borne encephalitis, and tick paralysis. Part 3 will address coinfection with multiple pathogens as well as methods of tick-bite prevention and tick removal.

MCP-1, KC-like and IL-8 as critical mediators of pathogenesis caused by Babesia canis

Canine babesiosis caused by the intraerythrocytic protozoan parasite Babesia canis is a tick-borne disease characterized by a host response that involves both cellular and humoral immunity. This study focuses on the secretion of cytokines Granulocyte-Macrophage Colony-Stimulating Factor (GM-CSF), Keratinocyte Chemotactic-like (KC-like), Interleukins (IL)-2, IL-7, IL-8, IL-10, IL-15, IL-18 and Monocyte Chemotactic Protein-1 (MCP-1) in babesiosis caused by Babesia canis upon treatment with Imizol®. We assessed time dependent changes in cytokine levels and tested whether these changes correlate with pathogenesis of the disease. Sixteen healthy dogs and 31 dogs infected with Babesia canis, of which 18 showed complications, were treated with Imizol®. One dog died during the study (3.2%). Longitudinal study was perfomed by monitoring dogs at the first day of presentation (day 1) and 6 days later (day 7). Our results show that higher MCP-1 levels on day 1 are positively associated with the occurrence of complications, (complicated vs. uncomplicated; p = 0.00016). A similar pattern was observed for KC-like on day 1 (p = 0.0326) and day 7 (p = 0.044). Moreover, babesiosis caused by B. canis produced a steady increase in IL-8 levels with a moderate to strong negative correlation with erythrocyte counts and hematocrit in uncomplicated diseased dogs only (Spearman's rank correlation coefficient rs = -0.582 and rs = -0.598 respectively). Like for MCP-1, KC-like levels also differed in complicated and uncomplicated diseased dogs on day 1 (p = 0.03236) and day 7 (p = 0.044). Furthermore, KC-like levels were strongly correlated with IL-8 levels (rs = 0.663-0.7) and non-segmented neutrophil counts (rs = 0.572-0.732) in both diseased groups. Analysis of ROC suggests the use of serum levels of MCP-1 and IL-7 as predictors of the occurrence of complications with an AUC of 0.906 and 0.896 respectively and linear combinations of MCP-1, KC-Like, IL-7 and GM-CSF with values up to AUC = 0.983. Cytokine cluster analysis presented in this study can contribute to a better understanding of the pathogenesis of babesiosis and serve as a prognostic tool for the early detection of cases with highest likelihood of developing complications. Overall, our studies show that infection by B. canis elicits a cytokine pattern that is distinct from that observed with B. rossi, and that some of the inflammatory mediators can be useful to predict complications. Our results also suggest targets for the development of novel therapeutic strategies in babesiosis caused by B. canis.

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.

Vertical Transmission of Babesia microti in BALB/c Mice: Preliminary Report

Babesia spp. (Apicomplexa, Piroplasmida) are obligate parasites of many species of mammals, causing a malaria-like infection- babesiosis. Three routes of Babesia infection have been recognized to date. The main route is by a tick bite, the second is via blood transfusion. The third, vertical route of infection is poorly recognized and understood. Our study focused on vertical transmission of B. microti in a well-established mouse model. We assessed the success of this route of infection in BALB/c mice with acute and chronic infections of B. microti. In experimental groups, females were mated on the 1st day of Babesia infection (Group G0); on the 28th day post infection (dpi) in the post- acute phase of the parasite infection (G28); and on the 90th and 150th dpi (G90 and G150 group, respectively), in the chronic phase of the parasite infection. Pups were obtained from 58% of females mated in the post-acute phase (G28) and from 33% of females in groups G90 and G150. Mice mated in the pre-acute phase of infection (G0) did not deliver pups. Congenital B. microti infections were detected by PCR amplification of Babesia 18S rDNA in almost all pups (96%) from the experimental groups G28, G90 and G150. Parasitaemia in the F1 generation was low and varied between 0.01-0.001%. Vertical transmission of B. microti was demonstrated for the first time in BALB/c mice.

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.

Absence of erythrocyte sequestration in a case of babesiosis in a splenectomized human patient

Background

The importance of vascular occlusion in the pathogenesis of human haemoprotozoal disease is unresolved.

Methods

Giemsa-stained tissue sections from a human case of Babesia microti infection in a splenectomized patient with chronic lymphocytic leukaemia and colon cancer were examined to ascertain the distribution of parasitized erythrocytes within the vascular lumen.

Results

No evidence of sequestration was observed.

Conclusion

This first report on the vascular location of B. microti in human tissue suggests that severe multi-organ failure due to babesiosis is independent of sequestration of parasitized erythrocytes. A similar pathogenesis may also cause multi-organ failure in other intraerythrocytic protozoal infections, including falciparum malaria.

Comparison of effects of uncomplicated canine babesiosis and canine normovolaemic anaemia on abdominal splanchnic Doppler characteristics--a preliminary investigation

A preliminary study was conducted to compare uncomplicated canine babesiosis (CB) and experimentally induced normovolaemic anaemia (EA) using Doppler ultrasonography of abdominal splanchnic vessels. Fourteen dogs with uncomplicated CB were investigated together with 11 healthy Beagles during severe EA, moderate EA and the physiological state as a control group. Canine babesiosis was compared with severe EA, moderate EA and the physiological state using Doppler variables of the abdominal aorta, cranial mesenteric artery (CMA), coeliac, left renal and interlobar, and hilar splenic arteries, and the main portal vein. Patterns of haemodynamic changes during CB and EA were broadly similar and were characterised by elevations in velocities and reductions in resistance indices in all vessels except the renal arteries when compared with the physiological state. Aortic and CMA peak systolic velocities and CMA end diastolic and time-averaged mean velocities in CB were significantly lower (P < 0.023) than those in severe EA. Patterns of renal haemodynamic changes during CB and EA were similar. However, the renal patterns differed from those of aortic and gastrointestinal arteries, having elevations in vascular resistance indices, a reduction in end diastolic velocity and unchanged time-averaged mean velocity. The left renal artery resistive index in CB was significantly higher (P < 0.025) than those in EA and the physiological state. Renal interlobar artery resistive and pulsatility indices in CB were significantly higher (P < 0.016) than those of moderate EA and the physiological state. The similar haemodynamic patterns in CB and EA are attributable to anaemia, while significant differences may additionally be attributed to pathophysiological factors peculiar to CB.

Comparative infectivity of Babesia divergens and a zoonotic Babesia divergens-like parasite in cattle

Babesia divergens-like parasites identified in human babesiosis cases in Missouri and Kentucky and in eastern cottontail rabbits (Sylvilagus floridanus) on Nantucket Island, Massachusetts, share identical small subunit ribosomal RNA gene sequences. This sequence is 99.8% identical to that of Babesia divergens, suggesting that the U.S. parasite may be B. divergens, a causative agent of human and bovine babesiosis in Europe. Holstein-Friesian calves were inoculated with cultured Nantucket Island Babesia sp. (NR831) and B. divergens parasites and monitored by clinical signs, Giemsa-stained blood films, PCR, and culture. The NR831 recipients did not exhibit clinical signs of infection and remained negative for all assays. The B. divergens recipients developed clinical infections and became positive by all assays. NR831 recipients were fully susceptible upon challenge inoculation with B. divergens. This study confirms that the Nantucket Island Babesia sp. is not conspecific with B. divergens based on host specificity for cattle.

Tick-borne infections in children: epidemiology, clinical manifestations, and optimal management strategies

Ticks can transmit bacterial, protozoal, and viral infections to humans. Specific therapy is available for several of these infections. Doxycycline is the antimicrobial treatment of choice for all patients, regardless of age, with Rocky Mountain spotted fever, human monocytic ehrlichiosis, or human granulocytic ehrlichiosis. Chloramphenicol has been used to treat these infections in children but is demonstrably inferior to doxycycline. In patients with Mediterranean spotted fever, doxycycline, chloramphenicol, and newer macrolides all appear to be effective therapies. Therapy of Lyme disease depends on the age of the child and stage of the disease. For early localized disease, amoxicillin (for those aged <8 years) or doxycycline (for those aged >/=8 years) is effective. Doxycycline, penicillin V (phenoxymethylpenicillin) or penicillin G (benzylpenicillin) preparations, and erythromycin are all effective treatments for tick-borne relapsing fever. Hospitalized patients with tularemia should receive gentamicin or streptomycin. Doxycycline and ciprofloxacin have each been investigated for the treatment of tularemia in outpatients; however, these agents do not yet have established roles in the treatment of this disease in children. Combination therapy with clindamycin and quinine is preferred for children with babesiosis; the combination of azithromycin and atovaquone also appears promising. Ribavirin has been recently shown to markedly improve survival in patients with Crimean-Congo hemorrhagic fever. The role of antiviral therapy in the treatment of other tick-borne viral infections, including other hemorrhagic fevers and tick-borne encephalitis, is not yet defined.

Babesia divergens, a bovine blood parasite of veterinary and zoonotic importance

Babesia divergens is an intraerythrocytic protozoan parasite, transmitted by the tick Ixodes ricinus, and is the main agent of bovine babesiosis in Europe. It is not only a cause of significant loss to the cattle industry; it can also infect immunocompromised humans, causing medical emergencies characterized by rapid fulmination and parasitemias that may exceed 70%. The current emphasis in Europe on sustainable agriculture and extensification is likely to lead to an increase in vector tick populations with increased risk of infection. Despite the veterinary and zoonotic importance of this parasite, relatively little research has been carried out on B. divergens, and many questions regarding the parasite's epidemiology and the host's response remain unanswered. A better understanding of the species' biology and host-parasite interactions may lead to improved control mechanisms and new trends in vaccine and antibabesial drug development. This review provides the first comprehensive summary of B. divergens biology, including its morphology, life cycle, and host specificity, and the current state of knowledge of both human and bovine infections.

Molecular characterization of a non-Babesia divergens organism causing zoonotic babesiosis in Europe

In Europe, most reported human cases of babesiosis have been attributed, without strong molecular evidence, to infection with the bovine parasite Babesia divergens. We investigated the first known human cases of babesiosis in Italy and Austria, which occurred in two asplenic men. The complete 18S ribosomal RNA (18S rRNA) gene was amplified from specimens of their whole blood by polymerase chain reaction (PCR). With phylogenetic analysis, we compared the DNA sequences of the PCR products with those for other Babesia spp. The DNA sequences were identical for the organism from the two patients. In phylogenetic analysis, the organism clusters with B. odocoilei, a parasite of white-tailed deer; these two organisms form a sister group with B. divergens. This evidence indicates the patients were not infected with B. divergens but with an organism with previously unreported molecular characteristics for the 18S rRNA gene.

Babesiosis in humans: a treatment review

Human infections with Babesia species, in particular Babesia microti, are tick-borne illnesses that are being recognised with increased frequency. Coinfection with ehrlichiosis and Lyme disease is also being recognised as an important feature of these tick-borne illnesses. Despite the superficial resemblance of Babesia to malaria, these piroplasms do not respond to chloroquine or other similar drugs. However, the treatment of babesiosis using a clindamycin-quinine combination has been successful. Data in animal models and case-reports in humans have suggested that an atovaquone-azithromycin combination is also effective. This was confirmed in a recent prospective, open, randomised trial of clindamycin-quinine versus azithromycin-atovaquone. This paper reviews the literature on the treatment of human babesiosis and the animal models of these human pathogens.

Gastrointestinal and hepatic manifestations of tickborne diseases in the United States

Signs and symptoms related to the gastrointestinal tract and liver may provide important clues for the diagnosis of various tickborne diseases prevalent in different geographic areas of the United States. We review clinical and laboratory features that may be helpful in detecting a tickborne infection. Physicians evaluating patients who live in or travel to areas where tickborne diseases are endemic and who present with an acute febrile illness and gastrointestinal manifestations should maintain a high index of suspicion for one of these disease entities, particularly if the patient has received a tick bite. If detected early, many of these potentially serious illnesses can be easily and effectively treated, thereby avoiding serious morbidity and even death.

Description of a new Babesia sp. infective for cattle in China

A Babesia species has been identified and shown to be transmitted by Hyalomma anatolicum anatolicum in China. When larvae, nymphs and adults developed from engorged females H. a. anatolicum collected from cattle in Xinjiang province were infested onto the Babesia-free calves, piroplasms of Babesia sp. were seen in blood smears from cattle infested with nymphs (2 calves), but not from the calves infested with larvae (1 calf or adult ticks (2 calves). This Babesia sp. proved to be of low virulence, causing 3% parasites which lasted 3-4 days.

The role of cytokines in immunity and immunopathogenesis of pirolasmoses

Cells involved in innate and adapted immunity produce cytokines capable of orchestrating the immune response to Babesia and Theileria infections. Thus, CD4-postive T cells recognise peptide fragments of the parasites in the context of the major histocompatibility complex (MHC) class II antigen and produce gamma interferon (IFN-gamma) to activate macrophages for enhanced phagocytosis and intracellular killing of the parasites. In addition, CD4-positive T cells produce interleukin 2 (IL-2) which is essential for the clonal expansion of CD8-positive T cells. The latter cells kill Theileria-infected host leucocytes in an MHC class I-dependent manner. On the other hand, the overproduction of proinflammatory cytokines contributes to disease progress.

Disease-specific diagnosis of coinfecting tickborne zoonoses: babesiosis, human granulocytic ehrlichiosis, and Lyme disease

To determine whether a unique group of clinical and laboratory manifestations characterize certain major deer tick-transmitted human pathogens in North America, we compared the symptoms, short-term complications, and laboratory test results of New England residents who became ill due to > or =1 of these pathogens. Patients completed a uniformly structured questionnaire and submitted blood samples for serologic and polymerase chain reaction (PCR) testing after developing symptoms of Lyme disease, human babesiosis, or human granulocytic ehrlichiosis (HGE). Complete blood count with thin blood smear, PCR, and immunoglobulin M antibody tests helped differentiate the acute manifestations of these diseases. Physicians should consider use of tests designed to diagnose babesiosis and HGE in patients with Lyme disease who experience a prolonged flulike illness that fails to respond to appropriate antiborrelial therapy.

Clinical and hematologic effects of experimental infection of dogs with recently identified Babesia gibsoni-like isolates from Oklahoma

OBJECTIVE

To characterize clinical and hematologic responses in dogs following experimental inoculation with Babesia gibsoni-like isolates from infected dogs in Oklahoma.

DESIGN

Prospective study.

ANIMALS

6 mixed-breed dogs.

PROCEDURE

2 dogs were inoculated with organisms from a naturally infected dog, and 3 were inoculated with organisms from a second naturally infected dog (1 of these 3 dogs was splenectomized 1 week prior to inoculation). One dog was not inoculated. Complete blood counts were performed weekly.

RESULTS

In the 5 dogs inoculated with organisms, parasites were initially detected 1 to 5 weeks after inoculation, and severity of parasitemia peaked with 1.9 to 6.0% of RBC infected by 4 to 6 weeks after inoculation. Parasitemia was easily detectable (> 0.1% of RBC infected) for 3 to 4 weeks. Clinical abnormalities included lethargy, fever, and pale mucous membranes but were mild to nearly inapparent in 2 dogs. All dogs developed regenerative anemia and marked thrombocytopenia. Thrombocytopenia developed before and lasted longer than the parasitemia. Profound but transient neutropenia was detected in some dogs. The splenectomized dog developed more severe parasitemia and anemia and more pronounced clinical abnormalities. Three dogs with intact spleens recovered without treatment.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggest that 2 or more genotypically distinct, but morphologically identical, small Babesia parasites can infect dogs in the United States. Compared with infection with small Babesia parasites from California, infection with these isolates resulted in less severe parasitemia and clinical abnormalities. Parasitemia was transient, indicating that identification of organisms in blood smears may be difficult in some dogs.

The mixed acid-base disturbances of severe canine babesiosis

Thirty-four dogs suffering from severe babesiosis caused by Babesia canis rossi were included in this study to evaluate acid-base imbalances with the quantitative clinical approach proposed by Stewart. All but 3 dogs were severely anemic (hematocrit <12%). Arterial pH varied from severe acidemia to alkalemia. Most animals (31 of 34; 91%) had inappropriate hypocapnia with the partial pressure of CO2 < 10 mm Hg in 12 of 34 dogs (35%). All dogs had a negative base excess (BE; mean of - 16.5 mEq/L) and it was below the lower normal limit in 25. Hypoxemia was present in 3 dogs. Most dogs (28 of 34; 82%) were hyperlactatemic. Seventy percent of dogs (23 of 33) were hypoalbuminemic. Anion gap (AG) was widely distributed, being high in 15, low in 12, and normal in 6 of the 33 dogs. The strong ion difference (SID; difference between the sodium and chloride concentrations) was low in 20 of 33 dogs, chiefly because of hyperchloremia. Dilutional acidosis was present in 23 of 34 dogs. Hypoalbuminemic alkalosis was present in all dogs. Increase in unmeasured strong anions resulted in a negative BE in all dogs. Concurrent metabolic acidosis and respiratory alkalosis was identified in 31 of 34 dogs. A high AG metabolic acidosis was present in 15 of 33 dogs. The lack of an AG increase in the remaining dogs was attributed to concurrent hypoalbuminemia, which is common in this disease. Significant contributors to BE were the SID, free water abnormalities, and AG (all with P < .01). Mixed metabolic and respiratory acid-base imbalances are common in severe canine babesiosis, and resemble imbalances described in canine endotoxemia and human malaria.

Septic shock due to babesiosis

We present the case of a 69-year-old man with an unremarkable past medical history and an intact spleen who developed shock and renal failure due to babesiosis. Despite hemodynamic parameters showing severe distributive shock with hyperdynamic cardiac function, the patient recovered fully after treatment with quinine sulfate and clindamycin.

Concurrent babesiosis and ehrlichiosis in an elderly host

An 85-year-old man, actively infected with Babesia microti and Ehrlichia chaffeensis, presented with fatigue and thrombocytopenia. He developed rhabdomyolysis and multiple organ failure, which led to death 6 days after initial presentation. To our knowledge, concurrent acute disease due to these 2 organisms has not been reported previously, although serologic studies have shown that some patients acquire both infections in life.

Severe babesiosis in Long Island: review of 34 cases and their complications

Thirty-four consecutive patients were hospitalized with diagnosis of severe Babesia infection over the course of 13 years. The average time from onset of symptoms to diagnosis was 15 days. When compared with uninfected febrile control patients, affected patients complained significantly more often of malaise, arthralgias and myalgias, and shortness of breath (P<.05), and they more often had thrombocytopenia and abnormal liver function (P<.05). Forty-one percent of patients with Babesia developed complications such as acute respiratory failure, disseminated intravascular coagulation, congestive heart failure, and renal failure. Analysis of data revealed that complicated babesiosis was more commonly associated with the presence of severe anemia (hemoglobin level <10 g/dL; P=.01) and higher parasitemia levels (>10%; P=.08). Patients were treated with a combination of drugs that included clindamycin, quinine, atovaquone, or azithromycin. Despite treatment, parasitemia persisted for an average of 8.5 days (range, 3--21 days). Exchange transfusion was performed for 7 patients, and it effectively reduced the high levels of parasitemia. Three patients died. Improved outcomes may result with prompt recognition and treatment of babesiosis.

The effect of the ovine host parasitaemia on the development of Babesia ovis (Babes, 1892) in the tick Rhipicephalus bursa (Canestrini and Fanzago, 1877)

Batches of Rhipicephalus bursa adult ticks were fed on two lambs with 10.0% (batch 1) and 0.3% (batch 2) Babesia ovis parasitaemia, respectively. Haemolymph and eggs were checked for parasites daily after detachment, before and after appearance of B. ovis in the lamb's blood.B. ovis kinetes were found in the haemolymph and eggs earlier in the engorged ticks detached before appearance of the parasite in the host blood. Rates of haemolymph and egg infection with B. ovis as well as the percentage of infected eggs were much higher in batch 1 (10% lamb parasitaemia) than in batch 2 ticks (0.3% lamb parasitaemia). In eggs incubated at 28 degrees C the optimal period to look for kinetes seems to be days 4-9. Heavily infected ticks laid fewer less eggs within a shorter oviposition period. Pre-oviposition, pre-hatching periods and egg hatchability were not affected. Various parasitic forms are described in the haemolymph and the eggs.

Renal involvement in dogs with babesiosis

Proteinuria, and renal tubular casts and epithelial cells in urine sediment, are commonly observed in both complicated and uncomplicated babesiosis, but do not necessarily reflect or predict renal failure. This study investigated the presence and degree of renal damage in canine babesiosis. Renal function and integrity were evaluated using serum urea and creatinine, serum electrolytes (sodium and potassium), fractional clearance of sodium (FcNa) and potassium (FcK), urine enzyme activity of gamma-glutamyl transpeptidase and alkaline phosphatase, urine protein:creatinine ratio, and urinalysis. One control group (n = 10) and 3 groups of babesiosis cases were studied: mild uncomplicated (n = 10), severe uncomplicated (n = 11), and complicated (n = 9). All babesiosis groups showed well-concentrated urine. Mean serum urea was elevated in the severe and complicated groups, and was significantly different from the control group. There was no statistically significant difference between the groups for creatinine, although the complicated group had a mean value above the normal reference range. Hypokalaemia was uncommon in all the groups. Hyperkalaemia was present in only 2 dogs in the complicated group. Marginal hyponatraemia was present in a minority of dogs in all groups. The serum electrolytes were not significantly different between groups. There was no overall elevation, nor any statistically significant difference in both the FcNa and FcK between the groups. Only 1 dog, in the complicated group, showed marked enzymuria. Proteinuria was a common finding and was significantly different between the severe and complicated groups and the control group. Some dogs in all groups had renal tubular epithelial cells in the urinary sediment, which increased in severity from the mild to the complicated groups and was significantly different from the control group. This study demonstrated that minimal renal damage occurs more often in canine babesiosis than significant damage or acute renal failure.

Morphological changes of Babesia gibsoni grown in canine red blood cell-substituted severe combined immune deficiency mice

Canine red blood cell-substituted severe combined immune deficiency (Ca-RBC-SCID) mice were prepared for canine Babesia gibsoni infection. The Ca-RBC-SCID mice infected with B. gibsoni developed a high level of parasitemia, and showed clinical symptoms such as anemia and hemoglobinuria, which are similar to those observed in dogs infected with B. gibsoni. The B. gibsoni parasites grown in Ca-RBC-SCID mice showed marked morphological changes, including a significantly larger size of parasites than those in dogs and abundant RBCs containing 4, 8, 16, and 32 parasites. The multiple infection may have resulted from 1 parasite because the posterior end of each parasite in a multiply infected cell was connected. The parasites grown in SCID mice retained their infectivity and virulence to dogs and their morphology was dramatically restored to the original state when they were returned to dogs.

Blood pressure changes in dogs with babesiosis

Systemic arterial blood pressures were measured in 30 dogs with acute babesiosis, 10 each with mild uncomplicated, severe uncomplicated and complicated disease. Ten healthy dogs were used as controls. Hypotension was defined as more than 3 standard deviations below the control mean. Normal mean pressures (+/-SD) were: systolic arterial pressure 151 (+/-11) mm Hg, diastolic arterial pressure 89 (+/-8) mm Hg and mean arterial pressure 107 (+/-10) mm Hg. Hypotension was the most frequent abnormality, and increased strikingly in incidence as disease severity increased, with 5/10 dogs in the complicated group being hypotensive for systolic, diastolic and mean arterial pressures, compared with 2/10 in the severe uncomplicated group and 0/10 in the mild uncomplicated group. Systolic, diastolic and mean arterial pressures in the complicated group and severe uncomplicated group, and systolic pressure in the mild uncomplicated group, were significantly lower than in the controls. There were no significant relationships between arterial pressures and age, pulse rate, respiratory rate, temperature, mucous membrane colour or haematocrit. There was a significant negative correlation between arterial pressures and white cell and immature neutrophil counts. Arterial pressures differed significantly between dogs that were clinically collapsed and those that were not, but not between survivors and non-survivors. Pulse pressure (systolic-diastolic) was low in 7/10 complicated, 1/10 mild uncomplicated, and 1/10 severe uncomplicated cases, and differed significantly between the complicated and control groups. The high incidence of hypotension in clinically severe babesiosis has important implications for therapy.

Can Babesia infections be used as a model for cerebral malaria?

Infections with certain species of Plasmodium and Babesia induce, among other symptoms, cerebral pathology. The finding of heavily parasitized cerebral capillaries upon postmortem examination has led to the assumption that blockage of capillaries with infected red blood cells caused the cerebral symptoms and subsequent death. As this type of cerebrovascular pathology is found both in humans dying from malaria and in cattle dying from babesiosis, the latter could possibly be used as an animal model for the study of human cerebral malaria. However, before such a model system is adopted, the experimental data concerning cerebral pathology of babesiosis needs critical evaluation. Here, Theo Schetters and Wijnand Eling review the pathological mechanisms in cerebral babesiosis and relate these to cerebral malaria. Finally, they discuss the use of animal model systems for specific aspects of the pathological picture.

Endothelial cell changes are associated with pulmonary edema and respiratory distress in mice infected with the WA1 human Babesia parasite

A C3H/HeN mouse model was established to study the pathogenesis of the human babesial parasites, WA1 and Babesia microti. To evaluate the course of parasitemia and the associated lesions, mice were inoculated intraperitoneally with either WA1-infected, B. microti-infected, or uninfected hamster red blood cells. WA1-infected mice developed dyspnea and moderate parasitemias, after which death occurred. Babesia microti-infected mice experienced low parasitemias with no apparent morbidity or mortality. WA1-infected mice were thrombocytopenic but not anemic. Hemograms for B. microti-infected mice were similar to controls. Postmortem examination of WA1-infected mice revealed prominent lesions in the lungs, including pulmonary edema and intravascular margination of leukocytes. No pulmonary changes were detected in B. microti-infected mice. Blood gas measurements of WA1-infected mice showed reduced oxygen saturation and pH, and increased carbonic acid compared to controls, indicating hypoxia and respiratory acidosis. Ultrastructure studies of WA1-infected lungs showed hypertrophied endothelial cells containing transcellular channels associated with protein-rich intra-alveolar fluid. Endothelial cell activation was demonstrated by an upregulation of intercellular adhesion molecule-1 in the lungs of WA1-infected mice. The results suggest that recruitment of inflammatory cells to the lungs in WA1-infected mice induces endothelial cell alterations, leading to pulmonary edema and acute respiratory failure.

Clinical, clinico-pathological and serological studies of Babesia ovis in experimentally infected sheep

Clinical, clinico-pathological and serological studies were performed in sheep experimentally infected with Babesia ovis. Acute babesiosis occurred in all the lambs infested with adult Rhipicephalus bursa ticks and in one lamb infested with the larvae. The rate of parasitaemia and the degree of anaemia were not correlated. Decrease in the packed-cell volume ranged from 30 to 40%. Parasitized erythrocytes were not observed to block capillaries in the brain, which explained the absence of nervous symptoms in acute babesiosis. The kidneys were the most severely affected organs, exhibiting acute glomerulonephritis. The lesions observed were suggestive of vascular alteration and vascular stasis, leading to anoxia of the tissues. A disseminated intravascular coagulation (DIC) syndrome was recorded in sheep infected with babesiosis. A marked increase in the enzymes of the transaminase groups, mainly aspartate aminotransferase (AST), was observed. Enzymatic changes (increases in AST, alanine aminotransferase (ALT) and lactic dehydrogenase (LDH) and decreases in sorbitol dehydrogenase (SDH), alkaline phosphatase (ALP) and malic enzyme (MEZ)), decreases in total proteins and albumin, and increases in urea and creatinine might reflect the degree of severity of the damage to the liver and kidney tissues. Most of the lambs (85%) that were infested with larvae, and all lambs infested with adult R. bursa ticks, reacted serologically to B. ovis antigen. The serological reactions following infestation with the larvae occurred much later than those following infestation with the adult stage. The lambs which were infested with larvae showed mild clinical reactions when challenged by infected R. bursa adults, as compared with the reactions to the challenge in naive control animals. The serological findings, in addition to the fact that one splenectomized lamb reacted to larval infestation with acute ovine babesiosis, show that the preimaginal stages of R. bursa can transmit B. ovis, usually causing a sub-clinical disease. It is suggested that infections derived from preimaginal ticks in the winter can preimmunize sheep for the subsequent more severe infections derived from adult ticks in the summer. Furthermore, in the absence of a reliable vaccine against B. ovis, grazing flocks in the enzootic regions should be exposed to the preimaginal stages during their activity period (October-February) before exposure to the adult ticks in spring and summer (April-July).

Amelioration of virulent Babesia bovis infection in calves by administration of the nitric oxide synthase inhibitor aminoguanidine

Calves undergoing initial infection with a virulent strain of the haemoprotozoan parasite Babesia bovis were treated with aminoguanidine (AG), an inhibitor of the inducible form of nitric oxide synthase (iNOS). The mean maximum parasitaemia of the AG treated calves was significantly lower than that of the control cattle. In addition, the febrile response and decrease in packed cell volume (PCV) observed during acute infection were significantly ameliorated in the AG treated cattle relative to the controls. However, AG had no effect on the multiplication of B. bovis in the microaerophilous stationary-phase (MASP) in-vitro culture system. These results provide evidence of a role for nitric oxide (NO) produced in response to acute infection in the pathology of bovine babesiosis.

Experimental infection with Babesia divergens in cattle persistently infected with bovine virus diarrhoea virus

Nine Norwegian Red cattle, aged 7-14 months, persistently infected with bovine virus diarrhoea virus (BVDV) were inoculated with a Swedish strain of Babesia divergens. Six persistently infected cattle of the same age and breed were kept as controls. Blood and serum samples were collected regularly during the observation period. Rectal temperatures were recorded every morning for 25 days post infection, and the animals were examined clinically on a daily basis. Sera were examined for antibodies to B. divergens by indirect immunofluorescence antibody test (IFAT). Eight of the infected animals developed fever of 2-5 days duration. Babesia divergens organisms appeared in the erythrocytes of all infected animals on the day after inoculation. The parasitaemia lasted for 4-11 days. One animal had a transient haemoglobinuria. Compared with the control group, there was a 20% decrease in the haematocrit. There was a transient lymphopenia and thrombocytopenia during the period of fever. There were no differences in mean numbers of neutrophils between the two persistently infected groups. Compared with cattle free of BVDV, the persistently infected cattle had consistently lower total leucocyte count that was mainly due to decreased mean numbers of neutrophils and monocytes. All infected animals develop antibodies > or = 1:1280 between day 7 and 10 post infection. The magnitude of the antibody response was considerably lower than that of BVDV-free animals inoculated with the same strain and dosage of B.divergens.

Experimental infection with Ehrlichia phagocytophila and Babesia divergens in cattle

Nine Norwegian Red Cattle, 9-12 months old, were inoculated simultaneously with Ehrlichia (Cytoecetes) phagocytophila and Babesia divergens. Ten cattle of the same breed and age were kept as controls. Clinical evaluation was done on a daily basis and rectal temperatures were recorded every morning for 4 weeks post inoculation. Blood and serum samples were collected regularly during the observation period. Sera were examined for the presence of antibodies to E. phagocytophila and B. divergens by an indirect immunofluorescence antibody test. All infected animals showed two periods of fever that corresponded to the proliferation of B. divergens and E. phagocytophila in the peripheral blood. The simultaneous infection did not induce more severe clinical symptoms than infection with either organism alone. Compared with the control group, there was a 25% decrease in the mean haematocrit. The leukogram showed a biphasic pattern and corresponded to the changes seen in infection with either organism alone. The simultaneous infection did not suppress antibody formation towards E. phagocytophila or B. divergens.

Prophylactic treatment of experimental canine babesiosis (Babesia canis) with doxycycline

Doxycycline provided satisfactory prophylaxis against experimental infection with a highly pathogenic strain of Babesia canis. Rectal temperature, parasitaemia, packed cell volume and serology were monitored for evaluation of the prophylactic effect. Although a daily dose of 5 mg kg-1 of doxycycline did not completely prevent clinical disease, symptoms remained moderate and a full recovery was obtained within 1 week. At a dose of 20 mg kg-1 day-1 no clinical symptoms were observed, but asymptomatic infection could not be ruled out.

Effect of passage of Babesia ovis in the gerbil (Acomys cahirinus) on the course of infection in splenectomized lambs

Splenectomized gerbils (Acomys cahirinus) have been found to be susceptible to Babesia ovis applied via blood inoculation, whereas intact gerbils were not infected. Blood from splenectomized latently infected gerbils caused infection in a splenectomized lamb. Intact Acomys cahirinus gerbils did not become infected by B. ovis, and all captured rodents in an enzootic area, intact and splenectomized, were found to be negative for B. ovis. It can thus be concluded that Acomys cahirinus does not serve as a natural reservoir for B. ovis.

Babesiosis in a six-day-old calf

Babesiosis was diagnosed in a six-day-old calf born indoors to a heifer which had been on a tick-infested pasture until 14 days before calving. The calf had typical symptoms of haemolytic anaemia and died after three days despite a blood transfusion. The erythrocytes in a blood smear made on the day it became ill were heavily infected with Babesia divergens and the lesions observed post mortem were similar to those described in babesiosis in adult cattle.

Concurrent Lyme disease and babesiosis. Evidence for increased severity and duration of illness

OBJECTIVE

To determine whether patients coinfected with Lyme disease and babesiosis in sites where both diseases are zoonotic experience a greater number of symptoms for a longer period of time than those with either infection alone.

DESIGN

Community-based, yearly serosurvey and clinic-based cohort study.

SETTING

Island community in Rhode Island and 2 Connecticut medical clinics from 1990 to 1994.

STUDY PARTICIPANTS

Long-term residents of the island community and patients seeking treatment at the clinics.

MAIN OUTCOME MEASURES

Seroreactivity to the agents of Lyme disease and babesiosis and number and duration of symptoms.

RESULTS

Of 1156 serosurvey subjects, 97 (8.4%) were seroreactive against Lyme disease spirochete antigen, of whom 14 (14%) also were seroreactive against babesial antigen. Of 240 patients diagnosed with Lyme disease, 26 (11%) were coinfected with babesiosis. Coinfected patients experienced fatigue (P = .002), headache (P < .001), sweats (P < .001), chills (P = .03), anorexia (P = .04), emotional lability (P = .02), nausea (P = .004), conjunctivitis (P = .04), and splenomegaly (P = .01) more frequently than those with Lyme disease alone. Thirteen (50%) of 26 coinfected patients were symptomatic for 3 months or longer compared with 7 (4%) of the 184 patients with Lyme disease alone from whom follow-up data were available (P < .001). Patients coinfected with Lyme disease experienced more symptoms and a more persistent episode of illness than did those (n = 10) experiencing babesial infection alone. Circulating spirochetal DNA was detected more than 3 times as often in coinfected patients as in those with Lyme disease alone (P = .06).

CONCLUSIONS

Approximately 10% of patients with Lyme disease in southern New England are coinfected with babesiosis in sites where both diseases are zoonotic. The number of symptoms and duration of illness in patients with concurrent Lyme disease and babesiosis are greater than in patients with either infection alone. In areas where both Lyme disease and babesiosis have been reported, the possibility of concomitant babesial infection should be considered when moderate to severe Lyme disease has been diagnosed.

A short term in vitro cultivation of Babesia rodhaini and Babesia microti

In vitro cultivation of Babesia rodhaini (BR) and Babesia microti (BM) was attempted. When RPMI1640 was supplemented with 30 or 40% of non-treated fetal bovine serum (FBS), the gas mixture of 3% CO2-8% O2 best supported the growth of both parasites. Under this optimized condition, the percent parasitized erythrocytes peaked to approximately 4- and 2-times initial values for Br and BM, respectively. The cultivated parasites retained the infectivity to the host mice. BM showed the characteristic feature of division during cultivation. However, the lots of FBS will have to be taken into consideration, since the FBS lots were shown to give large varieties to the results. Selection of the appropriate FBS lot may yield the better growth of these protozoa.

Immune responses to South African Babesia canis and the development of a preliminary vaccine

The immune responses of 2 Beagles to live parasites of an isolated B. canis strain were tested. The dogs were infected with live parasites and were carefully treated to allow the parasites to remain in the dogs' bodies for long enough to evoke an immune response. Once recovered from the initial infections, both dogs received 2 separate homologous challenges with live parasites. During the second challenge, neither dog showed clinical signs of disease. An experimental vaccine was developed against the isolated B. canis strain by growing parasites in a micro-aerophilous stationary phase cell culture system to provide (a) antigen-containing supernatant material and (b) pellet material containing dead parasites. Two dogs each were inoculated with the different formulations of the vaccine on 2 separate occasions. Three weeks after the second inoculation, all 4 dogs were challenged with live parasites. Three of the 4 dogs recovered from the challenge without any anti-babesial treatment.

The pathophysiology of canine babesiosis: new approaches to an old puzzle

The haemoprotozoan parasite, Babesia canis, is the cause of an economically important and potentially life-threatening disease of dogs in South Africa, the pathophysiology of which is incompletely understood. Available literature is reviewed, with emphasis on the pathophysiology of the anaemia and complications of babesiosis. The remainder of the review explores the possibility that pathophysiological mechanisms currently being investigated in human malaria and bovine babesiosis (in which, as in canine babesiosis, an intra-erythrocytic parasite causes multi-systemic pathology) might also be active in B. canis infections. The entity referred to as the multiple organ dysfunction syndrome is discussed as a proposed mechanism within which apparently unrelated aspects of babesiosis form a predictable pattern. The molecular mediators of multiple organ dysfunction, including cytokines, nitric oxide and free oxygen radicals, are generated by host tissues, and are now under active study to help elucidate the pathophysiology of malaria. The similarities between the manifestations of different diseases in different host species can be explained by the concept that the disease process is largely mediated by these molecules, generated by the host in response to the parasite, rather than arising directly from the parasite itself. The current direction of malaria research provides a basis for future research into the pathophysiology of canine babesiosis.

Increased erythrophagocytic activity of macrophages in dogs with Babesia gibsoni infection

To elucidate the mechanism of anemia caused by Babesia gibsoni infection in dogs, the erythrophagocytic activity of macrophages in infected dogs was investigated in vitro. In the present study, macrophages obtained from peripheral blood (PB-macrophages) and bone marrow (BM-macrophages) of splenectomized dogs with chronic B. gibsoni infection were examined. The BM-macrophages in the splenectomized dogs with chronic babesiosis exhibited an increased erythrophagocytic activity compared with those from splenectomized, non-infected dogs. In the infected dogs, erythrophagocytic activities of macrophages against both auto- and iso-erythorcytes from normal dogs were almost the same. Administration of an anti-protozoal drug, diminazene diaceturate, resulted in a decrease of the erythrophagocytic activity of BM-macrophages associated with an increase of the hematocrit value in splenectomized dogs with chronic babesiosis. In splenectomized dogs with acute babesiosis, erythrophagocytic activity of BM-macrophages was also elevated. Such a phenomenon was not, however, observed in splenectomized dogs with onion-induced hemolytic anemia. These results suggest that the erythrophagocytic ability of macrophages in the infected dogs might be accelerated by parasites per se through an unknown mechanism, resulting in severe anemia in spite of low parasitemia.

The pathogenesis of Babesia motasi (Wales) infection in sheep

Studies on the pathogenesis of Babesia motasi (Wales) infection following blood transfusion of infected blood to normal or splenectomised recipients showed that the intact animal is refractory to infection but that infection in splenectomised animals caused weight loss, fever, anorexia, lassitude and a macrocytic hypochromic anaemia which coincided with the peak of parasitaemia. There was an initial leucocytosis, largely due to a neutrophilia. The prepatent period following blood transfusion was 2-3 days. Unconjugated and conjugated (direct) bilirubin levels increased from pre-infection levels to peaks of 1.43 and 0.70 mg/100 ml of blood, respectively. Serum glutamic pyruvic acid transaminases (SGPT) increased slightly but serum glutamic-oxaloacetic acid transaminases (SGOT) and blood sugar (glucose) levels did not show significant changes after infection. Total serum protein levels increased temporarily and then returned to normal. Blood urea nitrogen levels increased, with biphasic peaks (76.32 and 86.29 mg/100 ml) on Days 2 and 8 post-patency. Clinical infections even in splenectomised sheep, were mild and of short duration, although recovered sheep remained carriers.