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Babesiosis Clinical Presentation

  • Author: Burke A Cunha, MD; Chief Editor: Michael Stuart Bronze, MD  more...
 
Updated: Mar 17, 2016
 

History

The history of babesiosis includes fever and chills. Patients with babesiosis have symptoms similar to those of malaria. Symptoms are related to the degree of red blood cell (RBC) parasitemia. The spectrum of disease manifestation is broad, ranging from a silent infection to a fulminant malarialike disease that results in severe hemolysis and, occasionally, death.

In the United States, infection with B microti in otherwise healthy individuals generally remains subclinical; however, symptomatic infection is common in asplenic patients, older patients, and patients with underlying medical conditions, including human immunodeficiency virus (HIV) infection. Because bovine babesiosis due to B divergens and B bovis in Europe mostly occurs in patients who are asplenic, such infections are generally clinically overt and frequently fatal.

Patients typically report a history of travel to an endemic area between May and September. This is the period during which the Ixodes tick is in its infectious nymph stage. Because the nymph, the primary vector, is only 2 mm in diameter when engorged, most patients do not recall a tick bite. The incubation period after the tick bite is usually 1-3 weeks but may occasionally be as long as 9 weeks.

Initial symptoms begin gradually and are nonspecific. Common symptoms include the following:

  • Malaise
  • Fatigue
  • Anorexia
  • Shaking chills
  • Fever – This may be sustained or intermittent, and temperatures may be as high as 40°C
  • Headache
  • Myalgias
  • Arthralgias
  • Nausea
  • Vomiting
  • Abdominal pain
  • Depression and emotional lability
  • Dark urine
  • Photophobia, conjunctival injection, sore throat, or cough – These are less common symptoms
  • Neck stiffness
  • Altered sensorium
  • Shortness of breath

In a series of 139 patients who were hospitalized with babesiosis in New York, the following were the most common symptoms[14] :

  • Fatigue, malaise, and weakness (91%)
  • Fever (91%)
  • Shaking chills (77%)
  • Diaphoresis (69%)

In some untreated patients, symptoms of babesiosis may last for months. Subclinical infections may spontaneously recrudesce after splenectomy and after immunosuppressive therapy.

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Physical Examination

Physical findings may vary, depending on the severity of disease. Most patients with babesiosis have few, if any, physical findings. Fever is generally present. A minority of patients have jaundice and splenomegaly.

Hepatomegaly may be noted. Petechiae may be present in a few patients. Ecchymoses have been noted occasionally. A rash similar to erythema chronicum migrans has been described, but this probably represents intercurrent Lyme disease. Slight pharyngeal erythema may occur. Babesiosis has been associated with shock and acute respiratory distress syndrome (ARDS). Rigors and altered mental status may be noted.

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Complications

The complications of babesiosis are related to the degree of intravascular hemolysis. The main complications include jaundice, hemoglobinuria, and potential renal failure. The following may be observed:

  • Shock
  • Death
  • Relapse
  • Spontaneous splenic rupture [16, 17]

Patients who have undergone splenectomy are unable to clear infected RBCs; this inability results in higher levels of parasitemia, eventually leading to hypoxemia and subsequent risk of cardiopulmonary arrest.

In severe cases, damage to RBC membranes, decreased deformability, and cytoadherence to capillaries and venules lead to pulmonary edema and respiratory failure. These respiratory problems begin after treatment has been initiated, at a time when intraerythrocytic death of parasites has been postulated to cause sensitivity to endotoxin. ARDS may occur through mechanisms such as endotoxemia, complement activation, immune complex deposition, cytoadherence, microemboli, and disseminated intravascular coagulation.

Cardiac complications of babesiosis include the following:

  • Myocardial infarction
  • Congestive heart failure

Renal complications of babesiosis include the following:

  • Renal insufficiency
  • Renal failure

Postsplenectomy patients may experience hemophagocytic syndrome, acute renal failure, and generalized seizures. Coma can occur, possibly as a consequence of severe sepsis, ARDS, or multiple organ dysfunction syndrome (MODS). Coinfection with Lyme disease is a possible complication.

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Contributor Information and Disclosures
Author

Burke A Cunha, MD Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Chief Editor

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, Oklahoma State Medical Association, Southern Society for Clinical Investigation, Association of Professors of Medicine, American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Acknowledgements

Edward Bessman, MD Chairman, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins University

Edward Bessman, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Itzhak Brook, MD, MSc Professor, Department of Pediatrics, Georgetown University School of Medicine

Itzhak Brook, MD, MSc is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians-American Society of Internal Medicine, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, Armed Forces Infectious Diseases Society, Association of Military Surgeons of the US, Infectious Diseases Society of America, International Immunocompromised Host Society, International Society for Infectious Diseases,Medical Society of the District of Columbia, New York Academy of Sciences, Pediatric Infectious Diseases Society, Society for Ear, Nose and Throat Advances in Children, Society for Experimental Biology and Medicine, Society for Pediatric Research, Southern Medical Association, and Surgical Infection Society

Disclosure: Nothing to disclose.

Vinod K Dhawan, MD, FACP, FRCP(C) Professor, Department of Clinical Medicine, University of California, Los Angeles, David Geffen School of Medicine; Chief, Division of Infectious Diseases, Rancho Los Amigos National Rehabilitation Center, Downey, California.

Vinod K Dhawan, MD, FACP, FRCP(C) is a member of the following medical societies: American College of Physicians, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, and Royal College of Physicians and Surgeons of Canada

Disclosure: Pfizer Inc Honoraria Speaking and teaching

Allan D Friedman, MD, MPH Chairman, Division of General Pediatrics, Dept of Pediatrics, Professor of Pediatrics, Virginia Commonwealth University, VCUH Health System

Allan D Friedman, MD, MPH is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Tarlan Hedayati, MD Assistant Professor of Emergency Medicine, Rush Medical College, John H Stroger Hospital of Cook County

Tarlan Hedayati, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Rick Kulkarni, MD Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

Cameron Nima Nourani, MD Resident Physician, Department of Emergency Medicine, John H Stroger Hospital of Cook County

Cameron Nima Nourani, MD is a member of the following medical societies: Emergency Medicine Residents Association

Disclosure: Nothing to disclose.

Om Prakash Sharma, MD, FRCP, FCCP, DTM&H Professor, Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Southern California Keck School of Medicine

Om Prakash Sharma, MD, FRCP, FCCP, DTM&H is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, American Osler Society, American Thoracic Society, New York Academy of Medicine, and Royal Society of Medicine

Disclosure: Nothing to disclose.

Sat Sharma, MD, FRCPC Professor and Head, Division of Pulmonary Medicine, Department of Internal Medicine, University of Manitoba; Site Director, Respiratory Medicine, St Boniface General Hospital

Sat Sharma, MD, FRCPC is a member of the following medical societies: American Academy of Sleep Medicine, American College of Chest Physicians, American College of Physicians-American Society of Internal Medicine, American Thoracic Society, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada, Royal Society of Medicine, Society of Critical Care Medicine, and World Medical Association

Disclosure: Nothing to disclose.

Barry J Sheridan, DO Chief, Department of Emergency Medical Services, Brooke Army Medical Center

Barry J Sheridan, DO is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Russell W Steele, MD Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Reference Salary Employment

Martin Weisse, MD Program Director, Associate Professor, Department of Pediatrics, West Virginia University

Martin Weisse, MD is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

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Peripheral smear showing babesiosis.
Ixodes scapularis, tick vector for babesiosis. Image courtesy of Centers for Disease Control and Prevention.
Blood smear showing Babesia species in erythrocytes. Image courtesy of Centers for Disease Control and Prevention.
Babesia species, tetrad formation. Image courtesy of Centers for Disease Control and Prevention.
 
 
 
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