Babesiosis Clinical Presentation
- Author: Burke A Cunha, MD; Chief Editor: Michael Stuart Bronze, MD more...
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:
Fever – This may be sustained or intermittent, and temperatures may be as high as 40°C
Depression and emotional lability
Photophobia, conjunctival injection, sore throat, or cough – These are less common symptoms
Shortness of breath
In a series of 139 patients who were hospitalized with babesiosis in New York, the following were the most common symptoms :
Fatigue, malaise, and weakness (91%)
Shaking chills (77%)
In some untreated patients, symptoms of babesiosis may last for months. Subclinical infections may spontaneously recrudesce after splenectomy and after immunosuppressive therapy.
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.
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:
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:
Congestive heart failure
Renal complications of babesiosis include the following:
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.
Vannier E, Gewurz BE, Krause PJ. Human babesiosis. Infect Dis Clin North Am. 2008 Sep. 22(3):469-88, viii-ix. [Medline].
Joseph JT, Roy SS, Shams N, Visintainer P, Nadelman RB, Hosur S, et al. Babesiosis in Lower Hudson Valley, New York, USA. Emerg Infect Dis. 2011 May. 17(5):843-7. [Medline].
Dobroszycki J, Herwaldt BL, Boctor F, Miller JR, Linden J, Eberhard ML, et al. A cluster of transfusion-associated babesiosis cases traced to a single asymptomatic donor. JAMA. 1999 Mar 10. 281(10):927-30. [Medline].
Gerber MA, Shapiro ED, Krause PJ, Cable RG, Badon SJ, Ryan RW. The risk of acquiring Lyme disease or babesiosis from a blood transfusion. J Infect Dis. 1994 Jul. 170(1):231-4. [Medline].
Jacoby GA, Hunt JV, Kosinski KS, Demirjian ZN, Huggins C, Etkind P, et al. Treatment of transfusion-transmitted babesiosis by exchange transfusion. N Engl J Med. 1980 Nov 6. 303(19):1098-100. [Medline].
Leiby DA. Babesiosis and blood transfusion: flying under the radar. Vox Sang. 2006 Apr. 90(3):157-65. [Medline].
Mintz ED, Anderson JF, Cable RG, Hadler JL. Transfusion-transmitted babesiosis: a case report from a new endemic area. Transfusion. 1991 May. 31(4):365-8. [Medline].
Wittner M, Rowin KS, Tanowitz HB, Hobbs JF, Saltzman S, Wenz B, et al. Successful chemotherapy of transfusion babesiosis. Ann Intern Med. 1982 May. 96(5):601-4. [Medline].
Wormser GP, Lombardo G, Silverblatt F, El Khoury MY, Prasad A, Yelon JA, et al. Babesiosis as a cause of fever in patients undergoing a splenectomy. Am Surg. 2011 Mar. 77(3):345-7. [Medline].
White DJ, Talarico J, Chang HG, Birkhead GS, Heimberger T, Morse DL. Human babesiosis in New York State: Review of 139 hospitalized cases and analysis of prognostic factors. Arch Intern Med. 1998 Oct 26. 158(19):2149-54. [Medline].
Gubernot DM, Lucey CT, Lee KC, Conley GB, Holness LG, Wise RP. Babesia infection through blood transfusions: reports received by the US Food and Drug Administration, 1997-2007. Clin Infect Dis. 2009 Jan 1. 48(1):25-30. [Medline].
Kuwayama DP, Briones RJ. Spontaneous splenic rupture caused by Babesia microti infection. Clin Infect Dis. 2008 May 1. 46(9):e92-5. [Medline].
Froberg MK, Dannen D, Bernier N, Shieh WJ, Guarner J, Zaki S. Case report: spontaneous splenic rupture during acute parasitemia of Babesia microti. Ann Clin Lab Sci. 2008 Autumn. 38(4):390-2. [Medline].
Persing DH, Mathiesen D, Marshall WF, Telford SR, Spielman A, Thomford JW, et al. Detection of Babesia microti by polymerase chain reaction. J Clin Microbiol. 1992 Aug. 30(8):2097-103. [Medline]. [Full Text].
Krause PJ, Spielman A, Telford SR 3rd, et al. Persistent parasitemia after acute babesiosis. N Engl J Med. 1998 Jul 16. 339(3):160-5. [Medline].
Cunha BA, Cohen YZ, McDermott B. Fever of unknown origin (FUO) due to babesiosis in a immunocompetent host. Heart Lung. 2008 Nov-Dec. 37(6):481-4. [Medline].
Krause PJ, Lepore T, Sikand VK, Gadbaw J Jr, Burke G, Telford SR 3rd, et al. Atovaquone and azithromycin for the treatment of babesiosis. N Engl J Med. 2000 Nov 16. 343(20):1454-8. [Medline].
Vyas JM, Telford SR, Robbins GK. Treatment of refractory Babesia microti infection with atovaquone-proguanil in an HIV-infected patient: case report. Clin Infect Dis. 2007 Dec 15. 45(12):1588-90. [Medline].
Wormser GP, Prasad A, Neuhaus E, Joshi S, Nowakowski J, Nelson J, et al. Emergence of resistance to azithromycin-atovaquone in immunocompromised patients with Babesia microti infection. Clin Infect Dis. 2010 Feb 1. 50(3):381-6. [Medline].
Krause PJ, Gewurz BE, Hill D, et al. Persistent and relapsing babesiosis in immunocompromised patients. Clin Infect Dis. 2008 Feb 1. 46(3):370-6. [Medline].
Cushing M, Shaz B. Transfusion-transmitted babesiosis: achieving successful mitigation while balancing cost and donor loss. Transfusion. 2012 Jul. 52(7):1404-7. [Medline].
Herwaldt BL, Linden JV, Bosserman E, Young C, Olkowska D, Wilson M. Transfusion-associated babesiosis in the United States: a description of cases. Ann Intern Med. 2011 Oct 18. 155(8):509-19. [Medline].
Hildebrandt A, Gray JS, Hunfeld KP. Human babesiosis in Europe: what clinicians need to know. Infection. 2013 Dec. 41(6):1057-72. [Medline].
Kavanaugh MJ, Decker CF. Babesiosis. Dis Mon. 2012 Jun. 58(6):355-60. [Medline].
Vannier E, Krause PJ. Human babesiosis. N Engl J Med. 2012 Jun 21. 366(25):2397-407. [Medline].
Wroblewski HA, Kovacs RJ, Kingery JR, Overholser BR, Tisdale JE. High risk of QT interval prolongation and torsades de pointes associated with intravenous quinidine used for treatment of resistant malaria or babesiosis. Antimicrob Agents Chemother. 2012 Aug. 56(8):4495-9. [Medline]. [Full Text].