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Babesiosis Differential Diagnoses

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

Diagnostic Considerations

Babesiosis usually manifests as an undifferentiated acute febrile illness resembling malaria. Patients who present with a malarialike illness always should be questioned regarding the possibility of previous exposure to malaria.

Patients who previously had non– P falciparum malaria may be experiencing a relapse. Such a relapse may be diagnosed on the basis of prior exposure or infection up to 40 years previously with a non-falciparum malaria. Diagnosis requires demonstration of plasmodia in properly prepared and stained thick or thin blood smears. Patients with recrudescent malaria may have low levels of parasitemia and usually have increased malaria immunoglobulin G (IgG) titers.

Patients should also be questioned about a previous history of Lyme disease. Although the signs and symptoms of Lyme disease differ from those of babesiosis, the tick vector associated with Lyme disease (I scapularis) may also transmit Babesia organisms. Coinfections of babesiosis and Lyme disease are not common but can occur.

Ehrlichiosis is an acute febrile infection resembling Rocky Mountain spotted fever (RMSF). Although seropositivity to Lyme disease and ehrlichiosis is common in endemic areas, coinfections of babesiosis with RMSF or ehrlichiosis (ie, “spotless” RMSF) are rare because these zoonoses are transmitted by Dermacentor ticks rather than Ixodes ticks. Increased Ehrlichia titers with an IgG titer of 1:64 or greater or a 4-fold or greater change in antibody titers on immunofluorescent antibody (IFA) testing is diagnostic of ehrlichiosis.

Patients with ehrlichiosis often have leukopenia, anemia, and thrombocytopenia. The erythrocyte sedimentation rate (ESR) is minimally elevated. levels of serum transaminases may be mildly increased in ehrlichiosis, as in babesiosis, typhoid fever, and RMSF. Typhoid fever, RMSF, and Lyme disease may be differentiated from babesiosis, ehrlichiosis, and malaria on the basis of the presence or absence of hemolytic anemia, which is not a typical feature of the first 3 conditions.

Except for Lyme disease and typhoid fever, thrombocytopenia is a feature of all of these infectious diseases. Leukopenia is a common finding in typhoid fever, RMSF, babesiosis, and ehrlichiosis but is not a characteristic finding in Lyme disease.

Splenomegaly may be present in patients with typhoid fever, malaria, babesiosis, ehrlichiosis, and RMSF but is not a feature of Lyme disease.

Arthropod-borne viral infections may be confused with babesiosis. However, arboviral illnesses are characterized by their extreme rapidity of onset and their clinical severity, neither of which is typical of babesiosis unless the spleen is absent.

Relative bradycardia is a cardinal finding in many infectious diseases, including many arboviral infections (eg, yellow fever, dengue fever, and African hemorrhagic fever [Ebola]). Relative bradycardia is a common finding in patients with malaria, RMSF, and babesiosis but is not a feature of Lyme disease.

In rare cases, typhoidal Epstein-Barr virus (EBV) infection, mononucleosis, or typhoidal tularemia may be confused with babesiosis. EBV-specific antibody testing and tube agglutination testing for tularemia can help exclude these diagnostic possibilities if they are considered in the differential diagnosis.

Typhoid fever is suggested by a severe headache and an apathetic facies with few, if any, localizing signs. Splenomegaly may be present later in the course of the illness. A normal or slightly decreased peripheral white blood cell (WBC) count is the characteristic hematologic finding; the presence of eosinophilia or thrombocytopenia suggests an alternate diagnosis. Typhoid fever may be diagnosed by staining or culturing the organism in reticuloendothelial system (RES) tissues or body fluids (blood, urine, or feces).

Typhoid fever may resemble babesiosis in its clinical presentation. As with babesiosis, physical signs are usually absent in patients. Patients with typhoid fever often present with constipation rather than diarrhea, which may be helpful because neither constipation nor diarrhea is a feature of babesiosis.

Headache is a prominent feature of malaria and typhoid fever but is less prominent with babesiosis and ehrlichiosis and is mild if present in Lyme disease.

Human monocytic ehrlichiosis (HME), human granulocytic anaplasmosis (HGA), and human granulocytic ehrlichiosis (HGE) may be diagnosed serologically in patients with a nonspecific febrile illness in endemic areas. These may also be diagnosed through Wright stain of peripheral blood smears or buffy-coat preparations that demonstrate regularly stained cytoplasmic inclusions in monocytes or, less commonly, lymphocytes, which are mulberry-shaped and are called morulae. Morulae are seen more frequently in HME than in HGE.

Babesiosis rarely affects the lungs. However, patients with babesiosis may develop noncardiogenic pulmonary edema, which may resemble pneumonia on chest radiography.

Differential Diagnoses

 
 
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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