eMedicine Specialties > Emergency Medicine > Infectious Diseases

Babesiosis: Differential Diagnoses & Workup

Author: Tarlan Hedayati, MD, Instructor of Clinical Emergency Medicine, Director of Observation Unit, Director of Chest Pain Unit, Department of Emergency Medicine, Los Angeles County/University of Southern California Medical Center
Coauthor(s): Joseph Choi, MD, Resident Physician, Department of Emergency Medicine, LAC+USC Medical Center, Keck School of Medicine, University of Southern California
Contributor Information and Disclosures

Updated: Apr 28, 2009

Differential Diagnoses

Anemia, Acute
Tick-Borne Diseases, Lyme
Bites, Insects
Tick-Borne Diseases, Q Fever
Malaria
Tick-Borne Diseases, Relapsing Fever
Tick-Borne Diseases, Colorado
Tick-Borne Diseases, Tularemia
Tick-Borne Diseases, Ehrlichiosis
Tick-Borne Diseases, Introduction

Workup

Laboratory Studies

  • In individuals who are asymptomatic, laboratory studies may be unremarkable.
  • Wright- or Giemsa-stained peripheral blood smear
    • This test reveals intraerythrocytic parasites (ring forms with a central pallor) and, rarely, pathognomonic tetrads of budding trophozoites, the so-called Maltese cross.
    • The smear result may be negative in individuals with asymptomatic infection.
    • Level of parasitemia does not correspond to severity of disease, although patients who are mildly ill may have less than 1% parasitemia and patients who are severely ill may have greater than 85% parasitemia. High parasite levels are especially seen in asplenic patients.
  • Complete blood count (CBC) with differential may demonstrate mild-to-severe hemolytic anemia, thrombocytopenia, atypical lymphocytes, and leukopenia.
  • Haptoglobin will be decreased.1
  • Liver function test results often reveal mildly elevated hepatic transaminase levels, erythrocyte sedimentation rate (ESR), lactic dehydrogenase (LDH) level, alkaline phosphatase level, and serum bilirubin level.
  • Urinalysis may reveal hemoglobinuria, proteinuria, and a dark color may be present.
  • Direct Coombs test result may or may not be positive.
  • Pulse oximetry results will be low in hypoxic patients with severe disease.

Imaging Studies

  • Chest radiography may be indicated for patients with respiratory complications including suspected pneumonia or ARDS.

Other Tests

  • Further testing specific for babesiosis takes place outside of the ED.
  • Inoculation of a golden hamster or mouse with B microti- infected patient blood or a gerbil with B divergens- infected blood and subsequent antibody analysis of the animal's blood is used to confirm diagnosis when peripheral blood smear and laboratory results are equivocal. However, this test requires checking the animal periodically over 6-8 weeks, making the test time- and labor-intensive and impractical for rapid diagnosis.
  • Polymerase chain reaction
    • Polymerase chain reaction (PCR) is more sensitive and equally specific when compared with peripheral smear evaluation and hamster inoculation.
    • PCR may be useful in monitoring the infection, although it cannot differentiate between acute/active forms and chronic forms of the disease.
  • Immunofluorescence antibody testing
    • Immunofluorescence antibody test (IFA) is considered the criterion standard for serologic detection of B microti infection.
    • This test is used to confirm the diagnosis when the peripheral blood smear result is negative.
    • A titer of greater than 1:64 is considered positive.
    • A greater than 4-fold rise in titer or a single titer greater than 1:256 is suggestive of acute infection, with a gradual decline seen over weeks to months
    • Correlation between severity of symptoms and titer levels is poor.
  • Enzyme-linked immunosorbent assay immunoglobulin M Lyme titer
    • Enzyme-linked immunosorbent assay (ELISA) immunoglobulin M (IgM) Lyme test is used because of the high percentage (25%) of patients co-infected with Lyme disease.
    • Co-infection increases the severity of disease; therefore, diagnosing and treating both infections is important.
  • Immunoblot antibody test
    • This test has similar sensitivity and specificity for diagnosing babesiosis as that of IFA.
    • Potential advantages over IFA include the lack of need for concentrated serum samples and ease of use, as immunoblot assays can be performed by generalist technicians versus trained microscopists.

Procedures

  • Because of the possibility of hemophagocytic syndrome, bone marrow biopsy is indicated in patients whose laboratory studies reveal pancytopenia and whose physical examination reveals hepatosplenomegaly, fever, coagulopathy, or lymphadenopathy.

More on Babesiosis

Overview: Babesiosis
Differential Diagnoses & Workup: Babesiosis
Treatment & Medication: Babesiosis
Follow-up: Babesiosis
Multimedia: Babesiosis
References
Further Reading
[ CLOSE WINDOW ]

References

  1. Vannier E, Gewurz BE, Krause PJ. Human babesiosis. Infect Dis Clin North Am. Sep 2008;22(3):469-88, viii-ix. [Medline].

  2. 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. Jan 1 2009;48(1):25-30. [Medline].

  3. 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. Autumn 2008;38(4):390-2. [Medline].

  4. Cunha BA, Cohen YZ, McDermott B. Fever of unknown origin (FUO) due to babesiosis in a immunocompetent host. Heart Lung. Nov-Dec 2008;37(6):481-4. [Medline].

  5. Berry A, Morassin B, Kamar N, Magnaval JF. Clinical picture: human babesiosis. Lancet. Feb 3 2001;357(9253):341. [Medline].

  6. Boustani MR, Gelfand JA. Babesiosis. Clin Infect Dis. Apr 1996;22(4):611-5. [Medline].

  7. Boustani MR, Lepore TJ, Gelfand JA, Lazarus DS. Acute respiratory failure in patients treated for babesiosis. Am J Respir Crit Care Med. Jun 1994;149(6):1689-91. [Medline].

  8. Brasseur P, Lecoublet S, Kapel N, Favennec L, Ballet JJ. Quinine in the treatment of Babesia divergens infections in humans. Eur J Clin Microbiol Infect Dis. Oct 1996;15:840-841. [Medline].

  9. Dobroszycki J, Herwaldt BL, Boctor F, et al. A cluster of transfusion-associated babesiosis cases traced to a single asymptomatic donor. JAMA. Mar 10 1999;281(10):927-30. [Medline].

  10. Feder HM, Lawlor M, Krause PJ. Babesiosis in pregnancy. N Engl J Med. Jul 10 2003;349(2):195-6. [Medline].

  11. Froberg MK, Dannen D, Bakken JS. Babesiosis and HIV. Lancet. Feb 28 2004;363(9410):704. [Medline].

  12. Gorenflot A, Moubri K, Precigout E, Carcy B, Schetters TP. Human babesiosis. Ann Trop Med Parasitol. Jun 1998;92(4):489-501. [Medline].

  13. Gratz NG. The vector-borne human infections of Europe: their distribution and burden on human health. WHO; 2004. 1-154. [Full Text].

  14. Gupta P, Hurley RW, Helseth PH, Goodman JL, Hammerschmidt DE. Pancytopenia due to hemophagocytic syndrome as the presenting manifestation of babesiosis. Am J Hematol. Sep 1995;50(1):60-2. [Medline].

  15. Gutman JD, Kotton CN, Kratz A. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 29-2003. A 60-year-old man with fever, rigors, and sweats. N Engl J Med. Sep 18 2003;349(12):1168-75. [Medline].

  16. Horowitz ML, Coletta F, Fein AM. Delayed onset adult respiratory distress syndrome in babesiosis. Chest. Oct 1994;106(4):1299-301. [Medline].

  17. Krause PJ. Babesiosis. Med Clin North Am. Mar 2002;86(2):361-73. [Medline].

  18. Krause PJ, Lepore T, Sikand VK, et al. Atovaquone and azithromycin for the treatment of babesiosis. N Engl J Med. Nov 16 2000;343(20):1454-8. [Medline].

  19. Krause PJ, Telford SR 3rd, Pollack RJ, et al. Babesiosis: an underdiagnosed disease of children. Pediatrics. Jun 1992;89(6 Pt 1):1045-8. [Medline].

  20. Krause PJ, Telford SR, Spielman A, et al. Concurrent Lyme disease and babesiosis. Evidence for increased severity and duration of illness. JAMA. Jun 5 1996;275(21):1657-60. [Medline].

  21. Leiby DA. Babesiosis and blood transfusion: flying under the radar. Vox Sang. Feb 2006;90(3):157-165. [Medline].

  22. Leiby DA, Chung APS, Gill JE, et al. Demonstrable parasitemia among Connecticut blood donors with antibodies to Babesia microti. Transfusion. Nov 2005;45:1804-1810. [Medline].

  23. Mylonakis E. When to suspect and how to monitor babesiosis. Am Fam Physician. May 15 2001;63(10):1969-74. [Medline].

  24. Perdrizet GA, Olson NH, Krause PJ, Banever GT, Spielman A, Cable RG. Babesiosis in a renal transplant recipient acquired through blood transfusion. Transplantation. Jul 15 2000;70(1):205-8. [Medline].

  25. Persing DH, Herwaldt BL, Glaser C, et al. Infection with a babesia-like organism in northern California. N Engl J Med. Feb 2 1995;332(5):298-303. [Medline].

  26. Pruthi RK, Marshall WF, Wiltsie JC, Persing DH. Human babesiosis. Mayo Clin Proc. Sep 1995;70(9):853-62. [Medline].

  27. Ryan R, Krause PJ, Radolf J, et al. Diagnosis of babesiosis using an immunoblot serologic test. Clin Diagn Lab Immunol. Nov 2001;8(6):1177-80. [Medline].

  28. Shoemaker RC, Hudnell HK, House DE, Van Kempen A, Pakes GE, COL40155 Study Team. Atovaquone plus cholestyramine in patients coinfected with Babesia microti and Borrelia burgdorferi refractory to other treatment. Adv Ther. Jan-Feb 2006;23(1):1-11. [Medline].

  29. Slovut DP, Benedetti E, Matas AJ. Babesiosis and hemophagocytic syndrome in an asplenic renal transplant recipient. Transplantation. Aug 27 1996;62(4):537-9. [Medline].

  30. Spach DH, Liles WC, Campbell GL, Quick RE, Anderson DE Jr, Fritsche TR. Tick-borne diseases in the United States. N Engl J Med. Sep 23 1993;329(13):936-47. [Medline].

  31. Weinberg GA. Laboratory diagnosis of ehrlichiosis and babesiosis. Pediatr Infect Dis J. Apr 2001;20(4):435-7. [Medline].

  32. Weiss LM, Wittner M, Tanowitz HB. The treatment of babesiosis. N Engl J Med. Mar 8 2001;344(10):773. [Medline].

  33. Wittner M, Lederman J, Tanowitz HB, Rosenbaum GS, Weiss LM. Atovaquone in the treatment of Babesia microti infections in hamsters. Am J Trop Med Hyg. Aug 1996;55(2):219-22. [Medline].

  34. Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. Nov 1 2006;43(9):1089-134. Epub 2006 Oct 2. [Medline].

[ CLOSE WINDOW ]

Further Reading

Clinical guidelines

Infectious Diseases Society of America practice guidelines for clinical assessment, treatment and prevention of Lyme disease, human granulocytic anaplasmosis, and babesiosis. Wormser GP, Dattwyler RJ, Shapiro ED, Halperin JJ, Steere AC, Klempner MS, Krause PJ, Bakken JS, Strle F, Stanek G, Bockenstedt L, Fish D, Dumler JS, Nadelman RB. The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2006 Nov 1;43(9):1089-134. PubMed

[ CLOSE WINDOW ]

Keywords

babesiosis, Babesia species, Ixodes tick, parasitic infection, intraerythrocytic parasitic infection, tick bite, hemolytic anemia, thrombocytopenia, atypical lymphocyte formation, acute respiratory distress syndrome, ARDS, Lyme disease, Ixodes scapularis, white-tailed deer, white-footed mouse, Peromyscus leucopus, adult tick vector

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Tarlan Hedayati, MD, Instructor of Clinical Emergency Medicine, Director of Observation Unit, Director of Chest Pain Unit, Department of Emergency Medicine, Los Angeles County/University of Southern California Medical Center
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.

Coauthor(s)

Joseph Choi, MD, Resident Physician, Department of Emergency Medicine, LAC+USC Medical Center, Keck School of Medicine, University of Southern California
Joseph Choi, MD is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

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.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
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

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.