History

Fact Explanation
Asymptomatic [5] Manifestation of symptoms is directly related to the number of parasites in the human body. [2] Some patients remain asymptomatic. [1]
Flu-like symptoms Patients complain of fever with or without chills and rigors, increased sweating, headache, fatigue, loss of appetite and nausea. [1,3]
Symptoms of hemolytic anemia [1,4,5] Babesiosis causes hemolytic anemia. Patients complain of jaundice, itching and dark urine. [1] Massive hemolysis produces malaise, chills, myalgia and anemia. These symptoms are much more significant in asplenic patients, immunocompromised patients and in elderly. [2]
Features of disseminated intravascular coagulation [1] Patients present with spontaneous bleeding manifestations.
History of travel to an endemic area [2] People tend to get tick bites where ticks are common and babesiosis is endemic.
Recent blood transfusion Donated blood from an asymptomatic person may transmit the disease. [2]
Skin rash Skin rash may present in some patients. [5]
Symptoms of central nervous system involvement [6] Patients complain of headache, photophobia, neck or back pain and altered sensorium.
References
  1. Babesiosis. Centers for Disease Control and Prevention. [online] [viewed 21 April 2014] Available from: http://www.cdc.gov/parasites/babesiosis/disease.html
  2. MARY J. HOMER, IRMA AGUILAR-DELFIN, SAM R. TELFORD III,PETER J. KRAUSE, DAVID H. PERSING. Babesiosis. Clin. Microbiol. Rev. [online] July 2000 vol. 13 no. 3 451-469. [viewed 21 April 2014] Available from: doi: 10.1128/CMR.13.3.451-469.2000
  3. 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. [online] Oct 26 1998;158(19):2149-54.[viewed 21 April 2014] Available from: doi:10.1001/archinte.158.19.2149.
  4. BOUSTANI MR, GELFAND JA. Babesiosis. Clin Infect Dis. [online] 1996;22:611–5. [viewed 21 April 2014] Available from: doi:10.1093/clinids/22.4.611
  5. ELEFTHERIOS MYLONAKIS. When to Suspect and How to Monitor Babesiosis. Am Fam Physician. [online] 2001 May 15;63(10):1969-1975. [viewed 21 April 2014] Available from: http://www.aafp.org/afp/2001/0515/p1969.html
  6. SPACH DH, LILES WC, CAMPBELL GL, QUICK RE, ANDERSON DE, FRITSCHE TR. Tick-borne diseases in the United States. N Engl J Med. [online] 1993;329:936–47. [viewed 21 April 2014] Available from: http://www.nejm.org/doi/pdf/10.1056/NEJM199309233291308

Examination

Fact Explanation
Fever Often patients are febrile. [1,3,4]
Jaundice If hemolytic anemia develops patients can have jaundice. [1,5]
Abdominal examination Hepatomegaly and splenomegaly can be detected. [2]
Skin rash Rash can be seen in some patients. However it is not common. [5]
Features of shock [5] These include hypotension, rapid thread pulse and cold clammy extremities.
Examination of the central nervous system [5] Patients have neck stiffness and altered sensorium.
References
  1. Babesiosis. Centers for Disease Control and Prevention. [online] [viewed 21 April 2014] Available from: http://www.cdc.gov/parasites/babesiosis/disease.html
  2. MARY J. HOMER, IRMA AGUILAR-DELFIN, SAM R. TELFORD III,PETER J. KRAUSE, DAVID H. PERSING. Babesiosis. Clin. Microbiol. Rev. [online] July 2000 vol. 13 no. 3 451-469. [viewed 21 April 2014] Available from: doi: 10.1128/CMR.13.3.451-469.2000
  3. 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. [online] Oct 26 1998;158(19):2149-54.[viewed 21 April 2014] Available from: doi:10.1001/archinte.158.19.2149.
  4. BOUSTANI MR, GELFAND JA. Babesiosis. Clin Infect Dis. [online] 1996;22:611–5. [viewed 21 April 2014] Available from: doi:10.1093/clinids/22.4.611
  5. ELEFTHERIOS MYLONAKIS. When to Suspect and How to Monitor Babesiosis. Am Fam Physician. [online] 2001 May 15;63(10):1969-1975. [viewed 21 April 2014] Available from: http://www.aafp.org/afp/2001/0515/p1969.html
  6. SPACH DAVID H., LILES W. CONRAD, CAMPBELL GRANT L., QUICK ROBERT E., ANDERSON DONALD E., FRITSCHE THOMAS R.. Tick-Borne Diseases in the United States. N Engl J Med [online] 1993 September, 329(13):936-947 [viewed 21 April 2014] Available from: doi:10.1056/NEJM199309233291308

Differential Diagnoses

Fact Explanation
Lyme disease [1] Both Lyme disease and Babesiosis may present as flu-like non-specific symptoms. Both diseases can co-exist in some patients. [1]
Malaria Patients present with fever, chills, sweats, headache, nausea, and vomiting. The diagnosis can be made by demonstration of malaria parasites in a blood picture. [2]
Disseminated intravascular coagulation Babesiosis is only one infective cause of disseminated intravascular coagulation. Other causes include severe trauma, solid or hematological malignancies, and obstetrical conditions (abruptio placentae and amniotic-fluid embolism). [3]
Meningitis Central nervous system involvement with headache, neck stiffness, and photophobia may mimic meningitis. [4]
References
  1. ELEFTHERIOS MYLONAKIS. When to Suspect and How to Monitor Babesiosis. Am Fam Physician. [online] 2001 May 15;63(10):1969-1975. [viewed 21 April 2014] Available from: http://www.aafp.org/afp/2001/0515/p1969.html
  2. Malaria. Centers for Disease Control and Prevention. [online] [viewed 21 April 2014] Available from: http://www.cdc.gov/malaria/about/disease.html
  3. MARCEL LEVI, HUGO TEN CATE. Disseminated Intravascular Coagulation. N Engl J Med [online] 1999; 341:586-592. [viewed 21 April 2014] Available from: DOI: 10.1056/NEJM199908193410807
  4. BASHIR H.E, LAUNDY M, BOOY R. Diagnosis and treatment of bacterial meningitis. Arch Dis Child [online] 2003;88:615-620. [viewed 21 April 2014] Available from: doi:10.1136/adc.88.7.615

Investigations - for Diagnosis

Fact Explanation
Full blood count Normocytic normochromia anemia with thrombocytopenia. [6] Leukopenia might be detected as well. [2]
Blood picture Babesia parasites can be seen in infected red blood cells. [1,2]
Indirect (immuno) fluorescent antibody tests (IFATs) [3] Recognizes the infection by identifying specific antigens of the tick.
Polymerase chain reaction (PCR) Detects the DNA of the tick. [4]
Antibody against tick This allows the detection of antibodies but after an acute infection antibodies may persist for up to about 6 years. So positive antibody test does not necessarily means an acute infection. [5]
References
  1. Babesiosis. Centers for Disease Control and Prevention. [online] [viewed 21 April 2014] Available from: http://www.cdc.gov/parasites/babesiosis/disease.html
  2. MARY J. HOMER, IRMA AGUILAR-DELFIN, SAM R. TELFORD III,PETER J. KRAUSE, DAVID H. PERSING. Babesiosis. Clin. Microbiol. Rev. [online] July 2000 vol. 13 no. 3 451-469. [viewed 21 April 2014] Available from: doi: 10.1128/CMR.13.3.451-469.2000
  3. CHISHOLM ES, RUEBUSH TK 2ND, SULZER AJ, HEALY GR. Babesia microti infection in man: evaluation of an indirect immunofluorescent antibody test. Am. J. Trop. Med. Hyg.[online] 1978: 27 (1):14–19. [viewed 21 April 2014] Available from: www.ncbi.nlm.nih.gov/pubmed/343608
  4. PERSING D. H., MATHIESEN D., MARSHALL W. F., TELFORD III S. R.,SPIELMAN A., THOMFORD J. W., CONRAD P. A. Detection of Babesia microti by polymerase chain reaction. J. Clin. Microbiol. [online] 1992: 30:2097–2103. [viewed 21 April 2014] Available from: http://jcm.asm.org/content/30/8/2097.abstract?ijkey=7097387bbfcf9dc974de484e019be3441ef86a9e&keytype2=tf_ipsecsha
  5. RUEBUSH T. K., JURANEK D. D., SPIELMAN A., PIESMAN J., HEALY G. R. Epidemiology of human babesiosis on Nantucket Island. Am. J. Trop. Med. Hyg. [online] 1981: 30 (5):937–941. [viewed 21 April 2014] Available from: www.ncbi.nlm.nih.gov/pubmed/7283012
  6. PANTANOWITZ L. Mechanisms of Thrombocytopenia in Tick-Borne Diseases. The Internet Journal of Infectious Diseases. [online] 2002: 2 (2). [viewed 21 April 2014] Available from: http://ispub.com/IJID/2/2/3023

Investigations - Fitness for Management

Fact Explanation
Full blood count Disseminated intravascular coagulation (DIC) is a known complication of the disease.[2] Full blood count allows early detection of thrombocytopenia in DIC.
Hepatic transaminases Since the hepatic transaminases increase with the development of DIC, assessment of baseline levels of liver enzymes is helpful. [1]
Prothrombin time and international normalized ratio (PT/INR) Evaluates the baseline clotting profile.
Serum bilirubin Unconjugated hyperbilirubinemia is present. [1]
Serum lactic dehydrogenase Elevated due to hemolysis. [1]
Renal function test Massive hemolysis can result in acute kidney injury.
CT or MRI In severe disease this will aid in evaluating the liver and spleen. [1]
References
  1. MARY J. HOMER, IRMA AGUILAR-DELFIN, SAM R. TELFORD III,PETER J. KRAUSE, DAVID H. PERSING. Babesiosis. Clin. Microbiol. Rev. [online] July 2000 vol. 13 no. 3 451-469. [viewed 21 April 2014] Available from: doi: 10.1128/CMR.13.3.451-469.2000
  2. Babesiosis. Centers for Disease Control and Prevention. [online] [viewed 21 April 2014] Available from: http://www.cdc.gov/parasites/babesiosis/disease.html

Management - General Measures

Fact Explanation
Health education Babesiosis is caused by tick bites. Tick bites should be prevented by avoiding their habitat areas. Cover the body properly when working outdoors. Chemical repellents like DEET (N,N-diethylmetatoluamide) and Permethrin can be applied to the skin or to the clothing to prevent tick bites. [1,2,3] Ticks are commonly found in leaf litter, brush, and overgrown grasses. It is better to avoid getting contact with them. After outdoor activities the whole body should be examined for the ticks especially behind the knees, groin area, between the toes, armpits, around the waist, inside the umbilicus, back of the neck, hairline, hair and around the ears. [1] If any tick is seen attached to the skin it should be removed immediately. [3]
Management of acute renal failure [2] Severe intravascular hemolysis may lead to acute kidney injury. Dehydration can increase the risk of acute kidney injury. So meticulous fluid management is mandatory. [2]
References
  1. Babesiosis. Centers for Disease Control and Prevention. [online] [viewed 21 April 2014] Available from: http://www.cdc.gov/parasites/babesiosis/disease.html
  2. MARY J. HOMER, IRMA AGUILAR-DELFIN, SAM R. TELFORD III,PETER J. KRAUSE, DAVID H. PERSING. Babesiosis. Clin. Microbiol. Rev. [online] July 2000 vol. 13 no. 3 451-469. [viewed 21 April 2014] Available from: doi: 10.1128/CMR.13.3.451-469.2000
  3. ELEFTHERIOS MYLONAKIS. When to Suspect and How to Monitor Babesiosis. Am Fam Physician. [online] 2001 May 15;63(10):1969-1975. [viewed 21 April 2014] Available from: http://www.aafp.org/afp/2001/0515/p1969.html

Management - Specific Treatments

Fact Explanation
Conservative management [1] Babesiosis is mild and self-limiting disease in majority of people. [2] Human is the dead-end host of Babesia species. However transfusion of blood from an infected person can spread the disease even sometime after the acute infection, because the ticks are known to survive for a long time in human body. [3] Patients should be advised not to donate blood in order to prevent the human to human transmission. [6]
Pharmacological management Combined therapy with clindamycin (600 mg orally, three times daily, or 1.2 g parenterally, twice daily) and quinine (650 mg of salt orally, three times daily) is effective. [2,3,5] Atovaquone and azithromycin is also an effective combination of treatment. [5]
Exchange transfusion Patients with severe infection may need exchange transfusion in order to remove infected red blood cells from the circulation. [4]
References
  1. Babesiosis. Centers for Disease Control and Prevention. [online] [viewed 21 April 2014] Available from: http://www.cdc.gov/parasites/babesiosis/disease.html
  2. MARY J. HOMER, IRMA AGUILAR-DELFIN, SAM R. TELFORD III,PETER J. KRAUSE, DAVID H. PERSING. Babesiosis. Clin. Microbiol. Rev. [online] July 2000 vol. 13 no. 3 451-469. [viewed 21 April 2014] Available from: doi: 10.1128/CMR.13.3.451-469.2000
  3. KRAUSE P. J., SPIELMAN A., TELFORD III S. R., SIKAND V. K., MCKAY K.,CHRISTIANSON D., POLLACK R. J., BRASSARD P., MAGERA J., RYAN R.,PERSING D. H. Persistent parasitemia after acute babesiosis. N. Engl. J. Med. [online] 1998: 339:160–165 [viewed 21 April 2014] Available from: DOI: 10.1056/NEJM199807163390304
  4. CAHILL K. M., BENACH J. L., REICH L. M., BILMES E., ZINS J. H.,SIEGEL F. P., HOCHWEIS S. Red cell exchange: treatment of babesiosis in a splenectomized patient. Transfusion [online] 1981: 21:193–198. [viewed 21 April 2014] Available from: DOI: 10.1046/j.1537-2995.1981.21281178156.x
  5. ELEFTHERIOS MYLONAKIS. When to Suspect and How to Monitor Babesiosis. Am Fam Physician. [online] 2001 May 15;63(10):1969-1975. [viewed 21 April 2014] Available from: http://www.aafp.org/afp/2001/0515/p1969.html
  6. EDOUARD VANNIER, PETER J. K., Update on Babesiosis. Interdisciplinary Perspectives on Infectious Diseases. [online] 2009: 2009. [viewed 21 April 2014] Available from: http://dx.doi.org/10.1155/2009/984568