Case 16

Case presentation
Case 16
Reporter: I2
Date: 94/11/28
Chief complaint, present illness, &

personal/past/family history
A 17-year-old girl who had never traveled outside the

United States, had recently spent the summer
working as a waitress in Nantucket,Mass.On her
return to her home in Washington, D.C., she
developed a headache, fatigue, fever, shaking
chills, joint and muscle aches, and other vague flulike symptoms, which persisted for a month.
She had been previously healthy,al-though she had
had a splenectomy due to injuries suffered in a ski
accident.
Physical examination
headache,fatigue,fever,shaking chills
joint and muscle aches, and other vague
flu-like symptoms
Laboratory tests
Blood count, and thick and thin blood smears.

The thin smears, stained with Giemsa stain,
intraerythrocytic,pleomorphic, ringlike and
crucifix-shaped structures, found peripherally
in the pale red blood cells.
Fig.16.1
Babesiosis ()
Intraerythrocytic protozoan malarialike illness
ETIOLOGY
Babesia, B. microti &B. divergens are the

most that cause human infections.
Hostsrodents,birds
ReservoirTicks
Vectors Ixodid (hard-bodied) ticks
Ixodes scapularis (I. dammini)
I. ricinus,.
EPIDEMIOLOGY
Ticks is prevalent:
Nantucket Island of Massachusetts
Block Island in Rhode Island
Long Island,Shelter Island, Fire Island in New
York
focal areas in Connecticut, Wisconsin, Minnesota
Between May~August
In Nantucket 60% of deer mice are infected
with B.
microti.
CLINICAL PRESENTATION
Varies widely and resembles malaria or

rickettsiosis
Gradual onset of irregular fever, chills, sweating,
muscle pain, and fatigue.
Mild hepatosplenomegaly and mild hemolytic
anemia progressing to jaundice, hemoglobinemia,
and renal failure.
The level of parasitemia may range from 1 to 50%.
DIAGNOSIS
History:tick bites, febrile persons living in

endemic areas
Laboratory exam
Laboratory Findings
Hemolytic anemia, normal to low leukocyte counts,

abnormal liver function.
Giemsa-stained blood smears :Ring forms &
pleomorphic intraerythrocytic organisms on
Unlike malaria, Babesia organisms do not produce
pigment in RBC
the absence of gametocytes and intracellular
pigmentation help distinguish babesiosis from malaria.
Indirect immunofluorescenceantibody test
Giemsa-stain
For differentiate nuclear and/or cytoplasmic morphology

of platelets, RBCs, WBCs, and parasites.
In Wright- and Giemsa-stain:
the cytoplasm appears blue.
the nucleus is relatively large, eccentrically located, and
red.
the distinct, rod-shaped, red-staining kinetoplast (a
specialized mitochondrial structure) contains extranuclear
DNA arranged as catenated minicircles and maxicircles
TREATMENT
Intact spleenself-limiting although symptoms may
persist for months .
Clindamycin(1.2 g Bid IV or 600 mg Tid po for 7~10 days)
Quinine(650mgTid po for 7 days)
Atovaquone(750mg po Bid for 7~10 days)
Azithromycin(600 mg po Qd for 7~10 days)
Severe infections (parasitemia/asplenic)in addition to
exchange transfusions
Occasionally, pulmonary edema may develop after
initiation of therapy.
Question 1
What is the probable diagnosis of this

patient's infection? Name the protozoan
blood parasite which is most likely to be
responsible for this infection.
Answer 1
DxBabesiosis
Protozoan B. microti & B. divergens are
the two that cause most human infections
Question 2
What are the ringlike and crucifix-shaped

structures seen in the peripheral
blood smear? Which aspect of the patient's
history led to your conclusion about
her diagnosis? Do you think that her history
of having a splenectomy would have
any relationship to her illness?
Answer 2
Ringlike&crucifix-shaped structuresmerozoite
Hints:
1.She had recently spent the summer working
as a waitress in Nantucket,Mass.
2.She had had a splenectomy due to injuries
suffered in a ski accident.
Question 3
Why is this infection common only in certain

geographical areas?
Answer 3
Ticks is prevalent:
Nantucket Island of Massachusetts
Block Island in Rhode Island
Long Island,Shelter Island, Fire Island in New York
focal areas in Connecticut, Wisconsin, Minnesota
Between May~August
In Nantucket 60% of deer mice are infected with B.
microti.
Question 4
Which other infections are transmitted by the

same vector?
Answer 4
VectorTicks ()
The tick of may simultaneously transmit
1.Borrelia burgdorferitheLyme disease
2.Ehrlichia (Anaplasma) speciesehrlichiosis
(Rickettsia, Ehrlichia)
=>Those coinfections may make clinical illness
more severe and warrant special therapy.
Question 5
Describe the life cycle of this parasite.
Answer 5
Ticks ingest Babesia while feeding, and

the parasite multiplies within the tick's gut
wall. The organisms then spread to the
salivary glands; their inoculation into a
vertebrate host by a tick larva, nymph, or
adult completes the cycle of transmission.
Asexual reproduction of Babesia within
RBCs1 produces two or four parasites
Question 6
In which other manner may this infection be

transmitted?
Answer 6
Blood transfusion
Acquired perinatally
Question 7
How do infections with this parasite in other

geographical areas differ from the case
described here?
Answer 7
The causative agent of babesiosis varies according

to geographical region.
Geographical
region
Protozoan
Vector
Northeastern
United States
California
Washington
Babesia microti
Babesia gibsoni
Ixodes tick
(transmits Lyme
disease)
unidentified
Europe
Babesia
divergens
Ixodes tick
Question 8
How may this infection be treated?
Answer 8
Intact spleenself-limiting although symptoms may

persist for months .
Clindamycin(1.2 g Bid IV or 600 mg Tid po for 7~10 days)
Quinine(650mgTid po for 7 days)
Atovaquone(750mg po Bid for 7~10 days)
Azithromycin(600 mg po Qd for 7~10 days)
Severe infections (parasitemia/asplenic)in addition to
exchange transfusions
Occasionally, pulmonary edema may develop after
initiation of therapy.
References
Harrison's Principles of Internal Medicine - 16th

Ed. (2005)
Infectious disease the clinicans guide to diagnosis
treatment and prevention 2005

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Case 16

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Case presentation

Chief complaint, present illness, &

A 17-year-old girl who had never traveled outside the

Blood count, and thick and thin blood smears.

Intraerythrocytic protozoan malarialike illness

Babesia, B. microti &B. divergens are the

Varies widely and resembles malaria or

History:tick bites, febrile persons living in

Hemolytic anemia, normal to low leukocyte counts,

For differentiate nuclear and/or cytoplasmic morphology

What is the probable diagnosis of this

What are the ringlike and crucifix-shaped

Why is this infection common only in certain

Which other infections are transmitted by the

Describe the life cycle of this parasite.

Ticks ingest Babesia while feeding, and

In which other manner may this infection be

How do infections with this parasite in other

The causative agent of babesiosis varies according

How may this infection be treated?

Intact spleenself-limiting although symptoms may

Harrison's Principles of Internal Medicine - 16th

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