Contributed by Sarah Navina, MD, Ming Yin, MD, PhD, and A. William Pasculle. ScD
Published on line in December 2002
The patient, a 58-years-old male with a history of splenectomy, presented to the emergency department in early August with fever, malaise and bodyache noted after returning from a two-day trip to Brazil. He had also visited Cape Cod about three weeks prior to this trip and gave a history of mosquito bites. His initial workup included screening for multiple infectious diseases including titres sent for West Nile virus, Lyme disease, Hepatitis, EBV and malaria, all of which were found to be negative. Amongst the routine lab investigations sent, a blood film for CBC. revealed intracellular ring forms in erythrocytes for which he was started on antimalarial therapy. His myalgias and leg weakness continued to worsen along with continuing low-grade fever. Within a week, he noticed, for the first time, dark colored urine and lightheadedness. A malaria smear done this time was found to have multiple intracellular and extracellular ring forms more compatible with a Babesia infection. (Figures 1, 2, 3 and 4). His P/E at this time showed BP 110/90, pulse 60/min and regular, respiration 18-20/min with no fever. He appeared moderately ill and was shivering during examination. His skin over upper back had diffuse erythema with no discrete rash.
His laboratory investigations were as follows: Na 138, K 4.3, Cl 100, CO2 25, BUN 20, Cr 1.0, Glucose 132. WBC 6.5 with polys 67%, bands 4%, lymphs 10%, monos 17%, and baso- 2%. Hb 13, Hct 37.5, platelets 161, Haptoglobin <5.8, APT 14.9, APTT 27.8, INR 1.3. AST 37, ALT 59, ALP 110, GGTP 121, total bilirubin 0.9, CPK <20. The degree of parasitemia was 4% at that time.
He was admitted for further management and started on intravenous Clindamycin and Doxycycline, oral Quinine sulfate. He was also vaccinated against Pneumococcus and H. influenza B. His hospital course was complicated by the development of bilateral pulmonary infiltrates and acute respiratory insufficiency which improved after an exchange transfusion. He became afebrile within the duration of his antibiotic therapy. He is presently in the hospital, recovering and under evaluation and rehabilitation therapy for bilateral lower extremity weakness thought to be unrelated to babesiosis.