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Pediatrics: General Medicine > Parasitology
Babesiosis
Article Last Updated: Mar 24, 2006
AUTHOR AND EDITOR INFORMATION
Section 1 of 11  
Author: 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 is a member of the following medical societies: American Academy of Pediatrics
Coauthor(s):
Vinod K Dhawan, MD, FACP, FRCP(C), Professor, Department of Clinical Medicine, University of California at Los Angeles; Professor of Medicine, Charles R Drew University of Medicine and Science; Chief, Division of Infectious Diseases, MLK-Harbor Hospital
Editors: Itzhak Brook, MD, MSc, Professor, Department of Pediatrics, Georgetown University School of Medicine; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc; Martin Weisse, MD, Program Director, Associate Professor, Department of Pediatrics, West Virginia University; Robert W Tolan Jr, MD, Chief of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine; Russell W Steele, MD, Professor and Vice Chairman, Department of Pediatrics, Head, Division of Infectious Diseases, Louisiana State University Health Sciences Center
Author and Editor Disclosure
Synonyms and related keywords:
babesiosis, human babesiosis, Babesia, Babesia microti, B microti, Babesia divergens, B divergens, Babesia bovis, B bovis, piroplasmosis
Background
Human babesiosis is a significant emerging tick-borne zoonotic disease. Malarialike protozoan parasites of the genus Babesia cause human babesiosis. Babesial parasites and those of the closely related genus Theileria have worldwide distribution, parasitizing the erythrocytes of wild and domestic animals. These parasites are commonly called piroplasms because of the pear-shaped forms found within infected red blood cells. Babesial infections in humans are infrequent and occur in limited geographic locations. Disease manifestations range from asymptomatic infection in healthy individuals to severe illness and death in those who are asplenic, elderly, or immunocompromised.
Babes first described babesiosis in Romanian cattle in 1888. Skrabalo was the first to identify a human infection caused by Babesia in 1957 in the former Yugoslavia. Earlier reports involved splenectomized patients with fulminant babesiosis. In 1969, infection with Babesia microti was described in a patient with an intact spleen from Nantucket Island off the coast of Massachusetts. Since then, more than 300 cases of human babesiosis have been reported. In the United States, babesiosis is endemic in the Northeast, particularly in the areas of Nantucket Island, Martha's Vineyard, Shelter Island, and parts of Long Island. In addition to the Northeast, cases have been reported from the Midwest and West Coast of the United States.
Of the more than 70 species worldwide in the genus Babesia, human infections are largely due to the rodent strain B microti (found only in the United States) and the cattle strains Babesia divergens and Babesia bovis (found only in Europe). Sporadic cases of babesiosis in Washington State and California have been described from a hitherto unknown species of Babesia, designated WA-1. Genetic sequence analysis of WA-1 strain has revealed piroplasm-specific, small-subunit ribosomal DNA. Phylogenetically, WA-1 strain Babesia is closely related to Babesia gibsoni, a canine pathogen. A fatal case of babesiosis was recently described in Missouri from a strain (MO-1) that was closely related to B divergens. Serologic studies that test for B microti do not detect infections due to these other strains of Babesia.
Babesia species in the host erythrocyte varies in size from 1-5 mm in length. B microti measures 2 by 1.5 mm, B divergens measures 4 by 1.5 mm, and B bovis measures 2.4 by 1.5 mm. They are pear-shaped, oval, or round. Their ring form and peripheral location in the erythrocyte frequently lead to their being mistaken for Plasmodium falciparum.
Babesiosis is a zoonotic disease and requires transmission from an animal reservoir to humans via a tick vector. In the northeastern United States, the black-legged deer tick Ixodes scapularis, also called Ixodes dammini (see Image 1), is the principal vector for transmitting the etiologic agent B microti. I scapularis is the same vector that transmits Lyme disease. Babesia species from rodents, primarily the white-footed deer mouse but also the field mouse, vole, rat, and chipmunk, are transmitted to humans during tick bites in endemic areas. Babesiosis understandably is more prevalent during the periods of tick activity such as spring and summer.
The tick I scapularis has 3 developmental stages, the larva, the nymph, and the adult, with each stage requiring a blood meal for development into the next stage. As a larva and nymph, the tick feeds on rodents, but as an adult, the tick prefers to feed on the white-tailed deer. Female ticks are impregnated while obtaining their blood meal on the deer, with the formation of up to 20,000 eggs.
While rodents are infected with Babesia (60% on Nantucket Island), the white-tailed deer does not carry the organism. B microti is transmitted from the larval phase of the tick to the nymphal phase (transstadial transmission) but not transovarially. Human infection is primarily produced by the bite of an infected nymph during a blood meal. Restocking of deer populations and curtailment of hunting has increased deer herds in certain areas. The proximity of deer, mouse, and tick create the conditions for human infection. Babesiosis is rarely acquired through blood transfusion. In transfusion-associated cases, sources of babesiosis have included platelets and frozen erythrocytes. The incubation period in transfusion-associated disease appears to be 6-9 weeks. Transplacental transmission has also occurred rarely.
The hard-bodied cattle tick Ixodes ricinus is thought to transmit bovine babesiosis from the cattle reservoir to humans in Europe.
Pathophysiology
Sporozoites enter the patient's blood stream during the tick bite and become intraerythrocytic. Upon infection of the host erythrocyte, mature B microti trophozoites undergo asynchronous asexual budding and divide into 2 or 4 merozoites. As parasites leave the erythrocyte, the membrane is damaged. The precise mechanism of hemolysis is unknown. Unlike in Plasmodium, the schizogony is asynchronous, and massive hemolysis does not occur.
The spleen offers a critical host defense against this infection, as suggested by the higher incidence and greater severity of babesiosis in asplenic patients. The spleen traps the infected erythrocytes, and their ingestion by the macrophages follows.
Complement activation by Babesia may lead to the generation of tumor necrosis factor (TNF) and interleukin-1 (IL-1). Decreased complement levels, increased circulating C1q-binding activity and decreased C4, C3, and CH50 levels are observed in patients with babesiosis. The generation of these primarily macrophage-produced mediators may explain many of the clinical features, such as fever, anorexia, arthralgias, myalgias, and the fulminant shock syndrome of bovine babesiosis.
The disease itself alters cellular immune function. Patients with acute babesiosis have an increase in T-suppressor lymphocytes, T-cytotoxic lymphocytes, or both and decreased responses to lymphocyte mitogens with a polyclonal hypergammaglobulinemia.
Frequency
United States
Human babesiosis is endemic in the northeastern coastal region of the United States, particularly Nantucket Island, Martha's Vineyard, Cape Cod (Massachusetts), Block Island (Rhode Island), eastern Long Island, Shelter Island, and Fire Island (New York). More recently, cases have been described from the Connecticut mainland and Washington State. In addition, infections with Babesia species have been reported in New Jersey, Maryland, Virginia, California, Wisconsin, Minnesota, Missouri, Washington State, Georgia, and Mexico. Disease prevalence in Cape Cod, as suggested by antibody to B microti, has been reported as 3.7%, whereas on Shelter Island in individuals with a high risk of exposure to ticks, it was 4.4% in June and reached 6.9% by October.
International
Babesiosis is rare in Europe, with cases reported from the former Yugoslavia, France, Russia, Ireland, and Scotland. All of the cases involved bovine Babesia and occurred in individuals who were splenectomized. One recent report describes human Babesia infection in Columbia.
Mortality/Morbidity
In a healthy individual with an intact spleen, babesiosis is rarely fatal; however, in a patient who is asplenic, babesiosis is generally quite severe and frequently fatal. In a 1998 review by White and colleagues, babesiosis was fatal in 9 of 139 (6.5%) patients who were hospitalized for the disease in New York from 1982-1993.
Age
Patients with clinical illness and intact spleens are usually aged 50 years or older, suggesting that age plays a factor in the severity of the clinical response. Previously healthy individuals with babesiosis are generally older (mean >60 y) than are patients with babesiosis with antecedent medical problems (mean 48 y). A 2004 publication by Vannier et al suggests that the age-associated decline in resistance to B microti is genetically determined.
History
The spectrum of disease manifestation is broad, ranging from a silent infection to a fulminant malarialike disease, which results in severe hemolysis and, occasionally, death. In the United States, infection with B microti in otherwise healthy individuals generally remains subclinical; however, symptomatic infection is common in patients who are asplenic, older patients, and those with underlying medical conditions, including human immunodeficiency virus infection. Because bovine babesiosis due to B divergens and B bovis in Europe mostly occurs in patients who are asplenic, such infections generally are clinically overt and frequently fatal.
- The incubation period after the tick bite usually is 1-3 weeks but may occasionally be as long as 9 weeks. Because the nymph, the primary vector, is only 2 mm in diameter when engorged, most patients do not recall a tick bite.
- Patients with clinical illness and intact spleens are usually aged 50 years or older, suggesting that age plays a factor in the severity of the clinical response. Previously healthy individuals with babesiosis generally are older (mean >60 y) than are patients with babesiosis with antecedent medical problems (mean 48 y).
- Initial symptoms begin gradually and are nonspecific. Common symptoms include the following:
- Malaise
- Fatigue
- Anorexia
- Shaking chills
- Fever (Fever may be sustained or intermittent, and temperatures may reach levels of 40ºC.)
- Headache
- Myalgias
- Arthralgias
- Nausea
- Vomiting
- Abdominal pain
- Depression and emotional lability
- Dark urine
- Photophobia, conjunctival injection, sore throat, cough (less common symptoms)
- In a series of 139 patients who were hospitalized with babesiosis in New York, the following were the most common symptoms:
- Fatigue, malaise, and weakness (91%)
- Fever (91%)
- Shaking chills (77%)
- Diaphoresis (69%)
- In some untreated patients, symptoms of babesiosis may last for months. Subclinical infections may recrudesce spontaneously after splenectomy and after immunosuppressive therapy.
Physical
Findings may vary depending on the severity of disease.
- Fever is generally present.
- Splenomegaly may be present in some patients.
- Hepatomegaly may be noted.
- Petechiae may be present in a few patients. Ecchymoses have been noted occasionally. Rash similar to erythema chronicum migrans (ECM) has been described, but this probably represents intercurrent Lyme disease.
- Slight pharyngeal erythema may occur.
- Jaundice may be observed.
- Babesiosis has been associated with shock and acute respiratory distress syndrome.
Causes
- Babesiosis is acquired through a tick bite and is caused by the rodent strain B microti (in the United States) and the cattle strains B divergens and B bovis (in Europe). The tick vectors are the hard-bodied I scapularis in the United States and I ricinus in Europe.
- A Babesia species, designated WA-1, was isolated from an immunocompetent man in Washington State.
- A fatal case of babesiosis from a strain (MO-1) that was closely related to B divergens was recently described in Missouri.
- Transfusion-associated babesiosis has been described. In transfusion-associated cases, sources of babesiosis have included platelets and frozen erythrocytes.
- Transplacental or perinatal transmission of babesiosis has been described.
Lyme Disease
Malaria
Other Problems to be Considered
Typhoid fever
Lab Studies
- Hemolytic anemia, decreased serum haptoglobin levels, and elevated reticulocyte counts are noted, and the anemia may occasionally be severe.
- The percentage of erythrocytes parasitized in clinical cases usually is 1-10% but has ranged from less than 1% to 85%.
- The total leukocyte count may be within the reference range or mildly decreased.
- Thrombocytopenia is common.
- The erythrocyte sedimentation rate may be elevated.
- Coombs test may react positively.
- Urinalysis reveals proteinuria and hemoglobinuria.
- BUN and serum creatinine levels may be elevated.
- The following usually have mildly elevated levels:
- Serum bilirubin
- Alkaline phosphatase
- Serum aspartate aminotransferase (AST)
- Serum glutamic-oxaloacetic transaminase (SGOT)
- Serum alanine aminotransferase (ALT)
- Serum glutamic-pyruvic transaminase (SGPT)
- Lactic dehydrogenase (LDH)
Other Tests
- Babesiosis is usually diagnosed by microscopic examination of Giemsa- or Wright-stained thin or thick blood smears (see Image 2).
- Babesia may be mistaken for malarial parasite, particularly the ring forms of P falciparum.
- Helpful features that distinguish Babesia from Plasmodium include the absence of brownish pigment deposits (hemozoin), the lack of synchronous stages (schizonts and gametocytes observed with Plasmodium species), and the occasional presence of tetrads of merozoites or Maltese-cross forms (see Image 3).
- Babesia varies more in shape and in size and may be observed outside erythrocytes with heavier infestation.
- An indirect immunofluorescent antibody (IFA) assay can be used to make a serologic diagnosis of babesiosis.
- A titer of 1:256 or greater is considered diagnostic for recent B microti infection. Most patients with an active infection develop serum titers 1:024 or greater within a few weeks. Antibody titers decline slowly over months to 1:256 or less.
- Titers of 1:32 or less indicate prior infection. Cross-reactions may occur in serum specimens from patients with malaria infections.
- Because of the antigenic differences, infections with WA-1 species and MO-1 strain Babesia are not detected by IFA for B microti. Test individuals whose exposure could have occurred on the West Coast of the United States for antibodies to the WA-1 species Babesia.
- Recently, a polymerase chain reaction (PCR)–based diagnostic assay was reported and holds great promise for increasing the detection rate of very low-level parasitemia. Persistence of antibody titers for B microti has been shown to correlate with the detection of babesial DNA by PCR. In 1998, Krause and colleagues reported the detection of babesial DNA by PCR for as long as 27 months after untreated infection.
- Currently, the suspected B microti infection can be confirmed through intraperitoneal inoculation of 1 mL of ethylenediaminetetraacetic acid (EDTA) whole blood into the peritoneum of golden hamsters. B divergens replicates readily in gerbils. Within 2-4 weeks, smears are positive in the infected animals.
- Consider the possibility of co-infection with Lyme disease because the 2 organisms share the same tick vector. Co-infection often results in increased duration and severity of illness.
Medical Care
Most of the otherwise healthy patients infected by B microti appear to have a mild illness and recover without specific chemotherapy; however, treatment is recommended for all diagnosed cases to prevent sequelae and potential transmission through blood donation.
- Babesiosis is generally treated with a combination of clindamycin (20 mg/kg/d for children; 300-600 mg IV/IM q6h for adults) and oral quinine (25 mg/kg/d for children; 650 mg q6-8h for adults) administered for 7-10 days. Occasional failure of this therapy has been reported.
- A combination of atovaquone and azithromycin appears to be a promising alternative. In a prospective nonblinded randomized study in 2000, Krause and colleagues found that a regimen of atovaquone (750 mg q12h) and azithromycin (500 mg on day 1 and 250 mg/d thereafter) was as effective as a combination of clindamycin (600 mg q8h) and quinine (650 mg q8h) in producing a clinical response and producing the clearance of parasitemia. All patients were treated for 7 days. Adverse effects were reported by 15% of the patients who received atovaquone and azithromycin, as compared with 72% of those who received clindamycin and quinine.
- The combination of clindamycin, doxycycline, and azithromycin was successfully used in a patient who was allergic to quinine.
- The combination of pentamidine with trimethoprim-sulfamethoxazole was reported to be successful in the treatment of B divergens infection in a patient in France who was splenectomized.
- The antitrypanosomal drug diminazene aceturate is effective against B microti infections in animals and has been administered to one patient who recovered from B microti infection. This patient developed a Guillain-Barré–like disorder. Diminazene was also used unsuccessfully in a fatal case of babesiosis due to B divergens.
- Exchange transfusions are used in patients who are profoundly ill with high levels of parasitemia and hemolysis. When used concurrently with chemotherapy, exchange transfusion reduces the level of parasitemia and may remove toxic erythrocyte, babesial, or macrophage-produced factors.
Consultations
Consult an infectious diseases specialist for appropriate antibiotic therapy.
Clindamycin plus quinine or, alternatively, atovaquone plus azithromycin are used to treat all patients to prevent sequelae and potential transmission through blood donation. Other antibiotic regimens have been reported in isolated case reports.
Drug Category: Antiprotozoal agents
Protozoal infections occur throughout the world and are a major cause of morbidity and mortality in some regions. Cinchona alkaloids (eg, quinine) are effective in eradicating the parasite.
| Drug Name | Quinine |
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| Description | Schizonticide. Inhibits growth of parasite by increasing the pH within intracellular organelles and possibly by intercalating into the DNA of the parasites. Used in combination with clindamycin. |
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| Adult Dose | 650 mg PO tid for 7-10 d |
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| Pediatric Dose | 25 mg/kg/d PO divided q6-8h for 7-10 d; not to exceed 650 mg/dose |
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| Contraindications | Documented hypersensitivity; optic neuritis; tinnitus; G-6-PD deficiency; history of black water fever |
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| Interactions | Aluminum-containing antacids may delay or decrease quinine bioavailability when administered concurrently; cimetidine increases quinine blood levels and creates the potential for toxicity; rifamycins decrease quinine concentrations by increasing hepatic clearance of quinine (effect can persist for several days after discontinuing rifamycins); concurrent administration of acetazolamide or sodium bicarbonate may increase toxicity by increasing quinine blood levels; quinine may enhance action of warfarin and other PO anticoagulants by decreasing synthesis of vitamin K–dependent clotting factors; digoxin serum concentrations may increase when digoxin is administered concurrently with quinine; important to monitor digoxin levels periodically; quinidine may decrease plasma cholinesterase activity, causing a decrease in the metabolism of succinylcholine |
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| Pregnancy | X - Contraindicated in pregnancy
|
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| Precautions | Caution in G-6-PD deficiency and tendency to develop granulocytopenia; prolonged treatment or overdosing with quinine may cause cinchonism; quinine has quinidinelike activity and thus can cause cardiac arrhythmias |
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| Drug Name | Atovaquone (Mepron) |
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| Description | A hydroxynaphthoquinone that inhibits the mitochondrial electron transport chain by competing with ubiquinone at the ubiquinone-cytochrome-c-reductase region (complex III). Inhibition of electron transport by atovaquone results in inhibition of nucleic acid and ATP synthesis in the parasites. Used in combination with azithromycin. |
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| Adult Dose | 750 mg PO bid for 7-10 d |
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| Pediatric Dose | 40 mg/kg/d PO divided bid for 7-10 d; not to exceed 1500 mg/d |
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| Contraindications | Documented hypersensitivity |
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| Interactions | May increase zidovudine serum levels; coadministration with rifamycin and trimethoprim/sulfamethoxazole may decrease atovaquone levels |
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| Pregnancy | C - Safety for use during pregnancy has not been established.
|
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| Precautions | Caution in elderly patients and in hepatic or renal impairment |
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Drug Category: Antibiotic agents
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
| Drug Name | Azithromycin (Zithromax) |
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| Description | One of the newer macrolide antibiotics. Plasma concentrations are very low, but tissue concentrations are much higher, making it valuable in treating intracellular organisms. Has a long tissue half-life. Used in combination with atovaquone. |
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| Adult Dose | 500 mg PO on day 1 and 250 mg/d thereafter |
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| Pediatric Dose | 20 mg/kg PO qd |
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| Contraindications | Documented hypersensitivity; hepatic impairment; coadministration with pimozide |
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| Interactions | May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks.
|
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| Precautions | Site reactions can occur with IV route; bacterial or fungal overgrowth may result with prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function, prolonged QT intervals, or pneumonia; caution in hospitalized, geriatric, or debilitated patients |
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| Drug Name | Clindamycin (Cleocin) |
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| Description | Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, inhibiting RNA-dependent protein synthesis. Used in combination with quinine to treat babesiosis. |
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| Adult Dose | 300-600 mg IV/IM divided q6h |
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| Pediatric Dose | 20 mg/kg/d IV/IM divided q6h |
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| Contraindications | Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis |
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| Interactions | Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin |
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| Pregnancy | C - Safety for use during pregnancy has not been established.
|
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| Precautions | Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis by allowing overgrowth of Clostridium difficile |
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Further Inpatient Care
- If the patient is critically ill, transfer the patient to the intensive care unit.
- Exchange transfusions are used in patients who are profoundly ill with high levels of parasitemia and hemolysis.
Deterrence/Prevention
- The prevention of babesiosis requires avoidance of areas endemic for I scapularis during May through September. This is especially important for individuals who are splenectomized and others who are immunocompromised.
- In endemic areas, wear clothing to cover the lower portion of the body (eg, long pants and socks). Because ticks may crawl up pants and legs, tucking pants into boots or socks or cinching the legs at the ankles is helpful. Wearing light-colored clothes enables the ticks to be spotted more easily.
- Diethyltoluamide (DEET) insect repellent applied to the skin or clothes is only partially repellant for hours.
- A spray containing permethrin (Duranon, Permanone) is far more effective; however, only apply the spray to clothes (eg, pants bottoms, socks, shirtsleeves).
- Inspect pets carefully for ticks before allowing them inside the home.
- Avoid tall grass and brush in endemic areas and restrict walks and hikes to well-worn roads or paths.
- Examine skin thoroughly for the presence of ticks. If a tick is found, speedy removal is indicated. Grasp the tick below the mouth with a small forceps or tweezers where it attaches to the skin and steadily pull the tick off.
- Discouraging blood donors from endemic areas during May through September, avoiding accepting donations from donors with fevers during the 2 months before intended donation, and not accepting donations from those with a history of tick bites can reduce transfusion-associated babesiosis.
Complications
- Shock
- Acute respiratory distress syndrome
- Death
- Relapse
Prognosis
- In healthy individuals with intact spleen, babesiosis rarely is fatal; however, in patients who are asplenic, babesiosis generally is quite severe and frequently fatal. In a 1998 review by White and colleagues, 9 of 139 (6.5%) patients who were hospitalized with babesiosis in New York State from 1982-1983 died. In Europe, most symptomatic patients are asplenic, and the mortality rate is over 50%.
Patient Education
- Advise patients to take precautions against tick exposure.
- Advise patients to refrain from donating blood until completely cured of babesiosis.
- For excellent patient education resources, visit eMedicine's Bites and Stings Center. Also, see eMedicine's patient education article Ticks.
Medical/Legal Pitfalls
- Failure to consider the diagnosis in the appropriate epidemiologic setting
- Administration of quinine therapy to a pregnant patient
Special Concerns
- The diagnosis may not be considered unless an appropriate epidemiologic history of exposure is solicited.
| Media file 1:
Ixodes scapularis, tick vector for babesiosis. Courtesy of the Centers for Disease Control and Prevention. |
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| Media file 2:
Babesiosis. Blood smear showing Babesia species in erythrocytes. Courtesy of the Centers for Disease Control and Prevention. |
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| Media file 3:
Babesiosis. Babesia species, tetrad formation. Courtesy of the Centers for Disease Control and Prevention. |
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Babesiosis excerpt Article Last Updated: Mar 24, 2006
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