Babesiosis and Red Blood Cell Exchange Transfusion: Consider It Early

ABSTRACT

INTRODUCTION: Babesiosis, or Babesia microti in the blood, is a rare tickborne parasitic illness. It is endemic to the Northeast and upper Midwest regions of the United States, in warmer summer months, and is a reportable disease. Babesia is transmitted by the bite of an infected Ixodes scapularis nymph tick (black-legged or deer tick). Many people remain asymptomatic, while others experience life-threatening illness. even with low parasite index, such as the case described. Cases are rising in Pennsylvania overall since 2010, but since the start of COVID-19 pandemic, our small community hospital in rural Northeastern Pennsylvania (NEPA) has seen 12 cases. DESCRIPTION A 63-year-old male presented with severe illness due to persistent Babesiosis parasitemia in a NEPA community hospital, with history of recent COVID-19 infection. He presented with fever, rigors, myalgias, diarrhea, and weakness. He reported history of tick bite two weeks prior to presentation. Initial exam was unremarkable. He was admitted to the hospital with hyponatremia, acute liver and kidney injury, anemia, thrombocytopenia, and elevated bilirubin. Babesia microti red blood cell (RBC) parasite index initially was 2%. He then became lethargic and hypotensive and parasite index escalated to 5% with worsening febrile illness, confusion, rapid atrial fibrillation, worsening acute kidney injury, and evidence of hemolysis and consumptive coagulopathy, despite standard-of-care antimicrobial regimen. He was fluid resuscitated and transferred to a higher level of care for urgent RBC exchange, which he obtained, and recovered after prolonged intensive care unit stay. DISCUSSION: Babesiosis can present indolently or acutely with flu-like and hemolytic illness. Those at higher risk of illness are elderly, and those with asplenia, baseline liver or kidney dysfunction, or immunocompromised status. Babesia cases are rising all over the country. Our single small hospital has seen 12 cases in the past 3 years. It is a possibility that the recent COVID-19 infection created a relative immunocompromised and pro-inflammatory state leading to susceptibility to the parasite. Illness can be life-threatening. Even with low parasitemia index, early RBC exchange should be considered if end organ dysfunction is present and clinical course is not improving.