Profound autoimmune hemolysis and Evans syndrome in two asplenic patients with babesiosis

Case Report: Concurrent Babesiosis and GCA/PMR

BACKGROUND

Babesiosis is a tick-transmitted illness caused by intraerythrocytic protozoa of the genus babesia. The severity of babesiosis ranges from asymptomatic infection to fatal disease. Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are common interrelated inflammatory disorders that almost occur in people aged over 50 years. This report presents the first case of concurrent babesiosis and GCA/PMR in an old person.

CASE PRESENTATION

A 63-year-old man was admitted to the hospital with a 1-month history of fevers, accompanied by headache, muscle pain and fatigue. Laboratory tests revealed hemolytic anemia, with elevated C-reactive protein, serum IL-6 and erythrocyte sedimentation rate. FDG positron-emission tomography-computed tomography (PET-CT) scan exhibited increased uptake in aortic wall, multiple medium-to-large arteries and soft tissues. A blood smear revealed Babesia microti intracellular ring forms. Babesia microti infection was further confirmed by polymerase chain reaction (PCR) test. This patient was diagnosed as concurrent babesiosis and GCA/PMR. He was treated with glucocorticoid and antimicrobial therapy.

CONCLUSIONS

Concurrent babesiosis and GCA/PMR is rare. Further studies are needed to understand the mechanism of interaction between babesiosis and human immune system.

Transfusion transmitted babesiosis: A systematic review of reported cases

BACKGROUND

Transfusion transmitted babesiosis (TTB) has a high mortality rate but may go unrecognized, particularly in non-endemic areas. We therefore conducted a systematic review to better characterize clinical aspects of TTB.

METHODS

A literature search was conducted in PubMed and CINAHL databases, from which 25 eligible articles describing 60 TTB patients met criteria for data extraction.

RESULTS

Symptom evaluation was provided for 25 implicated donors: 18/25 (72%) were asymptomatic while 7/25 (28%) had mild flu-like symptoms but were asymptomatic at time of donation. It was common for a single donor or donation to infect multiple patients. Where reported, species included B. microti - 54/60 (90%), B. duncani - 3/60 (5%), and B. divergens-like/MO-1 - 1/60 (2%). Most TTB patients (44/60, 73%) resided in endemic states, while most TTB deaths 6/9 (67%) occurred in non-endemic states. Severity of hemolysis was proportional to degree of parasitemia. Mortality in our series was 9/60 (15%); most deaths occurred at extremes of the age spectrum: 6/9 non-survivors were aged >55 years, 2/9 were <1 year, only 1/9 was 2-54 years. Number of comorbidities was higher among non-survivors (median = 4) compared to survivors (median = 1).

CONCLUSIONS

All implicated donors (for which symptoms data were reported) resulting in TTB infections were asymptomatic at the time of donation, and it was common for a single donor or donation to infect multiple patients. Mortality of TTB appeared highest among those with more comorbidities and in non-endemic states. Heightened awareness of this diagnosis is key in its recognition.

Serendipitous Finding of Asymptomatic Babesiosis in a Patient With Symptomatic Thrombocytopenia

We report a case of isolated immune thrombocytopenic purpura (ITP) as a result of babesiosis infection. The patient initially presented with a history, physical exam and laboratory findings consistent with idiopathic thrombocytopenic purpura. She was treated with standard of care therapy without clinical response. Daily evaluation of the peripheral smear ultimately revealed a red blood cell inclusion, identified and confirmed as a low-titer babesiosis infection indicative of past exposure. As described below, isolated thrombocytopenia related to babesiosis infection has not been reported prior to the patient’s presentation. There are a few cases reported to show a relationship between babesiosis and autoimmune hemolytic anemia without an understood pathophysiologic mechanism. We review the literature, propose a possible pathophysiologic mechanism of disease and consider the implications of swift identification to prevent clinical deterioration.

Evans syndrome: clinical perspectives, biological insights and treatment modalities

Evans syndrome (ES) is a rare and chronic autoimmune disease characterized by autoimmune hemolytic anemia and immune thrombocytopenic purpura with a positive direct anti-human globulin test. It is classified as primary and secondary, with the frequency in patients with autoimmune hemolytic anemia being 37%–73%. It predominates in children, mainly due to primary immunodeficiencies or autoimmune lymphoproliferative syndrome. ES during pregnancy is associated with high fetal morbidity, including severe hemolysis and intracranial bleeding with neurological sequelae and death. The clinical presentation can include fatigue, pallor, jaundice and mucosal bleeding, with remissions and exacerbations during the person’s lifetime, and acute manifestations as catastrophic bleeding and massive hemolysis. Recent molecular theories explaining the physiopathology of ES include deficiencies of CTLA-4, LRBA, TPP2 and a decreased CD4/CD8 ratio. As in other autoimmune cytopenias, there is no established evidence-based treatment and steroids are the first-line therapy, with intravenous immunoglobulin administered as a life-saving resource in cases of severe immune thrombocytopenic purpura manifestations. Second-line treatment for refractory ES includes rituximab, mofetil mycophenolate, cyclosporine, vincristine, azathioprine, sirolimus and thrombopoietin receptor agonists. In cases unresponsive to immunosuppressive agents, hematopoietic stem cell transplantation has been successful, although it is necessary to consider its potential serious adverse effects. In conclusion, ES is a disease with a heterogeneous course that remains challenging to patients and physicians, with prospective clinical trials needed to explore potential targeted therapy to achieve an improved long-term response or even a cure.

Babesia microti: from Mice to Ticks to an Increasing Number of Highly Susceptible Humans

Babesia microti, a zoonotic intraerythrocytic parasite, is the primary etiological agent of human babesiosis in the United States. Human infections range from subclinical illness to severe disease resulting in death, with symptoms being related to host immune status. Despite advances in our understanding and management of B. microti, the incidence of infection in the United States has increased. Therefore, research focused on eradicating disease and optimizing clinical management is essential. Here we review this remarkable organism, with emphasis on the clinical, diagnostic, and therapeutic aspects of human disease.

Autoimmune hemolytic anemia associated with babesiosis

BACKGROUND

Babesiosis is endemic in selected areas in North America. Babesia infection is commonly associated with anemia, thrombocytopenia, hyponatremia and elevated liver enzymes. Autoimmune hemolytic anemia (AIHA) is known to be caused by parasitic and viral infections but has not been well characterized.

CASE PRESENTATION

We describe two cases diagnosed with babesiosis triggering severe AIHA. One case had history of splenectomy, and the other was an elderly patient. Older, immunocompromised and asplenic patients may be particularly at risk for post-babesiosis AIHA (PB-AIHA).

CONCLUSIONS

The pathogenesis for conventional AIHA and PB-AIHA appears to be different, since splenectomy is a treatment for conventional AIHA, whereas PB-AIHA is seen more often in asplenic patients. Further investigation into this intriguing mechanism of host immune response to babesiosis may help to elucidate the overall mechanism of infection- triggered AIHA.

Post-Babesiosis Warm Autoimmune Hemolytic Anemia

Background Babesiosis, a tickborne zoonotic disease caused by intraerythrocytic protozoa of the genus babesia, is characterized by nonimmune hemolytic anemia that resolves with antimicrobial treatment and clearance of parasitemia. The development of warm-antibody autoimmune hemolytic anemia (also known as warm autoimmune hemolytic anemia [WAHA]) in patients with babesiosis has not previously been well described. Methods After the observation of sporadic cases of WAHA that occurred after treatment of patients for babesiosis, we conducted a retrospective cohort study of all the patients with babesiosis who were cared for at our center from January 2009 through June 2016. Data on covariates of interest were extracted from the medical records, including any hematologic complications that occurred within 3 months after the diagnosis and treatment of babesiosis. Results A total of 86 patients received a diagnosis of babesiosis during the 7.5-year study period; 18 of these patients were asplenic. WAHA developed in 6 patients 2 to 4 weeks after the diagnosis of babesiosis, by which time all the patients had had clinical and laboratory responses to antimicrobial treatment of babesiosis, including clearance of Babesia microti parasitemia. All 6 patients were asplenic (P<0.001) and had positive direct antiglobulin tests for IgG and complement component 3; warm autoantibodies were identified in all these patients. No alternative explanation for clinical hemolysis was found. WAHA required immunosuppressive treatment in 4 of the 6 patients. Conclusions We documented post-babesiosis WAHA in patients who did not have a history of autoimmunity; asplenic patients appeared to be particularly at risk.

Hematologic manifestations of babesiosis

BACKGROUND

Babesiosis, a zoonotic parasitic infection transmitted by the Ixodes tick, has become an emerging health problem in humans that is attracting attention worldwide. Most cases of human babesiosis are reported in the United States and Europe. The disease is caused by the protozoa of the genus Babesia, which invade human erythrocytes and lyse them causing a febrile hemolytic anemia. The infection is usually asymptomatic or self-limited in the immunocompetent host, or follows a persistent, relapsing, and/or life threatening course with multi-organ failure, mainly in the splenectomized or immunosuppressed patients. Hematologic manifestations of the disease are common. They can range from mild anemia, to severe pancytopenia, splenic rupture, disseminated intravascular coagulopathy (DIC), or even hemophagocytic lymphohistiocytosis (HLH).

CASE PRESENTATION

A 70 year old immunocompetent female patient living in New York City presented with a persistent fever, night sweats, and fatigue of 5 days duration. Full evaluation showed a febrile hemolytic anemia along with neutropenia and thrombocytopenia. Blood smear revealed intraerythrocytic Babesia, which was confirmed by PCR. Bone marrow biopsy was remarkable for dyserythropoiesis, suggesting possible HLH, supported by other blood workup meeting HLH-2004 trial criteria.

CONCLUSION

Human babesiosis is an increasing healthcare problem in the United States that is being diagnosed more often nowadays. We presented a case of HLH triggered by Babesia microti that was treated successfully. Also, we presented the hematologic manifestations of this disease along with their pathophysiologies.

Diagnosis, Treatment, and Prevention of Lyme Disease, Human Granulocytic Anaplasmosis, and Babesiosis: A Review

IMPORTANCE

Lyme disease, human granulocytic anaplasmosis (HGA), and babesiosis are emerging tick-borne infections.

OBJECTIVE

To provide an update on diagnosis, treatment, and prevention of tick-borne infections.

EVIDENCE REVIEW

Search of PubMed and Scopus for articles on diagnosis, treatment, and prevention of tick-borne infections published in English from January 2005 through December 2015.

FINDINGS

The search yielded 3550 articles for diagnosis and treatment and 752 articles for prevention. Of these articles, 361 were reviewed in depth. Evidence supports the use of US Food and Drug Administration-approved serologic tests, such as an enzyme immunoassay (EIA), followed by Western blot testing, to diagnose extracutaneous manifestations of Lyme disease. Microscopy and polymerase chain reaction assay of blood specimens are used to diagnose active HGA and babesiosis. The efficacy of oral doxycycline, amoxicillin, and cefuroxime axetil for treating Lyme disease has been established in multiple trials. Ceftriaxone is recommended when parenteral antibiotic therapy is recommended. Multiple trials have shown efficacy for a 10-day course of oral doxycycline for treatment of erythema migrans and for a 14-day course for treatment of early neurologic Lyme disease in ambulatory patients. Evidence indicates that a 10-day course of oral doxycycline is effective for HGA and that a 7- to 10-day course of azithromycin plus atovaquone is effective for mild babesiosis. Based on multiple case reports, a 7- to 10-day course of clindamycin plus quinine is often used to treat severe babesiosis. A recent study supports a minimum of 6 weeks of antibiotics for highly immunocompromised patients with babesiosis, with no parasites detected on blood smear for at least the final 2 weeks of treatment.

CONCLUSIONS AND RELEVANCE

Evidence is evolving regarding the diagnosis, treatment, and prevention of Lyme disease, HGA, and babesiosis. Recent evidence supports treating patients with erythema migrans for no longer than 10 days when doxycycline is used and prescription of a 14-day course of oral doxycycline for early neurologic Lyme disease in ambulatory patients. The duration of antimicrobial therapy for babesiosis in severely immunocompromised patients should be extended to 6 weeks or longer.

Evans Syndrome Secondary to Common Variable Immune Deficiency

Evans syndrome is an underdiagnosed condition consisting of simultaneous or sequential combination of autoimmune hemolytic anemia and immune-mediated thrombocytopenia. We report a case of severe Evans syndrome presenting as altered mental status, a rare presenting sign of the disease. This case highlights the difficulty in diagnosing Evans syndrome and provides a review of the literature and management strategies for treating the disorder.