Life-threatening Babesiosis Treated with Exchange Transfusion
Case Presentation: An 80-year-old female presented to the emergency department with fever, dyspnea, and constitutional symptoms. She was febrile at 39.8 °C, but was otherwise hemodynamically stable. Laboratory abnormalities consisted of anemia with hemoglobin of 6.9 g/dL (range:12.0-16.0 g/dL) and thrombocytopenia with platelet count of 28 10E3/uL (range:130-400 10E3/uL). Peripheral blood smear revealed intraerythrocytic inclusions compatible with babesiosis with 30% parasitemia, and she was started on clindamycin and quinine. Although her parasitemia declined to 22% the following day, she continued to deteriorate clinically with the development of renal and hepatic failure. Therefore, exchange transfusion was undertaken with reduction of parasitemia to 5% ten hours after transfusion and complete resolution of parasitemia four days later. Her multiorgan failure also resolved with correction of the parasitemia and she was discharged to home.
Discussion: Babesiosis is an emerging tick-borne infection endemic to the Northeastern US that presents with fever and acute hemolysis. While antibiotics are effective in most infections, patients with splenectomy or immunosuppression can have more fulminant disease that may lead to multiorgan failure and death in up to 6%, which may be attenuated by addition of exchange transfusions.
Conclusions: Patients with Babesia infection with high levels of parasitemia (>10%) and significant anemia (<10 g>/dl) are at high risk for end-organ failure and death. Prompt exchange transfusion may more quickly reduce their disease burden and inflammatory mediators, which may be life-saving. Exchange transfusion should be initiated in situations of worsening clinical status coupled with anemia, high parasite burden, or end-organ damage.