LymeNet Home LymeNet Home Page LymeNet Flash Discussion LymeNet Support Group Database LymeNet Literature Library LymeNet Legal Resources LymeNet Medical & Scientific Abstract Database LymeNet Newsletter Home Page LymeNet Recommended Books LymeNet Tick Pictures Search The LymeNet Site LymeNet Links LymeNet Frequently Asked Questions About The Lyme Disease Network LymeNet Menu

LymeNet on Facebook

LymeNet on Twitter




The Lyme Disease Network receives a commission from Amazon.com for each purchase originating from this site.

When purchasing from Amazon.com, please
click here first.

Thank you.

LymeNet Flash Discussion
Dedicated to the Bachmann Family

LymeNet needs your help:
LymeNet 2020 fund drive


The Lyme Disease Network is a non-profit organization funded by individual donations.

LymeNet Flash Post New Topic  New Poll  Post A Reply
my profile | directory login | register | search | faq | forum home

  next oldest topic   next newest topic
» LymeNet Flash » Questions and Discussion » Medical Questions » Persistent and relapsing babesiosis in immunocompromised patients 2008

 - UBBFriend: Email this page to someone!    
Author Topic: Persistent and relapsing babesiosis in immunocompromised patients 2008
TerryK
Frequent Contributor (5K+ posts)
Member # 8552

Icon 1 posted      Profile for TerryK     Send New Private Message       Edit/Delete Post   Reply With Quote 
1: Clin Infect Dis. 2008 Feb 1;46(3):370-6.Links
Persistent and relapsing babesiosis in immunocompromised patients.

Krause PJ, Gewurz BE, Hill D, Marty FM, Vannier E, Foppa IM, Furman RR, Neuhaus E, Skowron G, Gupta S, McCalla C, Pesanti EL, Young M, Heiman D, Hsue G, Gelfand JA, Wormser GP, Dickason J, Bia FJ, Hartman B, Telford SR 3rd, Christianson D, Dardick K, Coleman M, Girotto JE, Spielman A.

Division of Infectious Diseases, Connecticut Children's Medical Center, and Department of Pediatrics, University of Connecticut School of Medicine, Farmington, Connecticut 06106, USA. [email protected]

BACKGROUND: Human babesiosis is a tickborne malaria-like illness that generally resolves without complication after administration of atovaquone and azithromycin or clindamycin and quinine.

Although patients experiencing babesiosis that is unresponsive to standard antimicrobial therapy have been described, the pathogenesis, clinical course, and optimal treatment regimen of such cases remain uncertain.

METHODS: We compared the immunologic status, clinical course, and treatment of 14 case patients who experienced morbidity or death after persistence of Babesia microti infection, despite repeated courses of antibabesial treatment, with those of 46 control subjects whose infection resolved after a single course of standard therapy.

This retrospective case-control study was performed in southern New England, New York, and Wisconsin. RESULTS: All case patients were immunosuppressed at the time of acute babesiosis, compared with <10% of the control subjects.

Most case patients experienced B cell lymphoma and were asplenic or had received rituximab before babesial illness. The case patients were more likely than control subjects to experience complications, and 3 died.

Resolution of persistent infection occurred in 11 patients after 2-10 courses of therapy, including administration of a final antimicrobial regimen for at least 2 weeks after babesia were no longer seen on blood smear.

CONCLUSIONS: Immunocompromised people who are infected by B. microti are at risk of persistent relapsing illness. Such patients generally require antibabesial treatment for >or=6 weeks to achieve cure, including 2 weeks after parasites are no longer detected on blood smear.

PMID: 18181735 [PubMed - in process]

Posts: 6285 | From Oregon | Registered: Jan 2006  |  IP: Logged | Report this post to a Moderator
CaliforniaLyme
Frequent Contributor (5K+ posts)
Member # 7136

Icon 1 posted      Profile for CaliforniaLyme     Send New Private Message       Edit/Delete Post   Reply With Quote 
This is a total change from previously where Krause said that you would treat for an X amount of time and then persistent parasitaemia on blood smear was OKAY!!!

Glad he is waking up and smelling the coffee!!!

--------------------
There is no wealth but life.
-John Ruskin

All truth goes through 3 stages: first it is ridiculed: then it is violently opposed: finally it is accepted as self evident. - Schopenhauer

Posts: 5639 | From Aptos CA USA | Registered: Apr 2005  |  IP: Logged | Report this post to a Moderator
JRWagner
Frequent Contributor (1K+ posts)
Member # 3229

Icon 1 posted      Profile for JRWagner     Send New Private Message       Edit/Delete Post   Reply With Quote 
Thanks Terry.

Too bad these Drs. did not mention the fact that our tests for Babesia only cover two ot three strains...out of many.

Peace, Love and Wellness,
JRW

Posts: 1414 | From Ny, Ny | Registered: Oct 2002  |  IP: Logged | Report this post to a Moderator
Tincup
Honored Contributor (10K+ posts)
Member # 5829

Icon 7 posted      Profile for Tincup         Edit/Delete Post   Reply With Quote 
Oh TerryK... you are my hero!

EXACTLY what I needed today to make a point with Feder in CT!

He said in his NEJM letter, "... nor is there any published clinical evidence that an active tick-borne coinfection is the explanation for symptoms in the vast majority of patients with post-Lyme disease syndrome."

And his own buddies proved him wrong... in CT too! HA!

I told him he ought to jump ship in my last letter to him. Maybe now he will see he is going to be left hanging or dragged into the AG investigation if he keeps on the same course.

This should also help patients get the treatment they need paid for by insurance! Mepron and Zith ain't cheap!

AND.. you can tell I am excited... it should help justify the treatment we are getting and give the LLMD's proof people need to be treated.

What a find!!! Perfect timing!!!

And WORMSER, et al had to admit we can still be sick after treatment... and we may have ongoing symptoms! Bet THAT hurt!!!

NO POST LYME SYNDROME!!!!

Thanks TerryK. I've already shared it with credit to you. It will do good!

You've make me a happy camper today. Thanks!

[Big Grin]

--------------------
www.TreatTheBite.com
www.DrJonesKids.org
www.MarylandLyme.org
www.LymeDoc.org

Posts: 20353 | From The Moon | Registered: Jun 2004  |  IP: Logged | Report this post to a Moderator
Aligondo Bruce
LymeNet Contributor
Member # 6219

Icon 1 posted      Profile for Aligondo Bruce     Send New Private Message       Edit/Delete Post   Reply With Quote 
this is fantastic. many of these guys are idsa types. what they are suggesting without saying so is that some cases of chronic lyme are due to babesia and require massive and repeated doses of abx regimens.
Posts: 523 | From Stillwater,OK,USA | Registered: Sep 2004  |  IP: Logged | Report this post to a Moderator
oxygenbabe
Frequent Contributor (1K+ posts)
Member # 5831

Icon 1 posted      Profile for oxygenbabe     Send New Private Message       Edit/Delete Post   Reply With Quote 
Krause is a decent guy.
Remember, he pioneered the mepron/zith for babesia.
He's done careful work.
This is good new work too.

Posts: 2276 | From united states | Registered: Jun 2004  |  IP: Logged | Report this post to a Moderator
lou
Frequent Contributor (5K+ posts)
Member # 81

Icon 1 posted      Profile for lou     Send New Private Message       Edit/Delete Post   Reply With Quote 
Umm, wasn't Krause involved in the lyme vaccine testing on kids?
Posts: 8430 | From Not available | Registered: Oct 2000  |  IP: Logged | Report this post to a Moderator
TerryK
Frequent Contributor (5K+ posts)
Member # 8552

Icon 1 posted      Profile for TerryK     Send New Private Message       Edit/Delete Post   Reply With Quote 
Glad you are finding it useful but I wish we could see the full article. Seems like there are usually caveats. Maybe I'm just too suspicious. [Big Grin]

Anybody have access to it that could share it with us?

Terry

Posts: 6285 | From Oregon | Registered: Jan 2006  |  IP: Logged | Report this post to a Moderator
treepatrol
Honored Contributor (10K+ posts)
Member # 4117

Icon 1 posted      Profile for treepatrol     Send New Private Message       Edit/Delete Post   Reply With Quote 
quote:
Originally posted by JRWagner:
Thanks Terry.

Too bad these Drs. did not mention the fact that our tests for Babesia only cover two ot three strains...out of many.

Peace, Love and Wellness,
JRW

yep!!! [bonk]

--------------------
Do unto others as you would have them do unto you.
Remember Iam not a Doctor Just someone struggling like you with Tick Borne Diseases.

Newbie Links

Posts: 10564 | From PA Where the Creeks are Red | Registered: Jun 2003  |  IP: Logged | Report this post to a Moderator
cjnelson
LymeNet Contributor
Member # 12928

Icon 1 posted      Profile for cjnelson     Send New Private Message       Edit/Delete Post   Reply With Quote 
YEAH!!!!!!!!!

--------------------
Seeking renewed health & vitality.
---------------------------------
Do not take anything I say as medical advice - I am NOT a dr!

Posts: 830 | From TN | Registered: Aug 2007  |  IP: Logged | Report this post to a Moderator
Allie
LymeNet Contributor
Member # 10778

Icon 1 posted      Profile for Allie     Send New Private Message       Edit/Delete Post   Reply With Quote 
Here it is...

MAJOR ARTICLE
Persistent and Relapsing Babesiosis in Immunocompromised Patients

Peter J. Krause,1,3

Benjamin E. Gewurz,6,7

David Hill,19,20

Francisco M. Marty,6

Edouard Vannier,8

Ivo M. Foppa,12

Richard R. Furman,13

Ellen Neuhaus,4

Gail Skowron,15

Shaili Gupta,5

Carlo McCalla,14

Edward L. Pesanti,2

Mary Young,16

Donald Heiman,17

Gunther Hsue,18

Jeffrey A. Gelfand,7

Gary P. Wormser,14

John Dickason,10

Frank J. Bia,5

Barry Hartman,13

Sam R. Telford III,11

Diane Christianson,1,3

Kenneth Dardick,2

Morton Coleman,13

Jennifer E. Girotto,1,3 and

Andrew Spielman,9,a

1Division of Infectious Diseases, Connecticut Children's Medical Center, and Departments of 2Medicine and 3Pediatrics, University of Connecticut School of Medicine, Farmington, 4Division of Infectious Diseases, Rockville General Hospital, Rockville, and 5Division of Infectious Diseases, Yale New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut; 6Divisions of Infectious Diseases, Brigham and Women's Hospital, Dana‐Farber Cancer Institute, and 7Division of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, 8Division of Geographic Medicine and Infectious Diseases, Tufts-New England Medical Center and Tufts University School of Medicine, and 9Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, 10Burlington Medical Associates, Burlington, and 11Tufts University School of Veterinary Medicine, Grafton, Massachusetts; 12Arnold School of Public Health, University of South Carolina, Columbia; 13Division of Hematology/Oncology and Division of Infectious Diseases, Weill Cornell Medical College, New York, and 14Division of Infectious Diseases, New York Medical College, Valhalla, New York; 15Division of Infectious Diseases, Roger Williams Medical Center, Boston University School of Medicine, Providence, Rhode Island; 16Division of Infectious Diseases, Georgetown University Medical Center, Georgetown University School of Medicine, Washington, D.C.; 17Specialists in Infectious Diseases, Boca Raton, Florida; 18Department of Medicine, William Beaumont Army Medical Center, El Paso, Texas; and 19National Travel Health Network and Centre and 20London School of Hygiene and Tropical Medicine, London, United Kingdom

Received 29 August 2007; accepted 24 September 2007; electronically published 20 December 2007.

*

The contents of this article are solely the responsibility of the authors and do not necessarily represent the official view of the National Center for Research Resources or the National Institutes of Health.
*

aDeceased.

Reprints or correspondence: Dr. Peter J. Krause, Connecticut Children's Medical Center, 282 Washington St., Hartford, CT 06106 [email protected]

Background. Human babesiosis is a tickborne malaria‐like illness that generally resolves without complication after administration of atovaquone and azithromycin or clindamycin and quinine. Although patients experiencing babesiosis that is unresponsive to standard antimicrobial therapy have been described, the pathogenesis, clinical course, and optimal treatment regimen of such cases remain uncertain.

Methods. We compared the immunologic status, clinical course, and treatment of 14 case patients who experienced morbidity or death after persistence of Babesia microti infection, despite repeated courses of antibabesial treatment, with those of 46 control subjects whose infection resolved after a single course of standard therapy. This retrospective case‐control study was performed in southern New England, New York, and Wisconsin.

Results. All case patients were immunosuppressed at the time of acute babesiosis, compared with <10% of the control subjects. Most case patients experienced B cell lymphoma and were asplenic or had received rituximab before babesial illness. The case patients were more likely than control subjects to experience complications, and 3 died. Resolution of persistent infection occurred in 11 patients after 2-10 courses of therapy, including administration of a final antimicrobial regimen for at least 2 weeks after babesia were no longer seen on blood smear.

Conclusions. Immunocompromised people who are infected by B. microti are at risk of persistent relapsing illness. Such patients generally require antibabesial treatment for 6 weeks to achieve cure, including 2 weeks after parasites are no longer detected on blood smear.

Human babesiosis is a zoonotic malaria‐like illness that usually resolves 1-2 weeks after administration of a single course of atovaquone and azithromycin or clindamycin and quinine [1, 2]. Babesiosis is caused by intraerythrocytic protozoa that reproduce by budding and generate as many as 4 merozoites that allow progression of the infection by invading other erythrocytes. Extracellular forms are observed in heavily parasitized cases [3, 4]. Clearance of parasites is dependent on both the innate and adaptive branches of the immune system. Although asymptomatic parasitemia may persist for 1 year, relapse of symptoms and anemia rarely occur in people who are otherwise healthy, even in the absence of specific antibabesial therapy [5]. Data from case reports have suggested that symptomatic babesiosis may persist or relapse in certain immunodeficient patients; however, no systematic analysis of the pathogenesis, clinical course, and treatment of this syndrome has yet been performed [6-11].

There may be a direct association between certain primary or acquired immunodeficiency syndromes and the failure to contain acute babesial illness. Such immunosuppressed patients may be at risk of systemic complications of babesial illness and may require prolonged courses of antimicrobial therapy to contain and ultimately eradicate infection. Accordingly, we compared the clinical characteristics and outcome of babesiosis among patients who experienced persistent or relapsed illness despite antibabesial therapy with those of patients whose acute illness was cured after a single course of therapy. In particular, we employed a case‐control strategy to determine whether the presence of identifiable immunosuppressive conditions correlated with disease outcome and to determine the optimal therapy to achieve cure.


Methods


Case patients and control subjects. The group of case patients consisted of people who did not clear acute Babesia microti infection, as evidenced by the persistent presence of parasites on blood smear, symptoms, and anemia for >1 month after administration of a single course of standard antibabesial therapy of atovaquone and azithromycin or clindamycin and quinine for 7-10 days. The group of control subjects consisted of patients who also experienced B. microti infection but whose blood smear cleared and symptoms resolved within 1 month after a single course of such standard therapy.

Study protocol. We reviewed clinical and laboratory information on 14 case patients and 189 control subjects who experienced babesiosis during the period 1991-2005. Case patients were directly referred to 1 of the authors P.J.K., whereas the control subjects were enrolled in a longitudinal study of tickborne infection [12]. As part of that study, participating physicians attempted to enroll any patient experiencing an illness suggestive of babesiosis that occurred during the months of May through September from 1991 to 2005, among residents living in areas in southern New England where B. microti is endemic. Study physicians followed a study protocol that included obtaining a written informed consent, completing a history, and performing a physical examination. They recorded comorbid conditions, clinical course, and antibabesial therapy for these patients. They obtained another medical history at least once within the month following the diagnosis of babesiosis and then repeatedly until the patient became asymptomatic. In some cases, a sample of blood was obtained during the acute and convalescent stages of illness for B. microti-specific serological and PCR assays.

Diagnosis of newly acquired B. microti infection required the presence of symptoms consistent with babesiosis and the recognition of piroplasms by means of a Giemsa‐stained thin blood smear. Babesial symptoms included fever, chills, sweats, fatigue, headache, and myalgia. In all but 2 case patients, amplification of B. microti DNA in blood by PCR and/or a 4‐fold increase in B. microti antibody in paired acute‐ and convalescent‐phase serum samples were detected. None of 14 case patients experienced concurrent Lyme disease or human granulocytic anaplasmosis. Of the 189 control subjects, only 46 subjects who experienced babesiosis alone and not simultaneous Lyme disease or human granulocytic anaplasmosis were included in the analysis. Treatment regimens and duration were prescribed at the discretion of the primary care physicians or infectious disease consultants. We defined a ``hematologic complication'' as anemia severe enough to require a blood transfusion or exchange transfusion, a ``pulmonary complication'' as the presence of pulmonary edema or acute respiratory distress syndrome, and a ``renal complication'' as impairment of renal function severe enough to require dialysis. We defined ``cure'' as the absence of parasites on smear and symptoms for >3 months after cessation of antibabesial therapy. The procedures were approved by the Human Subjects Committees of the Connecticut Children's Medical Center Hartford, CT and the Harvard School of Public Health Boston, MA.

Statistical methods. We compared proportions using Fisher's exact test and ORs with exact 95% CIs. Real‐valued variables were compared between case patients and control subjects with use of Wilcoxon 2‐sample tests with normal approximation. These analyses were performed using SAS, version 9 SAS Institute.


Results


Immune status of study population. Study subjects included 14 case patients whose standard antibabesial therapy failed and 46 control patients who cleared babesial infection after a single course of atovaquone and azithromycin or clindamycin and quinine. All but 3 of the study subjects lived in southern New England; 2 subjects acquired their infection in southern New York, and 1 acquired it in Wisconsin. The age and sex distributions were similar among case patients and control subjects; median ages were 60 and 66 years, and male subjects comprised 64% and 61% of the subject groups, respectively. All of the case patients had evidence of immune suppression at the time of babesial illness, compared with only 7% of control subjects . Most case patients experienced B cell lymphoma and were asplenic and/or received immunosuppressive medication within 18 months of the onset of babesial illness table 1. The 1 HIV‐infected subject met the case definition for AIDS, with a CD4 cell count of 28 cells/μL at the time of acute babesiosis. None of the control subjects had both an immunosuppressive illness and asplenia, and none received immunosuppressive medication. Patients who do not respond to a course of standard antibabesial therapy are likely to have medical conditions that severely impair immune function.

Table 1. Clinical characteristics of case patients and control subjects with preexisting immunosuppressive conditions who experienced babesiosis.

Severity and outcome of illness of study population. We examined whether case patients who experienced persistent or relapsed babesiosis despite standard antibabesial therapy experienced more severe acute illness than did control subjects who cleared infection after standard therapy. Peak parasite load, the number of babesiosis‐related hospital admissions, the frequency of complications, and fatal outcome were greater among case patients than among control individuals table 2. The parasite load decreased in all but 1 case patient after an initial course of standard antibabesial therapy, but each case patient subsequently experienced persistent or increased parasitemia accompanied by continued or worsening symptoms and anemia. One subject had no improvement in parasitemia and had a deteriorating clinical course during initial therapy that required an additional 2 months of therapy for cure. People who are immunosuppressed and who do not respond to initial antibabesial therapy are more likely to experience severe illness and to have a worse outcome than are subjects who respond to standard therapy.


Table 2. Severity of infection among case patients and control subjects.

Antibabesial therapy for case patients. We determined the type and duration of antibabesial therapy that was most effective in clearing parasitemia and symptoms among our case patients. Although multiple courses of antibabesial drug therapy were used, no single drug combination was uniformly effective in achieving cure table 3. In contrast, the duration of therapy was associated with successful outcome. Drug combinations that resulted in cure were administered for a minimum of 6 weeks in all but 1 case ; median duration, 14 weeks; range, 1.5-100 weeks. Similar antimicrobial combinations that failed to permanently clear parasitemia were administered for a shorter duration ; median duration, 1.5 weeks; range, 0.25-22 weeks; .


Table 3. Antibabesial therapy and outcome among patients who did not respond to standard therapy.

Antibabesial therapy was discontinued on 16 occasions when no parasites were observed on blood smear. Relapse occurred in 5 cases, at 3, 5, 6, and 7 weeks and at 3 months after cessation of therapy. In these instances, antibiotic treatment was discontinued <2 weeks after the apparent clearance of parasites 1, 1, 6, 8, and 13 days. In contrast, apparent cure of infection occurred in 11 cases when antibiotic treatment was discontinued 2 weeks after parasites were no longer detected on blood smear median duration, 6 weeks; range, 2-100 weeks; OR not defined; 95% CI, 8.03-∞; . These subjects have remained asymptomatic without parasitemia for a median of 13 months range, 4-79 months after antibiotic treatment was discontinued. Antibabesial therapy was discontinued on 14 other occasions because the parasite frequency decreased to <1%. Relapse of infection occurred in all these cases. Because only 3 case patients received exchange transfusion early in the course of infection, we could not evaluate the efficacy of this mode of therapy on outcome in our case patients. Cure of immunocompromised patients whose initial antibabesial therapy fails generally is associated with the use of antibabesial treatment for 6 weeks, including 2 weeks after parasites are no longer detected on blood smear.

Discussion


Asymptomatic babesial infection may persist for months or years in previously healthy patients, especially if the infection is not diagnosed and promptly treated [5]. These patients usually clear infection with or without antibabesial therapy. They may transmit babesia when they donate blood, and such transmission is an uncommon but well‐recognized complication of the infection [13-16]. We now report a series of immunocompromised patients who experienced persistent and relapsing symptomatic babesiosis despite the use of standard antibabesial therapy. Previous individual case reports of a neonate, 2 patients experiencing malignancy, and several patients with AIDS have shown that the duration of ``cure'' after completion of antibabesial therapy in some immunocompromised hosts is uncertain [4, 6-11, 16]. Two of our case patients experienced persistent infection despite a year of intermittent antibabesial therapy, and 1 patient experienced recrudescence 3 months after parasites were no longer detected on blood smear. Plasmodium ovale or Plasmodium vivax malaria may recrudesce years after completion of therapy that does not include primaquine, because of hypnozoites in the liver. Although plasmodia are related intraerythrocytic Apicomplexa protozoa, no such extraerythrocytic stage has been described for babesia. Certain immunocompromised hosts who travel or reside in areas where babesiosis is endemic may develop persistent symptomatic babesiosis that is unresponsive to standard antimicrobial therapy.

We attempted to characterize immunologic deficits that result in persistent symptomatic babesiosis. Most of our study patients experienced B cell lymphoid malignancies, and most were treated with rituximab‐containing regimens, including all 3 subjects who died. Rituximab depletes CD20+ B cells, including the majority of the B cell lineage, before plasma cell differentiation [17]. The rituximab‐depleted cell population includes naive B cells, the same cells that would be responsible for antibody production in response to a new babesial infection.

Because plasma cells generally are differentiated cells from B cells that have been stimulated by antigen in the past, it is reasonable to expect that most people do not have antibabesial plasma cells before initial infection. Thus, rituximab‐treated patients would be left with little or no antibabesial B cell activity. Rituximab has been associated with fatal reactivation of viral and fungal infections and a recent case of chronic relapsing babesiosis in a patient with lymphocyte predominant Hodgkin disease [8, 18-20]. After completion of treatment, rituximab remains detectable in serum for 3-6 months. B cell counts begin to increase at 6 months and generally return to normal by 12-18 months. All but 1 of our rituximab‐treated case patients received the drug within 18 months after the onset of babesial illness. Approximately three‐fourths of our case patients also were asplenic; the spleen is an important site for B cell activation. Previous studies have not identified persistent relapsing babesiosis in asplenic patients, although asplenia is a well‐recognized cause of severe and sometimes fatal babesial infection [21, 22]. A meaningful comparison of antibabesial antibody concentrations and avidity between case and control subjects was not possible, but babesial antibody could not be detected in 1 of our case patients who died. All these data support the importance of B cell function in eradicating babesial parasites. Broader immunosuppression appears necessary for persistent babesial illness, however. Animal models have suggested the importance of both cellular and humoral immunity in clearing babesial infection [23-26]. Furthermore, our data and those of others [6-11] suggest that an array of immunosuppressive diseases are associated with persistent relapsing babesiosis and that additional immunosuppression--from asplenia or chemotherapeutic agents or both--usually are associated with this condition. Physicians caring for significantly immune‐impaired patients who develop babesiosis should be aware of their increased risk of developing persistent relapsing disease and should discontinue immunosuppressive therapy until the infection has resolved.

Selection of case patients and control subjects may introduce selection bias and thus compromise the validity of a case‐control study [27]. Although control subjects were recruited from our longitudinal tickborne diseases study, most case patients were referred to 1 of us P.J.K. for assistance with case management. The strong association that we observed between a subset of case patients with hematologic malignancies and the risk of developing persistent babesiosis might partially have been explained by selection bias, if referral of cases had been influenced by the presence or absence of such hematologic conditions. Persistent relapsing babesiosis appears to be unusual in the general population, however, and physicians in the longitudinal study referred all cases meeting the case definition, regardless of underlying medical condition. Finally, the episodes of recrudescent babesiosis in our case patients occurred either before or after the babesial transmission season and thus were unlikely to represent reinfection.

We attempted to identify a management strategy that would permanently eradicate persistent B. microti infection in people who do not to respond to a single course of standard antibabesial therapy. Because of the difficulty encountered in clearing infection, our case patients received a series of antimicrobial drugs. Although no systematic therapeutic approach was used, the type of antibiotic regimen did not appear to influence outcome. In contrast, the duration of antibiotic therapy appeared to be associated with cure. Eradication of disease occurred only when antibabesial therapy was administered for 2 weeks after parasites were no longer detected on thin blood smear and, generally, for 6 weeks. Relapse of infection always occurred when antibiotic treatment was discontinued before parasites were no longer visible on blood smear, even if <1% of erythrocytes were infected. These data suggest that antimicrobial resistance was not a factor in the failure of antibabesial therapy. There are no reports of babesial resistance to atovaquone and azithromycin or clindamycin and quinine, although drug resistance is well described for Plasmodium species [28]. Antibiotics may serve to restrain parasite growth until a sufficient antibabesial immune response develops, especially with immune recovery following cessation of immunosuppressive medication.

The incidence and geographic distribution of human babesiosis has markedly expanded since the first report of Babesia divergens infection in a Yugoslavian farmer 50 years ago [12, 29, 30]. Five other Babesia species have been found subsequently to infect humans, including B. microti, Babesia duncani formerly known as ``WA‐1'', EU‐1, MO‐1, and TW‐1 [8, 31-35. B. microti, a species that perpetuates in mice, is the most frequent cause of human babesiosis and the source of an increasing number of human infections in the northeastern and northern midwestern United States, Asia, and Europe [12, 29, 36, 37]. The increasing incidence and geographic dispersion of human babesiosis, coupled with a growing number of immunocompromised people who live or travel in areas where babesiosis is endemic, emphasize the need for a better understanding and management of complicated babesial infection.

We conclude that immunocompromised patients who experience babesiosis and whose initial antibabesial therapy fails may experience a prolonged and relapsing course of disease, accompanied by severe complications. Patients with conditions that significantly impair immune function and who travel or reside in areas endemic for babesiosis should be advised to minimize their risk of tick exposure. Those who experience babesiosis and whose initial course of standard antibabesial therapy fails should be re‐treated for 2 weeks beyond the time when no parasites are observed on blood smear. Most of these patients will require antibabesial antibiotics for 6 weeks. These patients should be monitored for 3 months after apparent cure, and blood smears should be examined for intraerythrocytic parasites if the patients develop symptoms that are suggestive of babesiosis.

Acknowledgments


We thank Peter Baute, Peter Brassard, Linda Closter, Johanna Daily, Fil Dias, Joseph Gadbaw, Tim Lepore, Janice Miller, June Murli, Molly Davidson‐Price, Ray Ryan, and Vijay Sikand, for their contributions.

Financial support. National Center for Research Resources, a component of the National Institutes of Health M01 RR06192 to P.J.K..

Potential conflicts of interest. All authors: no conflicts.
References


* 1. Wittner M, Rowin KS, Tanowitz HB, et al. Successful chemotherapy of transfusion babesiosis. Ann Intern Med 1982; 96:601-4.
First citation in article, PubMed
* 2. Krause PJ, Lepore T, Sikand VK, et al. Atovaquone and azithromycin for the treatment of human babesiosis. N Engl J Med 2000; 343:1454-8.
First citation in article, CrossRef, PubMed
* 3. Sun T, Tenenbaum MJ, Greenspan J, et al. Morphologic and clinical observations in human infection with Babesia microti. J Infect Dis 1983; 148:239-48.
First citation in article, PubMed
* 4. Setty S, Khalil Z, Schori P, Azar M, Ferrieri P. Babesiosis: two atypical cases from Minnesota and a review. Am J Clin Path 2003; 120:554-9.
First citation in article, CrossRef, PubMed
* 5. Krause PJ, Spielman A, Telford SR, et al. Persistent parasitemia following acute babesiosis. N Engl J Med 1998; 339:160-5.
First citation in article, CrossRef, PubMed
* 6. Falagas ME, Klempner MS. Babesiosis in patients with AIDS: a chronic infection presenting as fever of unknown origin. Clin Infect Dis 1996; 22:809-12.
First citation in article, PubMed
* 7. Froberg MK, Dannen D, Bakken JS. Babesiosis and HIV. Lancet 2004; 363:704.
First citation in article, CrossRef, PubMed
* 8. Haselbarth K, Tenter AM, Brade V, Krieger G, Hunfeld KP. First case of human babesiosis in Germany--clinical presentation and molecular characterization of the pathogen. Int J Med Microbiol 2007; 297:197-204.
First citation in article, CrossRef, PubMed
* 9. Benezra D, Brown AE, Polsky B, Gold JWM, Armstrong D. Babesiosis and infection with human immunodeficiency virus HIV. Ann Intern Med 1987; 107:944.
First citation in article, PubMed
* 10. Clark IA, Budd AC, Hsue G, et al. Absence of erythrocyte sequestration in a case of babesiosis in a splenectomized human patient. Malar J 2006; 5:69.
First citation in article, CrossRef, PubMed
* 11. Stowell CP, Gelfand JA, Shepard JO, Kratz A. Case 17-2007--a 25‐year‐old woman with relapsing fevers and recent onset of dyspnea. N Engl J Med 2007; 356:2313-9.
First citation in article, CrossRef, PubMed
* 12. Krause PJ, McKay K, Gadbaw J, et al. Increasing health burden of human babesiosis in endemic sites. Am J Trop Med Hyg 2003; 68:431-6.
First citation in article, PubMed
* 13. Dobroszycki J, Herwaldt BL, Boctor F, et al. A cluster of transfusion‐associated babesiosis cases traced to a single asymptomatic donor. JAMA 1999; 281:927-30.
First citation in article, CrossRef, PubMed
* 14. McQuiston JH, Childs JE, Chamberland ME, Tabor E. Transmission of tick‐borne agents by blood transfusions: a review of known and potential risks in the United States. Transfusion 2000; 40:274-84.
First citation in article, CrossRef, PubMed
* 15. Leiby D. Babesiosis and blood transfusion: flying under the radar. Vox Sang 2006; 90:157-65.
First citation in article, CrossRef, PubMed
* 16. Simonsen KA, Harwell JI, Muriel FR, Lainwala S. A cluster of transfusion associated Babesia microti infections in very low birth weight infants [abstract 750038]. In: Program and abstracts of the 19th Annual Meeting of the Eastern Society for Pediatric Research Philadelphia. 2007:29.
First citation in article
* 17. Cheson BD. Monoclonal antibody therapy for B‐cell malignancies. Semin Oncol 2006; 33:S2-14.
First citation in article, CrossRef, PubMed
* 18. Iyer A, Mathur R, Deepak BV, Sinard J. Fatal adenoviral hepatitis after rituximab therapy. Arch Pathol Lab Med 2006; 130:1557-60.
First citation in article, PubMed
* 19. Perceau G, Diris N, Estines O, Derancourt C, Levy S, Bernard P. Late lethal hepatitis B virus reactivation after rituximab treatment of low‐grade cutaneous B‐cell lymphoma. Br J Dermatol 2006; 155:1053-6.
First citation in article, CrossRef, PubMed
* 20. van der Velden WJ, Blijlevens NM, Klont RR, Donnelly JP, Verweij PE. Primary hepatic invasive aspergillosis with progression after rituximab therapy for a post transplantation lymphoproliferative disorder. Ann Hematol 2006; 85:621-3.
First citation in article, CrossRef, PubMed
* 21. Hatcher JC, Greenberg PD, Antique J, Jimenez‐Lucho VE. Severe babesiosis in Long Island: review of 34 cases and their complications. Clin Infect Dis 2001; 32:1117-25.
First citation in article, Abstract, PubMed
* 22. Rosner F, Zarrabi MH, Benach JL, Habicht GS. Babesiosis in splenectomized adults: review of 22 reported cases. Am J Med 1984; 76:696-701.
First citation in article, CrossRef, PubMed
* 23. Jacobson RH, Parrodi F, Wright IG, Fitzgerald CJ, Dobson C. Babesia bovis: in vitro phagocytosis promoted by immune serum and by antibodies produced against protective antigens. Parasitol Res 1993; 79:221-6.
First citation in article, CrossRef, PubMed
* 24. Chen D, Copeman DB, Hutchinson GW, Burnell J. Inhibition of growth of cultured Babesia microti by serum and macrophages in the presence or absence of T cells. Parasitol Int 2000; 48:223-31.
First citation in article, CrossRef, PubMed
* 25. Chen D, Copeman DB, Burnell J, Hutchinson GW. Helper T cell and antibody responses to infection of CBA mice with Babesia microti. Parasite Immunol 2000; 22:81-8.
First citation in article, CrossRef, PubMed
* 26. Vannier E, Borggraefe I, Telford SR, et al. Age‐associated decline in resistance to Babesia microti is genetically determined. J Infect Dis 2004; 189:1721-8.
First citation in article, Abstract, PubMed
* 27. Wacholder S, McLaughlin JK, Silverman DT, Mandel JS. Selection of controls in case‐control studies. I. Principles. Am J Epidemiol 1992; 135:1019-28.
First citation in article, PubMed
* 28. Daily JP. Antimalarial drug therapy: the role of parasite biology and drug resistance. J Clin Pharmacol 2006; 46:1487-97.
First citation in article, CrossRef, PubMed
* 29. Homer MJ, Aguilar‐Delfin I, Telford SR, Krause PJ, Persing DH. Babesiosis. Clin Microbiol Rev 2000; 13:451-69.
First citation in article, CrossRef, PubMed
* 30. Skrabalo A, Deanovic A. Piroplasmosis in man: report on a case. Doc Med Geogr Trop 1957; 9:11-6.
First citation in article, PubMed
* 31. Persing D, Herwaldt BL, Glaser C, et al. Infection with a Babesia‐like organism in the western United States. N Engl J Med 1995; 332:298-303.
First citation in article, CrossRef, PubMed
* 32. Conrad PA, Kjemtrup AM, Carreno RA, et al. Description of Babesia duncani n sp Apicomplexa: Babesiidae from humans and its differentiation from other piroplasms. Int J Parasitol 2006; 36:779-89.
First citation in article, CrossRef, PubMed
* 33. Herwaldt BL, Persing DH, Precigout EA, et al. A fatal case of babesiosis in Missouri: identification of another piroplasm that infects humans. Ann Intern Med 1996; 124:643-50.
First citation in article, PubMed
* 34. Herwaldt BL, Caccio S, Gherlinzoni F, et al. Molecular characterization of a non‐Babesia divergens organism causing zoonotic babesiosis in Europe. Emerg Infect Dis 2003; 9:942-8.
First citation in article, PubMed
* 35. Shih C, Liu L, Chung WC, Ong SJ, Wang CC. Human babesiosis in Taiwan: asymptomatic infection with a Babesia microti‐like organism in a Taiwanese woman. J Clin Microbiol 1997; 35:450-4.
First citation in article, PubMed
* 36. Foppa I, Krause PJ, Spielman A, et al. Entomologic and serologic evidence of zoonotic transmission of Babesia microti in eastern Switzerland. Emerg Infect Dis 2002; 8:722-6.
First citation in article, PubMed
* 37. Wei Q, Tsuji M, Zamoto A, et al. Human babesiosis in Japan: isolation of Babesia microti‐like parasites from an asymptomatic transfusion donor and from a rodent from an area where babesiosis is endemic. J Clin Microbiol 2001; 39:2178-83.
First citation in article, CrossRef, PubMed

Posts: 300 | From Northeast | Registered: Dec 2006  |  IP: Logged | Report this post to a Moderator
AliG
Frequent Contributor (1K+ posts)
Member # 9734

Icon 1 posted      Profile for AliG     Send New Private Message       Edit/Delete Post   Reply With Quote 
quote:
Originally posted by JRWagner:

Too bad these Drs. did not mention the fact that our tests for Babesia only cover two ot three strains...out of many.


Anyone else wonder if it may be possible to have more than one strain?

Is it possible that one strain may be taken down by Tx & then produce a negative AB test, when another strain may still be viable?


[confused]

I've recently read that Malaria can cause false positive HIV tests. I had googled "Western Blot false-positive".

HIV=immune deficiency, No? I wondered if Babesia could do the same since it is very similar to Malaria.

I had been told by my LLMD that, when Babesia & Lyme co-exist in the human body, they actually help each other survive. One takes the immune system down while the other attacks you.


Thanks for posting this Terry! [Big Grin] [Roll Eyes]

--------------------
Note: I'm NOT a medical professional. The information I share is from my own personal research and experience. Please do not construe anything I share as medical advice, which should only be obtained from a licensed medical practitioner.

Posts: 4881 | From Middlesex County, NJ | Registered: Jul 2006  |  IP: Logged | Report this post to a Moderator
   

Quick Reply
Message:

HTML is not enabled.
UBB Code is enabled.

Instant Graemlins
   


Post New Topic  New Poll  Post A Reply Close Topic   Feature Topic   Move Topic   Delete Topic next oldest topic   next newest topic
 - Printer-friendly view of this topic
Hop To:


Contact Us | LymeNet home page | Privacy Statement

Powered by UBB.classic™ 6.7.3


The Lyme Disease Network is a non-profit organization funded by individual donations. If you would like to support the Network and the LymeNet system of Web services, please send your donations to:

The Lyme Disease Network of New Jersey
907 Pebble Creek Court, Pennington, NJ 08534 USA


| Flash Discussion | Support Groups | On-Line Library
Legal Resources | Medical Abstracts | Newsletter | Books
Pictures | Site Search | Links | Help/Questions
About LymeNet | Contact Us

© 1993-2020 The Lyme Disease Network of New Jersey, Inc.
All Rights Reserved.
Use of the LymeNet Site is subject to Terms and Conditions.