Acute Severe Hepatitis and Hepatic Necrosis Caused by Babesiosis

Abstract

Babesiosis is a rare, tick-borne human infection transmitted by the Ixodes ticks. The presentation can range from asymptomatic to severe symptoms, and, although rare, multiorgan failure can occur. Here we present a case of acute liver failure and massive hepatic necrosis caused by babesiosis. A 48 year old previously healthy Haitian male presented to an outside ER with a one-day history of acute abdominal pain, nausea, vomiting and diarrhea. His initial laboratory data revealed a leukocytosis to 24.5, as well as elevated transaminases with AST of 575, ALT of 236, and total bilirubin 2.7. Testing for acute viral hepatitis was negative and an MRI/MRCP ruled out a biliary obstruction. He was treated with broad spectrum antibiotics, however his AST markedly rose to 6,643 and ALT to 3,695. Blood smear showed schistocytes, concerning for hemolytic uremic syndrome, and the patient was transferred to our University Hospital for initiation of plasmapheresis. His clinical presentation to our facility included septic shock, respiratory failure, renal failure, and acute liver failure. A peripheral blood smear showed an intracellular ring form, with multiple extracellular ring forms, consistent with babesiosis. Despite treatment with clindamycin and quinine, in addition to broad spectrum antibiotics, and maximum vasopressor and ventilatory support, the patient's clinical status continued to decline, and he experienced multiple cardiac arrests leading to his eventual death. On post-mortem his liver pathology showed massive confluent hepatic necrosis. Other autopsy features included splenomegaly, diffuse alveolar hemorrhage, and an ischemic large and small bowel. Cause of death was determined to be confluent hepatic necrosis due to babesiosis.Clinical manifestations of babesiosis vary from asymptomatic presentations to less commonly hemolytic anemia and severe organ dysfunction, including adult respiratory distress syndrome and acute liver failure. While the entire mechanism of pathogenesis is not entirely understood, hepatic injury and failure is thought to be the byproduct of a pro-inflammatory cytokine storm coupled with severe organ hypoperfusion, rather than direct hepatotoxicity from the organism itself. This case demonstrates a rare case of acute hepatitis progressing to multiorgan failure caused by babesiosis. Although rare, babesiosis should be suspected in cases of elevated transaminases and liver failure without a clear diagnosis.