DOUBLE STRIKE: A CASE OF BABESIOSIS AND ANAPLASMOSIS PRESENTING AS SEVERE HEMOLYTIC ANEMIA AND SEPTIC SHOCK IN A HEALTHY 25-YEAR-OLD MALE

Abstract

SESSION TITLE: Critical Care 5 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Lyme disease was first identified in 1981. The first case of babesiosis was reported from Nantucket Island, Massachusetts, in 1969. Since the late 1980s, the disease spread from the islands off the New England coast to the mainland. Cases have also been reported across the United States, Europe, and Asia.In a person experiencing severe illness, more symptoms, and a longer recovery, co-infection should be highly suspicious. The CDC recommends that physicians consider possible co-infection with babesia or anaplasma when patients have more severe symptoms of Lyme disease. We are presenting a case of severe babesiosis and anaplasmosis that presented as severe hemolytic anemia and septic shock in young 25 year old male. CASE PRESENTATION: A healthy, 25 year old male, dog-owner, with Down syndrome presented with generalized malaise, intermittent fevers, chills, sweating, abdominal pain, intermittent neck pain that progressively worsened over a week. His fever was ranging from 101-105 Fahrenheit and spiked nocturnally. He had raked the yard 2 weeks ago and his parents were concerned about a tick bite, however no tick or rash was ever found. Physical exam was remarkable for hepatosplenomegaly. Upon admission he was found on septic shock requiring pressor support. Labs revealed severe pancytopenia and mildly elevated transaminases. CT scan of abdomen and pelvis showed mild hepatosplenomegaly and fatty liver. Given the severity of presentation he was started empirically on broad spectrum coverage including vancomycin, piperacillin/tazobactam, doxycycline, atovaquone, azithromycin, clindamycin and quinine to cover tick-borne disease. Positive buffy coat and intra-erythrocytic inclusions suggesting with co-infection of babesia and anaplasmosis were found. Lyme disease titer was negative but could be falsely so in the first 3-4weeks of infection. Septic shock with severe anemia resolved after 3 days. He had daily peripheral smear and babesia smears to assess for level of parasitemia – on admission it was at 1%, and then peaked to 2% and after clindamycin it decreased to 1%. He became clinically more stable and was continued on azithromycin, atovaquone, clindamycin given possible quinine toxicity and doxycycline for anaplasmosis. Daily smears for Babesia were required to assess level of parasitemia. DISCUSSION: The etiological agents responsible Lyme disease (Borrelia), human granulocytic anaplasmosis (Anaplasma), and babesiosis (Babesia microti) are primarily transmitted by the backlegged tick, Ixodes scapularis. Babesiosis is a malaria-like protozoan infection of erythrocytes that is transmitted by Ixodes. Babesia is a malaria-like parasite or “piroplasm” which infects red blood cells. Babesia microti is the commonest piroplasm infecting humans. CONCLUSIONS: Ticks can carry multiple infective agents including lyme, babesia, and anaplasmosis, placing patients as risk of a more severe presentation. Reference #1: 1. Diuk-Wasser MA1, Vannier E2, Krause PJ3. Coinfection by Ixodes Tick-Borne Pathogens: Ecological, Epidemiological, and Clinical Consequences. Trends Parasitol. 2016 Jan;32(1):30-42. https://doi.org/10.1016/j.pt.2015.09.008. Epub 2015 Nov 21. DISCLOSURES: No relevant relationships by Sylvia Alarcon Velasco, source=Web Response No relevant relationships by Amnah Andrabi, source=Web Response No relevant relationships by Preeyanka Sundar, source=Web Response