Babesia exchange transfusion is a life-saving procedure reserved for the most severe cases. In their article, “Repeat exchange transfusion for treatment of severe babesiosis,” Radcliffe and colleagues describe the case of a 73-year-old immunocompromised woman with 43% parasitemia who required two exchange transfusions and 12 weeks of treatment to survive this tick-borne infection.
The Case: When Babesia Exchange Transfusion Became Necessary
Approximately 1 month after camping in New Hampshire, the woman developed malaise, headaches, weakness, anorexia, and nausea, which lasted for 4 days. She did not recall having a tick bite.
The patient had triple risk factors for severe Babesia:
- Prior splenectomy for immune-mediated thrombocytopenia
- Longstanding rheumatoid arthritis (autoimmune disorder)
- Immunosuppression therapy with weekly etanercept
A blood smear revealed a parasitic burden of 43% and anemia with hemoglobin 9.2 mg/dL. “She was started on azithromycin and clindamycin and transferred to our hospital,” writes Radcliffe.
ICU Admission and First Babesia Exchange Transfusion
The woman was admitted to the intensive care unit for hypotension. She initially needed fluids and vasopressors, as well as supplemental oxygen for a pulse oximetry of 88%.
Her treatment was changed to include IV clindamycin, oral quinine sulfate, and oral doxycycline as empiric treatment for possible co-infection with Lyme disease and/or Anaplasmosis.
On day 1, she received her first babesia exchange transfusion of 12 units. This dropped the parasite load from 43% to 7.6%—an 81.5% reduction.
Parasitemia Rebounds: Second Babesia Exchange Transfusion Required
However, “despite a post-exchange drop in parasitemia to 7.6%, it rebounded to 11.4% on hospital day 5 accompanied by new onset high fevers and hypoxia,” explains Radcliffe.
On day 5, she received her second exchange transfusion, which lowered parasitemia to 2.2%.
“She improved after a second exchange transfusion and ultimately resolved her infection after 12 weeks of anti-babesial antibiotics,” writes Radcliffe.
This pattern of relapse despite aggressive treatment mirrors other cases of Babesia in asplenic patients.
Extended Treatment After Babesia Exchange Transfusion
She underwent extended treatment due to persistent parasitemia: 1.7% at day 9 and <1% at day 19.
“Antibiotics were discontinued as follows: atovaquone/proguanil at 61 days post-discharge, doxycycline at 72 days post-discharge, and azithromycin at 86 days post-discharge,” writes Radcliffe.
This 12-week course far exceeds the standard 7-10 day treatment for uncomplicated Babesia—underscoring why immunocompromised patients need individualized care.
What Makes This Case Significant
There are only 6 other cases in the literature documenting exchange transfusions in patients with Babesia. Unfortunately, one of those patients died.
“Our present case is instructive,” the authors explain, “because two ETs were necessary for cure despite a marked lowering of parasitemia after the first ET (81.5% reduction) and an extended anti-parasitic regimen…”
The authors conclude: “These cases highlight the need to remain vigilant when managing babesiosis in highly immunocompromised patients.”
For patients who continue to relapse after standard treatment, tafenoquine may be an option to consider.
Editor’s Note
This patient’s case should serve as a reminder of the risk Babesia poses for immunocompromised patients with autoimmune disorders such as rheumatoid arthritis. The combination of splenectomy, autoimmune disease, and immunosuppressive therapy created a perfect storm.
I have seen elderly patients and those on immunosuppressive medications struggle to clear this infection. Treatment decisions must be individualized based on the patient’s response—not arbitrary timelines.
Frequently Asked Questions
What is a babesia exchange transfusion?
An exchange transfusion removes infected red blood cells and replaces them with healthy donor cells. It’s reserved for severe cases with high parasite loads—typically above 10%.
When is exchange transfusion needed for Babesia?
Exchange transfusion is typically considered when parasitemia exceeds 10%, when patients are severely ill, or when they don’t respond to antimicrobial treatment alone. This patient had 43% parasitemia.
How many exchange transfusions are needed?
Most patients need one, but this patient required two. Her parasitemia rebounded from 7.6% to 11.4% after the first transfusion before the second brought it down to 2.2%.
Why are immunocompromised patients at higher risk?
Patients on immunosuppressive drugs, without a spleen, or with autoimmune disorders cannot clear the parasite effectively. This patient had all three risk factors.
How long is treatment after exchange transfusion?
This patient required 12 weeks of anti-parasitic antibiotics—far longer than the standard 7-10 day course for uncomplicated Babesia.
References
- Krause PJ. Human babesiosis. Int J Parasitol. 2019;49(2):165-74.
- Krause PJ, Gewurz BE, Hill D, et al. Persistent and relapsing babesiosis in immunocompromised patients. Clin Infect Dis. 2008;46(3):370-6.
- Radcliffe C, Krause PJ, Grant M. Repeat exchange transfusion for treatment of severe babesiosis. Transfus Apher Sci. 2019.
