Babesia Symptoms: 5 Different Clinical Presentations
Babesia symptoms can vary dramatically from patient to patient — making diagnosis particularly challenging. This case series describes five elderly patients with Babesia, each presenting differently.
Babesiosis is a tick-borne infection that affects red blood cells and may range from mild illness to life-threatening disease, particularly in older adults or immunocompromised patients.
Case 1: Fever, Chills, and Mental Changes
A 78-year-old white female was admitted with fever, chills, lethargy, fatigue, and marked changes in sensorium. “She had a maximum temperature of 100.6°F (38.1°C); sepsis was considered for this patient,” writes Paparone, a Nurse Practitioner (NP) from the Atlantic County Health Department in Northfield, New Jersey.
A tick-borne illness was considered due to multiple tick bites, abnormal liver function tests, anemia, and thrombocythemia. Peripheral smear was positive for Babesia, and she had a Babesia IgM of 1:160 and Anaplasma IgM of 1:320.
The woman’s mentation and lethargy dramatically improved when treated with doxycycline and the combination of atovaquone and azithromycin.
Case 2: Gastrointestinal Bleeding
A 90-year-old white female was admitted for rectal bleeding with a hemoglobin of 7.6 g/dL and a low platelet count of 103 × 10⁹/L. The bleeding resolved with an octreotide infusion.
The woman also had fever spikes to 100°F and a positive smear for Babesia. Her illness resolved with azithromycin and atovaquone.
Case 3: Fever, Malaise, and Hearing Loss
A 57-year-old white male was admitted with fever, malaise, and chills. His temperature rose to 101°F during his 5-day hospital stay.
Anaplasmosis was suspected due to elevated liver enzymes, leukopenia, and thrombocytopenia. Intravenous doxycycline, oral clindamycin and quinine were prescribed. But he tested positive for Babesia.
His hospital course was complicated by acute hearing deterioration. Quinine was stopped and treatment was changed to oral azithromycin and oral atovaquone.
Case 4: Lethargy and Blurred Vision
An 81-year-old white male was admitted with increasing lethargy, weakness, chills, and blurred vision. Babesia was diagnosed on peripheral smear.
Serologic studies demonstrated Anaplasma IgG of 1:256 and Babesia IgM and IgG of 1:320.
He was discharged after a 10-day course of azithromycin and doxycycline. Because of intolerance to azithromycin, he was switched to clindamycin and quinine to complete a 14-day course of therapy.
Case 5: Recurrent Fevers in an Immunocompromised Patient
An 85-year-old white male was admitted with intermittent recurring fevers and chills.
He had a history of hairy cell leukemia, splenectomy, atrioventricular block (pacemaker), gouty arthritis, prostatic hypertrophy, and polymyalgia rheumatica.
Babesia infection was diagnosed with 10.4% of his red blood cells infected. He was treated with azithromycin and atovaquone, with doxycycline added due to possible co-infection.
He was discharged on day 8 but readmitted with weakness and inability to ambulate. Persistent parasitemia required additional treatment adjustments before his peripheral smear became negative at 5.5 weeks.
Babesia Symptoms: Five Different Presentations
Each of the five cases presented differently:
- Fever, chills, lethargy, fatigue, and mental status changes
- Gastrointestinal bleeding
- Fever, malaise, and chills
- Lethargy, weakness, chills, and blurred vision
- Recurrent fevers and chills
Babesia Symptoms vs Lyme Disease Symptoms
Babesia symptoms often overlap with Lyme disease because both infections are transmitted by ticks and frequently occur together.
- Babesia symptoms: fevers, chills, night sweats, anemia, fatigue, and shortness of breath
- Lyme disease symptoms: joint pain, neurologic symptoms, facial palsy, and cognitive problems
Because co-infection is common, clinicians should consider babesiosis when patients with Lyme disease develop persistent fevers, night sweats, or unexplained anemia.
Co-infections
Three of the five cases with Babesia symptoms were treated for co-infections without confirmatory serologic tests. Two cases were treated for suspected Anaplasma infection.
Treatment Tolerance
Azithromycin and atovaquone were well tolerated in elderly patients ranging from 78 to 90 years old.
Quinine was stopped due to hearing loss in one subject. Clindamycin and quinine were stopped in another subject because of gastric distress and rash.
Despite anemia and thrombocytopenia, none of the five patients required blood transfusions.
In severe cases, red blood cell exchange transfusion may be required to rapidly decrease parasitemia.
“Exchange transfusions are recommended for cases of severe babesiosis in patients with parasitemia of 10% or greater, severe anemia, or organ impairment,” writes Paparone.
Clinical Perspective
This case series illustrates the wide range of Babesia symptoms. Patients may present with nonspecific symptoms and may not recall a tick bite.
Clinicians should maintain a high index of suspicion for babesiosis in endemic areas, particularly in older adults or immunocompromised patients.
References
- Paparone P, Paparone PW. Variable clinical presentations of babesiosis: A case series. Nurse Pract. 2017;42(11):1-7.
Related Reading
- Babesia and Lyme: What Patients Need to Know
- Geriatric Babesia: Why Older Patients Need Longer Treatment
- Babesia Treatment Protocol
Dr. Daniel Cameron, MD, MPH
Lyme disease clinician with over 30 years of experience and past president of ILADS.
Symptoms • Testing • Coinfections • Recovery • Pediatric • Prevention
