Delayed Babesia Diagnosis: Why Follow-Up Visits Matter
A delayed Babesia diagnosis can occur when symptoms emerge after initial Lyme disease treatment, highlighting the importance of follow-up care.
Doctors treated a 67-year-old woman for early Lyme disease with a 21-day course of amoxicillin after she presented with an erythema migrans rash. (She was allergic to doxycycline.)
Near the end of treatment, she developed fever (102.9°F), myalgias, dizziness, and fatigue. Concern for sepsis or a tick-borne co-infection led to hospital admission.
Clinicians suspected anaplasmosis and babesiosis, given thrombocytopenia and neutropenia.
“When patients present with a tick bite or suspected tick-borne infection, it is important to recognize that a single tick can serve as a common vector for multiple infections.”
Her hemoglobin and platelet levels continued to fall, and she was transferred to Mayo Clinic. Laboratory testing revealed pancytopenia.
PCR testing confirmed Babesia microti with a parasite load of 0.4%, writes Hoversten.
After treatment with azithromycin and atovaquone, her symptoms resolved, except for mild fatigue.
Why Babesia Diagnosis Can Be Delayed
The authors suggest that early infection may involve a low parasite burden, insufficient to cause symptoms or trigger testing during the initial evaluation.
They recommend considering babesiosis in patients who remain febrile after 48 hours of appropriate Lyme therapy or who develop unexplained anemia or thrombocytopenia.
Differential Diagnosis in Delayed Cases
Abnormal blood counts are not typical of Lyme disease, making co-infection more likely than persistent Lyme alone.
Other conditions considered included viral infections, HIV, hepatitis C, malaria, and drug-induced cytopenias.
Babesia cases have also increased in regions such as western Wisconsin, where this patient resided.
Delayed Diagnosis in Other Cases
Delayed Babesia diagnosis has been reported in multiple case studies, often following an initial Lyme disease presentation.
Some patients developed worsening symptoms weeks after an erythema migrans rash, similar to this case.
Delayed Babesia Diagnosis in Newborns
Delayed diagnosis has also been reported in infants following maternal Lyme disease.
In one case, a 4½-week-old infant presented with fever and was found to have 2% parasitemia. In another, an initially asymptomatic infant developed anemia and neutropenia weeks later despite earlier positive PCR testing.
These cases highlight the importance of ongoing monitoring when co-infection is possible.
Clinical Takeaway
Delayed Babesia diagnosis can occur after Lyme treatment, making follow-up and co-infection evaluation essential.
References
- Hoversten K, Bartlett MA. Diagnosis of a tick-borne coinfection in a patient with persistent symptoms following treatment for Lyme disease. BMJ Case Rep. 2018.
- Marcus LC, Steere AC, Duray PH, et al. Fatal pancarditis in coexistent Lyme disease and babesiosis. Ann Intern Med. 1985.
- Surgers L, Belkadi G, Foucard A, et al. Babesiosis and Lyme co-infection case report. Med Mal Infect. 2015.
- Saetre K, Godhwani N, Maria M, et al. Congenital babesiosis after maternal infection. J Pediatric Infect Dis Soc. 2017.
Related Reading
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
And, unfortunately, 10 days of treatment does not eradicate it because of it’s life cycle. It takes a minimum of SIX months. Been there done that, still fighting it after sever years.
I had a case of Babesia late this February. I had a rough time of it, spent 4 days in ICU. Took apovaquone/Azithromycin 10 days, felt good. Went off the drugs, illness came back in 2 weeks. Was placed back on the drugs, been on them for 7 weeks so far. I still have pancytopenia. Obviously, some cases take a far longer time to resolve. I feel good now, but am concerned with the slow resolution of blood deficiencies like reds, whites, and platelets. Is this slow resolution common? I have an experienced physician helping me with the problem and hope I can pull out of this. All things considered, I feel well and am busy with my extensive summer gardens.
The first Babesia paper enrolled patients with a combination of Lyme and Babesia. They were caught early when the parasite was visible in the red blood cells. They prescribed 10 days of Zithromax along with Mepron. I have patients who have failed a 10 day course only to get better with a longer course. I am glad longer term therapy worked for you. I would also see a hematologist if have not seen one.