Delayed Babesia Diagnosis After Lyme Disease Treatment
Babesia symptoms may emerge after Lyme treatment.
Persistent fever and cytopenias can signal coinfection.
Follow-up visits remain important after early Lyme disease.
Doctors diagnosed and 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. (The woman was allergic to doxycycline.)
Near the end of treatment, the woman developed fevers (102.9°F), myalgias, dizziness, and fatigue. Due to concerns that she may have sepsis or an ongoing tick-borne infection, she was admitted to the hospital.
Clinicians were particularly worried about anaplasmosis and babesiosis because the patient had 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.”
Babesia Diagnosed After Lyme Disease Treatment
The woman’s hemoglobin and platelet counts continued to fall, and she was transferred to Mayo Clinic in Rochester, Minnesota.
Laboratory testing revealed pancytopenia, a deficiency involving red blood cells, white blood cells, and platelets.
Watch video: Tick-borne co-infections
PCR testing was positive for Babesia microti, and blood smear testing demonstrated a parasite load of 0.4%, according to Hoversten and colleagues. [1]
PCR testing for Anaplasma, Borrelia burgdorferi, and Ehrlichia was negative.
After a 10-day course of azithromycin and atovaquone, the patient’s symptoms resolved except for lingering fatigue.
Why Can Babesia Diagnosis Be Delayed?
The authors could not fully explain the delay in diagnosis.
“However, it is possible that patients have mild parasite load during their initial evaluation, not severe enough to cause systemic symptoms to warrant further evaluation,” the investigators explained.
Hoversten suggested that concurrent babesiosis should be considered in patients with Lyme disease who remain febrile after 48 hours of appropriate antimicrobial therapy or those with unexplained anemia and thrombocytopenia.
Laboratory Clues Suggesting Coinfection
Hoversten noted that the patient’s CBC abnormalities were not typical of uncomplicated Lyme disease.
“The patient’s abnormalities in CBC are not typical of Borrelia infections; therefore, a co-infection was of greater concern than recrudescent Lyme disease.”
Other possible causes considered included:
- Viral infections
- HIV
- Hepatitis C
- Malaria
- Drug-induced cytopenias
Ehrlichia was considered less likely because it is transmitted by a different tick species and is less common in the Midwestern United States.
The patient lived in Wisconsin, where Babesia cases have increased in recent years.
Other Reports of Delayed Babesia Diagnosis
The authors noted that delayed babesiosis diagnosis and Lyme-Babesia coinfections have been described previously in the literature.
Marcus and colleagues [2] and Surgers and colleagues [3] both described patients who initially presented with erythema migrans before developing worsening symptoms several weeks later that ultimately led to a babesiosis diagnosis.
Delayed Babesia Diagnosis in Newborns
Delayed Babesia diagnosis has also been reported in newborn infants born to mothers treated for Lyme disease during pregnancy.
Infant 1
A 4½-week-old male presented with fever, sleepiness, and irritability.
His mother had been diagnosed with Lyme disease during the third trimester after developing an erythema migrans rash and was treated with amoxicillin. Testing of the infant revealed 2% parasitemia for Babesia. [4]
Infant 2
An 18-day-old female infant was initially asymptomatic despite a positive Babesia microti PCR assay.
One week later, she developed neutropenia and symptomatic anemia with tachycardia, pallor, and malaise.
The mother had also been diagnosed with Lyme disease during pregnancy.
Clinical Perspective
Because Ixodes scapularis ticks may transmit multiple infections simultaneously, coinfection should be considered in patients whose symptoms worsen or persist despite appropriate Lyme disease treatment.
Persistent fever, anemia, thrombocytopenia, or unexplained fatigue after treatment may warrant further evaluation for Babesia coinfection, particularly in endemic regions.
FAQ: Delayed Babesia Diagnosis
Can Babesia symptoms appear after Lyme disease treatment?
Yes. Some patients may develop worsening symptoms or laboratory abnormalities after initial Lyme disease treatment due to an unrecognized Babesia coinfection.
What laboratory findings can suggest Babesia?
Anemia, thrombocytopenia, neutropenia, and pancytopenia may raise concern for babesiosis.
Can one tick carry multiple infections?
Yes. Ixodes ticks may transmit Lyme disease, Babesia, Anaplasma, and other tick-borne pathogens simultaneously.
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;2018.
- Marcus LC, Steere AC, Duray PH, Anderson AE, Mahoney EB. Fatal pancarditis in a patient with coexistent Lyme disease and babesiosis. Demonstration of spirochetes in the myocardium. Ann Intern Med. 1985;103(3):374-376.
- Surgers L, Belkadi G, Foucard A, Lalande V, Girard PM, Hennequin C. Babesiosis and Lyme disease co-infection in a female patient returning from the United States. Med Mal Infect. 2015;45(11-12):490-492.
- Saetre K, Godhwani N, Maria M, et al. Congenital Babesiosis After Maternal Infection With Borrelia burgdorferi and Babesia microti. J Pediatric Infect Dis Soc. 2017.
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.