Can Babesia Appear After Lyme Disease Treatment?
Persistent fever after Lyme disease may signal a co-infection
Babesiosis can become apparent weeks after an erythema migrans rash
Follow-up evaluation may help identify a delayed diagnosis
Babesiosis may be diagnosed during or after Lyme disease treatment, particularly when a patient develops persistent fever, fatigue, anemia, thrombocytopenia, or other unexplained symptoms.
Babesia does not develop as a result of Lyme disease treatment. More often, the infection was transmitted at the same time as Lyme disease but did not become clinically apparent until later. Standard Lyme disease antibiotics, including doxycycline and amoxicillin, do not treat Babesia microti.
This Mayo Clinic case highlights the importance of considering tick-borne co-infections when recovery does not follow the expected course.
Because a single Ixodes tick can transmit multiple pathogens, clinicians may need to evaluate for co-infections when symptoms worsen rather than improve after treatment for Lyme disease.
Persistent Symptoms After Lyme Disease Treatment
Doctors diagnosed a 67-year-old woman with early Lyme disease after she presented with an erythema migrans rash. Because she was allergic to doxycycline, she was treated with a 21-day course of amoxicillin.
Near the end of treatment, she developed a fever reaching 102.9°F, along with myalgias, dizziness, and fatigue. Because clinicians were concerned about possible sepsis or a tick-borne co-infection, she was admitted to a local hospital.
“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.”¹
Clinicians were particularly concerned about anaplasmosis and babesiosis because of abnormalities in her blood counts.
The woman’s condition continued to worsen, and she was transferred to Mayo Clinic in Rochester, Minnesota.
Watch video: Tick-Borne Co-Infections
How Babesia Was Diagnosed
Laboratory testing revealed pancytopenia—a deficiency of red blood cells, white blood cells, and platelets.
PCR testing was positive for Babesia microti. A thick blood smear demonstrated a Babesia parasite load of 0.4%, according to Hoversten and Bartlett.¹
Additional PCR testing for Anaplasma, Borrelia burgdorferi, and Ehrlichia was negative.
After treatment with azithromycin and atovaquone for 10 days, the patient’s symptoms resolved except for lingering fatigue.
Why Babesia Was Suspected
The patient’s blood count abnormalities were not typical of uncomplicated Lyme disease and raised concern for a co-infection.
Hoversten and Bartlett explained that “the patient’s abnormalities in CBC are not typical of Borrelia infections; therefore, a co-infection was of greater concern than recrudescent Lyme disease.”¹
The authors could not determine exactly why the diagnosis was delayed. However, they suggested that some patients may initially have a parasite burden too low to produce symptoms severe enough to prompt additional testing.
Other Possible Diagnoses
Clinicians considered several alternative diagnoses.
Ehrlichia infection was considered but was less common in Wisconsin, where the patient lived. Viral infections, HIV, hepatitis C, malaria, and drug-induced cytopenias were also evaluated as possible explanations for her illness.
The authors noted that cases of babesiosis had increased in western Wisconsin, making the diagnosis increasingly relevant in that region.
When Should Babesia Be Considered?
Hoversten and Bartlett suggested considering babesiosis in patients with Lyme disease who remain febrile after 48 hours of appropriate antimicrobial therapy or who develop unexplained anemia or thrombocytopenia.¹
Persistent fever does not automatically indicate babesiosis. Other infections, medication reactions, inflammatory responses, and unrelated medical conditions may produce similar symptoms and should also be evaluated.
For a broader discussion of tick-borne co-infections, see Lyme disease co-infections and Babesia and Lyme disease.
Other Reports of Delayed Babesia Diagnosis
Delayed recognition of babesiosis has also been reported elsewhere in the medical literature.
Marcus and colleagues described a patient with Lyme disease and babesiosis who developed fatal cardiac complications.²
Surgers and colleagues reported a patient whose worsening symptoms several weeks after an erythematous rash ultimately led to the diagnosis of Lyme disease and Babesia co-infection.³
These reports resemble the timeline in the Mayo Clinic case, where babesiosis became apparent only after Lyme disease treatment had begun.
Congenital Babesiosis Cases
Delayed diagnosis is not limited to adults. Similar delays have been reported in newborns with congenital babesiosis following maternal tick-borne infections.
One report described two infants diagnosed with babesiosis several weeks after their mothers had been treated for Lyme disease during pregnancy.⁴
Infant 1: A 4½-week-old boy developed fever, sleepiness, and irritability. Testing revealed 2% parasitemia for Babesia.
Infant 2: An 18-day-old girl initially appeared well despite a positive Babesia microti PCR test. One week later, she developed anemia and neutropenia that required hospitalization and treatment.⁴
These cases illustrate how Babesia infection may initially produce few recognizable symptoms and become clinically apparent later.
Frequently Asked Questions
Can Babesia appear after Lyme disease treatment?
Yes. Babesiosis may become clinically apparent during or after Lyme disease treatment. This usually reflects an existing co-infection that was not treated by standard Lyme disease antibiotics rather than a new infection caused by treatment.
Can one tick transmit Lyme disease and Babesia?
Yes. The same Ixodes tick can transmit both Borrelia burgdorferi, which causes Lyme disease, and Babesia microti, which causes babesiosis.
Why might Babesia symptoms appear later?
A patient may initially have a low parasite burden or symptoms that overlap with Lyme disease. As a result, babesiosis may not become recognizable until fever, anemia, thrombocytopenia, night sweats, or worsening fatigue develops.
Does doxycycline or amoxicillin treat Babesia?
No. Doxycycline and amoxicillin treat bacterial infections but do not treat the Babesia parasite. Babesiosis requires different medications, commonly atovaquone combined with azithromycin.
What symptoms may suggest Babesia after Lyme disease treatment?
Persistent or recurrent fever, chills, night sweats, marked fatigue, anemia, thrombocytopenia, or worsening symptoms despite appropriate Lyme disease treatment may raise concern for babesiosis.
Can Babesia be missed initially?
Yes. The parasite burden may be low early in the illness, and symptoms can overlap with those of Lyme disease or other infections. These factors may delay recognition and diagnosis.
Clinical Takeaway
Babesiosis may not be apparent when Lyme disease is first diagnosed. In this case, worsening fever, fatigue, and abnormal blood counts led to the identification of Babesia microti after Lyme disease treatment had already begun.
Persistent fever, anemia, thrombocytopenia, or worsening symptoms during or after Lyme disease treatment should prompt consideration of a tick-borne co-infection such as babesiosis.
This article is for informational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment.
Related Articles
- Babesia and Lyme Disease
- Night Sweats and Lyme Disease
- Lyme Disease and Pregnancy
- Autonomic Dysfunction and Lyme Disease
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. 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.