Babesia Infection After Lyme Disease Treatment: An Inside Lyme Podcast
Babesia coinfections may appear after Lyme disease treatment
Symptoms may emerge weeks after initial improvement
Delayed diagnosis may affect recovery and treatment
In this Inside Lyme podcast, I discuss a 67-year-old woman with a Babesia infection after Lyme disease treatment. Could this delay explain why some patients remain ill or relapse after initially improving?1
Hoversten and her colleague first discussed this case in the British Medical Journal Case Reports in 2018.1
One would expect tick-borne infections to occur at the same time.
One would be wrong, as this case illustrates.
A 67-year-old woman from Wisconsin had extensive tick exposure as an avid gardener who spent considerable time outdoors. She did not recall a tick bite but did notice a rash consistent with an erythema migrans rash.
She was prescribed amoxicillin for three weeks because she was allergic to doxycycline.
Near the end of her three-week course of amoxicillin, she became ill. Her fever rose to 102.9°F. She complained of myalgias, dizziness, and fatigue.
Her blood tests showed mild anemia, thrombocytopenia, neutropenia, and markedly elevated C-reactive protein levels. A low neutrophil count can be seen with tick-borne infections, while elevated inflammatory markers provide evidence of inflammation but not its cause.
Because doxycycline alone does not adequately treat Babesia infection, patients with persistent fever, anemia, sweats, or ongoing symptoms after Lyme disease treatment may prompt consideration of coinfections.1
She was admitted to the hospital where physicians considered sepsis or a tick-borne infection.
Her red blood cell count and platelet count continued to decline.
She was transferred to a second hospital.
There was no evidence of sepsis. Blood cultures remained negative after five days.
Babesia Infection Diagnosed Weeks After Lyme Disease Treatment
She was diagnosed with the parasite Babesia microti by PCR and peripheral smear testing.1
Typically, Babesia is identified using thick blood smears, although this patient demonstrated parasites on thin smear with 0.4% parasitemia.
Babesia infections can range from asymptomatic illness to severe disease. Older age and underlying health conditions may increase risk for complications. In this case, the patient was older than age 50 and had a history of colon cancer.
She was prescribed azithromycin plus atovaquone for 10 days. By day 5 of treatment, her fever resolved and her platelet count had more than doubled.
Despite treatment response, the authors reported persistent fatigue after completion of therapy.1
The authors discussed the nearly three-week gap between the woman’s erythema migrans rash and her diagnosis of Babesia. This was not the first report describing delayed Babesia presentation.
The authors cited papers describing a 3- to 4-week delay in the onset of Babesia symptoms.2 I described a paper in an earlier podcast where two babies contracted Babesia from their mothers and did not present until after hospital discharge.
This delay may explain why some Lyme disease patients relapse after initially improving with doxycycline or amoxicillin. Standard Lyme disease treatment does not adequately treat Babesia infection.
Patients with Babesia may present with fatigue, sweats, dizziness, anemia, air hunger, or persistent symptoms despite Lyme disease treatment.
What Can We Learn From This Babesia Infection Case?
- Babesia infection may occur weeks after Lyme disease onset or treatment.
- Persistent symptoms following Lyme treatment may occasionally reflect an unrecognized coinfection.
- Delayed recognition may increase hospitalization risk or prolong recovery.
Questions Raised by This Case
- Should Babesia testing be considered when patients present with erythema migrans in endemic regions?
- Would Babesia infection have been recognized without the earlier Lyme diagnosis?
- Should Lyme disease patients return for follow-up if symptoms evolve?
- Could earlier diagnosis have prevented hospitalization?
- What explains persistent symptoms after Babesia treatment?
Treating a Babesia Infection or Coinfection In My Practice
In my practice, each individual requires a careful assessment. That is why I order a broad range of blood tests for other illnesses in addition to tick-borne infections. I also arrange consultations with specialists as needed.
Many patients are complex, as highlighted in this Inside Lyme Podcast series.
We need more doctors with skills recognizing Babesia in a patient with Lyme disease. We hope that professionals evaluating individuals with Lyme disease can use this case to remind them to look for Babesia with Lyme disease.
Frequently Asked Questions
Can Babesia symptoms appear after Lyme disease treatment?
Yes. Babesia symptoms may emerge weeks after Lyme disease diagnosis or treatment.1
Does doxycycline treat Babesia infection?
No. Doxycycline does not adequately treat Babesia infection. Different antimicrobial therapy is typically required.
Can Babesia cause anemia?
Yes. Because Babesia infects red blood cells, anemia and thrombocytopenia may occur.
Clinical Takeaway
Delayed Babesia infection after Lyme disease treatment raises important diagnostic questions for clinicians managing persistent symptoms.
When patients worsen or relapse after initially improving, coinfections such as Babesia may warrant reconsideration.
Inside Lyme Podcast Series
This Inside Lyme case series is discussed on Facebook and made available on podcast and YouTube. As always, your likes, comments, and shares help spread awareness.
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Related Articles
Babesia and Lyme disease coinfections
Common Lyme disease coinfections
Persistent Lyme disease symptoms
Air hunger in 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:bcr-2018-226950.
- 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;7(3):e149-e154.
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
I was just diagnosed with Lyme disease and I think I have had it for a long time. I had been bitten by a tick in early spring but my doctor was not worried and never ordered test. I became extremely ill. Fatigued, nauseous, just didn’t feel good. I soon started getting these spells where I would suddenly feel like I was going to pass out, then I would start dry heaving and then I would be okay. Then suddenly it would happen again. I went to emergency room with pain in my left arm left chest and jaw and they did a bunch of bloodwork. My potassium was down to 2.4 and they said that was the cause and gave me potassium. After some time I felt somewhat better and thought I would be ok. About 3 months later it all began again, my potassium was low again despite my being on supplements daily since the first time. After about two weeks I felt again somewhat better but not normal. Still suffering from fatigue and swelling in my leg so bad that at times I could barely walk. About a month ago I began having massive pain in my legs but it felt like it was deep. My leg muscles ached so bad that it’s hard to even stand up. I went to get my knee checked out but my other leg had swollen to about three times it’s normal size and the pain in my muscles and joints was beyond anything I have ever felt. The doctor ordered a test for Lyme disease and it was positive. I am now on doxycycline and it’s been a week with no changes in swelling or symptoms. How long before I start feeling better? The pain is debilitating, the swelling is still massive dispute taking ibuprofen and Tylenol and I am not able to take anything else for the pain because I have had a previous issue with opiates and have been in recovery for years and doing great. I already suffer with chronic depression and this doesn’t help. The pain is so bad and I don’t know what to do at this point I’ve been sick for months with short spirts of feeling okay. Please help me to understand what could be happening
I have Lyme disease patients with similar stories. I don’t typically see much change after a week of doxycycline if one had been ill for a long time. I have seen Lyme disease increase pain even from old injuries. I also advise my patients to work with other specialists to rule out other causes of illness.