Neurological Manifestations of Babesiosis
Neurological manifestations of babesiosis can mimic transient ischemic attacks (TIAs) with confusion, slurred speech, ataxia, and cognitive impairment — leading doctors to miss the underlying tick-borne infection.
Two patients in their 70s presented with stroke-like neurologic symptoms that resolved completely after treatment for babesiosis with antibiotics and antiparasitics. Their cases highlight a critical gap: neurologic symptoms from babesiosis are often under-recognized and frequently attributed to Lyme disease or anaplasmosis instead, delaying appropriate treatment.
The Typical Babesiosis Picture
Individuals with babesiosis can experience fevers, chills, myalgias, anorexia, headache, nausea, and vomiting. According to the authors, “The least common are shortness of breath, sore throat, neck stiffness, emotional lability, photophobia, and dark urine.”
This typical presentation emphasizes flu-like symptoms and hemolytic anemia. But what happens when babesiosis presents primarily with neurologic symptoms? These cases can easily be missed.
Two Cases of Stroke-Like Babesiosis
In their study entitled “Atypical Presentation of Babesiosis With Neurological Manifestations as Well as Hematological Manifestations,” the authors summarize two cases that presented with stroke-like or transient ischemic attack (TIA)-like signs and symptoms.
Both patients were in their 70s with multiple co-morbidities. They were admitted to the hospital “with similar symptoms of confusion/cognitive impairment, slurred speech, ataxia, fever, myalgias and chills, urinary frequency, and urgency,” the authors wrote. Neither patient had traveled outside the country or noticed a tick bite.
The constellation of symptoms — confusion, slurred speech, and ataxia — immediately suggests stroke or TIA. In elderly patients with vascular risk factors, this is often the first diagnosis considered. But fever, myalgias, and chills do not fit a simple cerebrovascular event. That combination should raise suspicion for infection affecting the nervous system.
Patient #1: Successful Triple Treatment
The first patient was treated successfully for babesiosis, anaplasmosis, and Lyme disease with a combination of atovaquone, azithromycin, and doxycycline for a total duration of 10 days.
This patient had evidence of multiple tick-borne co-infections. The neurologic symptoms resolved with treatment, suggesting that the deficits were infection-related rather than caused by permanent vascular damage.
Patient #2: Critical Illness Requiring ICU Support
The second patient was “initially started on broad-spectrum antibiotics, vancomycin and piperacillin-tazobactam, for suspicion of sepsis,” wrote the authors. He also received a blood transfusion along with fluid resuscitation and required pressor support with midodrine for hypotension.
This patient was critically ill. Initial treatment for presumed sepsis did not cover babesiosis, which requires antiparasitic therapy.
The patient was later treated successfully for babesiosis, Lyme disease, and Mycoplasma pneumoniae with a combination of atovaquone, azithromycin, and doxycycline for a total duration of 10 days.
Once the correct diagnosis was made and appropriate treatment initiated, the patient recovered. Without antiparasitic therapy, the infection would not have resolved.
The Knowledge Gap in Babesiosis
According to the authors, there are few reports in the literature describing neurologic manifestations of babesiosis involving cognitive and motor dysfunction. Neurologic findings in tick-borne illness are more often attributed to Lyme disease or anaplasmosis.
This creates a diagnostic blind spot. Babesiosis is often viewed primarily as a blood-borne infection causing hemolytic anemia rather than a cause of neurologic dysfunction.
As these cases demonstrate, babesiosis can produce stroke-like neurologic symptoms. Missing the diagnosis delays appropriate treatment and may increase the risk of severe complications.
The Authors’ Warning
“There is a huge gap in knowledge about tick-borne infections, especially babesiosis, which is grossly under-studied and underdiagnosed,” the authors concluded.
“This is a diagnosis associated with complete recovery on prompt diagnosis and treatment, and it could be fatal if left undiagnosed or with a delayed diagnosis.”
Both patients recovered completely after appropriate treatment. If babesiosis had not been considered, the outcomes could have been very different.
The Diagnostic Challenge
Editor’s note: These cases were well documented. However, it is more difficult to publish cases involving babesiosis with neurologic involvement when parasites are not seen on a red blood smear and laboratory testing is negative.
Babesiosis diagnosis often relies on blood smear, PCR, and serologic testing. Yet these tests can be negative in cases of low parasitemia. When clinical suspicion is high, empiric treatment may sometimes be warranted.
Clinical Perspective
These cases challenge the conventional view of babesiosis as primarily a hematologic disease. While hemolytic anemia remains the classic presentation, neurologic manifestations can dominate the clinical picture in some patients.
The stroke-like presentation may be explained by several mechanisms:
- Red blood cell destruction leading to anemia and reduced oxygen delivery to the brain
- Inflammatory cytokine release causing endothelial dysfunction
- Microvascular injury impairing cerebral perfusion
- Possible direct effects of parasitized red blood cells on blood flow
Both patients were elderly with multiple comorbidities. Older adults with vascular risk factors may be more vulnerable to neurologic complications when babesiosis causes anemia and systemic inflammation.
The co-infection pattern is also notable. One patient had babesiosis, anaplasmosis, and Lyme disease, while the other had babesiosis, Lyme disease, and Mycoplasma pneumoniae. Multiple simultaneous infections can compound immune stress and worsen neurologic symptoms.
The treatment duration in these cases was 10 days, shorter than what I often use for babesiosis with neurologic involvement. In my clinical practice, I typically treat for 4–6 weeks or longer depending on clinical response.
Importantly, both patients experienced complete neurologic recovery once the infection was treated. This suggests that the neurologic symptoms reflected reversible inflammatory changes rather than permanent structural brain injury.
Frequently Asked Questions
Can babesiosis cause stroke-like symptoms?
Yes. Babesiosis can cause confusion, slurred speech, ataxia, and cognitive impairment that resemble stroke or transient ischemic attack.
Why is neurologic babesiosis often missed?
Clinicians often attribute neurologic symptoms in tick-borne illness to Lyme disease or anaplasmosis rather than babesiosis.
Do parasites need to be seen on blood smear to diagnose babesiosis?
No. Blood smears can be negative in cases of low parasitemia. PCR testing and serology can assist diagnosis.
Can babesiosis be fatal?
Yes. Severe babesiosis can be fatal if diagnosis and treatment are delayed, particularly in elderly or immunocompromised patients.
Why do coinfections occur?
Ticks can transmit multiple pathogens simultaneously, resulting in combined infections such as babesiosis, Lyme disease, and anaplasmosis.
Is 10 days of treatment sufficient?
It depends on the severity of illness. Some patients require longer treatment courses to ensure parasite clearance and prevent relapse.
Related Reading:
Babesia: What Lyme Patients Need to Know
The Case of an Untreated Babesia Infection
Babesia Symptoms Can Be Deadly: A Family’s Story
Case Series Shows Wide Range of Babesia Symptoms
Understanding Lyme Disease Coinfections
Neurologic Lyme Disease: When Infection Affects the Brain
References:
- Venigalla T, Adekayode C, Doreswamy S, Al-Sudani H, Sekhar S. Atypical Presentation of Babesiosis With Neurological Manifestations as Well as Hematological Manifestations. Cureus. 2022.
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
The case reports are very important since babesia and the neurological manifestations are so hard to validate and recognize in the clinical setting. Excellent work! would be further validated if they made a longer follow up. I am curious to know if the treatment was long lasting. Is babesia a relapsing illness? The symptom characteristics I am familiar with include a dull long lasting headache and what patients refer to as “ air hunger”. Would the dark urine be related to porphyria ? Has anyone investigated the cause of the dark urine?
It would be interesting to know better how babesia impacts the neurological system and why. Many thanks. ABK
I often find that Babesia helps early on but has to be treated longer to resolve the infection.
After a full 2 year regimen of atovaquone, proguanil, azithromycin, along with negative diagnostic tests for the organism Babesia, and a full year of these negative test results, I was taken off these medicines. During the 2 year period, my blood values were mostly suboptimal. Very gradually, my blood values improved with the exception of my high bilirubin (6.0), very low haptoglobin, and platelets (100k). A couple weeks ago, I went off the meds I was taking for the Babesia. After a 2 week wait, I had blood work done. All of these 3 values improved greatly! Bilirubin halved, haptoglobin approaching normality, BUT platelets remained at 100k. I can’t figure out these platelets. Urine has shown much less reddish tint, also. I’m guessing the atova was the culprit, but I could be wrong. What say you?
thanks so much
Oops! I said platelets were considerably improved but that was incorrect. They’ve been pretty much the same during the med regimen, low. The lowest they got was 22k, the highest before the recent blood test was 128k. I will be submitting to another round of blood work within 2 weeks and I’ll see how things are going.
Good morning,
I was diagnosed with Babesia in 2007. Doctors treated the Lyme with Docycycline twice. No treatment for the Babesia.
I am really curious to know if others go through drenching sweats and chills at the same time. It continues daily it’s embarrassing and ruins my clothing.
I hope someone can enlighten me.
Thank you
Sydney- I also have what you described. I have tried to explain it to many drs. They just dont seem to understand what I mean. It feels like the inside of my body is boiling. I can touch my skin and know that it is cool to the touch, but I can not feel the cold. I just dont say this well- When in a flare- I am so hot and sweaty that I can hardly stand it- I go outside in winter in short sleeves to cool off. I have been told that my autonomic nervous system is damaged from the long term Lyme and Babesia and I believe that is where this comes from. When treatment works- it goes away. So I know it “isn’t all in my head”. Thanks
Jan,
Hi. Thanks for your response. How about your legs and arms looking mottled?
Told my psychiatrist once, she said dead people have mottled skin and moved on
Some of my patients have recurring blue hands and feet from autonomic problems related to a tick borne illness
Is there any evidence for kidney damage (CKD) caused by Babesiosis?
I have not seen CKD due to Lyme disease in my practice.
Do any patients with Lyme/Babesia have to deal with
Ear and nose cartilage becoming very pain to the touch?
Mine is not everyday, it just pops up out of the blue.
Sydney
I have not asked my patients about their ear and nose cartilage. I have patients whose skin is very painful or burning from a tick borne illness. Their symptoms typically clear if there tick borne infection is treated
Lyme can cause deterioration of cartilage I’ve read because it hungry for collagen. There’s a fb group that a guy started because he started having serious problems with rib slippage as a result of Lyme
This happens to me! I will wake up with an ear that hurts so bad. But the outside part, not like an ear infection.
I am currently being treated for Lyme/Babesia/ Mycoplasma pneumoniae. Have you heard of utilizing bacteriaphages for treatment? I’m in the process and am already seeing some changes for the better. My migraines have been reduced as well as my brain fog. I originally went on antibiotics for 2 years with no luck. Just wanted to pass this on for others.
I suffered from acute, sudden onset feelings of nausea and anxiety (terror really) that lasted for only a minute or two, but followed with confusion, lesser anxiety, brain fog and memory issues. This continued for 2-3 days with attacks recurring every hour for the first day and then lessening in intensity and frequency. There was 6 months between the first episode and the second, but only 2 months between the second and third. My regular physician was baffled and suggested therapy for the anxiety.
Because my wife suffers with long Lyme disease, she suggested that I see her specialist and get the iGeneX blood tests. I did this and was positive for Babesia and put on a four week course of Atovaquone and Azithromicyn. So far, I have had no more “attacks” and my mental clarity and anxiety are much improved.
Further, I am going to be consulting with a Neurologist to determine if anything else is needed.
I am glad you improved. It is reasonable to consult a neurologist given your symptoms were so severe