Anshul Patel, MD
Resident Physician
The Wright Center for Graduate Medical Education
Scranton, Pennsylvania
Disclosure information not submitted.
Viren Raheja, MD
Resident Physician - Internal Medicine
The Wright Center for GME, United States
Disclosure information not submitted.
Midiia Shuman
Resident Physician
St. Mary Medical Center, United States
Disclosure information not submitted.
Princy Shah
Resident Physician
The Wright Center for Graduate Medical Education, United States
Disclosure information not submitted.
Shams Tasnim, MD
Resident Physician
The Wright Center for Graduate Medical Education
Scranton, Pennsylvania, United States
Disclosure information not submitted.
Pragya Dhaubhadel
Associate
GCMC Infectious Diseases, United States
Disclosure information not submitted.
Title: Unmasking Babesiosis in a Cirrhotic: A Diagnostic dilemma
Introduction: Babesiosis is a zoonotic infection, with most cases in the US caused by Babesia microti. It’s presentation can be masked by an existing liver disease. Here we report a case of severe babesiosis that was unmasked in a patient with concomitant liver disease which proved to be a diagnostic dilemma.
Description: A 66-year-old male with a past medical history of alcoholic liver cirrhosis and hepatocellular carcinoma presented to the hospital complaining of diffuse abdominal pain. Examination was remarkable for a fever, hypotension, and abdominal distension. Labs were significant for platelets (46,000), INR of 2.27, AST/ALT (133/50), and bilirubin (5.5). A CT Abdomen showed splenomegaly and esophageal varices with no ascites. Patient was started on ceftriaxone, metronidazole, and lactulose. Due to hemodynamic compromise, the patient was subsequently transferred to the ICU, intubated and started on vasopressor therapy. Due to persistent fevers, infectious disease was consulted. Upon further questioning, it was found that his car was infested with mice. A zoonotic disease workup was revealed intra-erythrocytic Maltese crosses consistent with babesiosis with an estimated parasitemia >20%. Antibiotics were switched to meropenem, azithromycin, and atovaquone. Despite plasmapheresis, he went into DIC and multiorgan failure. As per family’s request, he was compassionately extubated and died.
Discussion: Babesiosis is transmitted to humans by the nymphal stage of Ixodes scapularis, which is much smaller than the adult ticks and hence can easily go unnoticed. White-footed mice are the primary hosts for nymphs. Studies have reported high seroprevalence in endemic areas, but clinical babesiosis is rare. Without a history of tick bite, the presentation of disease is fairly non-specific including fever and abdominal pain with lab findings of elevated bilirubin levels, transaminitis and thrombocytopenia. These findings mimic liver disease and hence it is often missed in patients with concomitant liver disease which can prove to be fatal. Mortality rates up to 9% in hospitalized patients and as high as 21% in the immunocompromised have been seen with babesiosis. It is an important differential in patients living in endemic areas with existing liver disease. Babesiosis is treatable and early detection can improve outcomes.