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Human Babesiosis – An Update
Patricia J. Holman
Department of Veterinary PathobiologyCollege of Veterinary Medicine and Biomedical
SciencesTexas A&M UniversityCollege Station, TX
Babesiosis
• Emerging tick-borne disease• Zoonosis caused by intraerythrocytic
protozoan parasites• Infections may range from
asymptomatic to severe, or even fatal• Most cases occur in the U.S.;
worldwide where ticks occur
• Phylum – Apicomplexa– Babesia, Plasmodium, Toxoplasma,
Cryptosporidium– Unique organelles comprise apical
complex
Electron micrographcourtesy of Dr. R.E. DroleskeyUSDACollege Station, TX
Babesia - Two-host life cycle
Tick Vertebrate
Salivary glands
Gut
Ovaries,Eggs
Gamont
Kinete
Zygote
Sexual reproduction in the vector tick Asexual reproduction in
mammalian red blood cells
1. Larvalticks hatch
3. Tick molts tonymph - now
infective
4. Tick feedson mice or
other hosts;transmits
2. Tick picks upinfection from
parasitemic host
5. Tick loses ability totransmit infectionduring molt from
nymph to adult unlessit feeds on an infected
host as a nymph
Babesia microtiTick transstadial
transmission
6. Adult tickfeeds on
host, thenfemales dropto lay eggs
Babesia divergens
Tick transovarial transmission
1. Adult tick picksup infection fromparasitemic host
2. Infectedlarval ticks
hatch 3. Tick feedson cattle orother hosts;
transmitsBabesia
Babesiosis
• Symptoms 1-6 wks after tick feeds• Variable
– Asymptomatic infection – Mild to moderate illness– Severe disease – usually
immunosuppressed• Medication• Splenectomy• HIV co-infection• Malignancy
Babesiosis• Symptoms
– Fatigue– Intermittent fever
• Chills, sweats, headache, arthralgia, anorexia, cough, nausea Asymptomatic infection
• Clinical Presentation– Fever, pallor– Splenomegaly– Hepatomegaly
• May last a week or months• Prolonged recovery; persistent parasitemia
Babesiosis – Severe form
• Most common complications– Respiratory failure– Congestive heart failure– DIC– Liver and kidney failure– Splenic rupture– Immunocompromised – 21% mortality
Diagnosis• CBC
– Hemolytic anemia with elevated reticulocytes– Thrombocytopenia– Normal to slightly decreased leukocyte count
• Blood chemistry– Elevated serum liver enzymes (~ ½ of
patients)– Proteinuria, elevated blood urea nitrogen and
serum creatinine
Diagnosis
• Microscopic identification– Giemsa stained thick or thin blood
films– Babesia ring forms can be mistaken
for malaria• Serology - IFA
– B. microti• B. duncani does not cross-react
– B. divergens • Sera from B. divergens or B. ventorum
patients cross react
Diagnosis
• Polymerase chain reaction– Highly sensitive and specific– Useful for extremely low parasitemias
• Confirm infection• Determine species
• FISH– Detects Babesia DNA in patient blood
film– Specific probe binds to DNA– Highly specific; not as sensitive as PCRIGeneX
Diagnosis
• Subinoculation into laboratory animals– 2-4 weeks for parasites to appear in
circulation– Hamster – Babesia microti– No known laboratory host for all of
the human Babesia spp.
Treatment• Atovoquone/azithromycin 7-10 days
– B. microti infections– 15% adverse reactions– Diarrhea and rash
• Clindamycin/quinine 7-10 days– Recommended for severe babesiosis– 72% adverse reactions– Diarrhea; tinnitus and hearing loss
• Exchange transfusion - severe illness
Prevention• Avoid areas with ticks, mice and deer
– Especially May-October– Especially immune compromised people
• Anti-tick strategies– Long sleeves, long pants tuck cuffs into
socks– Pyrethrins on clothing– DEET on exposed skin– Check for and remove ticks promptly after
possible exposure
Prevention II• Property
– Keep grass short– Remove leaf litter– Discourage mice
• Seal potential den holes• Pyrethrin treated cotton
– Discourage deer• “Deer proof” plants• Fencing
Prevention III
• Transfusion risk– No FDA approved test for donated
blood– Agencies prohibit donations by
people who live in or visit endemic areas– Research ongoing for ways to
inactivate organisms in blood
Zoonotic Babesia spp.• Europe
– Babesia divergens - France, Ireland, Great Britain (cattle production)
– Babesia venatorum – Austria, Italy, Germany– Babesia microti
• Asia, Africa, and South America– Babesia microti-like– B. divergens-like– Ovine Babesia-like
Babesia divergens• Most cases occur in France & British
Isles– 30 reported human cases – Associated with cattle– 84% asplenic patients; 42% fatality rate– Infection is considered a medical
emergency
• Hosts– Cattle, small mammals– Ixodes ricinus
Babesia venatorum
• Three documented cases– All asplenic and > 50 years– Mild to severe, but not fatal
• Parasites – typical paired pyriform• Hosts
– Roe deer– Ixodes ricinus
Zoonotic Babesia spp.
• United States– Babesia microti - Northeast
and upper midwest– Babesia duncani – Washington state (WA1-
3)– California CA1-6 (similar to B. duncani ?)– Babesia divergens-like – MO-1 and KY (Nantucket Island)– Babesia divergens-like –
Washington state
Babesia microti• Most cases occur in the U.S.
– > 300 known cases – not a reportable disease– Variable severity of disease
• Most symptomatic cases mild and self-limiting• Immune suppressed or >50 yrs at higher risk of
severe disease • 5% mortality rate
– Tick transmission May-October – Transfusion or blood product associated cases– Neonatal cases
Babesia microti
• U.S. endemic regions– Ixodes scapularis – White footed mouse– White-tailed deer maintain the vector
tick – B. microti cannot infect deer
• Parasites in tetrads in “paired” form
Babesia microti
• Not considered a major human pathogen in Europe– High prevalence in rodents– Ixodes trianguliceps vector tick – nest
dwelling– Ixodes ricinus
Babesia duncani
• Washington and California• Five cases
– Spleen intact individuals– Subclinical to severe illness– 2 were acquired via transfusion
• Seroprevalence 4 to 17%• Tick vector and reservoir host
unknown• Parasites in tetrads in “paired”
form
Babesia divergens-like
• One case in Washington state – Asplenic, > 50 years– Similar molecularly to Babesia divergens– Tick and reservoir host not known
Babesia divergens-like
• Two cases - MO-1 and KY– Both asplenic, > 50 years– Both severe disease, 1 death– Parasite endemic on Nantucket
Island • Eastern cottontail rabbits• Ixodes dentatus• Not infective to cattle• No human cases on Nantucket
Island
Babesia divergens-like cases of Human Babesiosis
• KY isolate– Critically ill man admitted to
emergency room in Kentucky• Fever • Chills• Bloody urine
• Immediately started on
doxycycline – Ehrlichiosis?
Babesia divergens-like KY
• Blood smear - Numerous babesia organisms• History
– Splenectomy 9 years previously– Tick exposure
• Recreational hunter• WTD and cottontail rabbits
Diagnosis and Treatment• Negative for Ehrlichia and Babesia microti• *** Babesia divergens *** (Beattie et al. 2002)
•Pathology - Asplenic•Morphology•18S rRNA gene sequence
• Hospitalized for 12 days• TX: Clindamycin, quinine, and doxycycline
• MO-1– Fever, chills, headache, sore throat, and joint
pain– No improvement with erythromycin– Fatal infection (Herwaldt et al, 1996)– MO-1 18S rRNA gene identical to KY
B. divergens-like MO-1
• Nantucket (rabbit isolate)– KY/MO-1 18S rRNA gene identical to NR (Goethert & Telford 2003)
– 16% of rabbits positive by PCR– Ixodes dentatus ticks, larval to nymphal stage
4% +
B. divergens-like NR
Babesia divergens Discrepancies
• Tick vector ? • Neither patient had traveled
outside of the US• No known infection in U.S. cattle
despite high cattle population in Kentucky and dairies on Nantucket Island
rRNA ITS1 & ITS2 Percent Identities
KY NR Bdiv
KY 100 100 94
NR 100 100 94
Bdiv 90 90 100
SSUrRNA ITS1
5.8S ITS2 LSUrRNA
Infection Studies• Source of parasites needed
– No blood from the case• Rabbits
– Limited by extremely low circulating parasitemias
• In vitro culture – Produce quantities for additional
characterization– Collaboration with Goethert and Telford,
Tufts University
Host erythrocyte specificity in vitro
Parasite Host RBC Serum supplement
Nantucket Rabbit (NR774)
B. divergens
HumanBovine
Cottontail rabbit
HumanBovine
Cottontail rabbit
Human Bovine Human
HumanBovineHuman
Growth
YesNoYes
YesYesNo
Results - Morphometric
Parasite
Host RBC Size Stddev
NR HumanCottontail rabbitBovine
4.3 µm ± 0.48
4.2 µm ± 0.56N/A
Bdiv HumanBovineCottontail rabbit
3.1 µm* ± 0.53
2.2 µm ± 0.36N/A
KY Human (blood) 4.1 µm ± 0.58
PCR Culture Day Controls Principals Controls Principals Aspl Spleen Aspl Spleen Aspl Spleen Aspl Spleen
-17 - - - - - - - - - - - - 4 + + - - - - + (4) - - - - - 5 - + - - - - + (2) + (4) - - - - 6 + + - - - - + (2) + (2) - - - - 7 + + - - - - + (1) + (2) - - - - 9 + + - - - - ND ND - - - -
10 + + - - - - ND ND - - - - 11 + + - - - - ND ND - - - -
PCR Culture Day Controls Principals Controls Principals Aspl Spleen Aspl Spleen Aspl Spleen Aspl Spleen
-17 - - - - - - - - - - - - 4 + + - - - - + (4) - - - - - 5 - + - - - - + (2) + (4) - - - - 6 + + - - - - + (2) + (2) - - - - 7 + + - - - - + (1) + (2) - - - - 9 + + - - - - ND ND - - - -
10 + + - - - - ND ND - - - - 11 + + - - - - ND ND - - - -
Cattle Infection Study
Conclusions• KY and NR are conspecific
– Identical 18S rRNA gene sequence– Identical ITS1 / ITS2 sequences– Size - large babesia – Morphology
• B. divergens distinct – ITS1 and ITS2 sequences vary from KY/NR– Size - small babesia in natural host– Morphology– Infective for cattle– Culture – Bovine RBC, not cottontail rabbit
Babesia divergens is not endemic in the U.S.
Acknowledgements
Dr. Andy Allen, Washington State University, Pullman, WA
Dr. Jim Beattie, Bowling Green Associated Pathologists, KY
Dr. Bob Droleskey, USDA, College Station, TXDr. Heidi Goethert, Tufts University, MADr. Sam Telford, Tufts University, MADr. Will Goff, USDA, Pullman, WADr. Don Knowles, USDA, Pullman, WAAngela Spencer & Lorien Schoelkopf
Funding: NIH RO3, USDA/ARS, Texas Agricultural Experiment Station