Probable Congenital Babesiosis in Infant, New Jersey, USA

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Probable Congenital Babesiosis in Infant, New Jersey, USA

 

Emerging Infectious Diseases

Volume 15, Number 5–May 2009

 

Sonia Sethi, David Alcid, Hemant Kesarwala, and Robert W. Tolan, Jr.

 

Author affiliations: The Children's Hospital at Monmouth Medical Center,

Long Branch, New Jersey, USA (S. Sethi); Saint Peter's University Hospital,

New Brunswick, New Jersey, USA (D. Alcid, H. Kesarwala, R.W. Tolan, Jr.);

Robert Wood Johnson Medical School, New Brunswick (D. Alcid); and Drexel

University College of Medicine, Philadelphia, Pennsylvania, USA (H. Kesarwala,

R.W. Tolan, Jr.)

 

 

Abstract

 

Only 2 neonates with transplacentally or perinatally acquired (congenital)

babesiosis have been reported. We describe a probable third congenital

case of babesiosis in a 26-day-old infant; transmission was determined on the

basis of a blood smear from the infant (15% parasitemia) and serologic

results from the infant and mother.

 

 

 

 

 

Victor Babes first described the pathogen of babesiosis in 1888 (1).

Babesiosis is a tick-borne malaria-like illness transmitted by the same Ixodes

spp. ticks that transmit Borrelia burgdorferi (2). It is endemic to the

northeastern and northwestern United States and also occurs in Europe and parts

of Asia. Babesiosis is an intraerythrocytic parasitic infection that

ranges from subclinical to severe (possibly fatal) disease with fever,

thrombocytopenia, hemolytic anemia, and hyperbilirubinemia. Appropriate

antimicrobial drug therapy, transfusion, and exchange transfusion remain the

mainstays

of treatment.

 

Babesiosis occurs rarely among neonates, although it is gaining increasing

attention as an emerging tick-borne zoonosis. In 1987, Esernio-Jenssen et

al. (3) reported an apparent case of transplacentally or perinatally

transmitted congenital babesiosis. In 1997, New et al. (4) reported another

case.

We describe a third case of probable congenital babesiosis in a 26-day-old

infant with 15% parasitemia. She was treated successfully with atovaquone

(Mepron; GlaxoSmithKline, Research Triangle Park, NC, USA) and azithromycin

(Zithromax; Pfizer, New York, NY, USA)....

 

 

 

 

 

Conclusions

 

Of 10 cases of babesiosis in neonates that have been reviewed (5), 2 were

congenital (3,4), 2 were transmitted by a tick bite (6), and 6 were

associated with transfusions (5,7–9). The 2 congenital cases (3,4) are

compared to

our probable congenital case (Table 2). All 10 of the affected neonates

were reported to have <9% parasitemia (5). The illness ranged from no

symptoms in 2 infants transfused with contaminated blood (8) to symptomatic

disease (as in our infant) with fever and hepatosplenomegaly in 5 of 7 (71%),

hemolytic anemia in 8 of 10 (80%), indirect hyperbilirubinemia in 4 of 5

(80%), and thrombocytopenia in 7 of 9 (78%) (5). Five of 8 (63%) patients

required erythrocyte transfusion (5). The infant we describe had all of these

manifestations as well as a higher parasite count than described previously

(5). Clearly, the spectrum of neonatal babesiosis is variable and must be

more fully elucidated, as must determinants of the illness's clinical course

and parasite clearance. In neonates, the degree of parasitemia may not

parallel the severity of the babesiosis.

 

The combination of quinine sulfate and clindamycin hydrochloride for

treatment of a newborn with transfusion-associated babesiosis was described in

1982 and subsequently became the first accepted treatment (7). A combination

of azithromycin with atovaquone for 7 to 10 days has emerged as an

alternative regimen (8,10–11), having been used successfully in 2 neonates

(8,10)

and several adults (11) in whom it appears to be safe and effective.

Finally, the addition of azithromycin or atovaquone to the clindamycin

hydrochloride plus quinine sulfate regimen has been proposed (2,8),

particularly if

parasitemia is slow to resolve.

 

Recently, our understanding of babesiosis and the methods of testing for

it have improved dramatically. Because babesiosis (and congenital

babesiosis) is an emerging tick-borne zoonosis, it is worthwhile to review the

state-of-the-art approach to its diagnosis in the context of the limitations to

diagnosis inherent in this particular case, including its retrospective

nature, the mother's lack of insurance and resultant unwillingness to undergo

any additional laboratory testing, and the loss to follow-up of the infant

and her migrant family.

 

Diagnosis of congenital babesiosis requires definitive evidence of

babesiosis, including evidence from reference laboratory species-specific IFA

testing, PCR confirmation, and evidence from reference laboratory evaluation of

peripheral blood smears, particularly blood smears with high parasitemia

(necessary because of the numerous species of Babesia endemic to the United

States, including B. microti, B. divergens–like, B. duncani, MO-1, CA-1,

and WA-1). Accurate diagnosis also requires collection of extensive

epidemiologic information about patients with suspected infections, including

their

recent and remote travel history, exposure to ticks, transfusion or

transplant. Follow-up for recrudescence is important, particularly for the

immunocompromised patient.

 

Our report of a probable third case of congenital babesiosis illustrates

the variability in the manifestations and clinical course of the illness,

suggesting a need for improvement in how the disease is recognized and for

evaluation of current treatment modalities.

 

 

 

 

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