DOI: 10.1097/TP.0b013e3181957694
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PMID: 19202454
Issn Print: 0041-1337
Publication Date: 2009/02/15
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Excerpt
Our patient presented with a 3-day history of fever, jaundice, and dark urine. She underwent liver transplantation 2 years earlier for hepatitis C infection. At the time of transplant, she had splenectomy due to laceration. She had not received a blood transfusion since the time of her transplant. She did not recall any tick bites, and she denied being in wooded areas recently. She denied any travel outside the Midwest. Her medications were notable for tacrolimus and metoprolol.
At admission she was afebrile. Physical examination, except for jaundice, was unremarkable. Blood tests were notable for a leukocyte count of 22.0 k/mm3 (6% bandemia), hemoglobin of 11 g/dL (normal 12–15), total bilirubin of 6.8 mg/dL (normal 0–1) of which 4.8 was indirect bilirubin, alkaline phosphatase of 86 IU/L (normal 25–125), aspartate aminotransferase of 212 U/L (normal 15–40), alanine aminotransferase of 25 U/L (normal 0–45), and creatinine of 4.2 mg/dL (normal 0.5–1.4). Urine analysis was positive for hemoglobinuria without red blood cells. She was hospitalized and broad-spectrum antibiotics were started. Over the next several hours she deteriorated, as evidenced by fever to 38.3°C and tachycardia. Within 12 hr of admission, we were alerted that her red blood cells contained parasite-like inclusions, and the diagnosis of severe babesiosis with 50% parasitemia (Fig. 1) was made morphologically. She was then transferred to the intensive care unit, where quinine sulfate, clindamycin, and exchange transfusion were initiated. Over the next several hours, her aspartate aminotransferase increased to 7000 IU/L, lactate dehydrogenase to 15,000 U/L (normal 100–240), and total bilirubin to 8.6 mg/dL. Despite exchange transfusion, she progressed to multisystem organ failure and died within 30 hr of admission.
This case is noteworthy for several reasons. First, there are few reports of babesiosis in the midwestern United States. Second, this case illustrates the severity of disease, even in the setting of prompt diagnosis and management. Our patient was at high risk of serious infection based onsevere parasitemia (>25%), prior splenectomy, immunocompromised status, and age. Though she did not reported history of tick bite, this is most likely the route of transmission. A recent study showed discrepancy between self-reported tick bites and seropositivity for Babesia (3). Finally, with the use of MEDLINE, we found three cases (4–6) of babesiosis after solid organ transplant (two after kidney and one after cardiac transplants). To our knowledge, this is the first reported case of babesiosis after liver transplantation.
This case report demonstrates that babesiosis should be considered in the differential diagnosis in asplenic patients with history of solid organ transplantation presenting with unexplained fever, jaundice, and intravascular hemolysis.
