Correspondence

Acute Babesiosis Caused by Babesia divergens in a Resident of Kentucky

N Engl J Med 2002; 347:697-698August 29, 2002

Article

To the Editor:

Babesia divergens is the primary cause of human babesiosis in Europe, resulting in fatality rates of 42 percent among persons who have undergone splenectomy and 5 percent among persons with intact spleens.1 The known vector tick, Ixodes ricinus, 2 is not indigenous to North America. We report what we believe to be the first human case of babesiosis caused by B. divergens in North America.

A 56-year-old man presented with a fever (temperature, 40°C), a hemoglobin level of 13.7 g per deciliter, a platelet count of 43,000 per cubic millimeter, and hemoglobinuria. He had had headaches for two weeks and had been treated with amoxicillin, without improvement. The history included splenectomy in 1993, a Caribbean cruise nine months earlier, and deer and rabbit hunting four weeks previously, but he had no recollection of a tick bite. Doxycycline therapy (100 mg twice daily) was initiated. The Giemsa-stained blood smear revealed characteristic B. divergens organisms (30 to 35 per 100 red cells) in singles, pairs, and tetrads (Figure 1Figure 1 Babesia divergens in a Giemsa-Stained Blood Smear (×1470).). Therapy with clindamycin (900 mg intravenously every eight hours) and oral quinidine (650 mg three times a day) was instituted. Defervescence began after 72 hours. Hemoglobinuria cleared by day 7. Polymerase-chain-reaction tests for Ehrlichia chaffeensis and B. microti were negative (MRL Reference Laboratories). When he was discharged on day 12 while continuing to take medication, he had a parasite count of 5 to 10 per 100 oil-immersion fields; he has not had a relapse for over a year.

The parasite small subunit ribosomal RNA gene was amplified from extracted DNA, cloned, and sequenced3,4 after appropriate measures were taken to prevent cross-contamination of samples. The resulting 1724-bp sequence differed at three nucleotide positions (99.8 percent homology) from that of B. divergens GenBank accession number U16370 (99.3 percent and 98.2 percent homology to B. divergens GenBank accession number V07885 and European Molecular Biology Organization accession number Z48751.1, respectively), as compared with less than 92 percent identity with B. microti (numbers AB032434, AF231349, AF231348, and U09833 according to the National Center for Biotechnology Information basic local alignment search tool [BLAST]).

This case is disturbing because it suggests that B. divergens infections may be emerging in North America. Although the source of this infection is unconfirmed, recent reports of molecular evidence of B. divergens in rabbits (27 percent of those tested) and ixodes species ticks on Nantucket Island, Massachusetts,5 suggest that the parasite was acquired while the patient was hunting rabbits.

Our findings indicate that B. divergens has caused human babesiosis in North America, that rapid, accurate diagnosis and treatment are lifesaving, and that blood banks must be aware of the potential for infection with babesia species in areas where such infections are not endemic. Physicians must consider the possibility of B. divergens infection in patients presenting with a rapid onset of fever, chills, intravascular hemolysis, and hemoglobinuria.

James F. Beattie, M.D.
Marie L. Michelson, M.D.
Medical Center at Bowling Green, Bowling Green, KY 42102

Patricia J. Holman, Ph.D.
Texas A&M University, College Station, TX 77843
pholman@cvm.tamu.edu

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