Correspondence

Case 29-2003: A 60-Year-Old Man with Fever, Rigors, and Sweats

N Engl J Med 2003; 349:2467December 18, 2003

Article

To the Editor:

In Case 29-2003 (Sept. 18 issue),1 it was hypothesized that the Howell–Jolly bodies seen in the blood smear of a patient with babesiosis were actually intracellular parasites (Babesia microti). In a recent case of babesiosis in an asplenic patient at our hospital, the blood smear contained both Howell–Jolly bodies and intracellular parasites.

Our patient was a 57-year-old man with a history of gastric cancer who had undergone a total gastrectomy and splenectomy. He presented with fevers and constitutional symptoms that had begun one month earlier, after he had visited Long Island, New York. Laboratory values on admission included a hematocrit of 33.6 percent, a platelet count of 60,000 per cubic millimeter, and a lactate dehydrogenase level of 2127 U per liter. Careful examination of the smear revealed 1-μm spherical inclusions of fragmented DNA, findings that are characteristic of Howell–Jolly bodies, as well as ring-shaped trophozoites, which are diagnostic of B. microti infection (Figure 1Figure 1Peripheral-Blood Smear (Wright–Giemsa Stain, ×1000).). Titers of IgG and IgM antibodies to B. microti were 1:2048 and 1:64, respectively. Although intracellular babesia may be confused with Howell–Jolly bodies, close inspection of the slide and a high index of suspicion should serve to differentiate between the two.

Jason Matthews, M.D.
Eileen Rattigan, M.D.
Herman Yee, M.D.
New York University School of Medicine, New York, NY 10016

1 References

1. 1

   Case Records of the Massachusetts General Hospital (Case 29-2003). N Engl J Med 2003;349:1168-1175
   Full Text | Web of Science | Medline

Author/Editor Response

We appreciate Matthews and colleagues' description of an asplenic patient with babesiosis. Their patient's blood smear showed the presence of Howell–Jolly bodies and intracellular parasites. In the patient described in Case 29-2003, an initial report on the blood smear also mentioned both of these findings; however, a closer review of the smear led to reclassification of all the intracellular inclusions as parasites. This conclusion confirms the correspondents' statement that a thorough inspection of the slide and a high index of suspicion should allow differentiation between these two types of inclusion.

Patients who are asplenic or who have functional hyposplenism are at increased risk for a number of infections, including B. microti infection.1 However, the patient in the Case Record had no history of a splenectomy and no disease known to be associated with functional hyposplenism.

Alexander Kratz, M.D., Ph.D.
Camille N. Kotton, M.D.
Massachusetts General Hospital, Boston, MA 02114

Joshua D. Gutman, M.D.
Family Medicine Associates, South Attleboro, MA 02703

1 References

1. 1

   Brigden ML. Detection, education and management of the asplenic or hyposplenic patient. Am Fam Physician 2001;63:499-506, 508
   Web of Science | Medline

Citing Articles (1)

Citing Articles

1. 1

   Kitsada Wudhikarn, Elizabeth H. Perry, Melissa Kemperman, Kathy A. Jensen, Susan E. Kline. (2011) Transfusion-transmitted Babesiosis in an Immunocompromised Patient: A Case Report and Review. The American Journal of Medicine 124:9, 800-805
   CrossRef