Babesia parasitemia rebound after red blood cell exchange

Abstract

Babesiosis is an increasingly recognized disease which may benefit from therapeutic apheresis (Category II/Grade 2C). Vulnerable populations include the splenectomized, those aged >50, those with malignancies, and the immunocompromised. In the setting of parasite levels > 10%, significant anemia, renal impairment, pulmonary compromise, or hepatic dysfunction, RBC exchange can rapidly reduce parasite burdens and decrease the bioavailability of proinflammatory cytokines. No previous report has shown such a rapid rebound in parasitemia despite adequate organism removal. Herein, we report a case of severe babesiosis in a splenectomized 56 year old male with a past medical history significant for benign multiple sclerosis. Following a week of flu-like symptoms, the patient presented to an outside hospital with anemia, elevated bilirubin, thrombocytopenia, and 15% of his RBCs containing Babesia forms on a peripheral smear. Despite initiation of appropriate antimicrobials, subsequent transfer to our facility revealed worsening parasitemia (25%), tachypnea, and hypoxia. An emergent two volume RBC exchange was performed, resulting in 15% post-exchange parasitemia. Twelve hours later, the parasitic burden had climbed to 30%. A second RBC exchange reduced the parasite burden to 1.5%. His post-procedural course was significant for diminishing periodic increases in parasitemia despite continued antimicrobial therapy. Rapid increases in parasitic burden following RBC exchanges can occur and post-procedural surveillance of parasitemia should be closely monitored to expedite additional exchanges.

Case Report: Overwhelming Babesia Parasitemia Successfully Treated Promptly With RBC Apheresis and Triple Therapy With Clindamycin, Azithromycin, and Atovaquone

“…Based on a large case series of 34 cases, in which 7 patients underwent RBC exchange, a parasitemia level >10% was associated with the decision to perform RBC exchange, an arbitrary threshold unsupported by high-quality evidence. Clinicians would still need to be vigilant about post-RBC exchange parasitemia rebound [ 6 ]. Further clinical trials are warranted to fully evaluate the role of RBC exchange.…”

Vascular access for red blood cell exchange

“…RBC exchange in patients with babesiosis and malarial infection can rapidly reduce parasitemia and is generally well tolerated . However, rebound increase in parasite burden can occur . A group at the Centers for Disease Control and Prevention who analyzed available data in 2013 did not recommend RBC exchange based on the lack of evidence showing efficacy with regard to outcomes despite demonstrated rapid parasite clearance times.…”

“…1,[6][7][8] However, rebound increase in parasite burden can occur. 9,10 A group at the Centers for Disease Control and Prevention who analyzed available data in 2013 did not recommend RBC exchange based on the lack of evidence showing efficacy with regard to outcomes despite demonstrated rapid parasite clearance times. However, ASFA disputed those findings by pointing out variations between approaches and continues to support the use of RBC exchange for severe malaria on an individual basis.…”

The unusual case of babesiosis causing disseminated intravascular coagulation with hemophagocytic lymphohistiocytosis

“…Sporozoites subsequently enter erythrocytes and undergo asexual replication leading to red blood cell (RBC) lysis 1,3 . Clinical manifestations range from asymptomatic to severe fulminant disease, leading to hemolytic anemia, thrombocytopenia, hemophagocytic lymphohistiocytosis (HLH), splenic rupture, or even disseminated intravascular coagulation (DIC) 4 4 …”

“…Clinical manifestations range from asymptomatic to severe fulminant disease, leading to hemolytic anemia, thrombocytopenia, hemophagocytic lymphohistiocytosis (HLH), splenic rupture, or even disseminated intravascular coagulation (DIC) 4 4 …”