A 56 year old male presented with traumatic rupture of the spleen. After splenectomy, he went on to develop severe hemolytic anemia and respiratory failure. His peripheral blood smear showed that he had Babesia microtii, and the degree of parasitemia rapidly progressed after splenectomy. Erythropheresis, a novel approach to parasitic intravascular hemolysis, was used with great success in his management.
A 56 year old male presented to the hospital after suffering a fall at home. He incurred a blunt injury to the abdomen, but did not seek medical care until the next day. The fall was followed by progressive pain in his abdomen, associated with nausea and lightheadedness. He had no known chronic medical conditions, but had a remote history of illicit substance use, and was still a heavy drinker. His physical examination showed a temperature of 100.2, blood pressure of 96/65 and heart rate of 110. He had tenderness in the left upper quadrant, but no signs of peritoneal irritation. A CT scan of his abdomen revealed a rupture of his spleen, and he underwent urgent splenectomy. On the second postoperative day, he became confused and combative, and was treated for alcohol withdrawal. He deteriorated over the course of the next day, developing severe intravascular hemolytic anemia (hemoglobin dropped from 11.6 gm/dL to 7.7 gm/dL), acute kidney injury (creatinine increased from 0.6 gm/dL to 4.0 gm/dL) and respiratory failure requiring mechanical ventilation. A peripheral blood smear obtained showed that he had Babesia microtii infection, and the degree of parasitemia was estimated at 44%. Given the rapid deterioration, a novel approach was utilized to clear the parasites from his blood. In addition to Clindamycin and Atovaqoune, a hemodialysis catheter was placed, and he underwent daily erythropheresis until parasitemia was undetectable(total of 4 sessions). His renal and respiratory failure resolved and he was extubated successfully.
Babesiosis is a tick-borne, zoonotic illness caused by the intraerythrocytic parasite Babesia. The primary tick vector is Ixodes scapularis. Once in the host, sporozoites invade erythrocytes, undergo asexual reproduction and destroy the cell when they leave to invade other erythyrocytes. A majority of patients have mild to moderate illness, manifesting as fever, chills, and malaise over the course of weeks to a few months, and accompanied by hemolytic anemia. About one third of infected patients remain asymptomatic for months to years. Severe disease, manifesting as organ failure (respiratory failure, renal failure, and disseminated intravascular coagulation), is rare, and is usually associated with immune suppression, infection with HIV, or asplenia. To our knowledge, this is the first case of rapid deterioration in an asymptomatic patient precipitated by splenectomy. Treatment of severe disease is usually with supportive care and antiparasitic agents. Erythropheresis is a means of replacing the patient’s red blood cells with donor cells while preserving plasma. The centrifugation apharesis system is similar to an extracorporeal membrane oxygenation circuit. It includes an extracorporeal circuit attached to the patient by a dialysis catheter. A roller pump transports the blood through the circuit. In erythropheresis, the patient’s red cells are discarded and donor packed red cells infused along with the patient’s own plasma. There are case reports of its efficacy in treating severe cases of Falciparum malaria, and given the similarity in pathogenesis, we utilized it in this case of Babesiosis with great success.
Severe hemolytic anemia can result from Babesiosis, especially in the setting of asplenia. In our patient, it developed overnight. In cases of severe parasitemia with multiorgan failure, erythropheresis appears to be a very effective treatment option, and can be considered as an adjunct to medical therapy.
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