Case Presentation: A 46 year old man living in southwestern Maine with a history of hypertension, hyperlipidemia, and obesity presented in late September with 2 days of numbness in the right foot that progressed to bilateral lower extremity weakness, numbness, and difficulty ambulating. Patient denied any recent illnesses, vaccinations, travel or known bites the month prior to symptom onset. He was found to have a wide ataxic gait, decreased sensation bilaterally from the toes to his knees, absent deep tendon reflexes at biceps, triceps, brachioradialis, patellar and achilles, and downward Babinski reflexes. Initial work up included urine porphyrin, urine heavy metal, HIV, ANA, RF, B12, folate, CBC with differential and CMP which were all unrevealing. MRI of brain, cervical, thoracic and lumbar spine were normal. Lumbar puncture demonstrated albuminocytologic dissociation, and therefore the patient was initiated on IVIG for Guillain-Barre syndrome. Tick panel testing for Lyme and Anaplasmosis was negative, but resulted positive for Babesiosis by PCR, and the patient was treated with atovaquone and azithromycin. Considering the CBC did not show anemia, thrombocytopenia, or RBC abnormalities and without the classic presentation such a gradual onset of fever fatigue and malaise the patient’s parasite load was likely low. His symptoms initially worsened to include mild upper extremity weakness before stabilizing. He did not require respiratory support. After acute and sub-acute rehab, he has slowly but significantly improved.
Discussion: Guillain-Barre syndrome (GBS) is an autoimmune disease believed to involve cellular and humoral immunity leading to demyelination of peripheral nerves. It presents with ascending paralysis, areflexia, and sometimes sensory loss. Seventy percent of cases have an inciting respiratory or gastrointestinal illness 1-3 weeks prior to onset. Common inciting agents include Campylobacter, viral infection (HHV, CMV, Epstein–Barr, HIV, hep E), several vaccines, and lymphomas. Babesiosis is a protozoan parasite infecting red blood cells, and is transmitted by the Ixodes scapularis tick mainly during the months of May through October. It usually presents with gradual onset of fever, fatigue, malaise, and generalized weakness. As with other tick-borne illnesses, patients may never see the attached tick and will be unaware of the exposure. Interestingly, this patient appeared to have limited symptoms and signs typical of Babesiosis infection, but lived in an endemic area during tick season. There are very few reported cases linking Babesiosis to GBS. The first case was reported in 1979 which attributed the syndrome to the anti-infective diminazene given for Babesiosis treatment. The second case in 1999 showed a clear correlation, while in a 2022 case the patient had multiple coinfections including Babesiosis. Fortunately, with appropriate treatment for both Babesiosis and GBS as well as intensive rehab, our patient is recovering.
Conclusions: Although apparently rare, we suggest that Babesiosis be considered as a plausible cause of Guillain-Barre syndrome. A high level of suspicion is necessary, and if lacking other more common etiologies of GBS, given our patient above, we suggest testing patients for tick borne illnesses when they live in endemic areas.