Case Presentation: A 52-year-old man presented with 3 weeks of intermittent fevers along with 3 days of epigastric pain and black stool in the setting of recent travel to the Poconos, Pennsylvania and Ecuador. While at his vacation home in the Poconos mountains, the patient spent time clearing away brush and ate cooked wild mushrooms from the countryside. During this trip, the patient developed intermittent high-grade fevers. The patient subsequently spent two weeks in the Ecuadorean Highlands for work. While there, the patient consumed herbal teas made of unclear ingredients and developed chills, fatigue, and dark colored urine while continuing to fever. Given that his fevers didn’t subside with Ibuprofen/Tylenol, the patient visited an Ecuadorean clinic one week prior to admission where he received Ceftriaxone, and he was discharged on a 5-day course of Cefuroxime. Lab studies at the time demonstrated a hemoglobin of 11, platelets of 64, elevated LFTs (AST: 147, ALT: 89, Alkaline Phosphatase: 287, Total Bilirubin 2.8, Direct Bilirubin 1.4) and positive Hepatitis A IgM and IgG titers. Following his return to the USA and during the 3 days prior to admission, the patient had new symptoms of poor PO intake, black stool, and delirium. At admission, the patient was febrile to 101.3 °F and tachycardic to 110. His hemoglobin was 6.3, platelets were 38, sodium was 124, and creatinine was 2.6. AST was 190, ALT was 60, Alkaline Phosphatase was 300. Physical exam was notable for jaundice, scleral icterus, abdominal pain, and bilateral non-pitting lower extremity edema. CT abdomen and pelvis demonstrated splenomegaly with concern for splenic infarcts and hepatomegaly. His blood parasite smear revealed Babesia with 1.5% Parasitemia (Figure 1).Given the severity of his anemia, thrombocytopenia, and hepatosplenomegaly, there was concern for possible co-infection, and treatment was started with oral Atovaquone, Azithromycin, and Doxycycline. IV Clindamycin was added briefly in the setting of poor oral intake. Ultimately, the parasitemia was cleared on blood parasites exam, and the patient was discharged on a 5-day course of Atovaquone, Azithromycin, and Doxycycline. At his follow-up appointment with Infectious Disease one week after discharge, his hemoglobin and platelets were 9.6 and 150, respectively. His creatinine, AST, ALT, and alkaline phosphatase downtrended to 1.8, 47, 40, and 216, respectively. On exam, his splenomegaly was resolving.

Discussion: While fever and malaise tend to be more common symptoms of babesiosis, jaundice, dark urine, and abdominal pain are less common but possible symptoms to be aware of. Given that vector of transmission for Babesia is the Ixodes tick, the chances of co-infection with Borrelia species are 50%, with co-infection resulting in a greater number of symptoms lasting for a longer duration. About half of patients hospitalized with Babesia experience complications, including ARDS, severe anemia, and renal failure. While a rarer complication, splenic rupture is usually preceded by abdominal pain. Relapse tends to occur in immunocompromised patients and is fatal in 20% of cases.

Conclusions: A diagnosis of babesia presenting with fever, dark urine, abdominal pain, and acute kidney injury is an atypical presentation of an already rare disease. This patient presentation highlights the importance of obtaining a thorough travel history during an infectious workup to guide the diagnostic workup.

IMAGE 1: Blood Parasites Exam, Babesia spp. at 1.5%