Case Presentation: An 82 year-old male with atrial fibrillation, hypertension, and Type 2 Diabetes Mellitus presented with hiccups for five days. He also endorsed non-productive cough for weeks, chills, dysuria, and dark urine, for which he had taken ciprofloxacin. History was also notable for a previous episode of intractable hiccups attributed to pneumonia. Family history was noncontributory. Our patient had no toxic habits and a review of systems was unremarkable. Upon arrival, he was febrile and tachycardic but in no acute distress. Examination revealed jaundice and abdominal distention. Pertinent labs included thrombocytopenia, acutely elevated BUN/Creatinine, and elevation of transaminases, alkaline phosphatase, and total bilirubin. Empiric antibiotics for presumed cholangitis were started, after which his mental status worsened. Repeat labs revealed a new coagulopathy with worsening anemia, high LDH, and low haptoglobin. Abdominal ultrasound showed splenomegaly, heterogenous liver, but no gallstones. A blood smear showed Babesiosis with >15% parasitemia; atovaquone, clindamycin, and azythromycin were started and the patient was transferred to MICU for erythrocytapheresis. Subsequently, he had worsening acidosis, hyperkalemia, and hypotension requiring bicarbonate drip and vasopressors. During a 2nd red cell exchange, he suffered a asystolic cardiac arrest and persistent multi-organ failure, after which he later expired.

Discussion: Our case is significant because it illustrates an easily misdiagnosed condition with potential for catastrophic outcome if treatment is delayed. Babesiosis is a malaria-like parasite which infects red blood cells. Symptoms include fever, chills, sweats, aches, loss of appetite, nausea, fatigue, or can even be asymptomatic. Severe illness is seen in elderly, asplenic, or immunocompromised patients and is associated with parasitemia >4%, alkaline phosphatase >125 units/L, and white blood cell counts >5 x 109/L. Diagnosis is often delayed without early strong clinical suspicion; similar nonspecific symptoms and labs are seen in bacteremia, hepatitis, vasculitides, and malignancy. Definitive diagnosis requires microscopic exam of thin blood smears. Treatment involves atovaquone and clindamycin plus either azithromycin or quinine. Historically patients with severe anemia (Hgb<10g/dL) or high grade parasitemia (>10%) have been treated with red cell exchange transfusion. However, a recent review of severe malaria revealed no statistical significant benefit of red cell exchange on mortality, and it is no longer recommended by the CDC.

Conclusions: Babesiosis is a rare but debilitating and potentially fatal illness, especially in the elderly or immunocompromised. Prompt diagnosis and treatment are essential but are often delayed due to non-specificity of presentation. Detailed history with congruent exam and lab findings should prompt early blood smear examination as early antimicrobial treatment is preferred over erythrocytapheresis.