Babesiosis-Associated Warm Autoimmune Hemolytic Anemia
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Department of Medicine, WellSpan Good Samaritan Hospital, Lebanon, PA, USA; 2Department of Medicine, University of California, San Francisco, USA; 3Department of Medicine, Medical Service, VA Medical Center, San Francisco, CA, USA; 4Department of Medicine, Johns Hopkins University, Baltimore, MD, USA.
KEY WORDS: babesiosis; autoimmune hemolytic anemia; peripheralblood smear; clinical image. J Gen Intern Med DOI: 10.1007/s11606-019-05506-5 © Society of General Internal Medicine 2019
84-year-old man with dementia presented with 4 A nmonths of fevers, night sweats, and dark urine. He lived in Central Pennsylvania and previously underwent splenectomy following a motor vehicle accident. Physical exam showed scleral icterus, palmar crease pallor, and jaundice. Laboratory studies showed hemolytic anemia and a positive direct antiglobulin test for warm autoantibodies. Serum parasitemia levels were 5% with elevated Babesia microti IgG and IgM titers. Peripheralblood smear was consistent with asplenia and warm autoimmune hemolytic anemia. Babesia extracellular (Fig. 1, red arrowhead) and intracellular ring forms were present (Fig. 2, thin arrows). He was diagnosed with warm autoimmune hemolytic anemia (WAHA) triggered by B. microti in the setting of asplenia and chronic infection. Babesiosis is associated with two mechanisms of hemolytic anemia. Non-immune-mediated hemolytic anemia occurs from merozoite egress and resolves with antibiotic treatment. WAHA, however, is a late complication that can develop 2 to 4 weeks following treatment, especially in asplenic patients.1,2 The peripheralblood smear provided valuable insight into multiple processes: Howell-Jolly bodies indicated asplenia, nucleated red blood cells signaled hemolysis, and spherocytes pointed to WAHA. He was treated with prednisone, azithromycin, and atovaquone. After 4 months, his hemoglobin normalized and parasite levels were undetectable.
Figure 1 Peripheral-blood smear showing a Howell-Jolly body (thin arrow) indicating asplenia, Babesia microti extracellular ring form (red arrowhead), spherocytes (blue arrowhead), and a nucleated red blood cell (thick arrow).
Prior Presentations: None. Received May 1, 2019 Revised September 27, 2019 Accepted October 16, 2019
Figure 2 Peripheral-blood smear demonstrating both Babesia microti intracellular (thin arrows) and extracellular (thick blue arrow) ring forms.
Santos et al.: Babesiosis-Associated Warm Autoimmune Hemolytic Anemia
Acknowledgments: The authors would like to thank Dr. Philip P. Peters for his initial review of the manuscript and preparation of the peripheral blood smear.
REFERENCES 1. 2.
Corresponding Author: Michael A. Santos, MD; Department of Medicine, WellSpan Good Samaritan Hospital, Lebanon, PA, USA (e-mail: [email protected]). Compliance with Ethical Standards: Conflict of Interest: The authors declare that they have no conflict of interest.
JGIM
Woolley AE, Montgomery MW, Savage WJ, et al. Post-Babesiosis Warm Autoimmune Hemolytic Anemia. N Engl J Med 2017;376:939-46. Narurkar R,
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