A 58‐year‐old man with alcoholic cirrhosis presented with anemia and hematochezia. Five weeks prior, he had received 2 units of red cells and 3 units each of platelets and plasma for anemia, thrombocytopenia, and coa‐gulopathy during an admission for a subarachnoid hemorrhage. Two weeks after discharge, he presented to the emergency department with hypotension after 3 episodes of brisk rectal bleeding. Emergent endoscopy revealed bleeding varices, and he underwent banding and transjugular intrahe‐patic portosystemic shunt procedure. Three days later, he developed a fever to 39.1°C. Physical examination revealed scleral icterus, a 2/6 apical holosystolic murmur, and abdominal distention with mild right upper quadrant tenderness. No rashes, edema, or arthritis were noted. Although not palpable, spleen size was 17 cm on abdominal CT. Laboratory studies showed a hemoglobin of 9.8 g/dL and platelets of 21,000/μL, but Howell‐Jolly bodies were not seen. Hemolysis was evidenced by marked hyperbilirubinemia (10 mg/dL), elevated lactate de‐hydrogenase (936 IU/L), low haptoglobin (<15 mg/dL), and reticulocyte count of 3.5%. Wright's and Giemsastained thin and thick blood smears revealed ring forms, suggestive of Babesia species. A confirmatory PCR was positive for Babesia microti. On further questioning, the patient stated he resided in Brooklyn, New York, and denied any known tick bites. He had emigrated from Mexico 24 years ago but had traveled to the region of Puebla 3 months prior. Although Babesia species have been identified in Mexico, none are known to infect humans. Hence, transmission of Babesia from the previous transfusion of donor packed red cells from an area of endemic Babesia, the northeast United States, was implicated and is under investigation. Intravenous azithromycin and atovaquone were initiated and continued for more than 8 weeks because of persistent parasitemia.
Babesia species are intraery‐throcytic protozoa contracted after bites from I xodes ticks, which are endemic to the northeastern and Midwestern United States. After an average incubation period of 3 weeks, fever and chills and muscle and joint pains develop, along with moderate intravascular hemolysis because of the intracellular reproduction of parasites. Splenectomized and immunocom‐promised patients are at greatest risk for active infection, and this case identifies patients with cirrhosis as an at‐risk group. Individuals may also acquire the infection after transfusion of Babesia‐infected blood products from asymptomatic carriers, especially in endemic areas. Systematic screening of the blood supply for Babesia is costly, slow, and labor intensive. More than 70 cases of transfusion‐transmitted infection with Babesia have been reported. In cirrhotic patients, markers of hemolysis are typically abnormal, making identification of Babesia infection even more difficult.
In endemic areas, babesiosis must be considered in susceptible patients presenting with hemolysis after a recent exposure to potentially tainted blood products.
K. Fichtel ‐ none; E. L. Esquivel ‐ none
To cite this abstract:Fichtel K, Esquivel E. Tick‐Ed Off by a Pint: Hemolysis in a Cirrhotic Patient. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 276. Journal of Hospital Medicine. 2011; 6 (suppl 2). https://www.shmabstracts.com/abstract/ticked-off-by-a-pint-hemolysis-in-a-cirrhotic-patient/. Accessed May 22, 2019.