Q: 22  year old male is admitted to Texas Medical Center with high spiking fever and symptoms consistent with Malaria. Patient has a recent history of travel to his hometown in Midwestern USA. After blood smear preparation, patient has been diagnosed with babesiosis instead of malaria, and has been started on a combination treatment of atovaquone and azithromycin.  Patient continue to deteriorate. Diagnosis has been confirmed meanwhile with PCR. What is the next line of treatment?

Answer:   Exchange transfusion

There are 2 combination treatments used in babesiosis

• atovaquone and azithromycin
• clindamycin and quinine

But in severe and life-threatening cases, exchange transfusion (ET) is indicated. Babesiosis is generally a subclinical infection in most normal hosts, but it can be life threatening in asplenic patients, older, or immunocompromised individuals progressing to coma, renal failure, or ARDS. ET is recommended to reduce the level of parasitized RBCs, to remove cytokines, and to improve the rheologic properties of the blood.