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Introduction History
Classification
Structure Lifecycle
Epidemiology
Pathogenesis Clinical features
Diagnosis
Treatment Animal models
Prevention
Introduction
Infection due to parasites belonging to genus Babesia
host to maintain transmission cycles Transmitted by ixodid ticks to their vertebrate hosts
History
Theobald Smith (July 31, 1859 December 10, 1934) Along with Kilbourne Discovered arthropod borne transmission in 1893 Cattle Febrile heamturia : Bloodied waters of Egypt
History
1957- 1st human case- Yugoslavian farmer
1968- 1st recognized in California (USA) 1976- Ixodes dammini identified as vector for B.
Classification
Taxonomic Classification
phylum Apicomplexa (also called Sporozoa), class Aconoidasida (Piroplasmea) order Piroplasmida families Babesiidae and Theileriidae;
Large(2.5-5m) Transovarial
Structure
Lifecycle
Epidemiology
WA-1 B. microti 300 cases
B. divergens
Temperate climates
Epidemiology
Frequency of B. microti & WA-1 in US > reported cases
Mortality in USA 5%
Survey in California 16% prevalence WA-1 Survey of Blood donors - 3-8% prevalence B. microti
Contd..
Sporadic cases Europe (France & British Isles),
Africa, Asia
Cattle Babesia (B. divergens, B. microti)
Mexico Transfusion- acquired Babesia several cases in USA, but none in Europe & elsewhere
India
Single case report
51 year old patient from Madhya Pradesh History Working nursing home in gwalior Fever, vomiting, headache, arthralgia No h/o tick bite or visit to endemic area No other family member No h/o splenectomy or blood transfusion
IJMM 2005;23:267-9
O/E Liver and spleen palpable Scleral icterus, passed dark coloured urine Investigations WBC count 1,900/cumm Platelet count 55,000/cumm LDH raised
confused P. Falciparum Antimalarial treatment no response Smear reviewed pear shaped, tetrad - babesiosis suspected HRP II negative Quinine + clindamycin Pt. afebrile within 2 days
Pathogenesis
Env
Host
Agent
elderly
preventing erythrocyte infection by binding the free sporozoites. progression stage organisms invade erythrocyte
innate immune system control growth rate of the merozoites NK cells and macrophages - soluble factors: IFN-g by NK
cells and TNF-a, nitric oxide (NO), and ROSs by macrophages (Mf).
intracellular degeneration inside the erythrocyte, as evidenced by the appearance of crisis forms.
Clinical features
Disease manifestations asexual reproductive stage
Predisposing factors +/ Mild to severe illness
Generalized weakness
Fever
Gastrointestinal symptoms (anorexia, nausea, abdominal pain, vomiting, diarrhea,
etc.) Headache Myalgia Weight loss Arthralgia Respiratory symptoms (cough, shortness of breath, etc.) Dark urine
Clinical examination
Hepatomegaly and splenomegaly Hemolytic anemia - lasts from several days to few
non-cardiogenic pulmonary edema (NCPE) is the most frequent manifestation not related
degree of parasitemia
splenic function and its onset may be early or late
pulmonary complications
Common Complications
Acute respiratory distress syndrome
Anemia requiring transfusion Congestive heart failure Disseminated intravascular coagulation Hypotension/shock Myocardial infarction Renal failure
HUMAN COINFECTION
Coinfection with B. microti & other tick-borne
serosurveys - 13% of Lyme disease patients in babesia-endemic areas are coinfected with B. microti
experience
more severe symptoms, resulting in fatality in rare cases persistence of postinfectious fatigue.
B. burgdorferi DNA persisted for prolonged periods B. microti - no significant effect on the duration of
parasitemia
Blood transfusion
Splenectomy
Diagnosis
Tick bite
Age
anemia & elevated procalcitonin levels is highly suspicious of babesiosis Laboratory tests
examination of stained blood smears
serologic evaluation with indirect (immuno) fluorescent
smears
most frequently used technique Wrights or Giemsa stain simple rings (annular), pear-shaped (pyriform), Maltese cross (tetrad form) High parasitemia present during
acute infections
varies
3 weeks to 12 weeks with the longest duration of smear positivity being 7 months for a splenectomized patient
Simple & rapid Showed 100% correlation with blood smear exam. (Mattia et al, 1993)
organisms.
Babesial organisms usually form tetrads ("Maltese
cross"), Do not have hemozoin pigments within the affected red blood cells Have extracellular merozoites
Serodiagnosis
IFATs - B. microti infections, chronic infections
Hamster-derived B. microti Ag Distinguish between B. microti, WA-1, B. divergens Specific and sensitive Diagnostic titers above 1:64 Higher cutoff titers (1:128 to 1:256) greater diagnostic specificity IgM and IgG Problematic in HIV, splenectomy Time consuming & labor intensive
IFAT
Antibody titers can remain elevated for as long as 13
months to 6 years after infection Although persistence of antibody does not necessarily reflect a measurable infection, levels of IgG antibody decline less rapidly in persistently infected patients
ELISA
ELISA Recombinant antigen - 4 antigens used
Showed high sensitivity & specificity Soluble whole parasite antigen (B. divergens)
Relationship between antibody titers, the presence of parasites, and the state of protective immunity is not clear
Antibodies may persist for long periods after the disease has cleared
PCR assay
Based on universal primer amplification of a fragment
of the small subunit rRNA gene Highly conserved among babesias Heterologous between Babesia spp. and other intraerythrocytic protozoal parasites as well as within the genus Babesia itself Distinguishes readily between B. divergens, B. microti, and Plasmodium spp., it provides a valuable adjunctive
Advantages over IFA testing. Less time consuming conducted by generalist technicians more readily be standardized sensitivity and specificity comparable to those of conventional IFAs
Quantities of parasite nucleic acid needed for defining phylogenetic relationships of these species,
asymptomatic individuals
Laboratory diagnosis
B. microti immunoblot kits
Animal Inoculation
Animal models
Rats
BALB/ c mice
Splenectomized calves Gerbils
Treatment
Prevention
Avoidance of or minimization of exposure to tick
infested areas Ase of tick repellents before entering a tick-infested area thorough examination of skin after exposure. Ticks found before attachment -removed, and Ticks found after attachment removed within 24 h limit the possibility of transmission Application of pesticide to host nests and on the coats of reservoir hosts can interrupt transmission
Vaccines
Live vaccines
living parasites cattle B. bovis & B. bigemina vaccine cattle Soluble parasite antigen (SPA) No effective B. microti vaccine MRA gene (Maltase cross form-related antigen) 37 kDa glycoprotein (Bd37)
Recombinant vaccines
Summary
Emerging disease
Common in the Americas Can be confused with plasmodium falciparum
infection
Diagnosis requires high index of suspicion Treatment involves use of At or Az or Clin + Quin
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