Human Babesiosis – An Update Patricia J Human Babesiosis – An Update Patricia J. Holman Department of Veterinary Pathobiology College of Veterinary Medicine and Biomedical Sciences Texas A&M University College Station, TX

Babesiosis Emerging tick-borne disease Zoonosis caused by intraerythrocytic protozoan parasites Infections may range from asymptomatic to severe, or even fatal Most cases occur in the U.S.; worldwide where ticks occur

Phylum – Apicomplexa Babesia, Plasmodium, Toxoplasma, Cryptosporidium Unique organelles comprise apical complex Electron micrograph courtesy of Dr. R.E. Droleskey USDA College Station, TX

Babesia - Two-host life cycle Sexual reproduction in the vector tick Asexual reproduction in mammalian red blood cells

Babesia divergens Tick transovarial transmission

Babesiosis Symptoms 1-6 wks after tick feeds Variable Asymptomatic infection Mild to moderate illness Severe disease – usually immunosuppressed Medication Splenectomy HIV co-infection Malignancy

Babesiosis Symptoms Clinical Presentation May last a week or months Fatigue Intermittent fever Chills, sweats, headache, arthralgia, anorexia, cough, nausea Asymptomatic infection Clinical Presentation Fever, pallor Splenomegaly Hepatomegaly May last a week or months Prolonged recovery; persistent parasitemia

Babesiosis – Severe form Most common complications Respiratory failure Congestive heart failure DIC Liver and kidney failure Splenic rupture Immunocompromised – 21% mortality

Diagnosis CBC Blood chemistry Hemolytic anemia with elevated reticulocytes Thrombocytopenia Normal to slightly decreased leukocyte count Blood chemistry Elevated serum liver enzymes (~ ½ of patients) Proteinuria, elevated blood urea nitrogen and serum creatinine

Microscopic identification Diagnosis Microscopic identification Giemsa stained thick or thin blood films Babesia ring forms can be mistaken for malaria Serology - IFA B. microti B. duncani does not cross-react B. divergens Sera from B. divergens or B. ventorum patients cross react

Polymerase chain reaction Diagnosis Polymerase chain reaction Highly sensitive and specific Useful for extremely low parasitemias Confirm infection Determine species FISH Detects Babesia DNA in patient blood film Specific probe binds to DNA Highly specific; not as sensitive as PCR IGeneX

Diagnosis Subinoculation into laboratory animals 2-4 weeks for parasites to appear in circulation Hamster – Babesia microti No known laboratory host for all of the human Babesia spp.

Treatment Atovoquone/azithromycin 7-10 days B. microti infections 15% adverse reactions Diarrhea and rash Clindamycin/quinine 7-10 days Recommended for severe babesiosis 72% adverse reactions Diarrhea; tinnitus and hearing loss Exchange transfusion - severe illness

Prevention Avoid areas with ticks, mice and deer Anti-tick strategies Especially May-October Especially immune compromised people Anti-tick strategies Long sleeves, long pants tuck cuffs into socks Pyrethrins on clothing DEET on exposed skin Check for and remove ticks promptly after possible exposure

Prevention II Property Keep grass short Remove leaf litter Discourage mice Seal potential den holes Pyrethrin treated cotton Discourage deer “Deer proof” plants Fencing

Prevention III Transfusion risk No FDA approved test for donated blood Agencies prohibit donations by people who live in or visit endemic areas Research ongoing for ways to inactivate organisms in blood

Zoonotic Babesia spp. Europe Asia, Africa, and South America Babesia divergens - France, Ireland, Great Britain (cattle production) Babesia venatorum – Austria, Italy, Germany Babesia microti Asia, Africa, and South America Babesia microti-like B. divergens-like Ovine Babesia-like

Babesia divergens Most cases occur in France & British Isles Hosts 30 reported human cases Associated with cattle 84% asplenic patients; 42% fatality rate Infection is considered a medical emergency Hosts Cattle, small mammals Ixodes ricinus

Babesia venatorum Three documented cases All asplenic and > 50 years Mild to severe, but not fatal Parasites – typical paired pyriform Hosts Roe deer Ixodes ricinus

Zoonotic Babesia spp. United States Babesia microti - Northeast and upper midwest Babesia duncani – Washington state (WA1-3) California CA1-6 (similar to B. duncani ?) Babesia divergens-like – MO-1 and KY (Nantucket Island) Babesia divergens-like – Washington state

Babesia microti Most cases occur in the U.S. > 300 known cases – not a reportable disease Variable severity of disease Most symptomatic cases mild and self-limiting Immune suppressed or >50 yrs at higher risk of severe disease 5% mortality rate Tick transmission May-October Transfusion or blood product associated cases Neonatal cases

Babesia microti U.S. endemic regions Ixodes scapularis White footed mouse White-tailed deer maintain the vector tick B. microti cannot infect deer Parasites in tetrads in “paired” form

Babesia microti Not considered a major human pathogen in Europe High prevalence in rodents Ixodes trianguliceps vector tick – nest dwelling Ixodes ricinus

Babesia duncani Washington and California Five cases Spleen intact individuals Subclinical to severe illness 2 were acquired via transfusion Seroprevalence 4 to 17% Tick vector and reservoir host unknown Parasites in tetrads in “paired” form

Babesia divergens-like One case in Washington state Asplenic, > 50 years Similar molecularly to Babesia divergens Tick and reservoir host not known

Babesia divergens-like Two cases - MO-1 and KY Both asplenic, > 50 years Both severe disease, 1 death Parasite endemic on Nantucket Island Eastern cottontail rabbits Ixodes dentatus Not infective to cattle No human cases on Nantucket Island

Babesia divergens-like cases of Human Babesiosis KY isolate Critically ill man admitted to emergency room in Kentucky Fever Chills Bloody urine Immediately started on doxycycline – Ehrlichiosis?

Babesia divergens-like KY Blood smear - Numerous babesia organisms History Splenectomy 9 years previously Tick exposure Recreational hunter WTD and cottontail rabbits

Diagnosis and Treatment Negative for Ehrlichia and Babesia microti *** Babesia divergens *** (Beattie et al. 2002) Pathology - Asplenic Morphology 18S rRNA gene sequence Hospitalized for 12 days TX: Clindamycin, quinine, and doxycycline

B. divergens-like MO-1 MO-1 Fever, chills, headache, sore throat, and joint pain No improvement with erythromycin Fatal infection (Herwaldt et al, 1996) MO-1 18S rRNA gene identical to KY

B. divergens-like NR Nantucket (rabbit isolate) KY/MO-1 18S rRNA gene identical to NR (Goethert & Telford 2003) 16% of rabbits positive by PCR Ixodes dentatus ticks, larval to nymphal stage 4% +

Babesia divergens Discrepancies Tick vector ? Neither patient had traveled outside of the US No known infection in U.S. cattle despite high cattle population in Kentucky and dairies on Nantucket Island

rRNA ITS1 & ITS2 Percent Identities SSUrRNA ITS1 5.8S ITS2 LSUrRNA rRNA ITS1 & ITS2 Percent Identities KY NR Bdiv 100 94 90

Infection Studies Source of parasites needed No blood from the case Rabbits Limited by extremely low circulating parasitemias In vitro culture Produce quantities for additional characterization Collaboration with Goethert and Telford, Tufts University

Host erythrocyte specificity in vitro Parasite Host RBC Serum supplement Nantucket Rabbit (NR774) B. divergens Human Bovine Cottontail rabbit Growth Yes No

Results - Morphometric Parasite Host RBC Size Stddev NR Human Cottontail rabbit Bovine 4.3 µm ± 0.48 4.2 µm ± 0.56 N/A Bdiv 3.1 µm* ± 0.53 2.2 µm ± 0.36 KY Human (blood) 4.1 µm ± 0.58

Cattle Infection Study

Conclusions KY and NR are conspecific B. divergens distinct Identical 18S rRNA gene sequence Identical ITS1 / ITS2 sequences Size - large babesia Morphology B. divergens distinct ITS1 and ITS2 sequences vary from KY/NR Size - small babesia in natural host Infective for cattle Culture – Bovine RBC, not cottontail rabbit

Babesia divergens is not endemic in the U.S.

Acknowledgements Dr. Andy Allen, Washington State University, Pullman, WA Dr. Jim Beattie, Bowling Green Associated Pathologists, KY Dr. Bob Droleskey, USDA, College Station, TX Dr. Heidi Goethert, Tufts University, MA Dr. Sam Telford, Tufts University, MA Dr. Will Goff, USDA, Pullman, WA Dr. Don Knowles, USDA, Pullman, WA Angela Spencer & Lorien Schoelkopf Funding: NIH RO3, USDA/ARS, Texas Agricultural Experiment Station