Fever and Jaundice case

79 year old male who lives in Wisconsin presents for 4 days of fever and jaundice, end up having babesiosis.

Differential Diagnosis of febrile jaundice:

1-Jaundice from Hemolytic anemia:

  • Malaria
  • Babesiosis
  • Any other infection with drug related hemolysis

2-Jaundice from liver disease:

  • Acute hepatitis
  • Ascending Cholangitis
  • Pancreatic Cancer: paraneoplastic fever and obstructive jaundice
  • Any infection with prior liver disease: Such as SBP, sepsis, Pneumonia, UTI in an alcoholic cirrhotic patient
  • With renal failure: Consider Leptospirosis

The diagnostic clues during the interview should search for camping, outdoor activities, travel history, alcohol abuse, type of work, medications, known history of gallstones. Ask about urine color and stool color!

The laboratory and imaging will help also such as liver ultrasound, Bilirubin D and indirect, retic count, liver function tests, peripheral blood smear(re:schistocytes).

INR to differentitate between DIC and microangiopathic hemolytic anemia such as in TTP/HUS.

  • Babesiosis is transmitted by tick (Ixodes scapularis) and caused by intraerythrocytic protozoa(babesia)
    Babesiosis cases are severe in elderly, splenectomized and immunosuppressed patients.
    Jaundice is not common 
    Prognostic factors: LDH>125, male gender, WBC>5,000
    Diagnosis via Giemsa-stain thin blood smear, indirect immunofluorescence, and serology Ig>64, PCR
    Treatment is not always indicated.
    Concomitant Lyme disease (B burgdorferi )and Human granulocytotropic anaplasmosis (Anaplasma phagocytophilum)is possible because of common vector

Treatment Protocols:
depends on the species, severity and duration depends on severity, progression, and may need to be repeated.

For B. Microti

  • Mild: Atovaquone (750 mg po q12h) and Azithromycin (500-100 mg pox1 then 250 mg po qd)
  • Severe:Clindaymycin (600 mg q6h) plus quinine (650 mg q 6-8h) – consider exchange transfusion when parasitemia>10%, significant hemolysis, renal, hepatic or pulmonary compromise

For B. divergens: frequently severe and rapidly progressive in asplenic patients, more frequently noted in Europe.

  • Exchange trasnfusion
    plus
  • Clindamycin plus quinine

Ref: You may refer to the original article in Mayo Clinic Proceedings.
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