Volume 22, Number 11—November 2016
CME ACTIVITY - Synopsis
Transmission of Babesia microti Parasites by Solid Organ Transplantation
||Patient A (index case-patient)
|Type of kidney transplant||Left||Right|
||Southcentral Wisconsin (urban, nonwooded area of Sauk County)
||Iowa (semirural area bordering southwestern Wisconsin)
|Cause of end-stage nephropathy||Type 2 diabetes mellitus||Type 1 diabetes mellitus|
|Pretransplant dialysis||Peritoneal dialysis in Wisconsin||Hemodialysis in Iowa|
|Other medical history
||Diabetic retinopathy; coronary artery disease
||Diabetic retinopathy (legally blind); hypertension
|Duration of hospitalization for renal transplantation, d‡||6 (late Aug–early Sep)||10 (late Aug–early Sep; patient had moderate delay in graft function)|
|Clinical manifestations potentially attributable to babesiosis
||Fever (39.4°C), sweats, fatigue, anorexia, dark urine
||Fever (38°C), fatigue, abdominal pain
|Babesia blood-smear examination|
|Date of first positive blood smear||Oct 20||Oct 23|
|Initial parasitemia level, %||8||1|
|Context for diagnosis||Platelet clumping prompted manual (nonautomated) review of blood smear||Diagnosis of case in patient A prompted evaluation of patient B during a routine clinic visit|
|Date of last positive blood smear
|Date of last B. microti PCR-positive blood specimen§
|B. microti IFA titer (date)|
|Pretransplant serum sample||<8 (Jul 30)||<8 (Aug 11)|
|Posttransplant serum sample
||4,096 (Oct 21)
||1,024 (Oct 23)
|Laboratory values when babesiosis was diagnosed (2, 6, and 16 wks after initiation of therapy)¶|
|Hematocrit, %#||21 (21, 45, 49)||35 (41, 37, 44)|
|Leukocyte count, x 109/L**||6.7||5.5|
|Platelet count, x 109/L||157||154|
|Haptoglobin, mg/dL||<8 (24, 67, 104)||ND (154, 223, 202)|
|Lactate dehydrogenase, U/L||747 (490, 220, ND)||495 (365, 344, 331)|
|Dates of hospitalization for babesiosis||Oct 20–24||None|
|Dates of 6-wk course of azithromycin and atovaquone||Oct 20–Dec 1||Oct 23–Dec 4|
*IFA, indirect fluorescent antibody; ND, not done.
†Neither patient had lived or traveled in babesiosis-endemic areas in Wisconsin (primarily, the northwestern and northcentral regions) or elsewhere.
‡Preparation of kidneys for transplantation included an in situ flush (initiated 25 min after the donor was declared brain dead and was extubated) with 2 L of University of Wisconsin solution (15), each of which was infused in <4 min; a flush with 200 mL of this solution after the kidneys were explanted; and continuous circulation with kidney perfusate solution until the kidneys were transplanted.
§Both patients had negative PCR results for followup blood specimens in February 2009.
¶Reference ranges: creatinine, 0.6–1.3 mg/dL; haptoglobin, 30–200 mg/dL; lactate dehydrogenase, 90–200 U/L.
#Hematocrit values posttransplantation were 37% (patient A) and 40% (patient B).
**Differential leukocyte counts were 73% neutrophils, 14% lymphocytes, and 13% monocytes for patient A; and 79% neutrophils, 12% lymphocytes, 8% monocytes, 1% eosinophils, and 1% basophils for patient B.
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