Transcript what is the diagnosis?

AN ELDERLY WOMAN
WITH A FEVER
Case Presentatoin
Dr M Haghighi
A woman in her seventies presented to the
emergency department because of a febrile illness
of one week's duration. She reported daily fevers
up to 104°F (40°C), rigors and sweats.
She also reported a dry cough, without shortness
of breath, sinus congestion, headache, abdominal
pain, nausea, vomiting, diarrhea, dysuria or urinary
frequency.
PAST MEDICAL HISTORY
She had hypertension and left bundle branch
block, a previous history of invasive melanoma
(status post excision in four years before) and, many
years before, Lyme disease. She had never had a
blood transfusion.
MEDICATIONS
She took verapamil daily.
ALLERGIES
She had no allergies.
SOCIAL HISTORY
She was retired, and had previously worked in an
office.
EPIDEMIOLOGICAL
HISTORY
 She lived in Tehran. She had traveled extensively, including
to Africa, Europe and South America. Her most recent
international trips were eight months earlier to South Africa
where she visited Kruger National Park and participated in
game drives and walking safaris and one year earlier to Kenya.
She did not take anti-malarial prophylaxis. She did
not report any recent sick contacts or insect bites.
PHY SICAL EXAMINATION
 The patient appeared diaphoretic, but was not in any acute
distress. The temperature was 104.7°F (40.4°C ), blood
pressure 122/69 mm Hg, pulse 68 beats per minute,
respirations 18 breaths per minute and oxygen saturation by
pulse oximetry 94% while breathing room air.
There were fine crackles in the bases of both
lungs, and the examination was otherwise normal.
STUDIES
 The level of hemoglobin was 12.0g/dl, white blood count
4,400 cells per cubic millimeter (61% neutrophils, 32%
lymphocytes, and 6% monocytes) and platelet count 52,000
per cubic millimeter (reference range 150,000-450,000).
 The level of aspartate aminotransferase was 193 U/L
(reference range 8-37 U/L) and alanine aminotransferase was
157 U/L (reference range 8-35 U/L). Results of other routine
laboratory tests and urinalysis were normal.
A chest radiograph revealed small bilateral pleural
effusions
Cultures of the blood and urine were sterile.
Thick and thin peripheral blood smears are
shown, The intraerythrocytic parasites were thought
to represent Plasmodium falciparum with 1.11%
parasitemia.
PERIPHERAL SMEAR,
WRIGHT-GIEMSA STAIN
PERIPHERAL SMEAR,
WRIGHT-GIEMSA STAIN
PERIPHERAL SMEAR,
WRIGHT-GIEMSA STAIN,
X1250 MAGNIFICATION
Atovaquone and proguanil hydrochloride (in
combination, 4 tabs orally, daily) were administered.
 On the evening of the first day, fevers persisted and the level of
parasitemia was 0.83%.
 On the second day, the maximum temperature was 104.2°F
(40.1°C). The platelet count was 62,000 per cubic millimeter and the
level of parasitemia 0.74%.
Malaria PCR was negative.
WHAT IS THE DIAGNOSIS?
 Thick and thin peripheral blood smears revealed intraerythrocytic ring
forms including multiple vacuolated forms (Figures 2 through 4). No
schizonts or gametocytes were visualized. Because of the persistent
fevers, the peripheral smears were reviewed and additional testing
performed.
 Malaria PCR was negative. Babesia PCR was positive for Babesia microti
; Babesia microti IgG and IgM were elevated at greater than 1:1024
(reference range less than 1:64) and greater than 1:320 (reference range
less than 1:20), respectively.
FINAL DIAGNOSIS
Babesiosis caused by Babesia microti.