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AN UNCOMMON CONCURRENCE OF BABESIOSIS AND ACETAMINOPHEN OVERDOSE: CASE REPORT

      TOPIC: Pulmonary Manifestations of Systemic Disease
      TYPE: Medical Student/Resident Case Reports
      INTRODUCTION: Babesiosis is a tick-borne illness caused by B. microti and other species and transmitted by the Ixodes tick. Acute respiratory distress syndrome (ARDS) can be a manifestation of babesiosis.
      CASE PRESENTATION: A 69 year old female with the past medical history of HTN, HLD and hypothyroidism who presented to hospital for 1 week of intermittent fever and generalized body aches. Patient denied any tick bites. She started to have intermittent fever around 40°C, nonproductive cough and generalized body aches, associated with night sweats, nausea, diarrhea. She took 1000mg Tylenol every 4 hours for fever and body aches for 1 week without improvement.Upon admission laboratory values were significant for hemolytic anemia (Hgb 9.4 g/dL, reticulocyte count 1.2%, LDH 4896 U/L, haptoglobin < 8mg/dL, total bilirubin 2.3 mg/dL), thrombocytopenia (platelet 38× 103/mm3) and leukopenia (WBC 2.7× 103/mm3), significantly elevated acetaminophen level (22.6), transaminitis (ALT 365 IU/L, AST 579 IU/L) and elevated INR (1.4). Blood parasite smear was positive for blood parasites (Malaria/Babesia: 9.6% RBC infected). Babesia Microti DNA RT-PCR was positive, Babesia Microti Ab (IgM) ≥ 1:320, Babesia Microti Ab (IgG) was 1:512, E. Chaffeensis Ab Ig G <1:64, E. Chaffeensis Ab Ig M <1:20, Lyme Ab Scr-Q <0.90. HIV and blood culture was negative. SARS-CoV-2 RNA was negative.Patient was admitted and received Acetylcysteine for acetaminophen toxicity, atovaquone, azithromycin, doxycycline for Babesia and borreliosis coverage. On day 2 of admission, acetaminophen level decreased to less than 10, transaminitis slowly improved. But patient developed shortness of breath, cough and hypoxia. Concerning severe babesiosis induced ARDS, chest CT angiogram was ordered and showed no evidence of pulmonary embolism but mild pulmonary interstitial edema. 2D Echo showed normal left ventricular systolic function and mild diastolic dysfunction. Patient received IV Lasix, symptoms improved and the CXR on day 6 showed pulmonary edema resolved.In the following days, patient continued to receive treatment for babesiosis, blood parasitemia cleared but Hgb decreased to 6.7 g/dL, patient received transfusion and Hgb level remained 7.9 g/dL on the day of discharge. 5 days after discharge, patient's Hgb level increased to 9 g/dL. 1 month after discharge, Hgb level increased to 12g/dL and transaminase level returned to normal.
      DISCUSSION: ARDS is a life-threatening condition characterized by severe hypoxemia due to pulmonary gas exchange failure. Though uncommon, tick-borne diseases could present with ARDS. Moreover, acetaminophen toxicity has also been linked to acute lung injury, making the correct diagnosis challenging. Early recognition and intervention led to a favorable outcome.
      CONCLUSIONS: ARDS can be an early onset manifestation after initiation of treatment for babesiosis and usually resolves with supportive treatment.
      REFERENCE #1: Autoimmune hemolytic anemia associated with babesiosis.Roshni Narurkar, Aleksandra Mamorska-Dyga, John C. Nelson and Delong Liu.Biomarker Research (2017) 5:14.
      REFERENCE #2: Yousef Nassar, Seth Richter. Babesiosis Presenting as Acute Liver Failure. Case Rep Gastroenterol 2017;11:769–773.
      REFERENCE #3: Boustani MR, Lepore TJ, Gelfand JA, Lazarus DS. Acute respiratory failure in patients treated for babesiosis. Am J Respir Crit Care Med. 1994 Jun;149(6):1689-91. doi: 10.1164/ajrccm.149.6.8004331.PMID: 8004331 Review.
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