An 80 year-old woman is brought to the emergency room by ambulance after being found by her daughter unconscious on the floor of the mother’s home in a central Connecticut town located in the United States.
The 80 year-old woman is independent and lives alone. Her daughter is use to checking on her daily by either telephone or by visiting her. The daughter had become concerned when various attempts to contact her by telephone that morning resulted in no response. The daughter finally became concerned and went to her home where she found her unconscious on the kitchen floor. She called for an ambulance and was reported to be semi-responsive by the paramedics upon arrival. She was accessed and stabilized and eventually rushed immediately to the emergency room for evaluation.
When she arrived to the emergency room she had become slightly more responsive. Her physical appearance was that of a healthy 80 year-old female but with a pallor look to her complexion. She complained about feeling extremely tired and feverish. She claimed that these symptoms had appeared within the last three days.
A review of her past medical records was not significant for any ongoing health problems other than an A1c that was 7.4 and a splenectomy performed at 35-years of age after an automobile accident. Blood specimens were drawn for a complete blood cell count (CBC), electrolyte panel, liver enzyme levels, and blood cultures. Urine was collected for a urinalysis and a urine culture.
Her physical examination was significant for a body temperature of 39 degrees centigrade. Her blood pressure and respiratory rate were within normal limits. The physical was also significant for the presence of numerous bug bites around the torso area and the removal of 3 engorged nymph ticks. The ticks were sent to the Microbiology Laboratory for confirmation and identification. Upon questioning the daughter about the bites and the ticks, it was discovered that her mother was a passionate vegetable gardener and would spend one to two hours a day tending to her garden. Ticks were a frequent problem in the garden due to a healthy population of deer and other wildlife constantly entering the yard trying to get access to the vegetable garden. The daughter mentioned that she had to occasionally remove them from her mother. She had provided some repellant for her to use but she was not compliant because she found the smell of the repellent repulsive.
Serum results were as follows. Her electrolyte results were all normal but for a serum glucose of 200mg/dl, and a slightly evaluated serum creatine and BUN. The liver enzymes aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were elevated as well as the alkaline phosphatase.
Her urinalysis results were significant for 1+ protein, 2+ urinary bilirubin, 1+ ketone, 3+ occult blood, and a brown color to her urine. There were no red or white blood cells noted in the microscopic examination.
Her CBC examination results were as follows:
| CBC RESULTS | PATIENT RESULT |
| White Blood Cell Count | 2.23 × 109/L |
| White Blood Differential Cell Count | atypical lymphocytes were noted |
| Red blood cell count | 1.9 x 10*12/L |
| Red Blood Cell Differential | There was 3+ hypo-chromic RBCs noted, and suspicious intracellular elements seen (see photo below) |
| Hemoglobin | Hemoglobin of 6.8 g/dL |
| Platelet Count | 50 × 109/L |
A Wright stained photo of the microscopic examination is shown below.
Can you answer the following about this clinical case study?
Can you identify the organism(s) seen in the Wright stained smear?
What are the main identifying characteristics in the smear, clinical history, and laboratory results that would point to your identification?
How is this organism transmitted to the human host?
What are some co-morbidities that would predispose a person to an acute infection with this pathogen?
What is the standard treatment for this infection?
Plasmodium falciparum
Anophele moscitos
Quinine IV
Hi Bertrand,
actually the woman is suffering from babesiosis and is infected with Babesia microti, closely related to the Plasmodium and many times mistaken for Plasmodium falciparum. Unlike the Plasmodium, Babesia microti is transmitted by the Ixodes tick. More to come in the clinical case summary to come. Thanks for commenting!
malaria, plasmodium falciparum, anofel mosqito
Hi Derya … actually the woman is suffering from babesiosis and is infected with Babesia microti, closely related to the Plasmodium and many times mistaken for Plasmodium falciparum. Unlike the Plasmodium, Babesia microti is transmitted by the Ixodes tick. More to come in the clinical case summary to come. Thanks for commenting!
thank you so much. I really enjoyed learning. I am grateful..When I examined the peripheral smear photograph, I made the final decision. Actually, I am not a microbiology expert, I am a clinical biochemistry specialist who also received training in diagnostic hematology.
Derya,
actually the woman is suffering from babesiosis and is infected with Babesia microti, closely related to the Plasmodium and many times mistaken for Plasmodium falciparum. Unlike the Plasmodium, Babesia microti is transmitted by the Ixodes tick. More to come in the clinical case summary to come. Thanks for commenting!