Paul-Erik Uggeldahl – Malaria from Ticks – Babesiosis
4). The duration of the disease is usually 1 – 2 weeks, but fatigue can last for months( 3).
Microscopic findings
The final diagnosis of babesiosis is usually made from examination of thin smears of blood stained using the Giemsa or Wright method( Fig. 1). It is possible using this technique to separate B. microti and B. divergens infections from each other and further from malaria. PCR is an important complementary investigation, as in anaplasmosis( HGA).
A curiosity that may be seen in blood smears is the so-called Maltese cross( Figs 2 and 3). This is seldom recognized, but pathognomonic to babesiosis caused by B. microti or B. duncani( 3). The Finns reported this cross of the protozoan in their B. divergens patient( 1).
Of course, the real Maltese cross with its special geometry is impossible to reproduce biologically. This is seen in the fine portrait of Michelangelo Merisi, more commonly known as Caravaggio; my favourite painter( Fig. 3). There are two portraits painted by him of the Grand Master of the Order, Alof de Wignacourt: one full figure, showing the master in armor and accompanied by a page, now in the Louvre; and then this( Fig. 3). Both produced in Malta( 13).
Malaria is the primary differential diagnostic disease. Malaria existed in Finland 100 years ago, spread by the malaria mosquito. When cowsheds were separated from human homes and swamps were dried malaria gradually disappeared from Finland and other Nordic countries, for example Sweden. This subject has( long ago) been discussed in Nordic dermatological meetings. The malaria mosquito may still exist, but without the protozoan.“ Malaria can be eliminated from consideration on the basis of a travel history and a careful review of blood smears( 3)”.
Treatment of babesiosis
B. divergens( Europe) and mild disease: clindamycin. Severe disease: clindamycin and quinine.
B. microti( USA) and mild disease: atovaquone and azithromycin. Severe disease: clindamycin and quinine( 4). quinine is not tolerated by all patients, but is not absolute necessary. The duration of treatment is short: usually 7 – 10 days.
Blood transfusions are recommended in all cases of severe infection with B. divergens, because we have no knowledge of exo-erythrocytic stages of B. divergens. Thus, the elimination of parasitic erythrocytes( the activation of the spleen) appears to be beneficial. At the same time the anaemia will be cured. Persons who have had their spleen removed are a risk group when infected, as in the first and fatal case reported in humans.
Malaria
The severity of babesiosis depends on the patient’ s immune response and the species of Babesia causing the infection( 3). In persons with normal health the disease is seldom severe. Persons over 50 years of age are reported to be at risk( 3)! The
Fig. 2. Blood smear in which the pathognomonic Maltese cross in an erythrocyte is visible in the centre of the figure. Published with permission from Alexander Salava.
42 Dermato-Venereology in the Nordic Countries
Forum for Nord Derm Ven 2017, Vol. 22, No. 2