Country singer presents malarialike symptoms

Bob was 70 when he developed persistent fever, night sweats, and weight loss. He had recently been admitted to a hospital for evaluation. A CT scan of the abdomen and pelvis showed an abnormality of the spleen that was concerning for a lymphoma.

He then underwent surgical removal of his spleen. No malignancy was found.

He continued to have fever for several more weeks and was sent to me for further evaluation.

He had no significant past medical history. He was married and driving a shuttle bus for a car dealership.

As I examined him, he appeared quite pale and somewhat frail. The whites of his eyes were yellow. He had a visible abdominal scar in the area where his spleen had been removed. There were no other significant abnormalities.

His basic lab tests, including a complete blood count, showed a mild anemia (decrease in red blood cell count) and thrombocytopenia (decrease in platelet count).

I reviewed his blood smear with a hematologist and pathologist. We found a number of abnormalities around and inside the red blood cells, which appeared very similar to parasites that cause a deadly form of malaria.

On further questioning, I learned that Bob had not traveled outside the United States, which would make malaria highly unlikely. Malaria is most commonly transmitted through the bite of the female Anopheles mosquito, and is not typically present here. It's far more common in parts of South America, Africa, and Asia.

I also learned that Bob was a country and western musician and that his band traveled up and down the East Coast. They had recently performed a summer concert series in Connecticut, New Jersey, and New York.

While there had been rare cases of malaria found in New Jersey, I still felt this was very unlikely.

I was more concerned about the possibility of a different parasitic infection, babesiosis.

The infection is caused most often by the parasite Babesia microti. This parasite is transmitted by the same tick that spreads Lyme disease.

As a result, in any area where Lyme disease is endemic, this parasite could also be present.

The deer tick, Ixodes scapularis, transmits babesia; Borrelia burgdorferi, the agent of Lyme disease; and a third condition, human granulocytic anaplasmosis (It's similar to Rocky Mountain spotted fever, minus the rash.) These ticks are most common in the northeastern United States and in some areas of the Midwest. They are most active during the late spring, summer, and early fall.

The ticks are tiny, sometimes no bigger than the tip of a pen, and unless you are specifically looking for them, they are easy to miss.

Bob told me that many of his concerts were outdoors in rural areas, on open plains where it would have been relatively easy to be bitten by a tick.

Further review of the blood smear did show parasite forms similar to the deadly form of malaria, Plasmodium falciparum.

The ring forms in the red blood cells, along with the appropriate exposure, were highly suspicious for babesia.

Testing sent to the Centers for Disease Control and Prevention along with DNA analysis confirmed the presence of babesia.

The parasite creates anemia by causing hemolysis or rupture of the red blood cells. The effects can range from minimally symptomatic to a life-threatening infection. In part, the severity relies on the status of the person's immune system; elderly and immune-compromised patients are prone to more severe illness.

Bob was started on a standard regimen of antibiotics to treat the infection. Unfortunately, he was not out of the woods yet.

Despite being on therapy, he was admitted to the hospital several more times with fever and profound anemia, requiring many blood transfusions.

Bob did not respond to the anti-parasite therapy as others do, largely because he no longer had a spleen.

The organ is a key part of the immune system, vital for eliminating certain types of bacteria and parasites from the body. Most patients can be cured of babesia infection after several weeks of antibiotics.

For Bob, we had to continue therapy for many months. It took nearly two years before we could clear the parasite from his bloodstream. He is doing very well today.

Although babesia and Lyme disease are spread by the same tick, treatment is quite different.

Babesia should be considered in a patient who is diagnosed with Lyme disease but has atypical features, or in someone who does not respond to standard Lyme therapy.

It's also a possibility in someone who presents with anemia, jaundice, and fever, especially if they have spent time in an area where Lyme disease is endemic.

And of course it should always be considered in a country bluegrass singer from Philadelphia.