Step 1: View clinicals

A 35-year-old man presents with fever for 14 days, along with fatigue, malaise, generalized arthralgia and myalgia, and a diffuse headache for the same duration. No other symptoms are present. He has been self-medicating himself with acetaminophen and has not sought medical attention thus far. He returned from a week-long hiking trip in rural Massachusetts around three weeks ago. He does not recall being bitten by insects. The several friends and family who traveled with him are healthy. There is no contact history with people with similar symptoms. He has a single stable long-term sexual partner. His medical, surgical and family histories are unremarkable. He does not smoke and only drinks socially. His basic investigations are as follows: WBC: 5,100/mm3 (4,600-11,00) Neu: 45% Lym: 37% Hb: 10.5 g/dL (11-18) MCV: 90 fL (80-96) MCH: 30 pg/cell (27-33) Plt: 196,000/mm3 (150,000-450,000) ALT: 80 IU/L (7-45) AST: 72 IU/L (8-48) Tot. bilirubin: 1.5 mg/dL (0.2-1.2) Dir. bilirubin: 0.3 mg/dL (0.1-0.4) Reticulocyte count: 8% Serum LDH: 800 IU/L (105-333) Direct antiglobulin test: negative Indirect antiglobulin test: negative Renal functions, chest x-rays, and a urinalysis are all normal.

Step 2: Order all relevant investigations

Thick + thin blood films

Thick blood films reveal numerous intraerythrocytic parasites. Thin blood films show reticulocytosis and pear-shaped trophozoites with blue cytoplasm and red chromatin. Multiple ring forms are identified, without hemozoin deposits. Maltese crosses are present. The parasitemia level is 0.3%. No morulae are found in the white blood cells.

Tick-borne disease serology panel

Babesia microti IgM titre: 1:256 (<1:20) Babesia microti IgG titre: 1:1024 (<1:64) Negative for Ehrlichia chaffeensis, Anaplasma phagocytophilum, and Lyme disease.

PCR for babesiosis

PCR is positive for Babesia microti.

HIV and hepatitis C screening

Negative for both HIV and Hepatitis C.

Step 3: Select appropriate management

Exchange transfusion

Score: ★★☆