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Variable clinical presentations of
babesiosis: A case series
Abstract: Human babesiosis continues to spread in multiple regions of the United States.
It is transmitted by Ixodes species ticks, as are Lyme disease and anaplasmosis.
Its variable clinical presentations, together with serologic detection limitations, require
that a high index of clinical suspicion be present for prompt diagnosis. This article
discusses case presentations showing the wide range of symptoms and presentations that
are possible with babesiosis.
By Pamela Paparone, DNP, APN and Philip W. Paparone, DO
uman babesiosis is an infectious, malaria-like disease caused by intraerythrocytic protozoa of the
genus Babesia; specifically, Babesia microti and
Babesia divergens.1-4 It is transmitted by Ixodes species ticks,
as are Lyme disease and anaplasmosis (formerly known as
ehrlichiosis). Babesia species are well-known pathogens in
animals. During the past half century in the United States,
they have been increasingly recognized as pathogens in
humans.1,5 Babesiosis may be acquired through the bite of an
infected tick, a blood transfusion, or by transplacental transmission.2,6-8 (See Ixodes scapularis [black-legged deer ticks].)
Most infection passes undetected (because the patient
may be unaware of the tick bite), especially in healthy
adults.6,7 However, in immunocompromised patients—
particularly those with hematologic disease and a history of
splenectomy—Babesia infection may be severe and lifethreatening.1
H
■ Epidemiology
The first reported case of babesiosis in the United States was
in 1968.9 It became a nationally notifiable disease in 2011,
and among the 27 states where it was notifiable in 2013, there
were 1,792 reported cases nationwide.5,10 Tick-borne and
transfusion-associated cases of babesiosis occur in multiple
parts of the country, including outside of areas of known
endemicity.5 The number of reported cases is rising steadily
in the United States and worldwide, owing in part to increased
medical awareness and improved diagnostic methods.1-3 (See
Reported cases of babesiosis in the United States in 2015.)
Health departments notify the CDC of babesiosis cases
via the National Notifiable Diseases Surveillance System
(NNDSS) using a standard case definition. In addition to
basic demographic information (age, gender, and county of
residence) provided via NNDSS, supplemental data (symptoms and history of transfusion) can be submitted to the
CDC using a disease-specific case report form (CRF).
Because babesiosis has been a reportable condition in some
states for years, state-developed CRFs had already been in
use to capture supplemental data.5
To promote standard data collection, the CDC developed a babesiosis CRF, which was approved by the Office of
Management and Budget in August 2011 (www.cdc.gov/
parasites/babesiosis/resources/babesiosis_case_report_Form.
pdf). Supplemental data, derived from the CDC’s or a state’s
Keywords: anaplasmosis, Babesia, babesiosis, infectious disease, intraerythrocytic forms, Ixodes, tick-borne infection
1 The Nurse Practitioner
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
Variable clinical presentations of babesiosis: A case series
CRF, were merged manually with NNDSS records by matching a case ID number or demographic data. If case records
had conflicting data, the more detailed record was considered correct.
As cases of babesiosis transmitted via tick bite or blood
transfusion occur in multiple parts of the United States,
including outside of areas of known endemicity, ongoing
national surveillance using the standard case definition will
provide a foundation for developing evidence-based prevention and control measures to reduce the burden of the disease. In addition, mapping based on this surveillance allows
for the identification of endemic areas, which aids the clinician in diagnosis.
Ixodes scapularis (black-legged deer ticks)
The images below are of Ixodes scapularis ticks, also
known as black-legged deer ticks. A. From left to right,
an unfed I. scapularis adult female, nymph, and adult
male. The sesame seed demonstrates relative size.
B. An unfed I. scapularis adult female (left) and a fully
engorged I. scapularis adult female (right).
■ Transmission and pathogenesis
The heightened recognition of tick-borne infection is
derived largely from the increasing incidences of human
babesiosis, anaplasmosis, and Lyme disease, both individually and together.11,12 Because these infections share the same
rodent reservoir and tick vector hosts, they can be cotransmitted to human hosts. 1,2,10,13-16 Coinfections involving
various combinations of these pathogens are common and
can be severe.12,14 The babesia parasite is suspected of causing proinflammatory cytokines that stimulate the production of nitric oxide, which may cause erythrocytic cellular
damage.2
Diagnostic procedures and clinical management of the
resulting disease syndrome are complicated by the diversity
of pathogens involved and by the unusual diversity and
duration of symptoms.
■ Clinical presentation
Common clinical features of babesiosis are similar to those
of malaria and range in severity from asymptomatic to
rapidly fatal. Most patients experience a viral infection-like
illness with fever, chills, sweats, myalgia, arthralgia, anorexia,
nausea, vomiting, or fatigue, and in some cases, patients may
develop hemolytic anemia.1-4,10 Most symptomatic patients
become ill 1 to 4 weeks after the bite of a B. microti-infected
tick and 1 to 9 weeks (but up to 6 months in one reported
case) after transfusion of contaminated blood products.6-8
A high index of clinical suspicion for babesiosis and the
possible presence of other tick-borne infections are required
for prompt diagnosis and proper treatment. Because the
clinical findings are nonspecific, lab studies are necessary to
confirm the diagnosis.
■ Diagnosis
Microscopic examination of blood smears is the current
gold standard for detecting Babesia infection, while polymerase chain reaction testing has promising diagnostic
value.1,2,16,17 Differentiating Babesia from malaria on peripheral smears can be difficult but rapidly resolved by the presence or absence of a history of travel.1 Peripheral smears for
Babesia allow for same day, or at the most, next day confirmation of the diagnosis. The case presentations described
below demonstrate the range of symptoms and clinical
presentations associated with babesiosis (with and without
coinfection) that can challenge the NP.
Source: Engleberg NC, Dermody T, DiRita V. Schaechter’s Mechanisms of
Microbial Disease. Philadelphia, PA; Wolters Kluwer Health/Lippincott Williams &
Wilkins; 2012.
2 The Nurse Practitioner
■ Treatment
Generally, treatment with atovaquone plus azithromycin is
used for patients with mild-to-moderate babesiosis, whereas
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
Variable clinical presentations of babesiosis: A case series
clindamycin plus quinine is recommended for patients with
severe disease; both treatment regimens are given for 7 to 10
days.1-4 All four drugs are used FDA off-label for babesiosis;
however, the dosage recommendations are supported by the
clinical guidelines.1-4,18 The dosage regimen for atovaquone
plus azithromycin for adult patients is atovaquone 750 mg
orally every 12 hours, and azithromycin 500 to 1,000 mg
orally on day 1 and 250 mg orally once daily for the subsequent days.1-4 Immunocompromised patients may require
higher doses of azithromycin.2-4
The dosage regimen for clindamycin plus quinine for
adult patients with severe disease is clindamycin 600 mg
orally every 8 hours or clindamycin 300 to 600 mg I.V. infusion every 6 hours, and quinine 650 mg orally every 6 to 8
hours.1-4 Dose adjustments of quinine are needed for patients
with severe chronic kidney disease.18,19 Of note, the only
FDA-approved preparation of oral quinine currently available in the United States is the 324 mg capsule.18,19 Previously,
the dosage available in the United States was a 325 mg capsule.
The change in the quinine preparation from 325 mg to 324
mg may result in minor dose disparities between some guideline dosage recommendations that were published before
the commercial preparation was changed.19,20
Although rare cases of resistance to atovaquone plus
azithromycin have been reported, this combination is effective in most patients.2 Atovaquone is contraindicated in
patients who develop or have a history of serious allergic or
hypersensitivity reactions to the drug or any of the drug’s
components. Azithromycin is contraindicated in patients
with known hypersensitivity to azithromycin or any macrolide or ketolide antibiotic and also in patients with a history of cholestatic jaundice or hepatic dysfunction. 18
Reported cases of babesiosis in the
United States in 2015
Most cases of babesiosis in the United States occur in
seven states, five of which are located in the Northeast
(MA, CT, RI, NY, and NJ) and two in the upper Midwest
(MN and WI). The geographic range of babesiosis has
expanded beyond these highly endemic areas and it is
now reported all along the northeastern seaboard and
inland, ranging from Maine to Maryland.1,2
During 2015, babesiosis was reportable in Alabama,
Arkansas, California, Connecticut, Delaware, Illinois,
Indiana, Louisiana, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, Montana, Nebraska, New
Hampshire, New Jersey, New York, North Dakota, Ohio,
Oregon, Rhode Island, South Carolina, South Dakota,
Tennessee, Texas, Utah, Vermont, Washington, West
Virginia, Wisconsin, and Wyoming.22
3 The Nurse Practitioner
Clindamycin is contraindicated in patients with a history of
hypersensitivity to clindamycin or lincomycin. Quinine is
contraindicated in patients with known hypersensitivity to
quinine, mefloquine, or quinidine; prolonged QT interval;
a glucose-6-phosphate dehydrogenase deficiency; or a history of myasthenia gravis or optic neuritis.18 Consult the
manufacturer’s prescribing label for complete prescribing
information for each drug.
Some patients, including those with severe illness, might
require or benefit from supportive care, such as antipyretics,
vasopressors (if the patient’s BP is low and unstable), blood
transfusions, exchange transfusions (in which portions of a
patient’s blood or blood cells are replaced with transfused
blood components), mechanical ventilation, and dialysis.
The NP should consider referral to an infectious-disease
specialist for patients who are pregnant, have an underlying
hematologic or oncologic problem, have had a splenectomy,
are allergic to first-line antibiotic agents, or have had an
unsatisfactory response to antibiotic therapy.
Red blood cell exchange transfusions are recommended
for cases of severe babesiosis in patients with parasitemia of
10% or greater, severe anemia (hemoglobin less than 10 g/dL),
or pulmonary, kidney or liver impairment.2-4 Exchange
transfusions are used to rapidly decrease parasitemia, correct
anemia, and help remove toxic byproducts produced by the
infection.2
■ Case presentations
The case presentations of patients with babesiosis show a
wide range of symptoms and clinical presentations. The case
presentations below are examples of cases that occurred in
southeastern New Jersey, where the disease is endemic. All
patients were hospitalized and treated in Atlantic County,
New Jersey (see Summary of data from babesiosis patients).
Case 1
Ms. A is a 78-year-old White female who was admitted with
fever, chills, lethargy, fatigue, and marked changes in sensorium. She had a maximum temperature of 100.6° F (38.1° C);
sepsis was considered for this patient. Multiple tick bites
were found. Pertinent lab findings included lactate dehydrogenase (LDH), 528 units/L; aspartate aminotransferase
(AST), 90 units/L; and alanine aminotransferase (ALT), 34
units/L. Her vitamin B12 and folate levels were normal.
Ms. A’s initial white blood cell (WBC) count was
5.0 × 109/L, but over the first 3 days of hospitalization, it
gradually dropped to 2.6 × 109/L. Her hemoglobin dropped
from 10.5 g/dL to a low of 8 g/dL, and her platelets were
initially 39 × 109/L but gradually increased as she continued
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
Variable clinical presentations of babesiosis: A case series
Summary of data from babesiosis patients
Patient
Age
Sex
Symptoms
Lab findings
Comments
Case 1
78 y
F
Fever, chills, lethargy,
fatigue, weakened cognition
Septicemia; anemia; leukopenia; thrombocytopenia; high
ALT, AST, and LDH; Babesia
(PS+); Anaplasma (S)
Sepsis was initial clinical
impression
Case 2
90 y
F
Fever, rectal bleeding
(hemorrhoids)
Anemia, Babesia (PS+)
Rectal bleeding was initial
chief complaint
Case 3
57 y
M
Fever, chills, malaise
Neutropenia, thrombocytopenia, leukopenia, high ALT and
AST, Babesia (PS+)
Suspected concurrent
anaplasmosis
Case 4
81 y
M
Lethargy, weakness, chills,
blurred vision
Anemia, hypocalcemia,
Babesia (PS+)
Suspected concurrent
anaplasmosis
Case 5
85 y
M
Fever, chills
Leukopenia, low hemoglobin, parasitemia, HowellJolly bodies, Babesia (PS+),
Anaplasma (S)
Refractory to usual treatment
because of hairy cell leukemia and splenectomy history
Key: F, female; M, male; PS+, positive peripheral smear; S, serology.
her course of treatment. Ms. A had 33% polymorphonuclear
leukocytes, 2% bands, 49% lymphocytes, and 13% monocytes. Peripheral smear was positive for Babesia, and she
had a Babesia immunoglobulin M (IgM) of 1:160 and Anaplasma (previously referred to as Ehrlichia) IgM of 1:320.
In view of Ms. A’s leukopenia and thrombocytopenia,
anaplasmosis was suspected, and she was treated with doxycycline 100 mg I.V. infusion every 12 hours, atovaquone suspension 750 mg orally twice daily, and azithromycin 500 mg
I.V. infusion every 24 hours. Doxycycline is the recommended
treatment for anaplasmosis and was administered to cover
the possibility of anaplasmosis in this patient. She was treated
with that regimen for 5 days. She was then started on doxycycline twice daily, and azithromycin 500 mg daily (both oral)
along with the atovaquone suspension of 750 mg twice daily
for a 14-day course of therapy. Ms. A made a dramatic
improvement in her mentation and resolution of her lethargy.
Case 2
Ms. C is a 90-year-old White female with a chief complaint
of rectal bleeding. On admission, her lab studies revealed
severe anemia with a hemoglobin of 7.6 g/dL and hematocrit
of 22.6%. Her platelet count was 103 × 109/L and peripheral
smear was positive for Babesia. Ms. C had spiking temperatures 100° F to 101° F (37.8° C to 38.3° C). Her rectal bleeding was controlled with an octreotide infusion to which she
4 The Nurse Practitioner
responded well (the bleeding ceased). Her peripheral smear
was positive for Babesia, and she was placed on an oral dose
of azithromycin 500 mg on day 1 and then 250 mg daily and
atovaquone suspension 750 mg twice daily to complete a
10-day course.
Case 3
Mr. E is a 57-year-old White male admitted with fever, malaise, and chills. His temperature had risen to 101° F (38.3° C).
His AST and ALT were 64 and 54 units/L, respectively, and
gradually rose to a peak of 90 and 87 units/L, respectively,
during his 5-day hospital stay. Mr. E’s WBC count decreased
from his initial hospital results to 2.9 x 109/L with a hemoglobin of 9.2 g/dL. His platelets were initially 60 × 109/L, but
dropped to 34 × 109/L at their lowest level. In view of his
elevated liver enzymes, leukopenia, and thrombocytopenia,
anaplasmosis was highly suspected, and he was started on
doxycycline 100 mg I.V. infusion every 12 hours.
Mr. E’s peripheral smear was positive for Babesia. He was
started on oral clindamycin 600 mg every 8 hours and oral
quinine 650 mg three times daily. Acute hearing deterioration
occurred, and the quinine was discontinued. Mr. E’s regimen
was then switched to oral azithromycin 500 mg on day 1 and
then 250 mg daily and oral atovaquone 750 mg twice daily.
He went on to complete only 7 days of therapy, and his
elevated liver enzymes and thrombocytopenia resolved. The
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
Variable clinical presentations of babesiosis: A case series
suspected anaplasmosis was not confirmed, as the Anaplasma
IgM was negative. However, Mr. E’s leukopenia and thrombocytopenia resolved on the above regimens.
Case 4
Mr. J is an 81-year-old White male who was admitted with
increasing lethargy, weakness, chills, and blurred vision.
He had a history of coronary artery disease and hypertension. His hemoglobin on admission was 12.1 g/dL and his
hematocrit was 35.4%. His WBC count was 5.3 × 109/L. By
day 2, his hemoglobin had dropped to 9.9 g/dL with a
hematocrit of 29%. His platelets were initially 54 × 109/L
and dropped to 46 × 10 9 /L, but on therapy, rose to
191 × 109/L.
Mr. J had 82% polymorphonuclear leukocytes, 10%
lymphocytes, and 6% monocytes. On the day of admission,
a peripheral smear was positive for Babesia. Subsequently,
serologic studies demonstrated an Anaplasma IgG of 1:256;
the IgM was negative. Babesia serologies were greater than
1:320, both IgG and IgM. Anaplasmosis was suspected with
Mr. J’s confirmed babesiosis, and he was started on azithromycin 500 mg I.V. infusion every 24 hours and doxycycline
100 mg twice daily.
At discharge on day 10, Mr. J was switched to clindamycin orally three times a day and quinine orally three times
a day because of intolerance to azithromycin, and he completed a 14-day course of therapy. He convalesced satisfactorily. His hemoglobin at discharge was 12.5 g/dL and WBCs
7.4 × 109/L; platelets improved to 137 × 109/L.
Case 5
Mr. K is an 85-year-old White male who was admitted with
fever and chills intermittently, recurring for several days
prior to admission. He had a history of hairy cell leukemia,
splenectomy, atrioventricular block (pacemaker), gouty
arthritis, prostatic hypertrophy, and polymyalgia rheumatica. In the ED, Mr. K had an immediate peripheral smear for
Babesia, and the intraerythrocytic parasite was demonstrated. He had been working on a golf course for the week
prior to admission.
A second peripheral smear was positive for intraerythrocytic parasites with 10.4% of his red blood cells infected.
Findings were also positive for Howell-Jolly bodies, which
are erthrocytic nuclear remnants associated with asplenia
or decreased splenic function. Mr. K was started on oral
azithromycin 500 mg on day 1 and then 250 mg daily and
atovaquone 750 mg suspension twice daily. Due to the possibility of concurrent tick-borne infection, he was also
started on oral doxycycline 100 twice daily.
5 The Nurse Practitioner
Over the course of day 1, Mr. K’s platelet count dropped
from 25 to 23 × 109/L, with blood urea nitrogen of 29 mg/
dL and creatinine of 1.2 mg/dL. His WBC count dropped
from 4.1 to 2.5 × 109/L and his hemoglobin dropped from
16 to 13 g/dL. He had 20% bands, 5% atypical lymphocytes,
47% polymorphonuclear leukocytes, and 23% lymphocytes.
Mr. K remained on doxycycline, azithromycin and atovaquone suspension for 8 days when he was discharged home.
Mr. K was readmitted the following day when he complained of the inability to ambulate and generalized weakness. He had peripheral smear positivity with babesiosis and
was serologically positive for anaplasmosis with both IgM
and IgG. Mr. K had continued on the prescribed antibiotic
regimen up until his readmission that day. Due to the persistence of parasitemia despite adequate therapy, he was
changed to clindamycin 600 mg I.V. infusion every 8 hours,
and quinine was also being administered.
Unfortunately, Mr. K developed gastric distress and a
generalized erythematous coalescing rash, which prompted
the discontinuation of the clindamycin and quinine. His
WBC count was 2.2 × 109/L and his hemoglobin was 9.5 g/dL.
Platelets had risen to 43 × 109/L, and he had 43% polymorphonuclear leukocytes, 10% bands, 42% lymphocytes, and
5% monocytes.
Because of the persistence of parasitemia, Mr. K underwent exchange transfusion. At that point, he had been
restarted on azithromycin 500 mg I.V. infusion every 24 hours
and atovaquone suspension 750 mg orally twice daily.
Azithromycin and atovaquone were continued for 5.5 weeks,
at which time he was parasite smear negative for Babesia.
Subsequently, a Babesia peripheral smear remained negative.
■ Discussion of case presentations
Case 1 shows the unusual effect of babesiosis on the sensorium in the older adult, as any infectious process can. The
patient’s cognitive function was dramatically improved
following treatment, despite the marked changes in mentation on admission. A coinfection with Anaplasma was suspected. In general, all cases of babesiosis need to be tested
for late Lyme disease, via Western blot, although not immediately addressed.1,2,4
Patients with concurrent babesiosis and anaplasmosis—
suspected or serologically-positive—are treated with doxycycline, which is equally effective for Lyme disease, early or
late. Generally, the greater number of concurrent tick-borne
infections and the higher the parasitimia load, the more
toxic the presentation.1,12
Case 2 shows the need to check the peripheral smear
for Babesia despite the rectal bleeding issue on admission.
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
Variable clinical presentations of babesiosis: A case series
This diagnostic test could have easily been omitted, causing a delay in the diagnosis. Such a delay in older adult
patients that results in delayed treatment can put these
patients at greater risk for severity of babesiosis. Generally,
the combination of clindamycin and quinine has a much
higher probability of intolerance and adverse reactions.
This combination is not the treatment of first choice for
babesiosis. Pertaining to anaplasmosis, the triad of leukopenia, transaminase elevation (mild or moderate), and
thrombocytopenia demands empiric treatment with doxycycline prior to serologic confirmation.1,2,4
A peripheral smear for Babesia is rapidly interpreted, is
inexpensive, and should be requested in evaluating all
patients with any degree of anemia—especially during the
spring and summer months in endemic areas. Serologic
studies are variable in developing positivity and are generally
less readily available.
Case 3 illustrates the importance of suspecting and
investigating the possibility of babesiosis and anaplasmosis coinfection in a patient presenting with a tick-borne
illness.
Case 4 demonstrates that no additional lab studies—
other than peripheral smear for Babesia—are needed to
confirm the diagnosis of babesiosis.
Case 5 exemplifies the therapeutic challenge and refractory response to treatment of babesiosis in patients with the
comorbidities of a hematologic disease and/or splenectomy.
■ Patient education
Heightened awareness of babesiosis as well as prompt
diagnosis and treatment are essential to prevention. Both
patients and the general public need to become more aware
of the existence of the disease and other tick-borne infections, especially individuals who live in or travel to regions
where babesiosis is found. The NP can play an active and
important role in providing patient education about the
disease. The basic points of information to communicate:
• What babesiosis is and its potential to be a life-threatening
illness
• How individuals acquire babesiosis (tick bite, transfusion,
or, rarely, vertical transmission)
• Where in the world babesiosis is found
• Signs and symptoms of babesiosis
• Note that many individuals do not have any symptoms
and do not get sick
• Importance of seeing a healthcare provider if babesiosis
is suspected
• Treatability of babesiosis and need for prompt diagnosis
and treatment.21
6 The Nurse Practitioner
Individuals who live in or travel to endemic areas
should avoid tick-infested areas; apply repellents and wear
long pants and long-sleeved shirts when outdoors; shower
soon after being outdoors; and check their entire body for
ticks.3 When outdoors, they should walk on cleared trails,
stay in the center of the trail, and minimize contact with
leaf litter, brush, and overgrown grasses (where ticks are
most likely to be found). If a tick is found attached to a
person’s body, it should be properly removed as soon as
possible.
The CDC offers a printable, one-page fact sheet for
patients and the general public that details the basic information for babesiosis awareness in addition to the link for the
CDC guide to proper removal of a tick attached to a person
(www.cdc.gov/parasites/babesiosis/resources/babesiosis_fact_
sheet.pdf).
■ Conclusion
This case series illustrates the need for the NP to appreciate
the variable clinical presentations of babesiosis to facilitate
prompt diagnosis, provide proper therapeutic management,
and avoid the poor outcomes associated with this disease.
Staying knowledgeable of babesiosis is essential. It is important for the NP to understand that infected patients may not
recall a tick bite and that clinical presentations may not only
be variable but also nonspecific, ranging from subclinical to
severe. The possibility of coinfection with other tick-borne
illnesses (Lyme disease and anaplasmosis) must be considered. Furthermore, the NP needs to assume an active role
in patient education to affect babesiosis awareness and prevention.
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Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
Variable clinical presentations of babesiosis: A case series
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20. Gelfand JA, Vannier EG. Clinical manifestations, diagnosis, treatment, and
prevention of babesiosis. UptoDate. 2017. www.uptodate.com.
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22. Centers for Disease Control and Prevention. Tickborne diseases of the
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babesiosis.html.
Pamela Paparone is an NP at the Atlantic County Health Department, Northfield, N.J.
15. Paparone PW, Glenn WB. Lyme disease with concurrent ehrlichiosis. J Am
Osteopath Assoc. 1994;94(7):568-570, 573, 577.
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clinicians need to know. Infection. 2013;41(6):1057-1072.
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diagnosis of Babesia microti infection in clinical practice. Ticks Tick Borne
Dis. 2015;6(3):376-382.
18. Facts and Comparisons. Drug. Facts and Comparisons 2013. St. Louis, MO:
Wolters Kluwer Health; 2013.
7 The Nurse Practitioner
Philip W. Paparone is a communicable disease physician at the Atlantic County
Health Department, Northfield, N.J.
The authors have disclosed no financial relationships related to this article.
DOI-10.1097/01.NPR.0000525721.83984.14
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
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