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Hemolysis, elevated liver enzymes, and thrombocytopenia, but not HELLP syndrome
Abstract Number: F-53
Abstract Type: Case Report/Case Series
Introduction: Babesiosis is rare in pregnancy, and results in hemolysis, elevated liver enzymes, and thrombocytopenia. In this report, we detail a case of babesiosis mistaken for HELLP syndrome.
Description: 34y G3P1 at 38 weeks was transferred from an outside hospital with the diagnosis of HELLP syndrome and anhydramnios on a magnesium infusion. The patient had PANCYTOPENIA (platelets 40,000/mm3, ANC 1,500/mm3, hct 32%), elevated liver enzymes, a urine protein to creatinine ratio of 0.3, and arthralgias. Shortly after arrival, her pathology smear became suspicious for a tickborne illness. The patient received twenty hours of magnesium before it was discontinued.
Due to thrombocytopenia, neuraxial placement was contraindicated. Pain control was via fentanyl PCA. She had a vaginal delivery, and the postpartum courses of her and her neonate were unremarkable, with no evidence of vertical transmission.
She was treated with atovaquone and azithromycin for babesiosis, and doxycycline to cover lyme and anaplasmosis. She avoided breastfeeding on atovaquone and doxycycline. The parasite was cleared by day 10.
Discussion: Babesiosis, an intra-erythrocyte parasitic infection that leads to cell lysis, is transmitted by the Ixodes scapularis tick, but there are reports of infections from blood transfusions. Symptoms include fever, chills, fatigue, sweats, chest pain, jaundice, and headache. The disease can progress to DIC, multi-organ failure, and death.
There are few reports in pregnancy. One case details a patient at 20 weeks with concomitant babesiosis and lyme. She underwent an uneventful cesarean section with spinal anesthesia at term. Four days postpartum she developed a coronary artery aneurysm due to either an inflamed and weakened vessel wall or an incidental event. There are no reports of CNS transfer when using neuraxial anesthesia. General anesthesia is not required for patients with babesiosis if the coagulation profile is appropriate.
Four reports suspect vertical transmission of Babesia microti in term pregnancies with infants becoming symptomatic at 3-6 weeks of life. One report discusses an asplenic patient at 30 weeks with fever and rigors whose amniotic fluid and newborn had evidence of babesia.
The most important differential diagnosis in this patient is HELLP syndrome. Although HELLP and babesiosis have similar symptoms and laboratory results, this patient’s leukopenia and specific blood smear were hallmarks of babesiosis. Due to serologic similarities and HELLP being more common, treatable cases of babesiosis could be missed leading to unwarranted magnesium or preterm delivery.
Conclusion: This case highlights how a tickborne illness can mimic the diagnosis of HELLP syndrome.
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