Cruising for bruising

A 83 year old man presents with anorexia, rigors and cough after a cruise along the Scandinavian coast/British Isles. Febrile 38.7C, tachycardic but haemodynamically stable, with marked thrombocytopenia(41), abnormal PT(15), renal impairment, raisedCRP, normal WC's including differential and CXR. Throat swab, serial blood cultures, MSU culture-negative. Despite IVfluids, broad spectrum antibiotics for presumed lower respiratory tract infection with AKI and delirium pyrexia persists, CRP rises to 223, and he develops abdominal pain, jaundice (Bilirubin158, AST249, ALT94, AlkP277), worsening renal function (Crea543) oliguria, anaemia (Hb7.6, haptoglobin<0.03g/l) with worsening confusion and bruising suggestive of a hepato-renal syndrome with DIC prompting transfer to the regional ID unit. PMH includes AVR/TAVI, PUD, Waldenstroem's macroglobulinaemia previously receiving IVIG's and Rituximab, last 3 months prior. Extensive travel history, Nigeria ('60ties,'90 and 2003)), Kenya, Malaysia/Taiwan, Indian Subcontinent ('70ties), South Africa ('97) Korea (2011). A blood film suggest malaria 20-30%parasitaemia, posing speciation difficulty. Of note he spent most summers on Great pond/Belgrade(Maine/USA), most recently 4 weeks before presentation, pointing towards epidemiological Babesiosis exposure particularly in an immunocompromised individual with a negative RDT for P.falciparum, later confirmed as 22% parasitaemia, B.microti ELISA+ve, IFAT+ve1:320 (negative blood-borne-virus-screen, Leptospira-DNA, Hantavirus-IF, B.burgdorferi and Anaplasma-IF). Despite IV Cefotaxime, Artesunate, po Doxycycline, Atovaquone/Azithromycin together with IVClindamycin/Quinine, - a pan-reactive auto-Ab panel, prevented Exchange transfusion-, he deteriorates rapidly despite full organ support and dies from multi-organ-failure. Ferritin elevation > 16.000 suggests Haemophagocytic Lymphohistiocytosis confirmed on post-mortem. Epidemiology, diagnosis, prognosis and treatment of Babesiosis will be discussed.