The symptoms manifested in cases of babesiosis are similar to symptoms of malaria. The extent of the symptoms depends on the extent of RBC destruction due to the parasite. The range can be from no overt symptoms to severe haemolysis which can be fatal. The affected patients may give a history of travel to the endemic areas. In patients with subclinical infection, there may be spontaneous development of the symptoms after splenectomy or after immunosuppressive therapy. Patients who are healthy and have a strong immune system, may remain asymptomatic or may suffer from mild to moderate symptoms.

The incubation period for patients bitten by the infected tick is about one to four weeks, while the incubation period for patients affected due to contaminated blood transfusion is about one week to six months. The most common symptoms include high grade fever ranging up to 40.9 °C (105.6 °F). In a study of 139 patients of babesiosis hospitalised at New York, the commonest symptoms noted were – fatigue/malaise/weakness (91%), fever (91%), shaking chills (77%), diaphoresis (69%) [6]. Splenomegaly is also detected. Along with fever there is severe malaise, fatigue, severe chills, sweating, anorexia, nausea, vomiting, weight loss, headache, myalgia, arthralgia, cough, sore throat, photophobia and depression. Haemoglobinuria is also one of the accompanying symptoms. The fatigue continues for several months even after other symptoms have subsided.
Immuno-suppressed patients, patients with HIV infection, the elderly patients and who have undergone splenectomy suffer from more severe and prolonged infections with relapses needing frequent hospitalisation.

Complications

The patients can experience certain complications which include disseminated intravascular coagulopathy and acute respiratory distress syndrome. Other complications may include liver, kidney or congestive heart failure, coma and death. Asplenic patients have a more prolonged disease course, higher morbidity and mortality and more overwhelming infection [7]. Shock, relapse and spontaneous splenic rupture too have been observed [8].

• Splenomegaly

  Intraoperatively, the patient was noted to have splenomegaly. Postoperatively, she developed fever and was found to have Babesia microti on blood smear with an otherwise negative fever evaluation. [ncbi.nlm.nih.gov]

  Babesia infection Hemolytic anemia due to babesiosis Hemolytic anemia, babesiosis Clinical Information Tickborne disease caused by infection with protozoa; occurs in wild and domestic animals; in humans causes malaria-like symptoms, myalgia, nausea and splenomegaly [icd9data.com]

  Definition (CSP) tickborne disease caused by infection with protozoa; occurs in wild and domestic animals; in humans causes malaria-like symptoms, myalgia, nausea and splenomegaly; classic zoonotic disease. [fpnotebook.com]

  The most common symptoms are fever (that can reach up to 40.9 °C and may be accompanied by splenomegaly), malaise and fatigue. [orpha.net]

  Splenomegaly may be observed on ultrasonography or with other imaging methods but it is a nonspecific finding. [cancertherapyadvisor.com]

• Fever

  Postoperatively, she developed fever and was found to have Babesia microti on blood smear with an otherwise negative fever evaluation. She was treated with atovaquone and azithromycin and made a full recovery. [ncbi.nlm.nih.gov]

  His fever subsided rapidly, and his hematocrit eventually returned to normal. A 34-year-old man came to the emergency room with a 3-day history of fevers (peak temperature, 40°C), accompanied by shaking chills. [doi.org]

• Anemia

  The disease is caused by the protozoa of the genus Babesia, which invade human erythrocytes and lyse them causing a febrile hemolytic anemia. [ncbi.nlm.nih.gov]

  Warm-antibody autoimmune hemolytic anemia (also known as warm autoimmune hemolytic anemia [WAHA]) is a type of anemia that is frequently seen in patients who have lymphoproliferative disorders or autoimmune conditions or who use certain medications. 9 [nejm.org]

  Laboratory tests revealed a hemolytic anemia, with a hemoglobin level of 8.6 g per deciliter. Nodular sclerosing Hodgkin's lymphoma, stage IIIB, had been diagnosed 12 years earlier, in 1994, and the patient underwent splenectomy at that time. [doi.org]

• Chills

  Images in Clinical Medicine Kyle Noskoviak, M.D., and Elizabeth Broome, M.D. 6 Citing Articles A 34-year-old man came to the emergency room with a 3-day history of fevers (peak temperature, 40°C), accompanied by shaking chills. [doi.org]

  This case emphasizes the need to consider tick-borne disease in anyone who presents with prolonged and undulating fevers, chills, headache, myalgias, and arthralgias. [ncbi.nlm.nih.gov]

• Fatigue

  The most common symptoms are fever (that can reach up to 40.9 °C and may be accompanied by splenomegaly), malaise and fatigue. [orpha.net]

  A 70 year old immunocompetent female patient living in New York City presented with a persistent fever, night sweats, and fatigue of 5 days duration. Full evaluation showed a febrile hemolytic anemia along with neutropenia and thrombocytopenia. [ncbi.nlm.nih.gov]

• Splenectomy

  The third patient underwent splenectomy for trauma and acquired babesiosis postoperatively from a blood transfusion. Our cases demonstrate the need to be vigilant for babesiosis in patients undergoing splenectomy. [ncbi.nlm.nih.gov]

• Nausea

  This is a case of a 71-year-old homosexual man who presented with a 4-day history of fever, weakness and headaches, near syncope, nausea and poor oral intake. [ncbi.nlm.nih.gov]

  Synonyms Babesia infection Hemolytic anemia due to babesiosis Hemolytic anemia, babesiosis Clinical Information Tickborne disease caused by infection with protozoa; occurs in wild and domestic animals; in humans causes malaria-like symptoms, myalgia, nausea [icd9data.com]

  Common early symptoms may include fever, chills, headache, body aches, loss of appetite, nausea, fatigue or a low red blood cell count (anemia). [nj.gov]

• Vomiting

  Nausea or vomiting ( P < 0.01) and diarrhea ( P < 0.01) along with hyperbilirubinemia ( P < 0.01) were predictive of severe infection, hospitalization, and prolonged antimicrobial therapy. [ncbi.nlm.nih.gov]

  Less frequently, some may experience sore throat, photophobia, vomiting, weight loss and depression. Symptoms can last 1-2 weeks but fatigue may persist for several months. [orpha.net]

  Symptoms of nausea, vomiting, headache, shaking chills, and bloody urine, can also occur. How is babesiosis diagnosed? Babesia infects red blood cells. As such, a decrease of red blood cells may be detected in severely affected patients. [cdph.ca.gov]

  Nausea, vomiting, reduced appetite, and depression can also occur. Some patients will develop enlarged livers or spleens. The usual disease course lasts weeks to several months, but some patients take even longer to fully recover. [columbia-lyme.org]

  Nausea, vomiting, headache, shaking chills, blood in the urine, and depression can occur. [encyclopedia.com]

• Abdominal Pain

  A 66-year-old splenectomized man was admitted to a Lisbon hospital after 1 week of fever, abdominal pain, anorexia and nausea. [ncbi.nlm.nih.gov]

  joint aches, paresthesias, mental dullness and slowing of reactions and responses, hypercoaguability, stomach pain, abdominal pain, emotional liability, „mental dullness”, kidney problems, influenza-like symptoms. [arminlabs.com]

  If symptoms occur, they may include fever, chills, headache, achy joints and muscles, fatigue, nausea, vomiting, abdominal pain and dark urine. Symptoms can last for up to several months. [mass.gov]

  Dark urine TABLE 1 Common Presenting Signs and Symptoms of Human Babesiosis Generalized weakness Fever Gastrointestinal symptoms (anorexia, nausea, abdominal pain, vomiting, diarrhea, etc.) [aafp.org]

  Additional early symptoms include joint pain (arthralgia), muscle pain (myalgia), chills, sweats, and headaches. Affected individuals may also have additional symptoms including nausea, vomiting, and/or abdominal pain. [rarediseases.org]

• Jaundice

  Jaundice, hepatosplenomegaly, anemia and conjugated hyperbilirubinemia developed in this preterm infant. The diagnosis was eventually made by blood smear, serology and polymerase chain reaction. [ncbi.nlm.nih.gov]

  Prolonged cases may show signs of anaemia and jaundice. Light-red to dark-red discolouration of the urine is often seen. The spleen is enlarged, sometimes several times its normal size, and the cut surface resembles raspberry jam. [web.archive.org]

  In others, hepatosplenomegaly with jaundice, mild to moderately severe hemolytic anemia, mild neutropenia, and thrombocytopenia may occur. Noncardiac pulmonary edema can develop in severe disease. [msdmanuals.com]

• Hepatomegaly

  On physical examination, fever, splenomegaly, hepatomegaly, or jaundice may be observed. [aldf.com]

  Patients may have hepatomegaly and splenomegaly. [mayomedicallaboratories.com]

• Hepatosplenomegaly

  Jaundice, hepatosplenomegaly, anemia and conjugated hyperbilirubinemia developed in this preterm infant. The diagnosis was eventually made by blood smear, serology and polymerase chain reaction. [ncbi.nlm.nih.gov]

  Manifestations of disease include fever, chills, sweating, myalgias, fatigue, hepatosplenomegaly, and hemolytic anemia. Symptoms typically occur after an incubation period of 1 to 4 weeks, and can last several weeks. [cdc.gov]

  The signs and symptoms include fever, chills, sweating, myalgias (muscle aches), fatigue, hepatosplenomegaly (enlargement of the liver and spleen) and hemolytic anemia (anemia due to break-up of red cells). [medicinenet.com]

  In others, hepatosplenomegaly with jaundice, mild to moderately severe hemolytic anemia, mild neutropenia, and thrombocytopenia may occur. Noncardiac pulmonary edema can develop in severe disease. [msdmanuals.com]

• Photophobia

  Less frequently, some may experience sore throat, photophobia, vomiting, weight loss and depression. Symptoms can last 1-2 weeks but fatigue may persist for several months. [orpha.net]

  Along with fever there is severe malaise, fatigue, severe chills, sweating, anorexia, nausea, vomiting, weight loss, headache, myalgia, arthralgia, cough, sore throat, photophobia and depression. [symptoma.com]

  Rash is an uncommon symptom in babesiosis. 1, 2, 3, 7 Signs of central nervous system involvement include headache, photophobia, neck and back stiffness, altered sensorium and emotional lability. 3, 7, 15 View/Print Table TABLE 1 Common Presenting Signs [aafp.org]

• Sweating

  A 70 year old immunocompetent female patient living in New York City presented with a persistent fever, night sweats, and fatigue of 5 days duration. Full evaluation showed a febrile hemolytic anemia along with neutropenia and thrombocytopenia. [ncbi.nlm.nih.gov]

  Symptoms (incubation time: 5 days–9 weeks): Rapid onset of beginning illness with severe fever, chills, headache (can be severe/dull, global, involves the whole head, described as if the head is in a vise), sweats (usually at night, but can be day-sweats [arminlabs.com]

• Petechiae

  Petechiae (small red or purple spots due to bleeding into the skin) and bruises may occur, most likely due to thrombocytopenia (low platelets, which causes abnormal blood clotting). [dermnetnz.org]

  This can result in spontaneous rupture of small blood vessels, causing bruising and formation of petechiae (small red spots on the skin). Because red blood cells are destroyed, severe babesia infection can mimic cancer. [rawlsmd.com]

• Myalgia

  This case emphasizes the need to consider tick-borne disease in anyone who presents with prolonged and undulating fevers, chills, headache, myalgias, and arthralgias. [ncbi.nlm.nih.gov]

  Approximate Synonyms Babesia infection Hemolytic anemia due to babesiosis Hemolytic anemia, babesiosis Clinical Information Tickborne disease caused by infection with protozoa; occurs in wild and domestic animals; in humans causes malaria-like symptoms, myalgia [icd9data.com]

  Definition (CSP) tickborne disease caused by infection with protozoa; occurs in wild and domestic animals; in humans causes malaria-like symptoms, myalgia, nausea and splenomegaly; classic zoonotic disease. [fpnotebook.com]

• Dark Urine

  After treatment with a chimeric anti-CD20 antibody preparation (Rituximab), the patient was hospitalised because of anaemia and dark urine from haemoglobinuria. [ncbi.nlm.nih.gov]

  Babesiosis can also cause a particular type of anemia, which makes a person develop jaundice (yellowing of the skin) and have dark urine. [healthvermont.gov]

  Common symptoms include extreme fatigue, aches, fever, chills, sweating, dark urine, and possibly anemia. [maine.gov]

  This type of anemia can lead to jaundice (yellow-colored skin) and dark urine. [capemaycountynj.gov]

• Kidney Failure

  Complications include very low blood pressure, liver problems, severe hemolytic anemia (a breakdown of red blood cells), and kidney failure. Babesiosis Diagnosis and Treatment Sometimes, babesia can be detected in blood examined under a microscope. [lymedisease.org]

  In these people, symptoms of babesiosis may resemble those of falciparum malaria (such as a high fever, anemia, dark urine, jaundice, and kidney failure). [merckmanuals.com]

  […] or heart attack Kidney failure The goals of diagnostic testing are to identify a Babesia infection or to rule out babesiosis as the cause of symptoms. [labtestsonline.org]

  failure) Diagnosing Babesia Like many stealth microbes, babesia is notoriously difficult to diagnose. [rawlsmd.com]

• Headache

  Although headache and lethargy are common symptoms, babesiosis is uncommonly associated with specific neurological dysfunction in humans. [ncbi.nlm.nih.gov]

• Lethargy

  Although headache and lethargy are common symptoms, babesiosis is uncommonly associated with specific neurological dysfunction in humans. [ncbi.nlm.nih.gov]

  The carrier state can last 2 or more years, but in the last month of life, the animals show signs of relapse characterized by a rise in parasitemia, increasing ascites, anorexia, and lethargy ( 116 ). [cmr.asm.org]

• Seizure

  Systemic effects such as toxic encephalopathy, anaphylaxis, and grand mal seizures have been noted with higher DEET concentrations ( 6 ). Finally, DEET ingestion may be fatal to both children and adults ( 6 ). [antimicrobe.org]

  Patients with positive smears or positive polymerase chain reaction (PCR) test results more than 3 months after initial treatment should be treated again, regardless of the presence or absence of seizures. [emedicine.com]

• Stroke

  In worse case scenario, this can cause mini-strokes. Blockage of small blood vessels from swollen blood vessels and increased clotting are one of the main ways babesia causes harm. [rawlsmd.com]

One must suspect babesiosis infection in patients with fever of unknown origin who reside in or have recently travelled to or from an endemic area or who have recently received a blood transfusion. The diagnosis detection depends on the extent of the infection and on the skills of the laboratory technician.

In patients who are asymptomatic the laboratory findings may not be conclusive. Laboratory testing includes a complete blood count (CBC). It may reveal haemolytic anaemia, lymphopenia, and thrombocytopenia. The erythrocyte sedimentation rate (ESR) may be increased.

Peripheral blood smears can be used to diagnose Babesiosis by microscopic examination of Giemsa-stained or Wright-stained blood smears which reveal the different forms of parasites in the RBCs. In patients suffering from an asymptomatic infection, the smear results may not be positive.

Serum chemistry shows elevated levels of serum creatinine and blood urea nitrogen. Liver function tests (LFTs) show elevated levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT) and alkaline phosphatise. It also reveals high bilirubin levels and reduced haptoglobin level1. Elevated Lactate dehydrogenase (LDH) levels reveal the extent of the severity of the infection.

Serological testing which includes Indirect immunofluorescent Antibody (IFA) assay of immunoglobulin M (IgM) or immunoglobulin G (IgG) can also be useful in confirming the diagnosis. However, Immunoblot antibody testing has greater sensitivity and specificity as compared to IFA testing.

Hamster inoculation includes intraperitoneal inoculation of Ethylene Diamine Tertraacetic Acid (EDTA) whole blood from the patient into the peritoneum of a hamster followed by antibody analysis of the animal blood. This test helps in diagnosis when above mentioned tests are non-conclusive.

Polymerase chain reaction (PCR) can help in confirming the diagnosis by detecting Babesia DNA in the patient's blood. A study found that PCR could detect babesial DNA as late as 27 months after an untreated infection [9]. PCR testing is more specific as compared with peripheral smear evaluation and hamster inoculation.

Urinalysis may reveal haemoglobinuria.

In cases of complications like acute respiratory distress syndrome or pneumonias, chest radiographs must be taken.

• Leukopenia

  Moreover, although leukopenia is common in patients with A phagocytophilum infection, the ANC is typically not in the neutropenic range as defined by a count of 1,800/μL or less; indeed, the frequency of absolute neutropenia may actually be higher in [doi.org]

  Additional laboratory findings may include abnormally low levels of platelets (thrombocytopenia) and white blood cells (leukopenia). In 20-25 percent of human babesiosis cases, affected individuals also have Lyme disease. [rarediseases.org]

  HALLMARK SIGN OF BABESIA: recurrent severe drenching sweats Signs and abnormal labs enlarged spleen and liver anemia (low hemoglobin) decreased platelets evidence of hemolysis (destruction of red blood cells) elevated liver function mild neutropenia / leukopenia [rawlsmd.com]

  Laboratory findings often include leukopenia, thrombocytopenia and increases in serum hepatic enzyme activities. [aafp.org]

  Normochromia, normocytic anemia, thrombocytopenia, and, occasionally, leukopenia may also be present. This may be due to TNF-mediated inflammation responses, similar to the pathogenesis of severe malarial infections. [cmr.asm.org]

• Reticulocytosis

  At 2 to 4 weeks after diagnosis, acute anemia, characterized by an elevated mean corpuscular volume (MCV), reticulocytosis, an undetectable haptoglobin level, and an increased LDH level, developed in all six patients ( Figure 1B ). [nejm.org]

• Hematocrit Decreased

  These include: Decreased red blood cells, hemoglobin and hematocrit Decreased platelet numbers (thrombocytopenia) Normal or slightly decreased white blood cell count Comprehensive metabolic panel (CMP) —the tests included in this panel are used to determine [labtestsonline.org]

• Hemoglobin Decreased

  Other lab tests That can be valuable for diagnosing babesia include complete blood count (CBC) showing decreased hemoglobin and low platelets, elevated reticulocyte count, and possibly decreased CD 57 and CD 8 white blood cells, but this only occurs in [rawlsmd.com]

• Babesia Microti

  Postoperatively, she developed fever and was found to have Babesia microti on blood smear with an otherwise negative fever evaluation. She was treated with atovaquone and azithromycin and made a full recovery. [ncbi.nlm.nih.gov]

  Lookback investigations of Babesia microti seropositive blood donors: seven year experience in a Babesia -endemic area. Transfusion. 2011;51. [Forthcoming]. ,, ,, ,. [doi.org]

The goal of medical therapy is to reduce morbidity and mortality, eradicate infection and prevent sequelae. Antimicrobial agents like atovaquone and azithromycin are administered to treat mild to moderate infection of babesiosis.

In a prospective study, it was noted that atovaquone plus azithromycin are as effective as clindamycin plus quinine in giving clinical relief and reducing parasitemia [10]. Treatment of severe infection includes oral quinine and intravenous clindamycin.

Doxycycline too has been used along with clindamycin and azithromycin in patients who were allergic to cinchone derived quinine. Parasitemia may continue to persist even after treatment with either drug regimen.

Complete or partial blood transfusion may be indicated in patients with severe infection. Repetition of the oral therapy may be required in patients who are immune-compromised or asplenic patients.

The prognosis of the disease is dependent on the species of the parasite and the general immune status of the patient. Most patients with a strong immune system have excellent recovery.

Parasites of the genus Babesia cause the disease Babesiosis. It is an illness which is spread from animals to humans hence, called a zoonotic disease. The parasite is transmitted through a tick bite.

Animals that act as reservoirs are horses, cattle and cats. Such cases have often been reported where the blood donor resided or travelled to an endemic area [3] [4]. The protozoan can easily be transmitted through transfusion of contaminated blood or blood products. Very rarely, it can be transmitted through the placenta from an infected mother to the foetus.

Prevalence of Babesiosis all over the world is not clearly known. It is commonly reported in The United States of America. Babesiosis is less common in other areas of the world like in Europe, Asia, Africa, Australia etc.

Since most patients who are infected with babesiosis are asymptomatic, the actual prevalence of the illness is unknown. Babesiosis is more common in asplenic patients, immune-compromised patients and elderly patients.

Babesiosis is transmitted from animals to humans by tick bite.
The ticks have 3 phases i.e. larva, nymph, and adult. Each of these feed on a blood meal to develop into the next phase. The larva and nymph feed on rodents while an adult feeds on other animals.

The signs and symptoms depend on RBC parasitemia. During the feed, the tick ingests Babesia from the host animal. Then these multiply in the gut wall of the tick and are stored in the salivary glands. These are then inoculated in the new host when the ticks feed on the host.

Once in the blood stream, the parasite infects the RBCs producing trophozoites. These then divide to form merozoites. While leaving the RBC, they damage the RBC membrane. This leads to decreased RBC conformability and increased RBC adherence causing pulmonary edema and acute respiratory distress syndrome in severe cases.

Haemolytic RBCs cause capillary blockage or micro-vascular stasis affecting the liver, spleen, kidneys and the CNS. Haemolytic anaemia is produced due to the rapid RBC destruction. Spleen aids in removal of the damaged RBCs. This explains the high occurrence and increased severity of this disease in asplenic patients [5].

Symptoms of fever, anorexia, arthralgia, myalgia etc. are manifested due to complement activation by Babesia.

There are no guidelines for prevention of Babesiosis.

Babesiosis is a tick-borne malaria-like parasitic illness caused by the protozoa Babesia. It can have a major impact on health, especially of animals.

Babesiosis is transmitted from vertebrate animals to humans [1] [2]. Its symptoms range from fever to haemolytic anaemia. The disease can be fatal.

Babesiosis is caused by a protozoa Babesia. It is a tick-borne malaria-like parasitic illness that infects the red blood cells. The symptoms can vary from no overt illness to highly fatal consequences.

It is a zoonotic disease that is transmitted from animals to humans by ticks. It can also be caused due to transmission of contaminated blood. The severity of the disease is higher in patients who are immuno-compromised or patients with HIV infection.

The incidence of the disease is high in patients who have undergone splenectomy. The signs and symptoms of this disease depend on the extent of RBC destruction due to the parasite. It takes about one to four weeks for the symptoms to appear in patients bitten by the infected tick. In cases where the disease is caused due to blood transfusion it may take one week to six months for the symptoms to appear.

The most common symptom is high grade fever ranging up to 40.9 °C that is 105.6 °F. The parasite enters the RBCs causing severe destruction. This leads to haemolytic anaemia. The damaged RBCs are trapped by the spleen. Hence, splenomegaly is also detected.

Along with fever there is severe malaise, fatigue, severe chills, sweating, anorexia, nausea, vomiting, weight loss, headache, muscle and joint pains, cough, sore throat, photophobia and depression. Blood in urine is also one of the symptoms. The fatigue continues for several months even after the symptoms have healed.

Complications due to Babesiosis are disseminated intravascular coagulopathy and acute respiratory distress syndrome.

Elevated Lactate dehydrogenase (LDH) and a well stained peripheral blood help in the diagnosis of the disease. Polymerase Chain Reaction Assay is a specific test for the diagnosis.

Medical therapy includes antimicrobial agents, oral quinine and intravenous clindamycin.

Patients with a strong immune system experience a complete recovery from the disease as compared to patients who are immuno-compromised.

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2. Vannier E, Krause PJ. Update on babesiosis. Interdiscip Perspect Infect Dis. 2009; 2009:984568.
3. Ngo V, Civen R. Babesiosis acquired through blood transfusion, California, USA. Emerg Infect Dis. May 2009;15(5):785-7.
4. Leiby DA. Transfusion-transmitted Babesia spp.: bull's-eye on Babesia microti. Clin Microbiol Rev. Jan 2011;24(1):14-28.
5. Martinot M, Zadeh MM, Hansmann Y, Grawey I, Christmann D, Aguillon S, et al. Babesiosis in immunocompetent patients, Europe. Emerg Infect Dis. Jan 2011;17(1):114-6.
6. White DJ, Talarico J, Chang HG, Birkhead GS, Heimberger T, Morse DL. Human babesiosis in New York State: Review of 139 hospitalized cases and analysis of prognostic factors. Arch Intern Med. Oct 26 1998;158(19):2149-54.
7. Wormser GP, Lombardo G, Silverblatt F, El Khoury MY, Prasad A, Yelon JA, et al. Babesiosis as a cause of fever in patients undergoing a splenectomy. Am Surg. Mar 2011;77(3):345-7
8. Kuwayama DP, Briones RJ. Spontaneous splenic rupture caused by Babesia microti infection. Clin Infect Dis. May 1 2008;46(9):e92-5.
9. Krause PJ, Spielman A, Telford SR 3rd, et al. Persistent parasitemia after acute babesiosis. N Engl J Med. Jul 16 1998;339(3):160-5.
10. Krause PJ, Lepore T, Sikand VK, Gadbaw J Jr, Burke G, Telford SR 3rd, et al. Atovaquone and azithromycin for the treatment of babesiosis. N Engl J Med. Nov 16 2000;343(20):1454-8.