639: HEMORRHAGIC SHOCK DUE TO SPONTANEOUS SPLENIC RUPTURE A RARE COMPLICATION OF BABESIOSIS

Abstract

Learning Objectives: Human babesiosis is an infection usually due to Babesia microti, a hemoprotozoan transmitted mainly by Ixodes scapularis ticks and endemic to specific areas of northeastern and midwestern United States. Clinical presentations of infection range from mild febrile illness to serious multi-organ failure. Spontaneous splenic rupture (SSR) is a rare life-threatening complication of babesiosis. This is a case of hemorrhagic shock due to SSR in a patient with severe B. microti infection. Methods: A 66 year-old immunocompetent man from southeastern Pennsylvania reported generalized malaise, weakness, anorexia, fevers, and chills for one week. He had a fever of 39.70C, tachycardia of 98 bpm, blood pressure of 101/65 mmHg, respiratory rate of 18/min, oxygen saturation of 95% on ambient air with scleral icterus, no rash, and no organomegaly. Laboratory studies showed anemia, thrombocytopenia, and hyperbilirubinemia with elevated lactate dehydrogenase and transaminases. Intraerythrocytic Babesia was seen on blood smear with parasitemia of 9.0%. Clindamycin, quinine, and doxycycline was started. On day 3 the patient became hypotensive to 86/45 mmHg, and lethargic with a distended abdomen. A new coagulopathy with a 4 gram drop in hemoglobin was noted. Parasitemia levels were 0.1%. Massive transfusion protocol was activated. Computed tomography of the abdomen/pelvis showed hemoperitoneum with the spleen as a likely source of bleeding. Emergent laparotomy confirmed SSR. He continued to bleed despite splenectomy and damage control packing of the abdomen. Interventional radiology (IR) performed an angiogram with embolization of a dorsal pancreatic artery pseudoaneurysm achieving hemostasis. Results: Splenic sequestration of platelets and histiocyte phagocytosis of infected erythrocytes leads to thrombocytopenia and rapid splenomegaly. However, the mechanism of SSR in babesiosis is unclear. Illness severity or high parasitemia levels do not correlate with SSR. Our patient had low parasitemia levels at the time of SSR. Non-surgical management is preferred in stable cases to minimize severe babesiosis with recurrent exposure. Emergent laparotomy for splenectomy is indicated in hemodynamically unstable patients. IR embolization is also a useful modality to control hemorrhage and was required in our patient. This case highlights the importance of recognizing SSR as a rare life-threatening complication of babesiosis and using a multidisciplinary approach to management.