IRBs and Public Health Pathology

Hello again! Welcome back to my latest check-in following my progress with Zika risk reduction and public health outreach. Partnering with the Sint Maarten Ministry of Health through my medical school has provided amazing resources to take a look at social determinants of risk under the purview of public health, integrating both medical sciences and community service.

Early on in this project, I discussed the early stages in conceiving and planning these public health works in my first post “An Arbovirus Abroad.” This of course seemed like the perfect name for the proposal my team and I authored at the end of our first semester together. Done under an elective service credit, our full Internal Review Board (IRB) proposal for research within the community was called “An Arbovirus Abroad: a Service Learning Project Exploring Public Health Outreach, Social Determinants of Health, and Partnerships with Local Government to Address Zika Virus Knowledge and Community Outcomes.” The goals were to strengthen our partnership with local government offices as we aligned our efforts with reducing infectious risk and addressing community knowledge and attitudes regarding Zika.

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Figure 1. Title Page of original IRB/Research Project Proposal under G. Jackson, Ph.D., Assistant Dean, Community Affairs and Service Learning at AUC School of Medicine

After we secured IRB approval, we began work quickly. Holding meetings with the Ministry’s representative consultant for their office of Collective Prevention Services (i.e. vector control) and scheduling the remaining work for the semester. With five new members of the “Z-Pack” we established a loose timeline with our advisor. Our new goal: integrate what we learned last semester and bring it to a conclusive change within the community.

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Figure 2. Title card from initial briefing meeting with members of the Z-Pack, including coordinating partner from the Ministry of Health (CPS office) Mr. G. Davelaar.

This integration of knowledge from literature review/research, evidence-based best practices, and forward moving progress are all things those of us in the medical laboratory profession are quite familiar with. Getting IRB approval for a lab-centric project is quite involved and requires meticulous proof and substantial support to posit any claim to the benefit/risk ratio involved with human or animal subjects. I remember from my own graduate and undergraduate research that without heaps of evidence, you will be hard pressed to continue in any direction. While public health is a different science, the basis on evidence-based research is still present. During our initial assessments, literature reviews, and brainstorming, the “Z-Pack” went through hundreds of scientific articles covering everything from infection control precedents, to social behavioral change, and even the use of media and fear to illicit change.

Laboratory scientists know the impact of their work, though it may not always be the most evident to the general public. The near 70% of diagnostic information that comes from our work, and the virtual entirety of neoplastic diagnoses rely heavily on our training, skill, and certified competency in evidence-based practices. ASCP has a long-standing mission of advocacy for patients in the way its members and affiliates represent the profession at large. I believe that having those years of experience under my belt and those letters behind my name give me a head start when executing translational research. Going from raw data, analyzing it, and bringing it to life is something we all inherently train to do—and do well!

So, up to date, my team has secured two measures to contribute to our research. First, we gave an educational presentation to a community after-school program in one of Sint Maarten’s endemic regions. We had tailored a wonderful presentation I discussed in a previous post which caught the eye of the Ministry of Health and has spread to numerous places around the island under their sponsorship. With the same success, we managed to reach school-aged children in an engaging way about Zika, their health, and source reduction. Our second event is slated for this weekend where we have partnered with the Muslim student-interest group (MSA) on campus to go with them on their routine visit to a local mosque on a school-sponsored student service day we call “Community Action Day.” While the MSA students engage with their local community, the “Z-Pack” will conduct a two-part effort: to conduct a grounds-inspection for source/vector control around the mosque, and deliver a presentation for both children and adults regarding Zika prevention behavior.

How do those two events connect with my theme of evidence-based lab scientists? Well, one of my engagements when at Northwestern Medicine was to teach a course discussing transfusion protocols and laboratory information to clinical nursing staff. Presenting information, or teaching people, new ways to think about their environment at work or home is a part of being interdisciplinary. I was able to speak with medical jargon to the clinical staff, but with the children I have to use my ability in translating medical knowledge to understandable facts while also keeping the audience interested. My team proved in our last school-aged project, that when children are engaged and enthusiastic about something they have learned, they will take those messages home with them and hopefully contribute to a positive outcome. As for the second example, what could be more directly appropriate for lab folks to understand here: a surprise inspection! Sure, no one’s losing any accreditation points here, but the fact remains that we all have experience from one side or another making sure that things are up to code on pre-determined conditions and protocols. We have an SOP from the Ministry regarding the items of inspections as they relate to source control, so translating them to a new site should prove interesting.

I’ll close this post off with an interesting piece recently posted by Ms. Susan M. Lehman, MA, MT (ASCP)SM where she discussed learner (i.e. student) experiences. She talked briefly about how online curriculums and other lab-skills courses may rely on more independent learning, changing the expectations of students. One of her students summarized it positively saying, “you get what you put into it.” That’s what I think about the service elective my work is associated with. It could be simple directed readings with great discussions, but what my “Z-Pack” team has and the skills we each bring to it have made the project and its partnerships exciting.

Thanks for reading!

 

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Constantine E. Kanakis MSc, MLS (ASCP)CM graduated from Loyola University Chicago with a BS in Molecular Biology and Bioethics and then Rush University with an MS in Medical Laboratory Science. He is currently a medical student at the American University of the Caribbean and actively involved with local public health.

Microbiology Case Study: 81 Year Old Man with Prior History of Bladder Cancer

Case history

An 81 year old man with prior history of bladder cancer treated with Bacillus Calmette–Guérin  (BCG) presented with dysuria. Three urine samples were sent for AFB culture.

Laboratory Workup

The urine samples were plated on 7H11 solid media and Middlebrook liquid media. Colonies grew in the liquid media in five days and the solid media in 6 days (Figure 1). The colonies were subcultured to 7H11 solid media and Lowenstein-Jensen (LJ) media.  At this time, the colonies were probed for Mycobacterium tuberculosis complex, M. avium complex and M. gordonae, all of which were negative.  The organism grew on all of the subcultured media within one day. This fulfilled the criteria for rapidly- growing Mycobacterium species given the organism had grown in less than 7 days on subculture from solid media to solid media.  The specimen was sent out to our reference laboratory for further speciation and was identified as Mycobacterium chelonae.

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Figure 1: 7H11 media with non-pigmented white colonies.

 

Discussion

Rapidly growing mycobacteria include many species, but the main clinically relevant species are M. fortuitum, M. chelonae, and M. abscessus. These organisms are widely distributed in nature and can survive nutritional deprivation and extreme temperatures. They have been isolated from soil, dust, natural surfaces, water, wild animals and domestic animals.  Risk factors for infection include patients with immunosuppression, organ transplant and autoimmune disorders. Immunocompetent patients are also at risk if they have had trauma or invasive medical procedures.  M. chelonae may cause a spectrum of human disease. The most common manifestations are cutaneous infection, osteomyelitis and catheter infections. Nosocomial outbreaks of M. chelonae have been reported and linked to various water sources, including water-based solutions, distilled water, tap water and ice.  Rapidly growing mycobacterium are generally resistant to the classic antituberculosis drugs (rifampin, ethambutol and isoniazid). M. chelonae is usually sensitive to aminoglycosides, however treatment should be determined by antibiotic susceptibility testing.  In our patient, we had expected the colonies to be M. bovis because of the patient’s history of BCG treatment which is a live attenuated strain of M. bovis. Cystitis induce by M. chelonae is a rare clinical manifestation. We believed this is a true infection, as opposed a contaminated patient sample, given the patient’s symptoms in conjunction with all three urine samples being positive for M. chelonae.

 

-Jill Miller, MD is a 4th year anatomic and clinical pathology resident at the University of Vermont Medical Center.

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-Christi Wojewoda, MD, is the Director of Clinical Microbiology at the University of Vermont Medical Center and an Assistant Professor at the University of Vermont.

Laying a Foundation for a Blended Curriculum Model

In the late 1990s—early 2000s—we were faced with a critical shortage of graduates in clinical/medical laboratory science, and we started evaluating the benefits of having our own program. Once we made the decision to seriously consider implementing our own program, I pitched a proposal for a blended model of curriculum delivery. My proposal was accepted by the Mayo Clinic School of Health Sciences as a pilot program to be supported by our newly created education technology center. Since our program and the education technology center were both new, we certainly experienced some growing pains. Also, had I known we’d have to reconstruct major elements of our online content every time we upgraded our content management system, I might have thought twice about it!

In the end, it was all worth it because today, we have an outstanding program built upon a solid foundation of both traditional and online content delivery that leverages our staff infrastructure and can be effectively managed and maintained over time.

In the curricular model developed for our academic program in Medical Laboratory Science (MLS), the didactic component is provided in an e-learning platform (Blackboard Learn) and is underscored by Transactional Distance Theory (Moore, 1991), in which the three modalities of learner interaction with content, instructor, and fellow students are integrated into the online module. Each lesson plan includes a laboratory module taught by traditional methods of interaction between the instructor and student in a classroom setting. A constructivist learning environment is facilitated, and each lesson plan is closely anchored in the context of the work the student will perform upon employment.

Here is a simple diagram of our curricular model:

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The following learning theories define our program curricular model:

  1. Transactional Distance Theory (e-learning theory): The online lesson plan includes learner-content interaction, learner-learner interaction, and learner-instructor interaction.
  2. Constructivism: The roles of both the teacher and student are redefined in this educational model. The teacher moves away from the traditional role of “sage on stage” to that of a “facilitator” of the student’s acquisition of knowledge. The student becomes a more active learner in this model, moving away from the traditional role of passive learner.
  3. Anchored Learning:
  • Information is taught in the context of how the learner will apply it once he or she is working.
  • The online homework lesson correlates with a hands-on laboratory lesson designed to reinforce the e-learning content.
  1. Reversing the Lecture-Homework Paradigm (Moses, 2002): The traditionally taught lecture is provided as an online homework assignment.

Embracing technology has provided a means by which we can improve our teaching methods and promote change in our education infrastructure. More than half of our didactic courses in our MLS Program apply the new education strategy I learned about as “reversing the lecture-homework paradigm” (more commonly known as “flipping the classroom”). Instead of going to lecture, our students complete web-supported didactic modules asynchronously as “homework” assignments, allowing more classroom time for laboratory instruction.

By providing more hands-on laboratory lessons, we are giving our students the opportunity to practice laboratory procedures and apply new learning material in a way that corresponds more closely with what they will do for a living after they graduate. Instead of giving the typical “one-directional lecture” with limited opportunity for dialogue, our instructors are able to spend more time with our students, teaching practical applications of the content, answering questions, and helping problem-solve.

References

  1. Moore, M. G. (1991). Editorial: Distance education theory. American Journal of Distance Education, 5(3), 1-6.
  2. Moses, G. A. (2002). e-Technology must enable big education goals. Proceedings of the 2002 e-Technologies in Engineering Education (eTEE) Conference, Switzerland, Vol. P01, Article 20, 142-145.

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-Susan M. Lehman, MA, MT(ASCP)SM graduated from the University of Wisconsin-Madison in 1983 with a BS in medical technology. She is program director for the Medical Laboratory Science Program and course director for Clinical Microbiology I and II; her areas of interest include distance education and education methodology.

Microbiology Case Study: A 60 Year Old Woman with a Skin Papule

Case history

A 60-year old woman residing in Vermont presented to the dermatology clinic for a routine annual skin exam. She had no complaints. On physical exam, a pink papule was seen on the patient’s back, with a centrally embedded tick (Figure 1). The tick was removed and sent for identification, with the plan to give a single prophylactic dose of doxycycline if identified as Ixodes scapularis.

Laboratory Identification

The tick was examined and noted to be less than 1 mm in size, with six legs (Figure 2). This was identified as the larval stage of Ixodes scapularis.

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Figure 1. Photograph of Ixodes scapularis larva embedded in the patient’s back. Six legs are visible.

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Figure 2. Photograph of the tick larva received in the laboratory, demonstrating a light tan-brown color.

 

Discussion

I scapularis, also known as the blacklegged tick, deer tick, or bear tick, is most clinically significant for its ability to transmit the pathogens Borrelia burgdorferi, Babesia spp., and Anaplasma phagocytophilum. It has four separate life stages (egg, larva, nymph, and then adult), spanning approximately 2 years. Each of these stages feeds on different preferred host animals.

Eggs are deposited on the ground by blood-engorged females in the late spring, where they subsequently hatch into 6-legged larvae. Because they have not yet fed, larva forms generally do not carry or transmit B. burgdorferi or other tick-borne pathogens. Trans-ovarial transmission of Borrelia, Anaplasma, or Babesia from adult I. scapularis females to eggs of is not a significant mode of pathogen transmission; however, in a similar tick species, I. ricinus (prominent in Europe), trans-ovarial transmission of Babesia divergens does occur, and so infection may be transmitted by larvae. The I. scapularis larvae will take their first blood meal from small mammals and birds, and then when engorged fall to the ground and molt into nymphs.

The nymph forms, which have already taken a blood meal, can carry pathogens and in fact are more likely to transmit pathogens to humans than the adult form of the tick. This is because the nymph form is much smaller (<2mm in size) than the adult form, and therefore is likely to go undetected when it attaches to a host. The nymphs are dormant over the winter, and re-activate the following spring to take their second meal. By fall, nymph forms have molted into adult ticks, which prefer to feed on white-tailed deer. However, while these deer support the tick population, they are not a large reservoir for Lyme disease. Rather, it is the white-footed mice preferentially fed upon by larvae and nymph forms that act as the main reservoir for B. burgdorferi, B. microti, and A. phagocytophilum. The female adults of I. scapularis are red to orange and larger than males, around 1/8 of an inch long, with a dark brown to black dorsal shield. If females do not feed in the fall, they can remain dormant over the winter and may emerge if the weather gets temporarily warmer (so the onset of cold weather does not necessarily mean the risk of tick exposure is over). Male adults do not take blood meals, and so do not transmit blood-borne pathogens.

To be considered in the differential diagnosis is Dermacentor variabilis, or the American dog tick. This tick species is larger than Ixodes spp., and adult forms have a white-to-gray collar on their backs. D. variabilis have more rectangular-shaped head and mouth parts than the deer tick. Both nymph and larvae forms are yellow-brown in color before feeding, and then turn gray once engorged. It is extremely uncommon for nymph and larval forms of D. variabilis to feed on humans, in contrast to I. scapularis. D. variabilis does not transmit Lyme disease, though in endemic areas it may transmit Rickettsia rickettsii or Francisella tularensis.

Because the tick in the presented case was identified as an I. scapularis larva, the patient was not treated with antibiotics as there was an exceedingly low risk of pathogen transmission.

 

-Alison Krywanczyk, MD is a 3rd year anatomic and clinical pathology resident at the University of Vermont Medical Center.

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-Christi Wojewoda, MD, is the Director of Clinical Microbiology at the University of Vermont Medical Center and an Assistant Professor at the University of Vermont.

An Arbovirus Abroad

Hello! My name is Constantine Kanakis and I am very happy to contribute to Lab Medicine’s online blog! As my first post, I would like to introduce myself, tell you a little bit about my interests in laboratory medicine, and also discuss Zika virus research I’m actively involved in.

I studied molecular biology at Loyola University and medical laboratory science at Rush University, both in Chicago. From undergraduate to graduate school, I was fortunate enough to work on research topics involving the neurology of nematodes, enzymatic plant assays, social justice/urban planning work, microbiological lab equipment development, and novel biochemical hematopoietic interventions. This comprehensive experience in research work provided a strong foundation which I have found useful in my career both in and out of the hospital laboratory. Other than research, I spent nearly nine years working in some of Chicago’s busiest hospitals. I learned the ropes in a variety of settings: trauma center transfusion medicine, academic center quality assurance, public health work, and community hospital laboratory work. I feel personally drawn to laboratory medicine and pathology, as it connects translational research to patient outcomes and puts us in a position to mobilize fellow professionals to improve health care in our communities.

This bridge from lab discoveries to bedside and beyond motivated me to write for this blog community. The current Zika virus outbreak as well as the start of my medical school career has provided a great opportunity for me to explore translational research and its direct impact into a local community. Currently, I am a second year medical student at American University of the Caribbean School of Medicine located on the island of Sint Maarten, in the Netherlands Antilles (Figure 1). I find myself in the epicenter of the now infamous viral epidemic of everyone’s new favorite Arbovirus: Zika. Studying in the Caribbean, I am actively involved in projects assessing the emergence of this viral phenomenon. Today, CDC lists countries with active infections with a Level 2 travel active warning notice, “[to] Practice Enhanced Precautions.” These projects have three tiers: laboratory studies, collaboration with local health partners, and integration of research with public health efforts. My location here provides ample opportunity to gather information at its source, most notably from our neighbors in Brazil, Puerto Rico, and even Florida. This island is high on the list of endemic countries with 1,730 suspected Zika cases reported as of July, 2016, however only 12% of those cases were serologically confirmed. The suspected cases have been rising in the last few months (Figure 2) and epidemiologists are watching the trends very closely.

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Figure 1. The Centers for Disease Control and Prevention (CDC), updates regions on the world map which have reported active Zika virus infections, CDC 5 October 2016.

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Figure 2. Suspected Zika viral infection cases per epidemiological week, Pan-American Health Organization (PAHO) and World Health Organization (WHO) 2016.

As a primer for those who are interested, the Zika virus is a Flavivirus/Arbovirus undergoing its second recent epidemic spread in the last decade. Discovered in the 1950s, it has been considered a minor viral infectious agent. To date, researchers near and far are exploring both potential vaccination and prevention measures, as well as infection control efforts as some claims link the virus to microcephaly, Guillain-Barre, and other various sequale. It is transmitted primarily by mosquito bites directly into the blood, though its antigenic presence has persisted in urine and even seminal fluid. Research in public health and epidemiology has also related the management of this outbreak to previous ones, including that of the 2014 Ebola epidemic. There is contention between various public health organizations and laboratory researchers in detailing any exact correlation of the viruses secondary effects as well as the difficulty in specific detection and diagnosis relative to reported vs. confirmed cases (Figure 3).

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Figure 3. A general demonstration of the purported Zika infection cases and how this reflects the true nature of the epidemic in the Caribbean in collaboration with the PAHO and WHO, from the Caribbean Public Health Agency (CARPHA) 2016.

Several research projects are starting here on campus, a majority of which involve serologic prevalence and surveillance studies. Some new studies are aimed directly at using commercially available testing, while others compound data from previously significant outbreaks of other arboviruses (e.g. Chikungynya, Dengue, Yellow Fever, West Nile). Our work in the laboratories here is also matched with significant public outreach. I am involved in one particular service and outreach project through the university here which targets the dissemination of Zika prevention/infection knowledge through various informational outlets such as town hall meetings, health drives for children, and vector control projects in the field. Our school-based task forces have been fortunate enough to form partnerships with the local Ministry of Public Health, Social Development, and Labor here on the island. And, coordinating with their Collective Prevention Services, they are now involved in reaching out to the community at large (see Figure 4).

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Figure 4: One of the newest school projects sponsored this year included a vector control initiative partnership with the Sint Maarten Red Cross, and the Ministry of Health’s Collective Prevention Services, conducting home inspections in areas of statistically high reportable cases, photo credit: A. Yancone 2016.

On a personal note, I will add that my wife and I, along with several of our friends here have ironically been “bitten by the Zika bug.” We all suffered the same relative symptoms (fever, malaise, myalgia, headaches, and the infamous maculopapular rash), so I can speak personally on the effects of an active Zika infection! Really though, it isn’t that bad; it felt like a bad flu—most locals are not too worried about Zika because they already have several other arthropod-borne viral infections to stay away from with significantly worse courses of infection. Chikungynya, Dengue Fever, Yellow Fever, West Nile, less often Plasmodium/Malaria, and others offer more of a threatening presence than the several day woes of a Zika infection. Moreover, those other infections sometimes have even worse complications and clinical presentations.

As I begin and continue my work through these projects, I will provide updates—both on our efforts here in the laboratory as well as our work in reaching out and partnering with local public health officials to try and make a positive impact on our local community. And since I am now “inoculated,” I’ll be happy to get really close to the action for all of you.

Thanks for reading!

 

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-Constantine E. Kanakis MSc, MLS (ASCP)CM graduated from Loyola University Chicago with a BS in Molecular Biology and Bioethics and then Rush University with an MS in Medical Laboratory Science. He is currently a medical student at the American University of the Caribbean and actively involved with local public health.

 

Microbiology Case Studies: Babesia vs. Malaria

Patient History: Case 1

A 55 year old Asian woman presented to an emergency department in southern New England in September with complaints of a high fever with chills for the past 5 days. She noted feelings of excessive tiredness, muscle aches, and headache. She also described a decrease in appetite and nausea with vomiting and diarrhea. On physical exam, she was febrile (103.8°F) and scleral icterus was identified. Laboratory workup revealed findings suggestive of hemolysis including increased LDH (401 U/L) and increased unconjugated bilirubin (1.7 mg/dL), despite hemoglobin & hematocrit values in the normal range (13.7 g/dL & 39.3%, respectively). Elevated liver enzymes were also noted; AST 81 U/L and ALT 72 U/L. When questioned regarding traveling history, she reported a trip to Spain and Portugal 5 months earlier. Though she acknowledged living in a rural area of the Northeastern U.S. and indicated that her husband was diagnosed with Lyme disease one year earlier, she denied both recent time outdoors and arthropod or mosquito bites.

Patient History: Case 2

A 31 year old African American woman with a history of sickle cell trait presented to an emergency department in southern New England in September complaining of fevers of 5 days duration. She described being asymptomatic in the mornings followed by high spiking fevers with muscle aches and dull frontal headaches in the evenings. A physical exam revealed a fever (103°F), but no evidence of meningismus. Laboratory workup revealed a mild, microcytic anemia (hemoglobin & hematocrit: 10.7 g/dL & 32.5%, MCV: 76.3 fL), a decreased absolute lymphocyte count and increased band neutrophils. When questioned regarding recent travel, she reported having returned from Africa 10 days earlier. While abroad, she had primarily been in Nigeria’s capital, but she had also visited rural areas. She did not recall having been bitten by mosquitos, but she did not take any anti-malarial prophylaxis. Further, she denied both recent travel to the woods in the Northeastern U.S. and recent arthropod bites.

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Figure 1. Peripheral blood smear from patient 1 showing ring-like forms which contain a small amount of cytoplasm and a chromatin dot as illustrated by the arrows. Both intra-erythrocytic and extra-cellular forms are present. Platelets are denoted by arrowheads.

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Figure 2. BinaxNOW lateral flow assay from patient 1 is negative for the various Plasmodium spp.

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Figure 3. Peripheral blood smear from patient 2 showing ring forms and trophozoites within red blood cells as denoted by arrows. Inset illustrates a scattered gametocyte. Platelets are denoted by arrowheads.

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Figure 4. BinaxNOW lateral flow assay from patient 2 is positive for non-falciparum malaria species as indicated by the faint positive reaction denoted by the red arrow in the T2 region.

 

For patient 1, given the results from the peripheral blood (Figure 1), the negative BinaxNow results (Figure 2) and her lack of recent travel to malaria endemic regions, her illness was attributed to infection by Babesia spp. Further serologic testing was positive for Babesia microti. She was seronegative for Anaplasma phagocytophilum, Borrelia burgdorferi, Ehrlichia chaffeenesis. This finding was confirmed by PCR of her blood, which detected B. microti, but failed to detect B. duncani or B. divergens/MO-1. Approximately 3% of her red blood cells contained intracellular parasites.

For patient 2, her disease was most consistent with an infection by a non-falciparum species of malaria, including P. ovale, P. vivax or P. malariae, given her recent travel to Nigeria and advanced forms seen in the peripheral blood (Figure 3). Further speciation was uncertain due to low parasitemia levels (<1%) and the findings were unable to exclude a mixed infection with a low P. falciparum burden.

Discussion

The clinical and laboratory presentations of babesiosis and malaria are quite similar despite the fact that each infection is caused by a distinct and highly unique microorganism. As seen in the two cases above, both illnesses often begin insidiously with fevers, headache and muscle & joint aches. The non-specific nature of the patient’s symptoms results in an unclear etiology unless key elements of the patient’s history, including exposure to insect and arthropod vectors and travel or habitation in endemic areas, are provided.

Examination of thick and thin blood smears is useful in the diagnosis of these two diseases. While both organisms have a very similar sized lifecycle forms which selectively infect red blood cells and prompt hemolysis, there are a few useful distinguishing characteristics. In the case of babesiosis, which is transmitted by the Ixodes scapularis tick in the United States, there are small ring like structures, both within red blood cells and extra-cellularly. The diagnostic tetrad form, known as a Maltese Cross, is helpful if identified but is not frequently observed in human infections. No advanced forms or pigment is present. In the case of malaria, which is transmitted via the female anopheline mosquito, protozoa are only found within red blood cells and advanced forms, including schizonts or gametocytes, are helpful in further speciation, if present. Other features, such as size of the infected red cell, number of merozoites, level of parasitemia and gametocyte shape, are helpful in the morphologic assessment of the Plasmodium spp.

Due to the pathogenic severity of P. falciparum, it is important that the microbiology laboratory has the ability to make the diagnosis in real time across all shifts. The BinaxNOW is an FDA approved lateral flow assay that is simple to perform and provides rapid diagnostics, though it isn’t as sensitive as microscopy. The test is comprised of two antigens: one specific to P. falciparum (T1) and one antigen common to all Plasmodium spp. (T2). The test will be positive for levels of parasitemia greater than 5,000 parasites per microliter.

As utilized in the above cases, other various laboratory modalities can aid in the diagnosis of babesiosis and malaria, including serologic tests and PCR, however, these tests may not be available in STAT situations. Using a variety of tests and obtaining a thorough travel history, will help the provider arrive at the correct diagnosis of blood protozoa.

 

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-JP Lavik, MD, PhD, is a 3rd year Anatomic and Clinical Pathology Resident at Yale New Haven Hospital.

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-Lisa Stempak, MD, is an Assistant Professor of Pathology at the University of Mississippi Medical Center in Jackson, MS. She is certified by the American Board of Pathology in Anatomic and Clinical Pathology as well as Medical Microbiology. Currently, she oversees testing performed in both the Chemistry and Microbiology Laboratories. Her interests include infectious disease histology, process and quality improvement and resident education.