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Concept: Babesia

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BACKGROUND: Mitochondrial (mt) genomes vary considerably in size, structure and gene content. The mt genomes of the phylum Apicomplexa, which includes important human pathogens such as the malaria parasite Plasmodium, also show marked diversity of structure. Plasmodium has a concatenated linear mt genome of the smallest size (6-kb); Babesia and Theileria have a linear monomeric mt genome (6.5-kb to 8.2-kb) with terminal inverted repeats; Eimeria, which is distantly related to Plasmodium and Babesia/Theileria, possesses a mt genome (6.2-kb) with a concatemeric form similar to that of Plasmodium; Cryptosporidium, the earliest branching lineage within the phylum Apicomplexa, has no mt genome. We are interested in the evolutionary origin of linear mt genomes of Babesia/Theileria, and have investigated mt genome structures in members of archaeopiroplasmid, a lineage branched off earlier from Babesia/Theileria. RESULTS: The complete mt genomes of archaepiroplasmid parasites, Babesia microti and Babesia rodhaini, were sequenced. The mt genomes of B. microti (11.1-kb) and B. rodhaini (6.9-kb) possess two pairs of unique inverted repeats, IR-A and IR-B. Flip-flop inversions between two IR-As and between two IR-Bs appear to generate four distinct genome structures that are present at an equi-molar ratio. An individual parasite contained multiple mt genome structures, with 20 copies and 2 - 3 copies per haploid nuclear genome in B. microti and B. rodhaini, respectively. CONCLUSION: We found a novel linear monomeric mt genome structure of B. microti and B. rhodhaini equipped with dual flip-flop inversion system, by which four distinct genome structures are readily generated. To our knowledge, this study is the first to report the presence of two pairs of distinct IR sequences within a monomeric linear mt genome. The present finding provides insight into further understanding of evolution of mt genome structure.

Concepts: DNA, Bacteria, Genome, Malaria, Plasmodium, Apicomplexa, Babesia, Theileria

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Piroplasmosis are among the most relevant diseases of domestic animals. Babesia is emerging as cause of tick-borne zoonosis worldwide and free-living animals are reservoir hosts of several zoonotic Babesia species. We investigated the epidemiology of Babesia spp. and Theileria spp. in wild ungulates and carnivores from Northern Italy to determine which of these apicomplexan species circulate in wildlife and their prevalence of infection.

Concepts: Disease, Apicomplexa, Switzerland, Italy, Austria, Babesia, Slovenia, Alps

52

Background Babesia microti, a tickborne intraerythrocytic parasite that can be transmitted by means of blood transfusion, is responsible for the majority of cases of transfusion-transmitted babesiosis in the United States. However, no licensed test exists for screening for B. microti in donated blood. We assessed data from a large-scale, investigational product-release screening and donor follow-up program. Methods From June 2012 through September 2014, we performed arrayed fluorescence immunoassays (AFIAs) for B. microti antibodies and real-time polymerase-chain-reaction (PCR) assays for B. microti DNA on blood-donation samples obtained in Connecticut, Massachusetts, Minnesota, and Wisconsin. We determined parasite loads with the use of quantitative PCR testing and assessed infectivity by means of the inoculation of hamsters and the subsequent examination for parasitemia. Donors with test-reactive samples were followed. Using data on cases of transfusion-transmitted babesiosis, we compared the proportions of screened versus unscreened donations that were infectious. Results Of 89,153 blood-donation samples tested, 335 (0.38%) were confirmed to be positive, of which 67 (20%) were PCR-positive; 9 samples were antibody-negative (i.e., 1 antibody-negative sample per 9906 screened samples), representing 13% of all PCR-positive samples. PCR-positive samples were identified all through the year; antibody-negative infections occurred from June through September. Approximately one third of the red-cell samples from PCR-positive or high-titer AFIA-positive donations infected hamsters. Follow-up showed DNA clearance in 86% of the donors but antibody seroreversion in 8% after 1 year. In Connecticut and Massachusetts, no reported cases of transfusion-transmitted babesiosis were associated with screened donations (i.e., 0 cases per 75,331 screened donations), as compared with 14 cases per 253,031 unscreened donations (i.e., 1 case per 18,074 unscreened donations) (odds ratio, 8.6; 95% confidence interval, 0.51 to 144; P=0.05). Overall, 29 cases of transfusion-transmitted babesiosis were linked to blood from infected donors, including blood obtained from 10 donors whose samples tested positive on the PCR assay 2 to 7 months after the implicated donation. Conclusions Blood-donation screening for antibodies to and DNA from B. microti was associated with a decrease in the risk of transfusion-transmitted babesiosis. (Funded by the American Red Cross and Imugen; ClinicalTrials.gov number, NCT01528449 .).

Concepts: Immune system, Antibody, Polymerase chain reaction, Blood, Lyme disease, ELISA, Blood transfusion, Babesia

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Human babesiosis is a tick-borne multisystem disease caused by Babesia species of the apicomplexan phylum. Most clinical cases and fatalities of babesiosis are caused by Babesia microti Current treatment for human babesiosis consists of two drug combinations, atovaquone + azithromycin or quinine + clindamycin. These treatments are associated with adverse side effects and a significant rate of drug failure. Here, we provide evidence for radical cure of experimental babesiosis in immunodeficient mice using a combination of an endochin-like quinolone (ELQ) prodrug and atovaquone. In vivo efficacy studies in mice using ELQ-271, ELQ-316, and the ELQ-316 prodrug, ELQ-334, demonstrated excellent growth inhibitory activity against the parasite, with potency equal to that of orally administered atovaquone at 10 mg/kg. Analysis of recrudescent parasites after ELQ or atovaquone monotherapy identified genetic substitutions in the Qi or Qo sites, respectively, of the cytochrome bc1 complex. Impressively, a combination of ELQ-334 and atovaquone, at doses as low as 5.0 mg/kg each, resulted in complete clearance of the parasite with no recrudescence up to 122 d after discontinuation of therapy. These results will set the stage for future clinical evaluation of ELQ and atovaquone combination therapy for treatment of human babesiosis.

Concepts: Pharmacology, Malaria, Babesiosis, Babesia

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Bovine piroplasmosis are tick-borne protozoan diseases caused by parasites of the genera Theileria and Babesia. Three Friesian cattle farms (F1-F3) with previous history of clinical piroplamosis were selected in Minorca (Balearic Islands, Spain). Blood samples were collected from 8 to 11 animals every two months throughout a year and, a newly developed multiplex DNA bead-based suspension array based on the Luminex(®) xMAP technology was used to monitor for the presence of piroplasms. The assay incorporated probes for Babesia divergens, Babesia bovis, Babesia bigemina, Babesia major, Babesia occultans, Theileria annulata and Theileria buffeli, and a Catch-all Theileria and Babesia (TB) control probe. An internal amplification control that was detected with a Luminex probe was also included to monitor for inhibition. Infection was detected in 87.5% of the samples, 38.7% as single infections and 48.8% as mixed infections. T. annulata was widespread in Farm F1, with all animals positive over the whole study; albeit less frequently, T. annulata was also detected in Farms F2 and F3. T. buffeli was the overall most prevalent piroplasm, with a wide distribution in Farms F2 and F3 but only occasionally detected in F1. B. bigemina was the most frequent Babesia species, but was absent from Farm F1. B. bovis, previously reported in Minorca, was only sporadically detected in F2 and F3. A further 3 Babesia species not previously found in Minorca were also identified: B. major present in the 3 farms; B. divergens detected once in 2 animals in F2; and B. occultans found in 4 animals in F2 and in 1 Hyalomma marginatum female tick collected from a positive animal. Sequencing confirmed the identity of B. occultans thus extending the distribution of this species to Mediterranean Europe. This study confirmed the endemic situation for piroplasm infection in the region and detected the presence of a large number of chronic asymptomatic carriers. More importantly, 3 Babesia species not previously detected in the region were detected for the first time.

Concepts: Apicomplexa, Mediterranean Sea, Spain, Babesiosis, Babesia, Theileria, Balearic Islands, Piroplasmida

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Bovine babesiosis is a tick-transmitted hemoprotozoan disease that is mainly caused by Babesia bovis and/or Babesia bigemina and is characterized by significant morbidity and mortality worldwide. This disease is widespread in most parts of China. However, it is difficult to rapidly discriminate between the B. bovis and B. bigemina species. To detect and distinguish these species, a loop-mediated isothermal amplification (LAMP) platform that targets specific sequences of the internal transcribed spacer (ITS) genes was developed. Specificity testing revealed that there was no cross-reaction with the other tick-borne parasites B. ovate, B. major, unnamed bovine Babesia, Theileria annulata, Theileria sinensis, Theileria sergenti, and Anaplasma marginale, or with bovine white blood cells. The sensitivity of the LAMP method was 0.1 pg DNA for both B. bovis and B. bigemina, which was superior to that of the classical PCR methods. This assay was evaluated for its diagnostic utility using blood samples collected from experimentally and naturally infected cattle in China. These findings indicate that the Babesia species-specific LAMP assay may have potential clinical application in the detection and differentiation of Babesia species, particularly in countries in which babesiosis is endemic.

Concepts: White blood cell, DNA, Gene, Epidemiology, Apicomplexa, China, Babesiosis, Babesia

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Hemoprotozoan parasites are responsible for significant economic losses in cattle. We screened Sri Lankan cattle populations for the presence of Babesia bovis, Babesia bigemina, Theileria annulata, and Theileria orientalis, using species-specific PCR assays. Out of 316 samples collected from animals in four different districts of Sri Lanka (Nuwara Eliya, Polonnaruwa, Ampara, and Jaffna), 231 (73.1%) were positive for at least one parasite species. All four parasite species were detected among the study groups from all of the districts surveyed. The first and second commonest hemoprotozoan parasites identified were T. orientalis (53.5%) and B. bigemina (30.1%), respectively. We found that the dry zones (Polonnaruwa, Ampara, and Jaffna) had more Babesia-positive animals than the hill country wet zone (Nuwara Eliya). In contrast, T. orientalis was the predominant species detected in Nuwara Eliya, while infection with T. annulata was more common in the dry zones. In addition, 81 (35.1%) of the 231 positive samples were infected with more than one parasite species. The presence of multiple parasite species among the different cattle populations is of clinical and economic significance. Therefore, island-wide control and prevention programs against bovine babesiosis and theileriosis are needed to minimize the financial burden caused by these parasites.

Concepts: Sri Lanka, Babesiosis, Tamil language, Tamil people, Babesia, Lanka, Northern Province, Sri Lanka, Jaffna

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A 12-year old mixed breed neutered bitch from Misiones, Argentina, was presented with a history of fever and epistaxis. Blood, bone marrow, and lymph node samples were collected for hematology and cytology. Mild regenerative anemia was recorded and large, round, poorly stained piroplasms (>2.5μm) were found within erythrocytes in blood and lymph node smears. Nested PCR-RFLP on blood and bone marrow samples was positive for piroplasm DNA. The 18S rRNA gene of piroplasms was targeted. A restriction pattern of a previously unreported piroplasm was observed. The PCR product was sequenced, and the sequence obtained had 99% identity with the Rangelia vitalii sequences from Brazil when compared by BLAST analysis. Further characterization of the detected piroplasm consisted of nearly full-length sequencing (1668bp) of the 18S rRNA gene of this organism. Those sequences were deposited in GenBank. A phylogenetic analysis indicated that they clustered together with Rangelia vitalii from Brazil but separately from large Babesia species of dogs such as Babesia canis, and from species of Theileria of dogs as well. This is the first report of Rangelia vitalii infection in Argentina, and the first case of canine rangeliosis diagnosed outside Brazil.

Concepts: DNA, Blood, Ribosomal RNA, Bone marrow, Sequence, Dog, Babesia, Piroplasmida

15

Babesiosis is an emerging zoonotic disease caused primarily by Babesia microti, an intraerythocytic protozoan. Babesia microti, like the causal agents for Lyme disease and anaplasmosis, is endemic to the northeastern and upper midwestern United States where it is usually transmitted by the blacklegged tick, Ixodes scapularis. Although babesiosis is usually a mild to moderate illness, older or immunocompromised persons can develop a serious malaria-like illness that can be fatal without prompt treatment. The most common initial clinical signs and symptoms of babesiosis (fever, fatigue, chills, and diaphoresis) are nonspecific and present diagnostic challenges that can contribute to delays in diagnosis and effective treatment with atovaquone and azithromycin (1). Results of one study revealed a mean delay of 12-14 days from symptom onset to treatment (2). Knowledge of the incidence and geographic distribution of babesiosis can raise the index of clinical suspicion and facilitate more prompt diagnosis and lifesaving treatment (1). The first known case of babesiosis in Wisconsin was detected in 1985 (3), and babesiosis became officially reportable in the state in 2001. Wisconsin babesiosis surveillance data for 2001-2015 were analyzed in 3-year intervals to compare demographic, epidemiologic, and laboratory features among patients with cases of reported babesiosis. To determine possible reasons for an increase in reported Babesia infection, trends in electronic laboratory reporting and diagnosis by polymerase chain reaction testing (PCR) were examined. Between the first and last 3-year analysis intervals, there was a 26-fold increase in the incidence of confirmed babesiosis, in addition to geographic expansion. These trends might be generalizable to other states with endemic disease, similar suburbanization and forest fragmentation patterns, and warming average temperatures (4). Accurate surveillance in states where babesiosis is endemic is necessary to estimate the increasing burden of babesiosis and other tickborne diseases and to develop appropriate public health interventions for prevention and practice.

Concepts: Epidemiology, Infectious disease, Malaria, Lyme disease, Tick, Ixodes scapularis, Babesiosis, Babesia

5

Background Babesiosis, a tickborne zoonotic disease caused by intraerythrocytic protozoa of the genus babesia, is characterized by nonimmune hemolytic anemia that resolves with antimicrobial treatment and clearance of parasitemia. The development of warm-antibody autoimmune hemolytic anemia (also known as warm autoimmune hemolytic anemia [WAHA]) in patients with babesiosis has not previously been well described. Methods After the observation of sporadic cases of WAHA that occurred after treatment of patients for babesiosis, we conducted a retrospective cohort study of all the patients with babesiosis who were cared for at our center from January 2009 through June 2016. Data on covariates of interest were extracted from the medical records, including any hematologic complications that occurred within 3 months after the diagnosis and treatment of babesiosis. Results A total of 86 patients received a diagnosis of babesiosis during the 7.5-year study period; 18 of these patients were asplenic. WAHA developed in 6 patients 2 to 4 weeks after the diagnosis of babesiosis, by which time all the patients had had clinical and laboratory responses to antimicrobial treatment of babesiosis, including clearance of Babesia microti parasitemia. All 6 patients were asplenic (P<0.001) and had positive direct antiglobulin tests for IgG and complement component 3; warm autoantibodies were identified in all these patients. No alternative explanation for clinical hemolysis was found. WAHA required immunosuppressive treatment in 4 of the 6 patients. Conclusions We documented post-babesiosis WAHA in patients who did not have a history of autoimmunity; asplenic patients appeared to be particularly at risk.

Concepts: Immune system, Cohort study, Lyme disease, Anemia, Hemolytic anemia, Hemolysis, Hematology, Babesia