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confused woman with Anaplasmosis and Babesia infection

Welcome to an Inside Lyme case study. I find that the best way to get to know Lyme disease is through reviewing actual cases.  I will be discussing a 78-year-old confused woman with an Anaplasmosis and Babesia infection.


A 78-year-old woman was evaluated in an emergency room with fever, chills, lethargy, fatigue, and confusion. Her maximum temperature was 100.6° F.

Her blood tests were quite abnormal. She had severe anemia, low white blood count, and low platelet count.

• Anemia (dropped from 10.5 g/dL to a low of 8 g/dL)
• Leukopenia (dropped from 5.0 × 10 9 /L to 2.6 × 10 9 /L)
• Thrombocytopenia (dropped to 39 × 10 9 /L)

The doctor initially considered sepsis. Sepsis is a potentially life-threatening illness triggered by an infection. The body’s immune response can be so strong that the body can attack itself and can lead to organ damage and death.


She also had multiple tick bites.

The doctors were able to identify the parasite that causes a Babesia infection in the woman’s red blood cells under the microscope. Babesia is a disease transmitted by the same tick that carries Lyme disease.

The doctors prescribed a combination of atovaquone and azithromycin for her Babesia infection. These medications are marketed under the names Mepron and Zithromax in the US.

The doctors were also concerned that the woman might suffer from another tick-borne illness called Anaplasmosis because of her low white blood count and low platelet count. Anaplasmosis had previously been called Ehrlichia.

The combination of atovaquone and azithromycin is not effective for Anaplasmosis. The doctors added doxycycline to the woman’s treatment.

The laboratory test confirmed that she had, in fact, an anaplasmosis and babesia infection. The IgM tests were positive for both conditions consistent with early infection.

The woman’s cognitive function improved dramatically following two weeks of treatment, according to the authors.

What can we learn from these cases?

  1. Tick-borne diseases can lead to confusion in the elderly.
  2. An individual with a tick-borne infection can be confused with sepsis.

What questions do these cases raise?

  1. How many elderly with tick-borne illnesses are confused?
  2. What if the parasites associated with the Babesia infection had not been seen in the red blood cells under the microscope? Would the woman have been diagnosed in a timely manner for Babesia?
  3. What would have happened to the woman if the doctors had not considered Anaplasmosis?
  4. What would have happened to the woman if the doctors had stopped treatment if the tests were negative?
  5. What is the long-term outcome for the elderly with tick-borne infections? Could the woman’s short term confusion described in this case lead to long term confusion?


In my practice, each individual requires a careful assessment. That is why I order a broad range of blood tests for other illnesses in addition to tick-borne infections. I also arrange consultations with specialists as needed.

Many patients are complex, as highlighted in this Inside Lyme Podcast series.

We need more doctors with skills diagnosing and treating Lyme disease in the elderly. We hope that a professional evaluating the elderly can use this case to remind them to look for Lyme disease and co-infections and treat accordingly.

Inside Lyme Podcast Series

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  1. Paparone P, Paparone PW. Variable clinical presentations of babesiosis. Nurse Pract. 2018;43(10):48-54.



Treatment recommendation:

The optimal dose and duration of antibiotic treatment for anaplasmosis has not been definitively established, but it is clear that A. phagocytophilum is highly sensitive to tetracyclines. Thus, oral doxycycline is the recommended treatment, at the same dose used for Ehrlichia infections: 200 mg/day in two divided doses. The usual treatment duration is 5-10 days, which is extended if there is suspected coinfection with B. burgdorferi, the agent of Lyme disease. In any case, treatment should continue for at least three days after the patient’s fever resolves. Response to treatment is usually rapid; if the patient remains febrile more than two or three days after initiation of doxycycline therapy, the diagnosis should be revisited.  As with Ehrlichia infections, rifampin is used in cases where doxycycline is contraindicated, such as pregnancy or allergy.

The CDC recommends a lower dosage. Lyme literate doctors know that some people need higher dosages. This is an important issue that has kept some from getting better. Consider and discuss with your practitioner.

Please see article for various treatments.  Dr. Horowitz states that Babesia is one of the most tenacious coinfections he deals with.  He recommends treatment of 9-12 months.  Studies have also shown that mono therapies like the singular use of Mepron to be ineffective as the pathogens develop resistance to it.  Lyme literate doctors typically utilize an overlapping treatment with numerous modalities to prevent this from happening.  I’ve heard many professionals state that once you start treating Babesia you need to see it through to completion.  So don’t start until you mean business and then stick it out.  Treatment is typically 3 weeks on, one week off.  In this article I state the treatment that worked for both my husband and I.  

FYI: Two weeks of treatment is hardly ever sufficient.

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