title: Profound autoimmune hemolysis and Evans syndrome in two asplenic patients with babesiosis.
abstract: BACKGROUND
  Evans syndrome (ES) is characterized by the simultaneous or sequential presence of multiple autoimmune cytopenias. It is often secondary to rheumatologic disorders or lymphoid malignancies, but has not previously been associated with babesiosis. Here we present two cases of severe cytopenias in asplenic patients precipitated by active babesiosis.
  
  
  METHODS
  The first patient had a history of Hodgkin's lymphoma in remission and autoimmune hemolytic anemia (AIHA) treated by splenectomy 12 years prior who presented with severe AIHA and thrombocytopenia after Babesia infection. The second patient had a history of ES requiring splenectomy, which relapsed after Babesia infection.
  
  
  RESULTS
  The complex presentation and medical histories of both patients made the diagnosis challenging. Both patients' cytopenias responded to therapy, although the use of immunosuppressive agents in patients with active hematologic infections was challenging and required a multidisciplinary approach.
  
  
  CONCLUSIONS
  These two cases illustrate the possibility of babesiosis to not only reactivate ES in asplenic patients, but also precipitate increased levels of immune deregulation, potentially provoking ES, a phenomenon not previously reported.
authors.affiliation: Department of Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire.
authors.forename: Joseph J
authors.initials: JJ
authors.lastname: Shatzel
authors.forename: Kelsey
authors.initials: K
authors.lastname: Donohoe
authors.forename: Ngoc-Quynh
authors.initials: NQ
authors.lastname: Chu
authors.forename: George
authors.initials: G
authors.lastname: Garratty
authors.forename: Kabir
authors.initials: K
authors.lastname: Mody
authors.forename: Elizabeth M
authors.initials: EM
authors.lastname: Bengtson
authors.forename: Nancy M
authors.initials: NM
authors.lastname: Dunbar
mesh_terms: D000328:Adult; D000744:Anemia, Hemolytic, Autoimmune / Q000209:etiology* / Q000601:surgery; D001404:Babesiosis / Q000150:complications* / Q000175:diagnosis; D001803:Blood Transfusion; D005260:Female; D006689:Hodgkin Disease / Q000150:complications; D006801:Humans; D016867:Immunocompromised Host; D008297:Male; D008875:Middle Aged; D018512:Parasitemia / Q000150:complications* / Q000175:diagnosis; D012074:Remission Induction; D013156:Splenectomy / Q000009:adverse effects; D013921:Thrombocytopenia / Q000209:etiology* / Q000601:surgery