Babesiosis Case Report Form

B

Form Approved

OMB No. 0920-0004

Exp. Date 6/30/2013

abesiosis Case Report Form

Patient’s name:

Date submitted:

_ _ / _ _ / _ _ _ _

(mm/dd/yyyy)

Address:

Clinician’s name:

Clinician’s Phone no.:

City:

NETSS ID No.: (if reported)

_

_

Case ID

Site

State

Classify case based on the CDC case definition:  Confirmed  Probable [circle: (a), (b)i, or (b)ii]  Suspect

Demographic and Clinical Data

For dates, be as specific as possible. However, approximates [e.g., mm/yyyy] are acceptable.

State of residence:

County of residence:

Zip code:

Sex:

Date of birth:

Age:

Postal

abrv: ____ ____

____________________________

____________

 Male

 Female

 Unknown

_ _ / _ _ / _ _ _ _

(mm/dd/yyyy)

______

 years

 months

 days

Race (check all that apply):



White



Alaska Native or American Indian



Pacific Islander

Ethnicity:

 Hispanic/Latino

 Not Hispanic/Latino

 Unknown



Black/African American



Asian



Not specified

Was the case-patient symptomatic?  Yes  No  Unk

If yes, date of onset: _ _ / _ _ / _ _ _ _ (mm/dd/yyyy)

Is the case-patient asplenic?  Yes  No  Unk

If splenectomy, date of surgery: _ _ / _ _ / _ _ _ _ (mm/dd/yyyy)

Clinical Manifestations

Yes No Unk

Yes No Unk

Yes No Unk

  

Fever

  

Headache

  

Myalgia

  

Anemia

  

Chills

  

Arthralgia

  

Thrombocytopenia

  

Sweats

Other clinical manifestations (specify):

Specify any complications in the clinical course of infection:

 Acute respiratory distress

 Congestive heart failure

 Renal failure

 None

 Disseminated intravascular coagulation (DIC)

 Myocardial infarction

 Other: ________________________________

Was the case-patient hospitalized (at least overnight) for this infection?  Yes  No  Unk

If yes, number of days: _____

Did the case-patient die?  Yes  No  Unk

If yes, date of death: _ _ / _ _ / _ _ _ _ (mm/dd/yyyy)

Was the death related to the infection?  Yes  No  Unk

Did the case-patient receive antimicrobial treatment for this infection?  Yes  No  Unk

If yes, which drugs (select all that apply)?  Clindamycin  Quinine  Atovaquone  Azithromycin  Other:________________

Epidemiologic Factors

Was the case-patient’s infection transfusion associated?

 Yes  No  Unk

Was the case-patient a blood donor identified during a transfusion investigation?

 Yes  No  Unk

In the eight weeks before symptom onset or diagnosis (use earlier date), did the case-patient:

Engage in outdoor activities?

 Yes  No  Unk

If yes, which:

 Camping  Yard work

 Hiking  Other:

 Hunting

Spend time outdoors in or near wooded or brushy areas?

 Yes  No  Unk

Notice any tick bites?

 Yes  No  Unk

When and where (geographic location)? __________________________________

Travel out of?

 County  State  Country

When and where? __________________________________________________

Laboratory Testing for Babesia

Please include available results, especially those relevant to case classification.

Test

Babesia species

Date specimen collected

Titer

Result

Test

Babesia species

Date specimen collected

Result

IFA – total antibody (Ig)

_ _ / _ _ / _ _ _ _

 Pos  Neg

 Indeterminate

Blood Smear

N/A

_ _ / _ _ / _ _ _ _

 Pos  Neg

 Indeterminate

IFA - IgG

_ _ / _ _ / _ _ _ _

 Pos  Neg

 Indeterminate

PCR

_ _ / _ _ / _ _ _ _

 Pos  Neg

 Indeterminate

IFA - IgM

_ _ / _ _ / _ _ _ _

 Pos  Neg

 Indeterminate

Other (specify):

_ _ / _ _ / _ _ _ _

 Pos  Neg

 Indeterminate

Immunoblot

_ _ / _ _ / _ _ _ _

N/A

 Pos  Neg

 Indeterminate

Other (specify):

_ _ / _ _ / _ _ _ _

 Pos  Neg

 Indeterminate

Public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

Case Definition

Confirmed case:

A case that has confirmatory laboratory results and meets at least one of the objective or subjective clinical evidence criteria, regardless of the mode of transmission (can include clinically manifest cases in transfusion recipients or blood donors).

Probable case:

(a) a case that has supportive laboratory results and meets at least one of the objective clinical evidence criteria (subjective criteria alone are not sufficient); or

(b) a case that is in a blood donor or recipient epidemiologically linked to a confirmed or probable babesiosis case (as defined above) and:

1. has confirmatory laboratory evidence but does not meet any objective or subjective clinical evidence criteria; or

2. has supportive laboratory evidence and may or may not meet any subjective clinical evidence criteria but does not meet any objective clinical evidence criteria.

Suspect case:

A case that has confirmatory or supportive laboratory results, but insufficient clinical or epidemiologic information is available for case classification (e.g., only a laboratory report was provided).

Clinical evidence

• Objective: one or more of the following: fever, anemia, or thrombocytopenia.

• Subjective: one or more of the following: chills, sweats, headache, myalgia, or arthralgia.

Epidemiologic evidence for transfusion transmission

Epidemiologic linkage between a transfusion recipient and a blood donor is demonstrated if all of the following criteria are met:

1. In the transfusion recipient:

1. Received one or more red blood cell (RBC) or platelet transfusions within one year before the collection date of a specimen with laboratory evidence of Babesia infection; and

2. At least one of these transfused blood components was donated by the donor described below; and

3. Transfusion-associated infection is considered at least as plausible as tick-borne transmission; and

2. In the blood donor:

1. Donated at least one of the RBC or platelet components that was transfused into the above recipient; and

2. The plausibility that this blood component was the source of infection in the recipient is considered equal to or greater than that of blood from other involved donors. (More than one plausible donor may be linked to the same recipient.)

Laboratory criteria for diagnosis

Laboratory confirmatory:

• Identification of intraerythrocytic Babesia organisms by light microscopy in a Giemsa, Wright, or Wright-Giemsa–stained blood smear; or

• Detection of Babesia microti DNA in a whole blood specimen by polymerase chain reaction (PCR); or

• Detection of Babesia spp. genomic sequences in a whole blood specimen by nucleic acid amplification; or

• Isolation of Babesia organisms from a whole blood specimen by animal inoculation.

Laboratory supportive:

• Demonstration of a Babesia microti Indirect Fluorescent Antibody (IFA) total immunoglobulin (Ig) or IgG antibody titer of greater than or equal to (  ) 1:256 (or 1:64 in epidemiologically linked blood donors or recipients); or

• Demonstration of a Babesia microti Immunoblot IgG positive result; or

• Demonstration of a Babesia divergens IFA total Ig or IgG antibody titer of greater than or equal to (  ) 1:256; or

• Demonstration of a Babesia duncani IFA total Ig or IgG antibody titer of greater than or equal to (  ) 1:512.

Notes: