Babesia duncani and Pediatric Neuropsychiatric Symptoms: A Case of Delayed Diagnosis and Recovery

A nine-year-old boy with severe behavioral dysregulation, anxiety, sensory disturbances, and profound fatigue experienced substantial improvement during treatment for suspected babesiosis, highlighting the challenges of recognizing atypical presentations of tick-borne illness.

Since COVID, pediatric visits now commonly involve conversations about frequent reports of psychiatric hospitalizations in children under 16, seizure-like activity with normal EEG, intrusive thoughts of harm, post-traumatic stress disorder, suicidal ideation, self-harm, violent behavior/language, fear of choking/food refusal, painful rejection of family members, social isolation, debilitating OCD, excessive allergies, and debilitating fatigue with children spending weeks in bed. There is also bed-wetting well beyond being potty trained, a need for alternative educational programs for children previously on or above grade level, and school avoidance to the point of jumping out of moving vehicles on the way to school. These are common reports within a naturopathic practice in New Hampshire, serving people infected with tick-borne infections and community-acquired illnesses throughout New England. These symptom presentations strongly suggest autoimmune encephalitis, with infection or an environmental trigger as the driver.

In most pediatric cases, a confirmed tick-borne infection (usually more than one), Mycoplasma pneumoniae, Group A Streptococcus, herpes infection, mold exposure, POTS, dysautonomia, immune globulin deficiency, MTHFR mutation, Mast Cell Activation, and a delayed diagnosis contribute to the constellation of symptoms. Post-traumatic stress disorder in both children and parents is also a common comorbidity.

Delayed diagnosis is the biggest risk factor determining severity and prognosis. Most patients who present to a practice with their parents have been sick for 3-9 months before working with a specialist in complex chronic illness. Most parents didn’t even know where to start to find care for a child who seemed to change overnight. Most are offered mood stabilizers, attention and focus medications, or antipsychotics. By the time they are seen for evaluation, there are signs of significant emotional trauma for the child and the family, and it is almost always a comorbidity requiring treatment or support. The difficulty comes from the fact that the child was sick for almost a year, with positive serology, and a pediatrician who disagreed with the diagnosis and supported interventions for his neuropsychiatric symptoms only.

The following case illustrates this with Babesia duncani, an intraerythrocytic protozoan transmitted by the deer tick, Ixodes scapularis. Ticks tested after feeding on patients frequently show Borrelia strains, Anaplasma, and Babesia spp. These are the most commonly found in deer ticks, and a single tick can carry all three at once. Typical clinical illness includes fever, chills, sweats, fatigue, headache, myalgia, and anorexia, with hemolytic anemia and thrombocytopenia occurring in more clinically apparent disease. There can also be hepatomegaly and splenomegaly, but it is not as commonly seen.  Not many cases fit the textbook presentation with clear signs of Babesia infection. This report describes a child whose clinical presentation was dominated by behavioral dysregulation, sensory intolerance, fatigue, somnolence, anxiety, and peripheral sensory symptoms rather than a conventional acute febrile babesiosis syndrome.

Case Presentation

A 9-year-old boy presented for an initial evaluation accompanied by his parents for a complex constellation of neuropsychiatric, physical, and sensory symptoms. His history was notable for a significant change in behavior and emotional dysregulation following an illness 11 months before the visit, characterized by a high fever of approximately 103°F lasting three to four days. Over the subsequent months, the family observed increasing migraines that were happening several times per month, irritability, aggression, anxiety, behavioral dysregulation, and episodes of running away. His symptoms became severe enough to require a 12-day inpatient psychiatric hospitalization, during which he was diagnosed with ADHD, anxiety, and depression.

His behavioral history included leaving school or jumping out of cars, aggression, and fire-setting. These behaviors had not been observed before the fever. At school, these difficulties had resulted in the implementation of accommodations addressing ADHD and elopement, as well as difficulty maintaining participation in after-school programs such as hockey. He also demonstrated obsessive or perseverative tendencies, particularly surrounding time management, along with periods of hyperfocus on activities such as Legos and Minecraft.

At the initial visit, his fatigue was severe. During the encounter, he slumped over and fell asleep in the chair four times and, on one awakening, appeared briefly confused about his surroundings. His mom reported this was typical recently but not common before he got sick a year ago. Despite this degree of fatigue, his history also included periods of high energy and hyperfocus.

Additional neurologic and sensory complaints included colorful visual hallucinations in dark environments, tinnitus, episodes of rapid heartbeat, repetitive or “looping” thoughts, occasional frightening thoughts and nightmares, and paresthesias involving the hands and feet. Sleep was disturbed by nightmares, and he was using melatonin. He also reported persistent lower-back pain and poor appetite. Gastrointestinal symptoms reportedly improved after removing gluten from his diet.

Parents brought in initial labs from another provider positive for Babesia duncani (WA-1) IgG 1:256 pm in two separate labs three months apart with no treatment introduced. Low Ferritin was also noted: 9 ng/mL (14-79 ng/mL), MCV 75.5 fL (77-95 fL), and RDW 18.0% (11-15%). Iron levels were elevated due to iron supplementation, which was discontinued at the time of our visit: 181 mcg/dL (50-120 mcg/dL). He was previously diagnosed with gluten intolerance based on a tissue transglutaminase level>250 U/mL (<15 U/mL) and antigliadin antibodies of 58.8 U/ml (<15 U/mL), with the same results identifying Babesia duncani. Elevated AST 33 U/L (12-32 U/L) with low protein and globulin levels. Eosinophilia 0.55 K cells/uL (0.06-0.52 K cells/uL), elevated basophils 0.08 K cells/uL (0.02-0.07 K cells/uL). IgG subclass 1 was low at 398 mg/dL (432-1080 mg/dL). ANA panel was positive, with ANA IFA positive, titer 1:40, and a mitotic/spindle-fiber pattern.

The family was simultaneously experiencing substantial psychosocial stress. His mother was undergoing treatment for stage IV breast cancer. They also reported the stress and trauma of his hospitalizations. When labs were positive for Babesia duncani, their pediatrician refused to treat and alluded to the fact that they needed to be stricter with their parenting.

“This report describes a child whose clinical presentation was dominated by behavioral dysregulation, sensory intolerance, fatigue, anxiety, and peripheral sensory symptoms rather than a conventional acute febrile babesiosis syndrome.”

Treatment and Laboratory Assessment

Medications were initiated at the initial appointment. Combination treatment included azithromycin 250mg once daily, atovaquone-proguanil 62.5 mg/25 mg (2 tablets) twice daily, and nystatin 500,000 units per oral tablet, 1 tablet twice daily, omega 3/DHA 1000mg per day, multivitamin (gummy) 1 per day, high-dose probiotic 100 billion CFUs per capsule, away from antibiotics. Iron was discontinued because the most recent labs showed elevated levels. Patient was asked to discuss discontinuing escitalopram daily due to QT prolongation risk and to switch to fluoxetine for management of anxiety. Patient was sent with lab orders to be completed 2-3 weeks later. Labs showed elevated eosinophils 531 cells/uL (15-500 cells/uL), ALT (34 U/L; 12-32 U/L), and a positive Babesia duncani IgG (1:256). Cytomegalovirus titers were elevated at 2.20 U/mL (<0.60 U/mL). Started acyclovir 400mg 1-2 times per day before the next follow-up.

Eight-Week Clinical Follow-up

At the follow-up, approximately eight weeks after the initial evaluation, the 9-year-old patient showed clinical improvement. Although fatigue persisted, somnolence observed at his initial visit had resolved. He no longer slumped over or fell asleep during the encounter. Both the patient and his mother reported that he was feeling better overall.

Neuropsychiatric symptoms had also improved. Irritability and agitation were less prominent, anxiety was described as mild compared with the previous visit, and sleep had become more regular. No recurrent fevers were reported. He continued to experience occasional sensory overload and stress-related nervous system symptoms but was functioning better academically, with improved school performance and grades compared with the previous year.

The patient reported substantial improvement in his peripheral sensory symptoms. Numbness and tingling in the fingers, feet, and intermittently both legs were estimated to be about 75% improved since starting treatment. Residual symptoms occurred primarily while at school and did not interfere with hockey. He maintained good exercise tolerance without dyspnea or difficulty recovering from physical activity. Occasional dizziness persisted, but he denied headaches or musculoskeletal pain.

He tolerated his treatment regimen well, with no reported abdominal pain, nausea, or vomiting. At follow-up, medications included azithromycin and atovaquone/proguanil for the previously identified Babesia duncani, as well as nystatin, a probiotic, acyclovir, fluoxetine, and Focalin XR.

Poor appetite remained an important concern. His mother reported that he frequently required prompting to eat and consumed relatively small amounts throughout the day. In addition to strict avoidance of gluten, he had developed increasing concern about accidental gluten exposure and expressed anxiety about gaining weight. He was working with a nutritionist. These eating behaviors and weight-related concerns warranted monitoring, with the patient being on stimulant therapy and his restricted diet.

Overall, the eight-week follow-up showed improvement in several of the most prominent features at initial evaluation, including profound daytime somnolence, irritability, agitation, sleep disturbance, and paresthesia. Residual concerns included persistent fatigue, intermittent dizziness and sensory symptoms, mild anxiety, hypervigilance surrounding gluten exposure, and particularly poor appetite with emerging concern about weight gain. Despite these ongoing symptoms, his functional status improved, as reflected by better school performance and continued participation in competitive hockey. The team agreed to continue treatment because it was well tolerated and improvements were reported.

Eight Weeks Later

At follow-up approximately eight weeks later, the patient showed marked clinical improvement. He reported resolution of his previous headaches, abdominal discomfort, dizziness, balance difficulties, numbness, tingling, and abnormal “creepy-crawly” sensations. He denied joint pain, excessive daytime sleepiness, night sweats, sore throat, or cough. His bowel movements normalized, his appetite improved, and he continued to tolerate a gluten-free diet.

There was also substantial improvement in his neuropsychiatric and functional symptoms. His anxiety and mood had improved, sleep was stable, and he no longer experienced sensory overload in the classroom. He attended school consistently without recent absences, performed satisfactorily academically, participated in hockey and exercise, and played violin at school. His last reported episodes of numbness, tingling, anxiety, and dizziness had occurred approximately two weeks before this visit.

Given his sustained clinical improvement, we planned to complete the remaining three weeks of the existing antimicrobial regimen and then closely monitor for symptom recurrence. We did not perform any laboratory testing at this visit. We advised adherence to a gluten-free diet and gastroenterology follow-up to monitor for celiac disease. We planned follow-up in approximately six to eight weeks.

At the subsequent follow-up approximately eight weeks later, the patient remained clinically stable and continued to demonstrate sustained improvement. He had discontinued his infection-directed medications approximately one month earlier without recurrence of his prior symptoms. He denied headaches, abdominal pain, generalized or joint pain, excessive fatigue, daytime somnolence, or other previously reported neurological symptoms. His sleep and energy levels remained normal, and he continued participating in hockey and his usual activities.

The patient had also successfully tapered off fluoxetine under psychiatric supervision and had been completely off the medication for approximately one week without apparent adverse effects. He remained on Focalin. His appetite remained somewhat limited, and his parents needed to encourage adequate caloric and protein intake.

Two months prior, testing showed a mildly elevated antibody response to Babesia duncani. However, given the absence of recurrent clinical symptoms after discontinuing treatment, we did not plan immediate repeat testing or additional infection-directed treatment. There was no need to put him through an unnecessary blood draw if it would not change the course of treatment.

The family was advised to monitor for recurrence of his prior symptom pattern, particularly substantial mood or behavioral changes, fatigue, headaches, abdominal or musculoskeletal pain, or excessive sleepiness. We encouraged nutritional support emphasizing adequate protein and a varied diet. We no longer considered routine follow-up for the prior illness necessary, with reassessment recommended if symptoms recurred or new concerns developed.

Discussion

This case is uncomplicated, with symptoms and labs aligning. We provided medications and supplemental support to treat the infection while supporting digestive health, viral load, and nutrition. This is not common in practices specializing in complex chronic illness where a diagnosis is handed on a platter. We used atovaquone and azithromycin (Peter J. Krause, Atovaquone and Azithromycin for the Treatment of Babesiosis, 2000), which is most common because of insurance coverage and effectiveness in less complicated cases of Babesia infection. Because of the patient’s age, we could not add tafenoquine (Krause, 2024) and methylene blue; tafenoquine is the first-line approach in adults to resolve infection and prevent relapse. Methylene blue is commonly added to prevent methemoglobinemia, which is almost certain with tafenoquine, and a G6PD test is always needed before administration.

With symptoms and labs confirming infection, parents were highly motivated to do whatever it took. Luckily, this child did not manifest intense symptoms while undergoing therapy, which is not usually the case. Both parents were on board and committed to seeing treatment through. The patient was also agreeable to taking the medications for the duration required to recover, whereas there is usually refusal due to symptoms and lack of understanding of the importance of therapy due to age.

Integration of treatment is not easy with families who have been through very intense trauma, watching their young child be hospitalized, on multiple medications to stabilize mental health, and watching their children engage in harmful behavior toward themselves or others. There is also so much trauma related to medical interactions with providers refusing to address infections and telling parents they need to improve their parenting. This can again delay treatment due to parents stopping therapy due to their own emotional triggers.

Due to the intensity of psychological symptoms in cases like this one, it is always recommended that the patient be supported by a psychiatrist, psychologist, or some form of therapeutic support for the child and the parents. Therapy is not always pursued because family responsibilities can be overwhelming, people can get stuck in survival mode, and they may feel the need to keep all family members on the same page.

In this patient, fatigue, somnolence, paresthesias, anxiety, sensory intolerance, and functional impairment improved during treatment, followed by sustained clinical stability after therapy was discontinued. By the final follow-up, he had returned to consistent school attendance, improved academics, and could play hockey and engage in other age-appropriate activities without recurrence of his earlier symptom pattern. This is not always the case. More commonly, the patient lands in the office having a long, winding road to search out a provider that will acknowledge and treat tick-borne infection, leading to unnecessary traumatic experiences that never needed to happen.  

Author: NDNR-emmabelle-2026.