4 mmol/L, WBC 5.3 × 109/L with atypical lymphocytes, platelets 135 × 109/L, and CRP 146 mg/L. Liver enzymes were elevated (ASAT 118 U/L, ALAT 183 U/L, ALP 314 U/L, GGT 165 U/L, and LDH 516 U/L). Serum bilirubin

and creatinine were within Nutlin-3a in vivo the normal range. All other tests including chest radiograph, urinalysis, ECG, and Coombs test were normal. Because of recent visits to tropical areas malaria was suspected. Scanty parasites were observed by quantitative buffy coat fluorescence microscopy, Giemsa-stained thick and thin blood smears, morphologically resembling Babesia spp., but malaria could initially not be excluded. Treatment with chloroquine was started prior to polymerase chain reaction (PCR) confirmation. The next day, after our patient had another overnight fever episode, the initial skin lesion

had developed into a classic erythema migrans, with additional lesions appearing on her back and extremities. A repeated thin blood smear demonstrated Babesia spp. A multiplex real-time PCR for malaria proved positive using a generic probe, but species-specific probes remained negative.1 Sequence analysis of the PCR amplicon showed identity to 18S rDNA sequences of Babesia microti, suggesting cross-reaction with the plasmodial primer/probe set. The diagnosis was confirmed by amplification and sequence analysis of a 238 nucleotide sequence of the same target using Babesia-specific primers.2 A biopsy of the skin lesion was taken for JNK inhibition Borrelia culture and PCR, and a serum sample for serological tests. The biopsy was positive for Borrelia burgdorferi by culture

and PCR. Serological tests proved positive for Babesia and Borrelia, and negative for Ehrlichia. Treatment was initiated with atovaquone and azithromycin, thus covering both agents. Blood films and PCR for babesiosis turned negative on day 13. Our patient was symptom free at her final checkup 6 weeks after initial presentation. Both infections were possibly acquired by one bite from Ixodes scapularis. Both Borrelia and Babesia as well as the agent of human granulocytic ehrlichiosis are transmitted by ticks (Ixodes spp.), have overlapping distribution areas, and are regularly found concomitantly in vector ticks, animal reservoirs, and in human seroprevalence studies in the United States and Europe.3–5 However, finding borreliosis Bupivacaine and babesiosis concomitantly in acutely ill patients is only infrequently described in literature.3 Without the history of having visited a malaria-endemic area the babesiosis in our patient could have gone undetected, given the high cure rate in immunocompetent individuals. In the United States, there are fewer babesiosis cases reported than Lyme disease cases, as human babesiosis coincides only in certain Lyme disease foci; furthermore, for these diseases there is no obligatory notification. Signs and symptoms of babesiosis may be unspecific, ranging from severe disease to resembling a viral illness.