Veterinary Parasitology 138 (2006) 147–160

www.elsevier.com/locate/vetpar

Chemotherapy against babesiosis

Henri J. Vial a,*, A. Gorenflot b
a
Dynamique Moléculaire des Interactions Membranaires, UMR 5539 CNRS/Université Montpellier II,
Case 107, Place Eugène bataillon, F-34095 Montpellier Cedex 5, France
b
ERT 1038 ‘‘Vaccination antiparasitaire’’, UFR Pharmacie, 15 Avenue Charles Flahault, F-34093 Montpellier Cedex 5, France

Abstract

Babesiosis is caused by a haemotropic protozoal parasite of the genus Babesia, member of the phylum Apicomplexa and
transmitted by the bite of an infected tick. There are many Babesia species affecting livestock, dogs, horses and rodents which
are of economic significance. Infections can occur without producing symptoms, but babesiosis may also be severe and
sometimes fatal caused by the intraerythrocytic parasite development. The disease can cause fever, fatigue and haemolytic
anemia lasting from several days to several months. There are a number of effective babesiacides, but imidocarb dipropionate
(which consistently clears the parasitaemia; often the only available drug on the market) and diminazene aceturate are the most
widely used. Some Babesia spp. can infect humans, particularly Babesia microti and Babesia divergens, and human babesiosis is
a significant emerging tick-borne zoonotic disease. Clinical manifestations differ markedly between European and North
American diseases. In clinical cases, a combination of clindamycin and quinine is administered as the standard treatment, but
also administration of atovaquone–azithromycin is successful. Supportive therapy such as intravenous fluids and blood
transfusions are employed when necessary. More specific fast-acting new treatments for babesiosis have now to be developed.
This should be facilitated by the knowledge of the Babesia spp. genome and increased interest for this malaria-like parasite.
# 2006 Elsevier B.V. All rights reserved.

Keywords: Babesiosis; Cattle; Human; Treatment; Chemotherapy; Babesia; Babesia bigemina; Babesia bovis; Babesia divergens; Babesia
canis; Babesia gibsoni; Babesia microti; Babesiacidal drugs; Piroplasmosis; Review

1. Introduction well-recognised disease of veterinary importance in

Babesiosis is a parasitic infection caused by
haemotropic protozoa of the genus Babesia, family
Babesiidae, order Piroplasmida, within the phylum
Apicomplexa. This malaria-like protozoan parasitizes
the erythrocytes of wild and domestic animals. It is a
* Corresponding author. Tel.: +33 4 67 14 37 45;
fax: +33 4 67 14 42 86.
E-mail address: vial-h@univ-montp2.fr (H.J. Vial).
cattle, horses and dogs, which has gained increasing
attention as an emerging zoonotic disease problem.
This organism may cause a malaria-like syndrome,
including fever, haemolysis and hemoglobinuria.
Babesia infections have probably been complicat-
ing the lives of humans since antiquity, primarily
through infections of domestic livestock. The first
recorded reference to babesiosis is probably in the
biblical book Exodus 9:3, which described a plague of
the cattle of the Egyptians Pharaoh Ramses II that

0304-4017/$ – see front matter # 2006 Elsevier B.V. All rights reserved.
doi:10.1016/j.vetpar.2006.01.048
148 H.J. Vial, A. Gorenflot / Veterinary Parasitology 138 (2006) 147–160
could have been red water fever of cattle (caused by
Babesia bovis) and could have included hemoglobi-
nuria as a prevalent sign. However, the genus was not
formally recognized until the work of Babes in 1888,
who described an intraerythrocytic pathogen (sus-
pected to be a bacterium) causing a febrile hemoglo-
binuria in Rumanian cattle (Babes, 1888). Shortly
thereafter, the agent of Texas Cattle Fever, initially
called Pyrosoma, was discovered by Smith and
Kilbourne in 1893 (Smith, 1893) and later identified
as Babesia bigemina. The first evidence that humans
could be infected with Babesia parasites was reported
by Wilson and Chowning (Wilson and Chowning,
1904), who described piriform, intraerythrocytic
inclusions like those described by Smith and
Kilbourne, in the blood of patients with Rocky
Mountain spotted fever in the western US. They called
this agent Pyroplasma hominis.
This review deals primarily with the treatment of
babesiosis in cattle. It is thought that these animals are,
from an economy point of view, the most severely
affected by Babesia infection. Equine babesiosis and
babesiosis of other animals are also discussed.
Epidemiology of human babesiosis and their current
treatment are described. Finally, treatments of
babesiosis have been established on empirical basis,
and should evolve on a more rational basis.
2. Characterization of the organism
Babesia are ubiquitous parasites with a world wide
distribution. They generally have two classes of hosts,
an invertebrate and a vertebrate host and the
maintenance of Babesia spp. is dependent on both
hosts. The specific Ixodid tick vector must feed on a
vertebrate reservoir host that is competent in main-
taining the Babesia organisms in an infectious state.
There are over 100 species within the genus
Babesia, family Babesiidae, order Piroplasmida,
within the phylum Apicomplexa. Species vary in size
from large (2.5–5 mm, represented by B. bigemina) to
small members (1.0–2.5 mm, such as B. bovis, Babesia
divergens and Babesia microti) (Homer et al., 2000;
Mehlhorn and Schein, 1984). In addition to Babesia,
there are two genera of veterinary importance,
Theileria and Cytauxzoon, included in the family
Babesiidae; they are outside the scope of this review.
The life cycle of Babesia is highly complex and can
be separated into three stages: (i) gamogony, i.e. a
sexual stage with formation and fusion of gametes
inside the gut of Ixodid tick vectors; (ii) sporogony, i.e.
asexual reproduction in salivary glands of the tick and
(iii) merogony, i.e. asexual dividing stage in the
erythrocytes of vertebrates (Kakoma and Mehlhorn,
1993). Following a bite by an infected tick, Babesia
sporozoites directly invade vertebrate erythrocytes
where asexual reproduction (called merogony) occurs.
B. microti and Babesia equi may first divide in
lymphocytes, in a way similar to that observed in
Theileria (for detailed discussion of the taxonomic
classification of these species see the contribution of
Uilenberg in this issue [ed.]).
The intraerythrocytic trophozoite multiplies and
forms two to four separate merozoites, and a seemingly
perpetual cycle of asexual reproduction is established,
despite the rapid development of a strong immune
response. The rapid intracellular multiplication leads to
destruction of the host erythrocyte, with release of new
parasites and subsequent infection and destruction of
other erythrocytes. One cycle of B. divergens asexual
intraerythrocytic reproduction takes about 8 h in vitro
(Valentin et al., 1991). A small percentage of
merozoites do not divide but turn into non-dividing
large and unusually shaped spherical gamonts which
remain inside erythrocytes (Mackenstedt et al., 1990).
They are ingested when a competent Ixodid tick take a
blood meal from an infected host and differentiate
further in the tick gut (gamogony).
3. Epidemiology and clinical presentation
The different Babesia species vary in host specifi-
city. The diseases are caused by the asexual reproduc-
tive stage of Babesia in the erythrocytes of the host and
the subsequent lysis of the host cells. For diagnosis, the
presence of intraerythrocytic parasites in animals or
humans can be demonstrated through examination of
stained blood smears (e.g. Giemsa). Morphologically,
Babesia needs to be distinguished from Plasmodium
spp. The diagnosis can also be established by serologic
evaluation, through indirect (immuno)fluorescent anti-
body assays and the polymerase chain reaction (PCR)
(Zintl et al., 2003). Many reviews have described the
parasite specificity, host susceptibility, symptoms and
 H.J. Vial, A. Gorenflot / Veterinary Parasitology 138 (2006) 147–160
outcome of the diseases and provide key referenced
details (Gelfand and Callahan, 1998; Gorenflot et al.,
1998; Homer et al., 2000; Kjemtrup and Conrad, 2000;
Weiss, 2002; Zintl et al., 2003). These reviews provide
the current key elements about animal (cattle and
domestic animals) and human babesiosis which are
needed to assess the current treatments.
3.1. Bovine babesiosis
Babesia infections have long been recognized as
an economically important disease of cattle. At least
six Babesia species appear responsible for bovine
babesiosis which is generally characterized by
extensive erythrocytic lysis leading to anemia,
icterus, hemoglobinuria and death. The tick-borne
protozoan parasites B. bovis and B. bigemina affect
cattle in tropical and subtropical areas. They impose a
great economic burden on the tropical and subtropical
developing countries, where raising cattle provides
milk and meat, badly needed protein sources of high
nourishing quality (Ristic, 1988; Roberts et al.,
1998).
B. bigemina is widespread in cattle and occurs
wherever Boophilus ticks are encountered, which
includes North and South America, southern Europe,
Africa, Asia, and Australia. Calves normally are
reasonably resistant to B. bigemina, or the infection
does not usually result in clinical disease. In older
animals, clinical signs can be very severe; however,
differences in pathogenicity may occur with various B.
bigemina isolates associated with different geographic
areas. The anemia may occur very rapidly, with 75%
or more of the erythrocytes being destroyed in just a
few days. After the onset of hemoglobinuria, the
prognosis is guarded. Mortality is extremely variable
and in the absence of undue stress most animals may
survive. Among fully susceptible older cattle, the
mortality may reach 50% without treatment, whereas
anemia is a contributory factor to the weakness and
loss of condition seen in cattle that survive the acute
phase of the disease (Aryeetey and Jimenez-Lucho,
2002; Purnell, 1981; Ristic, 1988).
B. bovis first identified in Argentina in 1934 (Rees,
1934) usually occurs in the same areas as B. bigemina
and in association with Boophilus ticks but has been
described in some parts of Europe where Boophilus
does not occur, which suggests other vectors. After
149
blood inoculation, the incubation time is usually 10–14
days, but can be shortened by large inocula. Infection
can persist for years, perhaps even the lifetime of the
animal. Infections of B. bovis resemble, in many
respects, those seen with B. bigemina, with fever and
cachexia but hemoglobinemia and hemoglobinuria are
not as consistently seen. In many cases, there is cerebral
involvement and respiratory distress syndromes that
can lead to death. B. bovis infection involves massive
intravascular sequestration of infected erythrocytes
carrying mature parasite stage (Allred, 2003; Aryeetey
and Jimenez-Lucho, 2002). It is generally conceded that
B. bovis is the more virulent of the two organisms.
Whereas the packed cell volume in most fatal infections
with B. bigemina will be well below 10%, death
commonly occurs with B. bovis when the packed cell
volume is 12% or higher. In the United States a tick
eradication program was essentially completed by
1943, and bovine babesiosis ceased to exist except in
the quarantine buffer zone adjacent to the Mexican
border (Graham and Hourrigan, 1977).
B. divergens appears to be a serious pathogen for
cattle in the United Kingdom and northern Europe
(Purnell, 1981). B. divergens produces a disease
syndrome similar to B. bigemina and B. bovis;
however, the cerebral form is rarely seen.
Additionally, there are also other bovine Babesia
species. As an example, Babesia major is a large
species only slightly smaller than B. bigemina,
transmitted by Haemaphysalis punctata which occurs
in the United Kingdom and northern Europe. It is
essentially non-pathogenic but can be induced to
produce clinical effects and even death by serial
passage in splenectomized calves (Purnell, 1981).
3.2. Equine babesiosis
Equine babesiosis is caused by Babesia caballi or
B. equi and is generally characterized by erythrocy-
tolysis leading to anemia, icterus, hemoglobinuria,
and death. The severity of clinical response is variable,
and in many cases spontaneous recovery may occur
following a febrile response with no marked hemo-
globinuria or anemia (Purnell, 1981). An array of
other Babesia species exist and a great number of
vertebrate species are also sensitive to these intraer-
ythrocytic parasites (Aryeetey and Jimenez-Lucho,
2002).
150 H.J. Vial, A. Gorenflot / Veterinary Parasitology 138 (2006) 147–160
3.3. Canine babesiosis
The large Babesia canis and the small Babesia
gibsoni are two organisms commonly known to infect
dogs. Both organisms have Ixodid tick vectors and are
found throughout Asia, Africa, Europe, the Middle
East, and North America, with B. canis being more
prevalent. Infection by B. gibsoni is increasing in
frequency, particularly in North America, although no
specific species of ticks in this region have been
proven to transmit the disease (Taboada, 1998). Three
(sub-)species of B. canis, named B. (c.) canis, B. (c.)
vogeli, and B. (c.) rossi have been identified using
restriction fragment length polymorphism (RFLP)
analysis of PCR-amplified small subunit ribosomal
RNA (Carret et al., 1999; for detailed discussion of the
taxonomic classification of these species see the
contribution of Uilenberg in this issue [ed.]).
Clinical symptoms of carrier dogs are common.
Cases of canine babesiosis with a wide variation of
severity of clinical signs also occur ranging from a
hyperacute, shock-associated, haemolytic crisis to an
unapparent subclinical infection. Infected dogs show
pyrexia, weakness, mucous membrane pallor, depres-
sion, lymphadenopathy, splenomegaly, and general
malaise. Both B. canis and B. gibsoni can cause an
acute haemolytic anemia with eventual potentially
chronic babesiosis. The anemia is usually normo-
chromic to hypochromic (Schetters et al., 1998;
Taboada, 1998). The (sub-)species of B. canis differ in
virulence (Schetters et al., 1997), geographic localiza-
tion and the tick species as vector (Uilenberg et al.,
1989).
3.4. Human babesiosis
The first human case of babesiosis was described in
1957 in a splenectomized Yugoslavian farmer
(Skrabalo and Deanovic, 1957). Babesia gained
attention in the United States in 1969, through an
infection with B. microti in a patient with an intact
spleen. In the last 30 years, Babesia has been
recognized as an important pathogen in humans
which are infected accidentally due to exposure to
established enzootic cycles. Later, piroplasms such as
WA-1 in Washington and MO-I in Missouri have been
identified with clinical presentations resembling
babesiosis. The clinical manifestations of babesiosis
differ markedly between the European and North
American cases.
Human babesiosis is unique in that its transmission
depends on the presence of an infected Ixodid tick and
a vertebrate host that serves as a reservoir, such as deer
or mice living in concert with each other. Human
babesiosis is caused by different Babesia parasites that
have distinct geographic distributions based on the
presence of competent hosts and have been recognised
as a primary agent of human disease: B. microti, a
rodent species, and B. divergens, a cattle species; more
rarely, infection has been related to ‘‘new’’ or other
species on the basis of molecular information. The
rising incidence is attributed to the increased exposure
of humans to the parasite; parasite reservoirs may
expand (e.g. B. microti-infected rodents), and humans
may live in closer proximity to the vectors (such as
Ixodes dammini ticks that feed mainly on deer).
In North America, babesiosis is caused predomi-
nantly by B. microti, a rodent-borne piroplasm, and
also occasionally by a newly recognized species, the
so-called Babesia WA-1 isolate. In the US, there have
been over 300 reported cases of infection with B.
microti but seroepidemiologic data suggest that many
cases are not reported (Kjemtrup and Conrad, 2000;
Weiss, 2002). After being bitten by an Ixodes tick, the
incubation period for the development of symptoms is
5–30 days. Parasitaemia ranges from 1 to 20% of the
erythrocytes in normosplenic individuals, and up to
80% in splenectomized individuals (Rosner et al.,
1984).
B. microti infections present a wide spectrum of
clinical manifestations, from an asymptomatic to
acute and fatal disease, which is more common among
the elderly and immunocompromised. The mortality
rate for clinically apparent infections of B. microti is
about 5% in the United States (Gelfand and Callahan,
1998; Homer et al., 2000; Kjemtrup and Conrad,
2000). Symptoms are similar to those seen with
malaria, except for the fatal cerebral form of the
Plasmodium falciparum malaria, which does not occur
with human babesiosis. Typically, symptoms are less
acute than those caused by B. divergens (see below).
In Europe, babesiosis is considerably less frequent
but clinically more severe. Since 1957, around 40
human cases of Babesia infections have been
identified and B. divergens is primarily the etiologic
species. Generally they coincide with bovine breeding
 H.J. Vial, A. Gorenflot / Veterinary Parasitology 138 (2006) 147–160
areas, and the tick responsible for transmission of B.
divergens to humans is likely Ixodes ricinus (which is
also the vector for the Lyme disease spirochete in
Europe) (Gorenflot et al., 1998; Telford and Spielman,
1998). In human infections with B. divergens,
parasitemias range from 1 to 50% (Gorenflot et al.,
1998) and the spectrum of disease is broad, ranging
from an apparently silent infection to a fulminate,
malaria-like disease.
The incubation period (i.e. the time of tick
transmission to the onset of symptoms) varies usually
from 1 to 6 weeks, and patients frequently complain of
general weakness and discomfort. Clinical disease
appears suddenly, generally with severe intravascular
haemolysis, hemoglobinuria and jaundice, myalgia,
chills and persistent non-cyclic fever (
40 8C). In the
most severe cases, patients develop a shock-like
picture, with renal failure and pulmonary oedema
(Homer et al., 2000; Kjemtrup and Conrad, 2000; Zintl
et al., 2003). The extreme end of the spectrum is often
described as a fulminating malaria-like infection.
Total hemoglobin level may fall to 70 g/l and values as
low as 40 g/l have been reported. Most patients have
been previously splenectomized and present fulminat-
ing, febrile haemolytic disease; mortality rate is
around 50% (Gelfand and Callahan, 1998; Gorenflot
et al., 1998; Homer et al., 2000). The cases due to B.
divergens infections in Europe are significantly more
severe than those caused by B. microti in the USA.
Immediate detection is essential because the disease
usually progresses extremely rapidly. The high
parasitaemia present during acute infection (varying
from 5 to 80%) can be easily detected microscopi-
cally; misdiagnosis with Plasmodium spp. has to be
prevented by attentive examination of stained blood
smears.
Only two cases of B. microti infections in Europe
have been reported so far. This is likely because of
limited or no interaction between the tick host for B.
microti in Europe and humans (Gorenflot et al., 1998;
Homer et al., 2000; Telford and Spielman, 1998).
4. Treatment
A list of compounds recognized as having
babesiacidal properties in vivo is shown in Table 1.
Their effective use depends on the regulatory rules of
151
each country and their commercial availability. The
most commonly used compounds are indicated below.
Supportive treatment is sometimes desirable, particu-
larly in valuable animals. Blood transfusions may be
life-saving in very anaemic animals. Anti-inflamma-
tory drugs, such as phenylbutazone, help relieve the
inflammatory processes that occur, particularly with
B. bovis infections. They are not within the scope of
this review.
4.1. Animal babesiosis
4.1.1. Available chemotherapeutics
For many years, three babesiacides, quinuronium
sulphate (Ludobal1, Bayer Ltd.), amicarbalide iso-
thionate (Diampron1, May and Baker Ltd.) and
diminazene aceturate (Berenil1, Hoechst Ltd.) were
available in most European countries for the treatment
of bovine babesiosis. In the 1970s, a fourth, imidocarb
dipropionate was introduced (Imizol; Schering-
Plough), and it rapidly became the product of choice
in those countries that licensed it because in addition
to its therapeutic utility, it also proved to be an
effective prophylactic at twice the therapeutic doses.
Quinuronium and amicarbalide were withdrawn
because of manufacturing safety issue, and dimin-
azene, which is widely used in the tropics as both a
babesiacide and a trypanocide was withdrawn from
Europe for marketing reasons.
Imidocarb dipropionate (N,N0 -bis(3-(4,5-dihydro-
1H-imidazol-2-yl)phenyl) urea) (Imizol1, Schering-
Plough Animal Health) is to be administrated
intramuscularly or subcutaneously, but not intrave-
nously. It is the only babesiacide that consistently
clears the host of parasites (Lewis et al., 1981) and
cattle treated with imidocarb may end up with a solid
sterile immunity. It is the only chemoprophylactic
drug on the market, which provides protection from
clinical diseases from 3 to 6 weeks but allows a
sufficient level of infection for immunity to develop
which is interesting in areas where babesiosis is
endemic. So far no other suitable prophylactics have
been identified. Long term persistence of low level
parasitaemia is now considered a disadvantage, both
for possible recrudescence and appearance of resistant
parasites. A number of acute phases of babesiosis were
not responsive to treatment with imidocarb and
resistance can be introduced in the laboratory (Zintl
152 H.J. Vial, A. Gorenflot / Veterinary Parasitology 138 (2006) 147–160

Table 1
List of recognized active compounds for in vivo chemotherapy against babesiosis

et al., 2003). But the suggestion that imidocarb may
select in vivo for pathogenic strains of parasites is
questionable, since the only study on this topic so far
assured that all isolates from animals that were still
parasitaemic on a second veterinary visit were still
fully susceptible to babesiacides (Gray and Parr,
1992).
Pharmacology and pharmacodynamic properties of
imidocarb and diminazene have been revisited and
evaluated by the European Agency for the Evaluation
 H.J. Vial, A. Gorenflot / Veterinary Parasitology 138 (2006) 147–160
of Medicinal Products and World Health Organiza-
tion. Their evaluation as veterinary drug residues in
food are provided by IPCS INCHEM (the Chemical
Safety Information from Intergovernmental Organi-
zations) (http://www.inchem.org/). The plasma half-
life of imidocarb was 207 min and 80% was
eliminated in 8 h in dogs given an intravenous bolus.
It seems to be eliminated through the urine and
faeces. Residues were found mainly in the liver and
some in the kidney. Toxicity (LD50) in rats was 450–
1200 mg/kg and imidocarb is safe in dogs up to
9.9 mg/kg, but causes pain upon injection. Acute
toxicity symptoms are consistent with a cholinester-
ase inhibitor activity.
4.1.2. Bovine babesiosis
Chemotherapy is generally effective against bovine
babesiosis, with essentially the same drugs used for B.
bigemina and B. bovis. The most commonly used
compounds are diminazene diaceturate (at a dose of 3–
5 mg/kg), imidocarb (1–3 mg/kg), and amicarbalide
(5–10 mg/kg). Successful treatment depends on early
diagnosis and the prompt administration of effective
drugs. There is less likelihood of success if treatment
is delayed until the animal has been weakened by fever
and anemia. Trypan blue was one of the first successful
treatments against B. bigemina. It is not effective
against B. bovis (Kuttler, 1981; The Gray Book, 1998).
Treatment of B. bigemina with imidocarb may
radically cure the infection, leaving the animal
susceptible to reinfection. For this reason, reduced
drug levels are sometimes indicated. Imidocarb has
also been successfully used as a chemoprophylactic,
that will prevent clinical infection for as long as 2
months but allow mild subclinical infection to occur as
the drug level decreases, resulting in premunition and
immunity (Kuttler, 1981; Kuttler et al., 1975;
Todorovic et al., 1973). Imidocarb also induces
radical cure of B. bovis, which is a small Babesia
species that is usually more difficult to treat; a second
treatment or slightly increased dose rates may be
desirable. Imidocarb may also affect the parasites in
the tick vector. For example, B. bovis-infected Babesia
annulatus ticks apparently lost their infectivity, when
placed on animals recently treated with imidocarb,
and their progeny failed to transmit infection (Kuttler
et al., 1975). In contrast, in a similar experiment with
B. bigemina in Boophilus decoloratus, ticks remained
153
infected following imidocarb treatment (Gray and
Potgieter, 1981).
4.1.3. Equine babesiosis
Both B. caballi and B. equi respond to the
babesiacidal drugs but B. equi is more refractory to
treatment than B. caballi. Imidocarb appears to be the
drug of choice for eliminating carrier status of infected
horses. In the case of B. caballi, 2 mg/kg given two
times at a 24-h interval appears effective. For the same
effect in B. equi-infected horses, 4 mg/kg is given four
times at 72-h intervals. This amount of drug
approaches the lethal dose for 50% of the inoculated
group (LD50) of 32 mg/kg when given in two 16 mg/
kg doses at 24-h intervals. Side effects characterized
by restlessness, abdominal pain, sweating, rolling,
heavy breathing, etc. are not uncommon following
imidocarb treatment at these high doses (Adams,
1981; Kuttler, 1981).
4.1.4. Canine babesiosis
Imidocarb diproprionate is currently available for
the treatment of babesiosis in dogs. Two injections
of imidocarb diproprionate at 5.0–6.6 mg/kg given
subcutaneously or intramuscularly at an interval of
2–3 weeks are reputed to be effective. In acute
babesiosis, the therapeutic response is rapid, with
increasing production of new red blood cells within
12–24 h. Another possible treatment is a single
intramuscular injection of diminazene aceturate at a
dose of 5 mg/kg (Birkenheuer et al., 1999; Taboada,
1998). Trypan blue can also be used intravenously at
a dose of 10 mg/kg, and would have fewer side-
effects than diminazene (Aryeetey and Jimenez-
Lucho, 2002; Birkenheuer et al., 1999; Milner et al.,
1997). Supportive therapy such as intravenous fluids
and blood transfusions should be employed when
necessary. Current chemotherapeutic agents used to
treat canine babesiosis would be incapable of
completely eliminating the disease at the recom-
mended dose; they only are capable of limiting
mortality and the severity of clinical signs (Birken-
heuer et al., 1999). Owners should be aware that
dogs that have survived babesiosis may remain
subclinically infected. These dogs may suffer a
relapse of disease in the future or serve as point
sources for the further spread of disease in a given
area.
154 H.J. Vial, A. Gorenflot / Veterinary Parasitology 138 (2006) 147–160
4.2. Human babesiosis
4.2.1. Chemotherapeutic treatment
Anti-babesial drug therapy is usually indicated for
moderately to severely symptomatic human infec-
tions. Almost all cases with severe B. divergens
infection in the past ended fatally with general organ
failure 4–7 days after outcome of hemoglobinuria
(Gorenflot et al., 1998; Kjemtrup and Conrad, 2000;
Zintl et al., 2003). In splenectomized patients, B.
divergens has an acute onset and is considered a
medical emergency. Chloroquine was the initial
pharmacologic agent thought to be effective (Schol-
tens et al., 1968). However, the observed improvement
could be attributed to the anti-inflammatory and
immunomodulating effects of chloroquine; there was
no correlation between the use of chloroquine and cure
(Homer et al., 2000; Zintl et al., 2003). In 1982, the
treatment of a patient with presumed transfusion-
acquired malarial infection who failed to respond to
chloroquine was changed to quinine and clindamycin.
This combination of quinine and clindamycin resulted
in a dramatic improvement and effectiveness in
humans and animals (Rowin et al., 1982; Wittner
et al., 1982). However, B. microti infection may persist
after adequate treatment with clindamycin and quinine
(Hatcher et al., 2001; Wittner et al., 1996) and adverse
effects attributed to quinine may occur in as many as
25% of the cases (Hatcher et al., 2001; Krause et al.,
2000). Using mouse models, it has recently been
demonstrated that, in addition to the babesiacidal
effect, clindamycin also increases the number of
splenic mononuclear cells and their phagocytic
activity, thus further adding to its effectiveness
(Wijaya et al., 2001).
Other antimicrobials and antimicrobial combina-
tions used in humans include pyrimethamine, chlor-
oquine and quinine, tetracyclins, clindamycin,
doxycyclin, and azithromycin. However, they have
not been used consistently and are not recommended
(Homer et al., 2000). Diminazene aceturate (Bere-
nil1), an antiprotozoal compound known to be
effective in veterinary cases failed to cure a patient
with a severe B. divergens infection (Zintl et al., 2003).
Pentamidine isothionate has been used to control the
clinical manifestations of babesiosis but is limited in
decreasing parasitaemia, as it does not eradicate the
organism (Francioli et al., 1981). A mild infection was
resolved after use of pentamidine and cotrimoxazole
(Raoult et al., 1987). Imidocarb, which is not licensed
for human use, was used successfully under special
license to treat two Irish patients infected with B.
divergens (Gorenflot et al., 1998; Kjemtrup and
Conrad, 2000; Zintl et al., 2003).
The hydroxynaphtoquinone, atovaquone, was
shown to be very efficient against B. divergens-
infected human erythrocytes in vitro and B. divergens-
infected gerbils in vivo. However, atovaquone mono-
therapy is not recommended in the treatment of human
babesiosis because recrudescences occurred with the
emergence of resistant organisms. On the other hand,
monotherapy with high doses of azithromycin
significantly suppressed parasitaemia in the hamster
model. Azithromycin in combination with atovaquone
or quinine has been effective in experimental animals
and in humans (Gray and Pudney, 1999; Shaio and
Yang, 1997; Weiss et al., 1993, 2001). Atovaquone
plus azithromycin demonstrated superiority as com-
pared to clindamycin and quinine in the prevention
and treatment of experimental babesiosis in hamsters
(Hughes and Oz, 1995; Pantanowitz et al., 2002;
Wittner et al., 1996). In a prospective, non-blinded,
randomized trial of 58 patients with non-life-
threatening babesiosis, the combination of azithro-
mycin and atovaquone showed no demonstrable
difference in efficacy when compared with clinda-
mycin and quinine with slow clearance of parasites
from the bloodstream, which could take as long as 3
weeks, but this combination had less adverse effects.
The most common adverse effects in the group on
clindamycin and quinine were cinchonism from the
quinine and diarrhoea (Krause et al., 2000). It is
unknown whether a higher dose of azithromycin may
lead to earlier resolution of fever and rapid clearance
of parasites.
In B. microti infection, the combination of quinine
(600 mg of salt orally, three time daily) and
clindamycin (600 mg orally, three times daily or
1.2 mg parenterally, twice daily) for 7–10 days
remains the most commonly used treatment for
adults. Pediatric dosages are scaled accordingly.
Atovaquone suspension (750 mg, twice daily), plus
azithromycin (500–1,000 mg per day) is also a very
effective treatment. Atovaquone/azithromycin has not
been studied in patients with high parasitaemia. In the
moderately to severely ill patient, it may be preferable
 H.J. Vial, A. Gorenflot / Veterinary Parasitology 138 (2006) 147–160
to initiate therapy with intravenously administered
clindamycin and quinine and then switch to oral
atovaquone/azithromycin in those who cannot tolerate
the former. In the severely ill patient, quinine can be
exchanged for quinidine and intravenously adminis-
tered along with clindamycin. Considering the
similarities between the site of action of clindamycin
and azithromycin, it has been suggested that a
combination of clindamycin and atovaquone may be
similarly efficacious with fewer adverse effects and
lower costs (Homer et al., 2000; Ranque, 2001; Weiss,
2002; Zintl et al., 2003). This possibility has not been
tested in practice.
Today, fast and aggressive therapy to reduce
parasitaemia, combining blood exchange transfusion
and chemotherapy, has reduced the mortality rate of B.
divergens in severe cases. At present, the recom-
mended treatment consists of massive blood exchange
transfusion followed by intravenous administration of
clindamycin. After clearance of the parasitaemia and
resolution of haemolysis, a non-regenerative anemia
may persist for at least 1 month, requiring additional
blood transfusion.
4.2.2. Supportive therapy
Patients with heavy parasitaemia are at risk for
developing severe clinical manifestations; the risk is
proportional to the level of parasitaemia. Similar to
malaria, babesiosis can be present in an overwhelming
manner, especially in the immunocompromised
patient, including the elderly and patients infected
with HIV. In Europe, B. divergens has induced severe
infections and high mortality rates, primarily in
splenectomized patients (see above).
In severe cases, whole-blood exchange or aphaer-
esis (Evenson et al., 1998; Gorenflot et al., 1987, 1990;
Pantanowitz et al., 2002; Zintl et al., 2003) has been
suggested as an adjunction measure to reduce the
parasite burden. Exchange transfusion replaces para-
sitized erythrocytes and effectively reduces the high
level of parasitaemia. Because Babesia has no exo-
erythrocytic stage, removal of parasitized erythrocytes
is curative. Generally, the advantages of exchange
transfusion include rapid reduction in parasite load,
correction of the anemia and rapid restoration of other
blood parameters, and the removal of parasite and
red cell debris, including toxic and harmful metabo-
lites (e.g. cytokines and other vasoactive substances).
155
Exchange transfusion is only advocated for the
treatment of critically ill patients or patients refractory
to conventional chemotherapy.
Infected patients may have prolonged persistence of
Babesia in the blood and may present a risk for blood
transfusion transmission of this disease. The blood
components that have been implicated in transfusion
babesiosis include erythrocytes, and platelet concen-
trates that contain residual erythrocytes. Based on
several epidemiological studies, the risk of transfusion-
acquired babesiosis in an endemic area (Connecticut)
was estimated to be 0.17% per unit of packed cells
(Pankova-Kholmyansky et al., 2003). Chemical and
physical manipulation of blood to inactivate microbes
including Babesia spp. are investigated (Grellier et al.,
1997; Zavizion et al., 2004)
5. Mechanism of action of current babesiacidal
drugs
The mechanisms by which the current babesiacides
inhibit the development of Babesia spp. proliferation
within erythrocytes are largely unknown. As the effect
of imidocarb on Trypanosoma brucei is antagonized by
excess polyamines, it is has been suggested that
imidocarb interferes with their production and/or use
(Bacchi et al., 1981). Imidocarb blocks the entry of
inositol into erythrocytes containing Babesia, resulting
in ‘starvation’ of the parasite (McHardy et al., 1986).
All compounds used against human babesiosis
have antimicrobial activity against other pathogens,
and their mechanisms of action may accordingly be
hypothesized; this is particularly the case of the
antimalarial quinine, the wide-spectrum antiparasitic
atovaquone (Baggish and Hill, 2002) and the
antibiotics clindamycin and azithromycin (Finch
et al., 2003). These hypotheses are outside the scope
of this review.
6. Prospectives and rationale for drug
development
6.1. The present situation
Currently the most important babesiacide used in
animals is imidocarb, and the development of resistance
156 H.J. Vial, A. Gorenflot / Veterinary Parasitology 138 (2006) 147–160
is a likely event. Moreover, imidocarb is associated
with residue problems and is not available worldwide,
including in Europe. It is clear that alternative
compounds have to be developed for the veterinary
market. Besides, none of the human treatments are fully
satisfactory considering the mortality associated with
human babesiosis. More particularly, treatment of B.
divergens infection is problematic with high mortality
rate, most often in splenectomized or immunocompro-
mised patients. As these have usually a severe
presentation and have a fulminating parasitaemia,
potent new babesiacidal compounds have to be found.
Several in vitro and in vivo models are available to
screen potential drugs. A number of Babesia spp. have
now been established in in vitro continuous culture
(Grande et al., 1997; Schuster, 2002) which may be used
for determination of parasite growth in the presence of
candidate antibabesial compounds. Different rodents
such as hamsters and gerbils can be infected by Babesia
parasites and can be used for in vivo drug testing. Since
B. microti is poorly propagated in vitro, animal models
have been the primary means of evaluating new drugs
for the treatment of this babesiosis. The Mongolian
gerbil Meriones unguiculatus has been used as an
experimental model for B. divergens and B. microti
infections (Weiss, 2002).
6.2. The unique position of Babesia parasites
It is striking to note that most of the compounds
reported with babesiacidal activity were first discovered
for other microbial infections, and then applied to
babesiosis, sometimes incidentally (see above for
quinine). However, Babesia spp. differ from other
Apicomplexa and specificity are not exploited enough.
Babesia parasites are restricted to erythrocytes and
multiply asexually with a reproductive time of around
10 h, whereas all other Apicomplexa are highly
cosmopolitan protozoan parasites capable of invading
and replicating within nucleated cells. Most of these
other parasites have to protect themselves from the host
cellular machinery (e.g. avoiding a fusion with the
lysosome) but benefit from the host cell machinery with
its metabolite-rich cytosol and reported close contact
with organelles from the host cells. The red blood cell
is a golden jail for protection from the immune system,
but it appears that proliferating Babesia parasites
must comply with a series of requisite events for the
duplication of their structural components. These
events occur in a strict temporal control order and
the intracellular parasite has to acquire an appropriate
dynamic. Notably, the non-dividing erythrocyte has lost
all import capacity and some carriers have been
eliminated. Consequently, the intracellular parasite has
to possess its own machinery and has also to exchange
nutrients and expel metabolites to assure its survival and
propagation.
6.3. Identification of drug targets
The identification of novel drug targets is usually
based upon metabolic pathways and cell structures
that are different between parasite and host and are
currently revolutionized by the advent of the
genomics. Programmes to sequence the genomes of
several Babesia species have now been funded. More
particularly, a programme to sequence B. bovis is
provided by The Wellcome Trust Sanger Institute
(http://www.sanger.ac.uk/Projects/B_bovis/) as part of
its microbial sequencing effort focusing on pathogens
and model organisms.
The challenge will be to identify genetic differ-
ences that are potential drug targets, for example,
parasite-specific genes essential for infection and
pathogenesis, novel metabolic pathways, unique
parasite-specific mechanisms of gene regulation and
RNA processing. Techniques to analyze the profile of
the parasite proteins and to identify functionally
important (essential) genes are needed. Efficient
procedures for transfection, conditional gene com-
plementation and target validation will be required to
rapidly elucidate novel potential pharmacological
targets. Due to the absence of a parasitophorous
vacuole plasma membrane, transfection of the
Babesia parasites might be less time consuming and
painful than that of the malarial parasites. Babesia is
closely related to Plasmodium which also proliferates
within erythrocytes. Many similarities exist between
malaria and babesiosis in their clinical manifestations,
their intraerythrocytic development in the mammalian
host, and their antigenic properties. An integrated
knowledge of both veterinary and human babesial and
plasmodial parasites is likely to aid in better under-
standing emerging human infections.
Indeed, it is evident that some drugs can be useful
for both of these erythrocyte-invading parasites. Thus,
 H.J. Vial, A. Gorenflot / Veterinary Parasitology 138 (2006) 147–160
atovaquone, whose antibabesial activity has been
reported above, is a ubiquinone (also called Coenzyme
Q) analogue that binds to the P. falciparum bc1
complex (complex III), at 1000-fold lower concentra-
tion than required for inhibiting rat mitochondria.
Consequently, atovaquone inhibits electron transport
linked to dihydroorotate dehydrogenase activity and
selectively inhibits plasmodial pyrimidine biosynth-
esis (Baggish and Hill, 2002; Fry and Pudney, 1992).
Another example resides in the recent morphological
and molecular identification of the apicoplast. Indeed,
Babesia, as other apicomplexan parasites, has
acquired (by secondary endosymbiosis of eukaryotic
algae) this plastid-derived non-photosynthetic orga-
nelle. The apicoplast contains circular extra-chromo-
somal DNA of 27–35 kb (Lang-Unnasch et al., 1998;
Wilson and Williamson, 1997), but most of the genes
have been relocated to the nucleus. Important
advances over the past 5 years indicate that this relic
plastid is an essential cellular compartment in which
the products of nuclear genes specifying several
prokaryotic biosynthetic pathways are concentrated
(Roos et al., 1999). Biosynthetic pathways of plastid-
derived organelles are potential drug targets against
parasitic Apicomplexa (Ralph et al., 2004; Seeber,
2003). Triclosan, an inhibitor that binds to FabI
(Surolia et al., 2004) also inhibits bovine and equine
Babesia growth (Bork et al., 2003) indicating the
existence and crucial role of type II fatty acid
biosynthesis in babesiosis-causing parasite.
6.4. Phospholipid metabolism pathway
Finally, our laboratory has developed a new
antimalarial pharmacological approach based on
inhibition of the plasmodial phospholipid metabolism.
The drugs mimic choline structure and inhibit de novo
phosphatidylcholine biosynthesis. Three generations of
compounds were rationally designed. Bisquaternary
ammonium salts showed powerful antimalarial activity,
with IC50 in the nanomolar range (Ancelin et al., 2003b;
Calas et al., 2000; Salom-Roig et al., 2005). The third
generation compounds are bis-thiazolium salts and
their non-ionic precursors: prodrugs, which in vivo can
become thiazolium drugs after enzymatic transforma-
tion (Vial et al., 2004). Compounds are accumulated in
P. falciparum-infected erythrocytes, which ensures
their potency and specificity. These molecules exert a
157
very rapid cytotoxic effect against malarial parasites in
the very low nanomolar range and are active in vivo
against Plasmodium vinckei-infected mice, with ED50
lower than 0.2 mg/kg. They also retain full activity
against P. falciparum and Plasmodium cynomolgi in
primate models with no recrudescence and at lower
doses (Ancelin et al., 2003a; Vial et al., 2004;
Wengelnik et al., 2002). We have also shown that
these compounds exert potent activity against B.
divergens and B. canis with activity in the low
nanomolar range. They are also active against babesial
infection in gerbil model (Vial and Gorenflot,
unpublished).
Despite the resemblance of Babesia to Plasmodium,
antimalarial drugs, such as chloroquine, proguanil,
mefloquine, halofantrine (and possibly artesunate) had
no activity in either human Babesia infections or the
hamster model. Indeed, Babesia differ from Plasmo-
dium in some essential aspects: (i) the vacuole
membrane is entirely lost shortly after invasion
(Rudzinska et al., 1976) and (ii) Babesia lack both a
cytostome and a digestive vacuole, do not degrade
hemoglobin very effectively, and do not form hemozoin
(Olliaro and Goldberg, 1995; Slomianny et al., 1983).
Thus, there is no doubt that discovery of new anti-
Babesia compounds will require specific research
devoted to these parasites to discover the biology of this
intracellular, rapidly dividing haemotropic protozoon.
Acknowledgement
We thank Anja Heckeroth for critical reading of the
manuscript.
References
Adams, L.G., 1981. Clinicopathological aspects of imidocarb dipro-
pionate toxicity in horses. Res. Vet. Sci. 31, 54–61.
Allred, D.R., 2003. Babesiosis: persistence in the face of adversity.
Trends Parasitol. 19, 51–55.
Ancelin, M.L., Calas, M., Bonhoure, A., Herbute, S., Vial, H.J.,
2003a. In vivo antimalarial activities of mono- and bis quatern-
ary ammonium salts interfering with Plasmodium phospholipid
metabolism. Antimicrob. Agents Chemother. 47, 2598–2605.
Ancelin, M.L., Calas, M., Vidal_Sailhan, V., Herbute, S., Ringwald,
P., Vial, H.J., 2003b. Potent inhibitors of Plasmodium phospho-
lipid metabolism with a broad spectrum of in vitro antimalarial
activities. Antimicrob. Agents Chemother. 47, 2590–2597.
158 H.J. Vial, A. Gorenflot / Veterinary Parasitology 138 (2006) 147–160
Aryeetey, R., Jimenez-Lucho, V., 2002. Babesiosis. Curr. Treat.
Options Infect. Dis. 4, 319–326.
Babes, V., 1888. Sur l’hémoglobinurie bactérienne du boeuf. C.R.
Acad. Sci., Ser. III Sci. vie 107, 692–694.
Bacchi, C.J., Nathan, H.C., Hutner, S.H., Duch, D.S., Nichol, C.A.,
1981. Prevention by polyamines of the curative effect of ami-
carbalide and imidocarb for Trypanosoma brucei infections in
mice. Biochem. Pharmacol. 30, 883–886.
Baggish, A.L., Hill, D.R., 2002. Antiparasitic agent atovaquone.
Antimicrob. Agents Chemother. 46, 1163–1173.
Birkenheuer, A.J., Levy, M.G., Savary, K.C., Gager, R.B., Breitsch-
werdt, E.B., 1999. Babesia gibsoni infections in dogs from North
Carolina. J. Am. Anim. Hosp. Assoc. 35, 125–128.
Bork, S., Yokoyama, N., Matsuo, T., Claveria, F.G., Fujisaki, K.,
Igarashi, I., 2003. Growth inhibitory effect of triclosan on equine
and bovine Babesia parasites. Am. J. Trop. Med. Hyg. 68, 334–
340.
Calas, M., Ancelin, M.L., Cordina, G., Portefaix, P., Piquet, G.,
Vidal-Sailhan, V., Vial, H., 2000. Antimalarial activity of com-
pounds interfering with Plasmodium falciparum phospholipid
metabolism: comparison between mono- and bisquaternary
ammonium salts. J. Med. Chem. 43, 505–516.
Carret, C., Walas, F., Carcy, B., Grande, N., Precigout, E., Moubri,
K., Schetters, T.P., Gorenflot, A., 1999. Babesia canis canis,
Babesia canis vogeli, Babesia canis rossi: differentiation of the
three subspecies by a restriction fragment length polymorphism
analysis on amplified small subunit ribosomal RNA genes. J.
Eukaryot. Microbiol. 46, 298–303.
Evenson, D.A., Perry, E., Kloster, B., Hurley, R., Stroncek, D.F.,
1998. Therapeutic apheresis for babesiosis. J. Clin. Apheresis
13, 32–36.
Finch, R., Greenwood, D., Norrby, S., Whitley, R., 2003. Antibiotic
and chemotherapy: anti-infective agents and their use in therapy.
Churchill Livingstone.
Francioli, P.B., Keithly, J.S., Jones, T.C., Brandstetter, R.D., Wolf,
D.J., 1981. Response of babesiosis to pentamidine therapy. Ann.
Intern. Med. 94, 326–330.
Fry, M., Pudney, M., 1992. Site of action of the antimalarial
hydroxynaphthoquinone, 2-[trans-4-(40 -chlorophenyl)cyclo-
hexyl]-3-hydroxy-1,4-naphthoquinone (566C80). Biochem.
Pharmacol. 43, 1545–1553.
Gelfand, J.A., Callahan, M.V., 1998. Babesiosis. Curr. Clin. Top.
Infect. Dis. 18, 201–216.
Gorenflot, A., Bazin, C., Ambroise-Thomas, P., 1987. Human
babesiosis. Treatment of severe forms. Presse Med. 16, 1099.
Gorenflot, A., Brasseur, P., Bonmarchand, G., Laneele, D., Simonin,
D., 1990. 2 cases of severe human babesiosis treated success-
fully. Presse Med. 19, 335.
Gorenflot, A., Moubri, K., Precigout, E., Carcy, B., Schetters, T.P.,
1998. Human babesiosis. Ann. Trop. Med. Parasitol. 92, 489–
501.
Graham, O.H., Hourrigan, J.L., 1977. Eradication programs for the
arthropod parasites of livestock. J. Med. Entomol. 13, 629–658.
Grande, N., Precigout, E., Ancelin, M.L., Moubri, K., Carcy, B.,
Lemesre, J.L., Vial, H., Gorenflot, A., 1997. Continuous in vitro
culture of Babesia divergens in a serum-free medium. Para-
sitology 115 (Pt 1), 81–89.
Gray, J.S., Parr, S.L., 1992. In vivo assays for drug resistance in
Babesia divergens using the Mongolian gerbil, Meriones ungui-
culatus. Res. Vet. Sci. 52, 126–128.
Gray, J.S., Potgieter, F.T., 1981. The retention of Babesia bigemina
infection by Boophilus decoloratus exposed to imidocarb dipro-
pionate during engorgement. Onderstepoort J. Vet. Res. 48, 225–
227.
Gray, J.S., Pudney, M., 1999. Activity of atovaquone against Babe-
sia microti in the Mongolian gerbil, Meriones unguiculatus. J.
Parasitol. 85, 723–728.
Grellier, P., Santus, R., Mouray, E., Agmon, V., Maziere, J.C.,
Rigomier, D., Dagan, A., Gatt, S., Schrevel, J., 1997. Photo-
sensitized inactivation of Plasmodium falciparum- and Babesia
divergens-infected erythrocytes in whole blood by lipophilic
pheophorbide derivatives. Vox Sang. 72, 211–220.
Hatcher, J.C., Greenberg, P.D., Antique, J., Jimenez-Lucho, V.E.,
2001. Severe babesiosis in Long Island: review of 34 cases and
their complications. Clin. Infect. Dis. 32, 1117–1125.
Homer, M.J., Aguilar-Delfin, I., Telford III, S.R., Krause, P.J., Persing,
D.H., 2000. Babesiosis. Clin. Microbiol. Rev. 13, 451–469.
Hughes, W.T., Oz, H.S., 1995. Successful prevention and treatment
of babesiosis with atovaquone. J. Infect. Dis. 172, 1042–1046.
Kakoma, I., Mehlhorn, H., 1993. Babesia of domestic animals. In:
Kreier, J.P. (Ed.), Parasitic Protozoa, second ed., vol. 7. Aca-
demic Press, San Diego, pp. 141–216.
Kjemtrup, A.M., Conrad, P.A., 2000. Human babesiosis: an emer-
ging tick-borne disease. Int. J. Parasitol. 30, 1323–1337.
Krause, P.J., Lepore, T., Sikand, V.K., Gadbaw, J., Burke, G.,
Telford, S.R., Brassard, P., Pearl, D., Azlanzadeh, J., Christian-
son, D., McGrath, D., Spielman, A., 2000. Atovaquone and
azithromycin for the treatment of babesiosis. N. Engl. J. Med.
343, 1454–1458.
Kuttler, K., 1981. Chemotherapy of babesiosis: a review. In: Ristic,
M., Kreier, J. (Eds.), Babesiosis. Academic Press, New York.
Kuttler, K., Graham, O., Trevino, J., 1975. The effect of imidocarb
treatment of Babesia in the bovine and in the tick (Boophilus
microplus). Res. Vet. Sci. 18, 198–200.
Lang-Unnasch, N., Reith, M.E., Munholland, J., Barta, J.R., 1998.
Plastids are widespread and ancient in parasites of the phylum
Apicomplexa. Int. J. Parasitol. 28, 1743–1754.
Lewis, D., Purnell, R.E., Francis, L.M., Young, E.R., 1981. The
effect of treatment with imidocarb diproprionate on the course of
Babesia divergens infections in splenectomized calves, and on
their subsequent immunity to homologous challenge. J. Comp.
Pathol. 91, 285–292.
Mackenstedt, U., Gauer, M., Mehlhorn, H., Schein, E., Hauschild,
S., 1990. Sexual cycle of Babesia divergens confirmed by DNA
measurements. Parasitol. Res. 76, 199–206.
McHardy, N., Woollon, R.M., Clampitt, R.B., James, J.A., Crawley,
R.J., 1986. Efficacy, toxicity and metabolism of imidocarb
dipropionate in the treatment of Babesia ovis infection in sheep.
Res. Vet. Sci. 41, 14–20.
Mehlhorn, H., Schein, E., 1984. The piroplasms: life cycle and
sexual stages. Adv. Parasitol. 23, 37–103.
Milner, R.J., Reyers, F., Taylor, J.H., van den Berg, J.S., 1997. The
effect of diminazene aceturate on cholinesterase activity in dogs
with canine babesiosis. J. S. Afr. Vet. Assoc. 68, 111–113.
 H.J. Vial, A. Gorenflot / Veterinary Parasitology 138 (2006) 147–160
Olliaro, P.L., Goldberg, D.E., 1995. The Plasmodium digestive
vacuole: metabolic headquarters and choice drug target. Para-
sitol. Today 11, 294–297.
Pankova-Kholmyansky, I., Dagan, A., Gold, D., Zaslavsky, Z.,
Skutelsky, E., Gatt, S., Flescher, E., 2003. Ceramide mediates
growth inhibition of the Plasmodium falciparum parasite. Cell.
Mol. Life Sci. 60, 577–587.
Pantanowitz, L., Telford III, S.R., Cannon, M.E., 2002. The impact
of babesiosis on transfusion medicine. Transfus. Med. Rev. 16,
131–143.
Purnell, R.E., 1981. Babesiosis in various hosts. In: Ristic, M.,
Kreier, J. (Eds.), Babesiosis. Academic Press, New York.
Ralph, S.A., Van Dooren, G.G., Waller, R.F., Crawford, M.J.,
Fraunholz, M.J., Foth, B.J., Tonkin, C.J., Roos, D.S., McFadden,
G.I., 2004. Tropical infectious diseases: metabolic maps and
functions of the Plasmodium falciparum apicoplast. Nat. Rev.
Microbiol. 2, 203–216.
Ranque, S., 2001. The treatment of babesiosis. N. Engl. J. Med. 344,
773–774.
Raoult, D., Soulayrol, L., Toga, B., Dumon, H., Casanova, P., 1987.
Babesiosis, pentamidine, and cotrimoxazole. Ann. Intern. Med.
107, 944.
Rees, C., 1934. Characteristics of the piroplasms Babesia argentina
and B. bigemina in the United States. Univ. Agri. Res. 45, 427–
438.
Ristic, M., 1988. Babesiosis of Domestic Animals and Man. CRC
Press, Boca Raton, FL, p. 275.
Roberts, F., Roberts, C.W., Johnson, J.J., Kyle, D.E., Krell, T., Coggins,
J.R., Coombs, G.H., Milhous, W.K., Tzipori, S., Ferguson, D.J.,
Chakrabarti, D., McLeod, R., 1998. Evidence for the shikimate
pathway in apicomplexan parasites. Nature 393, 801–805.
Roos, D.S., Crawford, M.J., Donald, R.G., Kissinger, J.C., Klimc-
zak, L.J., Striepen, B., 1999. Origin, targeting, and function of
the apicomplexan plastid. Curr. Opin. Microbiol. 2, 426–432.
Rosner, F., Zarrabi, M.H., Benach, J.L., Habicht, G.S., 1984.
Babesiosis in splenectomized adults. Review of 22 reported
cases. Am. J. Med. 76, 696–701.
Rowin, K.S., Tanowitz, H.B., Wittner, M., 1982. Therapy of experi-
mental babesiosis. Ann. Intern. Med. 97, 556–558.
Rudzinska, M.A., Trager, W., Lewengrub, S.J., Gubert, E., 1976. An
electron microscopic study of Babesia microti invading erythro-
cytes. Cell Tissue Res. 169, 323–334.
Salom-Roig, X., Hamzé, H., Calas, M., Vial, H., 2005. Dual
molecules as new antimalarials. Comb. Chem. High Throughput
Screen. 301, 114–123.
Schetters, T.P., Kleuskens, J., Scholtes, N., Gorenflot, A., 1998.
Parasite localization and dissemination in the Babesia-infected
host. Ann. Trop. Med. Parasitol. 92, 513–519.
Schetters, T.P., Moubri, K., Precigout, E., Kleuskens, J., Scholtes,
N.C., Gorenflot, A., 1997. Different Babesia canis isolates,
different diseases. Parasitology 115 (Pt 5), 485–493.
Scholtens, R.G., Braff, E.H., Healey, G.A., Gleason, N., 1968. A
case of babesiosis in man in the United States. Am. J. Trop. Med.
Hyg. 17, 810–813.
Schuster, F.L., 2002. Cultivation of Babesia and Babesia-like blood
parasites: agents of an emerging zoonotic disease. Clin. Micro-
biol. Rev. 15, 365–373.
159
Seeber, F., 2003. Biosynthetic pathways of plastid-derived orga-
nelles as potential drug targets against parasitic Apicomplexa.
Curr. Drug Targets Immune Endocr. Metabol. Disord. 3, 99–109.
Shaio, M.F., Yang, K.D., 1997. Response of babesiosis to a com-
bined regimen of quinine and azithromycin. Trans. R. Soc. Trop.
Med. Hyg. 91, 214–215.
Skrabalo, Z., Deanovic, Z., 1957. Piroplasmosis in man: report of a
case. Doc. Med. Geogr. Trop. 9, 11–16.
Slomianny, C., Charet, P., Prensier, G., 1983. Ultrastructural loca-
lization of enzymes involved in the feeding process in Plasmo-
dium chabaudi and Babesia hylomysci. J. Protozool. 30, 376–
382.
Smith, T., 1893. Investigations into the nature, causation, and
prevention of Texas or Southern cattle tick fever. In: Bureau
of Animal Industries, Bulletin no. 1, U.S. Department of Agri-
culture, Washington, DC.
Surolia, A., Ramya, T., Ramya, V., Surolia, N., 2004. ‘Fas’t inhibi-
tion of malaria. Biochem. J. 383, 401–412.
Taboada, J., 1998. Babesiosis. In: Greene, C. (Ed.), Infectious
Diseases of the Dog and Cat. WB Saunders, Philadelphia,
pp. 473–481.
Telford, S.R., Spielman, A., 1998. Babesiosis of humans. In: Collier,
L., Balows, A., Sussman, M. (Eds.), Topley and Wilson’s
Microbiology and Microbial Infections. Arnold, London,
England, pp. 349–359.
The Gray Book, 1998. Foreign Animal Diseases, Vol. Library of
Congress Catalog Card Number 17-12842. United States
Animal Health Association (http://www.usaha.org), Electronic
version at http://www.vet.uga.edu/vpp/gray_book/Handheld/
bab.htm#intro.
Todorovic, R.A., Vizcaino, O.G., Gonzalez, E.F., Adams, L.G.,
1973. Chemoprophylaxis (imidocarb) against Babesia bigemina
and Babesia argentina infections. Am. J. Vet. Res. 34, 1153–
1161.
Uilenberg, G., Franssen, F.F.J., Perié, N.M., Spanjer, A.A.M., 1989.
Three groups of Babesia canis distinguished and a proposal for
nomenclature. Vet. Q. 11, 33–40.
Valentin, A., Rigomier, D., Precigout, E., Carcy, B., Gorenflot, A.,
Schrevel, J., 1991. Lipid trafficking between high density lipo-
proteins and Babesia divergens-infected human erythrocytes.
Biol. Cell 73, 63–70.
Vial, H.J., Wein, S., Farenc, C., Kocken, C., Nicolas, O., Ancelin,
M.L., Bressolle, F., Thomas, A., Calas, M., 2004. Prodrugs of
bisthiazolium salts are orally potent antimalarials. Proc. Natl.
Acad. Sci. USA 101, 15458–15463.
Weiss, L.M., 2002. Babesiosis in humans: a treatment review. Expert
Opin. Pharmacother. 3, 1109–1115.
Weiss, L.M., Wittner, M., Tanowitz, H.B., 2001. The treatment of
babesiosis. N. Engl. J. Med. 344, 773.
Weiss, L.M., Wittner, M., Wasserman, S., Oz, H.S., Retsema, J.,
Tanowitz, H.B., 1993. Efficacy of azithromycin for treating
Babesia microti infection in the hamster model. J. Infect. Dis.
168, 1289–1292.
Wengelnik, K., Vidal, V., Ancelin, M.L., Cathiard, A.M., Morgat,
J.L., Kocken, C.H., Calas, M., Herrera, S., Thomas, A.W., Vial,
H.J., 2002. A class of potent antimalarials and their specific
accumulation in infected erythrocytes. Science 295, 1311–1314.
160 H.J. Vial, A. Gorenflot / Veterinary Parasitology 138 (2006) 147–160
Wijaya, A., Wulansari, R., Ano, H., Makimura, S., 2001. Effect of
clindamycin therapy on phagocytic and oxidative activity pro-
files of spleen mononuclear cells in Babesia rodhaini-infected
mice. J. Vet. Med. Sci./Jpn. Soc. Vet. Sci. 63, 563–566.
Wilson, L., Chowning, W., 1904. Studies in Pyroplasmosis hominis
(‘spotted fever’ or ‘tick fever’ of the Rocky Mountains). J. Infect.
Dis. 1, 31–57.
Wilson, R.J., Williamson, D.H., 1997. Extrachromosomal DNA in
the Apicomplexa. Microbiol. Mol. Biol. Rev. 61, 1–16.
Wittner, M., Lederman, J., Tanowitz, H.B., Rosenbaum, G.S., Weiss,
L.M., 1996. Atovaquone in the treatment of Babesia microti
infections in hamsters. Am. J. Trop. Med. Hyg. 55, 219–222.
Wittner, M., Rowin, K.S., Tanowitz, H.B., Hobbs, J.F., Saltzman, S.,
Wenz, B., Hirsch, R., Chisholm, E., Healy, G.R., 1982. Success-
ful chemotherapy of transfusion babesiosis. Ann. Intern. Med.
96, 601–604.
Zavizion, B., Pereira, M., de Melo Jorge, M., Serebryanik, D.,
Mather, T.N., Chapman, J., Miller, N.J., Alford, B., Bzik,
D.J., Purmal, A., 2004. Inactivation of protozoan parasites in
red blood cells using INACTINE PEN110 chemistry. Transfu-
sion (Paris) 44, 731–738.
Zintl, A., Mulcahy, G., Skerrett, H.E., Taylor, S.M., Gray, J.S., 2003.
Babesia divergens, a bovine blood parasite of veterinary and
zoonotic importance. Clin. Microbiol. Rev. 16, 622–636.