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Gestational diabetes initial management — USMLE Step 3 MCQ

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HardOB/GYNGestational diabetes initial managementUSMLE Step 3

A 72-year-old asplenic man from Massachusetts has fever, dyspnea, hemoglobin 6.8 g/dL, creatinine 2.8 mg/dL, bilirubin 6.1 mg/dL, and Babesia parasitemia of 18%. Atovaquone-azithromycin has been started, but oxygen requirement and hemolysis are worsening. Which additional intervention is most appropriate?

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Correct answer: E — Arrange urgent red-cell exchange transfusion with specialist consultation

The best answer is “Arrange urgent red-cell exchange transfusion with specialist consultation”. This patient has high-grade parasitemia plus severe hemolytic, pulmonary, and renal compromise, meeting IDSA criteria for considering red-cell exchange. Exchange removes parasitized erythrocytes and toxic inflammatory products while antimicrobial therapy continues. A rigid 30% threshold is not required, glucocorticoids do not treat parasitic hemolysis, plasma exchange targets the wrong compartment, and organ failure argues against delay.

Reference: IDSA 2020 Guideline: Babesiosis: https://www.idsociety.org/practice-guideline/babesiosis/