Background Naegleria fowleri is a climate-sensitive, thermophilic ameba found in warm, freshwater lakes and rivers. Primary amebic meningoencephalitis (PAM), which is almost universally fatal, occurs when N. fowleri–containing water enters the nose, typically during swimming, and N. fowleri migrates to the brain via the olfactory nerve. In August 2013, a 4-year-old child died of meningoencephalitis of unknown etiology in a Louisiana hospital. Methods Clinical and environmental testing and a case investigation were initiated to determine the cause of death and to identify potential exposures. Results Based on testing of CSF and brain specimens, the child was diagnosed with PAM. His only reported water exposure was tap water; in particular, tap water that was used to supply water to a lawn water slide on which the child had played extensively prior to becoming ill. Water samples were collected from both the home and the water distribution system that supplied the home and tested; N. fowleri were identified in water samples from both the home and the water distribution system. Conclusions This case is the first reported PAM death associated with culturable N. fowleri in tap water from a U.S. treated drinking water system. This case occurred in the context of an expanding geographic range for PAM beyond southern tier states with recent case reports from Minnesota, Kansas, and Indiana. This case also highlights the role of adequate disinfection throughout drinking water distribution systems and the importance of maintaining vigilance when operating drinking water systems using source waters with elevated temperatures.

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OBJECTIVE: To review the clinical use of noninvasive positive pressure ventilation (NPPV) in both acute hypoxic and hypercarbic forms of pediatric respiratory failure, including its mechanism of action and implementation. DATA SOURCES: Studies were identified through a MEDLINE search using respiratory failure, pediatrics, noninvasive ventilation, and mechanical ventilation as key words. STUDY SELECTION: All original studies, including case reports, relating to the use of noninvasive positive pressure in pediatric respiratory failure were included. Because of the paucity of published literature on pediatric NPPV, no study was excluded. DATA EXTRACTION: Study design, numbers and diagnoses of patients, types of noninvasive ventilator, ventilator modes, outcome measures, and complications were extracted and compiled. DATA SYNTHESIS: For acute hypoxic respiratory failure, all the studies reported improvement in oxygenation indices and avoidance of endotracheal intubation. The average duration of NPPV therapy before noticeable clinical improvement was 3 hrs in most studies, and NPPV was applied continuously for 72 hrs before resolution of acute respiratory distress. In patients with acute hypercarbic respiratory failure, application of NPPV resulted in reduction of work of breathing, reduction in CO(2) tension, and increased serum bicarbonate and pH. These patients are older than patients in the acute hypoxic respiratory failure group and, in addition to improved blood gas indices, they reported improvement in subjective symptoms of dyspnea. Improvement in gas exchange abnormalities and subjective symptoms occurred within the same time span (the first 3 hrs) as in the acute hypoxic respiratory failure group. However, use of noninvasive techniques in patients with acute hypercarbic respiratory failure continued after resolution of acute symptoms. Complications related to protracted use of NPPV were common in this group. CONCLUSIONS: NPPV has limited benefits in a group of carefully selected pediatric patients with acute hypoxic and hypercarbic forms of respiratory failure. The routine use of this technique in pediatric respiratory failure needs to be studied in randomized controlled trials and better-defined patient subsets.