A Fatal Case of Primary Amoebic Meningoencephalitis from Recreational Waters

Abstract

Background. Naegleria Fowleri is a single-cell, thermophilic amphizoid amoeba, and a rare known causative agent for primary amoebic meningoencephalitis with >97% mortality rate. The amoeba resides in freshwater lakes and ponds but can also survive in inadequately chlorinated pools and recreational waters. The mode of infection includes activities such as diving or jumping into freshwater or submerging the head under the water. Although most commonly seen in the southern United States, it is essential to keep this clinical suspicion in mind regardless of geography, as presenting symptoms can be very similar to classic bacterial meningitis. Case Summary. We report the first-ever case in the state of New Jersey of a 29-year-old male presented after a visit to a recreational water park in Texas five days before his presentation with altered mental status. In ICU, his ICP remained refractory to multiple therapies, including antibiotics and antivirals, external ventriculostomy drain, hypertonic saline, pentobarbital-induced coma, and bilateral hemicraniectomies. The CSF analysis revealed trophozoites indicating a protozoan infection, which we diagnosed in the neurocritical unit, and the patient was then immediately started with treatment that included amphotericin B, rifampin, azithromycin, and fluconazole. This suspicion was promptly confirmed by the Center for Disease Control (CDC). Unfortunately, despite all the aggressive intervention by the multidisciplinary team, the patient did not survive. Conclusion. As per the CDC, only four people out of 143 known infected individuals in the United States from 1962 to 2017 have survived. Symptoms start with a median of 5 days after exposure to contaminated water. Given the rarity of this case and its very high mortality rate, it is crucial to diagnose primary amoebic meningoencephalitis accurately as its presentation can mimic bacterial meningitis. It is vital to obtain a careful and thorough history, as it can aid in prompt diagnosis and treatment.

Current report on the prevalence of free-living amoebae (FLA) in natural hot springs: a systematic review

“…The occurrence of pathogenic FLA, especially in aquatic environments for recreational use such as hot springs, poses a major public health concern. Considering that fatal FLA infections in humans are acquired through swimming or contact with contaminated water sources as presented with recent cases (Hamaty et al 2020). In another perspective, the identification of contaminated water sources (including hot springs) and patient history may serve as life-saving information in providing the proper therapeutic regimens (Vargas-Zepeda et al 2005;Yadav et al 2012;Chomba et al 2017).…”

Genetic Detection of Amoebic Meningoencephalitis Causing by Naegleria Fowleri in Iraq: A Case Report

“…It is probably more associated with water activities such as diving and submerging the head, which can push water to the cribriform plate by a nasal cavity. PMA cases in many countries, such as the USA, recorded 143 PAM conditions from 1962 to 2017 ( 12 ).…”

“…Our patient showed signs including fever, chills, confusion, photophobia, respiratory distress, and meningeal agitation. PAM symptoms are non-specific and involve acute headache, fever with high grade, confusion, and stiffness neck, occurring death, in most conditions, is result-increasing pressure in the skull and hernia ( 12 ). N. fowleri enhances pore-formation proteins during contact of cells, which leads to the lysis of mammalian cells and excretion of cytolytic molecules involving hydrolase, phospholipase, neuraminidase, and phosphorolytic enzymes.…”

“…However, some cases in CT scan appear diffusion of cerebral edema ( 20 ). Besides, the diffusion sulcus appeared in the brain and encephalopathy due to hypoxia in one case infected with N. fowleri in USA ( 12 ). Meningitis cases suspicious need CSF specimens in their diagnosis; in addition to culture, gram stain, and diagnostic by molecular methods, also white blood cell count and biochemistry analysis ( 17 ).…”

Case of Primary Amebic Meningoencephalitis Associated with Surfing at an Artificial Surf Venue: Environmental Investigation

“…On September 20, 2018, CDC was notified of a possible case of PAM in a 29-year-old male New Jersey resident. The patient presented to a New Jersey hospital with fever and altered mental status and was treated presumptively for bacterial meningitis and viral encephalitis as described in the case report by Hamaty et al 13 When his condition did not improve with broad-spectrum antimicrobial therapy, a cerebrospinal fluid (CSF) sample was examined for organisms using Giemsa− Wright stain and was concerning for amebic infection. His clinical care team consulted CDC for empiric treatment recommendations for PAM and diagnostic confirmation.…”