Fatal Balamuthia mandrillaris brain infection associated with improper nasal lavage

Abstract

We report the case of a 69-year-old female who presented with a chronic nasal skin rash, new onset focal seizure, and a cerebral ring-enhancing lesion after a year of improper nasal irrigation. Despite aggressive and novel anti-amoebic treatment, she died as a result of a Balamuthia mandrillaris brain infection.

Nasal saline irrigation: a clinical update

“…The most recent case of PAM related to NSI occurred in 2018 in the state of Washington . The causative ameba in this case was Balamuthia mandrillaris , which has a more indolent course than N fowleri .…”

“…Official US Centers for Disease and Prevention (CDC) guidelines recommend using boiled water that has cooled (boiled for at least 1 minute or 3 minutes at an elevation of >6500 feet), microfiltered water (<1 μm pore), or bottled (distilled or sterile) water. In rare cases, NSI has been associated with primary amebic meningoencephalitis (PAM), which is most commonly caused by nasal exposure to Naegleria fowleri , a thermophilic ameba typically found in warm fresh water . Young males with recent fresh water exposure in warm climate geography seem to be most at risk .…”

Deadly amoeba infections from nasal and sinus irrigation: how should we discuss with our patients?

“…Very rarely, amoebic meningoencephalitis (AM) can be contracted from instillation of nonsterile water into the nasal cavity. The pathogenesis of this disease centers on migration of amoeba along the olfactory neuroepithelial tract leading to intracranial infection, and which is nearly always fatal . Four amoeba genera are known to be associated with human disease: Acanthamoeba spp, Balamuthia mandrillaris , Naegleria fowleri , and Sappinia diploidea …”

“…Over the last decade, 34 N fowleri infections have been reported and, over approximately the last 4 decades, 109 B mandrillaris infections have been identified, despite hundreds of millions of exposures . Four cases of AM linked to nasal irrigations or instillation of water into the nasal cavities have been reported in the US and surrounding territories . Two cases of primary AM due to N fowleri from tap water nasal irrigations were reported in 2012 in Louisiana .…”

“…One case of primary AM from N fowleri was reported in the US Virgin Islands in 2012 after ablution during prayer that included nasal rinsing with well water and rain water. In the fall of 2018, 1 case of granulomatous AM due to B mandrillaris was reported after nasal irrigation with tap water treated using a Brita filter (Brita, Oakland, CA) . No cases of AM from nasal irrigations with Acanthamoeba spp or S diploidea as the causative pathogen have been reported.…”