Cytopathogenicity of Balamuthia mandrillaris, an Opportunistic Causative Agent of Granulomatous Amebic Encephalitis

Balamuthia mandrillaris trophozoites ingest human neuronal cells via a trogocytosis-independent mechanism

BACKGROUND

Environmental protozoa need an adaptation mechanism to survive drastic changes in niches in the human body. In the brain parenchyma, Balamuthia mandrillaris trophozoites, which are causative agents of fatal brain damage, must acquire nutrients through the ingestion of surrounding cells. However, the mechanism deployed by the trophozoites for cellular uptake remains unknown.

METHODS

Amoebic ingestion of human neural cell components was investigated using a coculture system of clinically isolated B. mandrillaris trophozoites and human neuroblastoma SH-SY5Y cells. Cell-to-cell interactions were visualized in a three-dimensional manner using confocal and holotomographic microscopes.

RESULTS

The B. mandrillaris trophozoites first attached themselves to human neuroblastoma SH-SY5Y cells and then twisted themselves around the cytoplasmic bridge. Based on fluorescence-based cell tracking, the B. mandrillaris trophozoites then inserted invadopodia into the cytoplasm of the human cells. Subsequently, the human protein-enriched components were internalized into the trophozoites in the form of nonmembranous granules, whereas the human lipids were dispersed in the cytoplasm. Intervention of trogocytosis, a process involving nibbling on parts of the target cells, failed to inhibit this cellular uptake.

CONCLUSIONS

Human cell ingestion by B. mandrillaris trophozoites likely differs from trogocytosis, suggesting that a pathogen-specific strategy can be used to ameliorate brain damage.

Facial Balamuthia mandrillaris infection with neurological involvement in an immunocompetent child

Cutaneous infection by Balamuthia mandrillaris is a rare condition that is sometimes complicated by life-threatening CNS involvement. It often evades timely diagnosis due to its rarity and non-specific clinical manifestations. Patients can be either immunocompetent or immunocompromised. It is probably transmitted via inhalation or inoculation through broken skin, and then spreads to the brain and other organs through haematogenous spread. It is important for clinicians to be aware of this disease because rapid diagnosis and subsequent therapy has, in some cases, been associated with survival. In this Grand Round, we report the case of a 7-year-old boy who presented with large, chronic plaques on his face. Several biopsies showed non-specific granulomatous inflammation. The patient deteriorated rapidly and died within 1 month of displaying abnormal symptoms in the CNS. Immunohistochemical staining of skin tissue identified B mandrillaris as the infectious agent. The diagnosis was confirmed with PCR, which detected B mandrillaris DNA in formalin-fixed skin tissue sections. B mandrillaris infection should be considered in the differential diagnosis of patients with chronic granulomatous lesions. We also reviewed the epidemiology, B mandrillaris in nature and in the laboratory, clinical manifestations, histopathology, diagnosis, and treatment of infection.

Balamuthia mandrillaris: An opportunistic, free-living ameba - An updated review

Balamuthia mandrillaris is an opportunistic, free-living ameba that is pathogenic to humans. It has a worldwide distribution but is mainly detected in warmer regions. Balamuthia infections are rare but have been reported in both immunocompetent and immunocompromised individuals of all ages. B. mandrillaris can enter through wounds on the skin or the nose and cause cutaneous lesions and the usually fatal Balamuthia amebic encephalitis (BAE). Infection usually spreads from the lungs or through nerve fibers, and attacks the central nervous system, forming granulomatous lesions and necrosis in the brain. Balamuthia infection is usually chronic, and patients initially present with nonspecific symptoms, including headache, nausea, myalgia, and low-grade fever. As the disease progresses, the patient becomes paralyzed and comatose, often leading to death. Lack of knowledge of predisposing factors, specific treatment, and standardized detection tools have resulted in a nearly cent percent fatality rate. Although only about 200 cases have been reported worldwide since its characterization in the 1990s, the number of reported cases has increased over the years. BAE is an emerging disease and a major health concern. Few patients have survived Balamuthia infections with antimicrobial treatment that has largely been empirical. Early diagnosis is the key and requires familiarity with the disease and a high degree of suspicion on the part of the diagnostician. There are currently no specific treatment and prevention recommendations. This review highlights our current understanding of B. mandrillaris in terms of its pathogenicity, genomics, and novel diagnostic and therapeutic approaches against BAE infections.

Three encephalitis-causing amoebae and their distinct interactions with the host

Naegleria fowleri, Balamuthia mandrillaris, and Acanthamoeba spp. can cause devastating brain infections in humans which almost always result in death. The symptoms of the three infections overlap, but brain inflammation and the course of the disease differ, depending on the amoeba that is responsible. Understanding the differences between these amoebae can result in the development of strategies to prevent and treat these infections. Recently, numerous scientific advancements have been made in the understanding of pathogenicity mechanisms in general, and the basic biology, epidemiology, and the human immune response towards these amoebae in particular. In this review, we combine this knowledge and aim to identify which factors can explain the differences between the lethal brain infections caused by N. fowleri, B. mandrillaris, and Acanthamoeba spp.

Enrichment of free-living amoebae in biofilms developed at upper water levels in drinking water storage towers: An inter- and intra-seasonal study

Free-living amoebae (FLA) are ubiquitous organisms present in various natural and artificial environments, such as drinking water storage towers (DWST). Some FLA, such as Acanthamoeba sp., Naegleria fowleri, and Balamuthia mandrillaris, can cause severe infections at ocular or cerebral level in addition to being potential reservoirs of other pathogens. In this work, the abundance and diversity of FLA was evaluated in two sampling campaigns: one performed over five seasons in three DWST at three different levels (surface, middle and bottom) in water and biofilm using microscopy and PCR, and one based on the kinetics analysis in phase contrast and confocal microscopy of biofilm samples collected every two weeks during a 3-month period at the surface and at the bottom of a DWST. In the seasonal study, the FLA were detected in each DWST water in densities of ~20 to 25amoebaeL^-1. A seasonal variation of amoeba distribution was observed in water samples, with maximal densities in summer at ~30amoebaeL^-1 and minimal densities in winter at ~16amoebaeL^-1. The FLA belonging to the genus Acanthamoeba were detected in two spring sampling campaigns, suggesting a possible seasonal appearance of this potentially pathogenic amoeba. Interestingly, a 1 log increase of amoebae density was observed in biofilm samples collected at the surface of all DWST compared to the middle and the bottom where FLA were at 0.1-0.2amoebae/cm². In the kinetics study, an increase of amoebae density, total cell density, and biofilm thickness was observed as a function of time at the surface of the DWST, but not at the bottom. To our knowledge, this study describes for the first time a marked higher FLA density in biofilms collected at upper water levels in DWST, constituting a potential source of pathogenic micro-organisms.

First Draft Genome Sequence of Balamuthia mandrillaris, the Causative Agent of Amoebic Encephalitis

The free-living amoeba Balamuthia mandrillaris is a rare but highly lethal agent of amoebic encephalitis in humans and many other mammalian species. Here, we announce the first draft genome sequence of the original 1990 isolate cultured from the brain of a deceased mandrill baboon.

Disseminated Balamuthia mandrillaris Infection

Balamuthia mandrillaris is a rare cause of human infection, but when infections do occur, they result in high rates of morbidity and mortality. A case of disseminated Balamuthia infection is presented. Early diagnosis and initiation of recommended therapy are essential for increased chances of successful outcomes.

In vitro growth, cytopathic effects and clearance of monolayers by clinical isolates of Balamuthia mandrillaris in human skin cell cultures

Balamuthia mandrillaris is a free-living ameba (FLA) that has been isolated or its DNA identified in soil, dust and water. It causes a fatal central nervous system infection in humans and animals. Although it is environmental as Acanthamoeba and Naegleria fowleri, the two other free-living amebae that also cause CNS infections in humans and other animals, Balamuthia does not feed on bacteria as the other FLA. In the laboratory, it can be grown on a variety of mammalian cell cultures. In this study we examined the ability of three different Balamuthia isolates to grow on several different human skin cell cultures including the WT/A keratinocyte cell cultures. A corneal isolate of Acanthamoeba castellanii was used for comparison.

Novel culture medium for the axenic growth of Balamuthia mandrillaris

Until now, for axenic cultivation of Balamuthia mandrillaris, the BM-3 culture medium and the Modified Chang's special medium have been the only ones recommended, but they have some disadvantages, as both require many components and their preparations are laborious. Therefore, we developed a novel culture medium for B. mandrillaris axenic cultivation. Each one of the 11 components of BM-3 was combined with Cerva's medium as basal culture medium. Ten strains of B. mandrillaris including the reference strain CDC:V039 and 9 environmental isolates were used during trials. After testing all combinations, the basal medium complemented with 10× Hank's balanced salt solution was the only one that supported confluent growth of B. mandrillaris. Cell shape and motility of trophozoites were normal. This developed medium is as useful as BM-3 for axenization. The development of a cheaper and easy-to-prepare medium for B. mandrillaris opens the possibility of increasing its study.

Delivery of amphotericin B nanosuspensions to the brain and determination of activity against Balamuthia mandrillaris amebas

Amphotericin B was formulated as nanosuspensions to develop a nanoparticulate brain delivery system. Nanosuspensions were produced with different surfactant solutions by high-pressure homogenization and then characterized by laser diffractometry and photon correlation spectroscopy. Before in vitro and in vivo testing all nanosuspensions were investigated for protein adsorption by two-dimensional polyacrylamide gel electrophoresis to predict brain-targeting capacities. Selected nanosuspensions were tested for amebicidal activity against Balamuthia mandrillaris, an agent of lethal encephalitis. Our results indicate that nanosuspensions coated with polysorbate 80 and sodium cholate markedly increased drug brain delivery and inhibited the parasite in vitro, though less in vivo. From the clinical editor: The antifungal Amphotericin B was formulated as nanosuspensions to develop a nanoparticulate brain delivery system. The results indicate that nanosuspensions coated with polysorbate 80 and sodium cholate markedly increased drug brain delivery and inhibited the parasite in vitro, though less in vivo.

Detection of Balamuthia mandrillaris DNA by real-time PCR targeting the RNase P gene

Background

The free-living amoeba Balamuthia mandrillaris may cause fatal encephalitis both in immunocompromised and in – apparently – immunocompetent humans and other mammalian species. Rapid, specific, sensitive, and reliable detection requiring little pathogen-specific expertise is an absolute prerequisite for a successful therapy and a welcome tool for both experimental and epidemiological research.

Results

A real-time polymerase chain reaction assay using TaqMan^® probes (real-time PCR) was established specifically targeting the RNase P gene of B. mandrillaris amoebae. The assay detected at least 2 (down to 0.5) genomes of B. mandrillaris grown in axenic culture. It did not react with DNA from closely related Acanthamoeba (3 species), nor with DNA from Toxoplasma gondii, Leishmania major, Pneumocystis murina, Mycobacterium bovis (BCG), human brain, various mouse organs, or from human and murine cell lines. The assay efficiently detected B. mandrillaris DNA in spiked cell cultures, spiked murine organ homogenates, B. mandrillaris-infected mice, and CNS tissue-DNA preparations from 2 patients with proven cerebral balamuthiasis. This novel primer set was successfully combined with a published set that targets the B. mandrillaris 18S rRNA gene in a duplex real-time PCR assay to ensure maximum specificity and as a precaution against false negative results.

Conclusion

A real-time PCR assay for B. mandrillaris amoebae is presented, that is highly specific, sensitive, and reliable and thus suited both for diagnosis and for research.

Balamuthia mandrillaris interactions with human brain microvascular endothelial cells in vitro

Balamuthia amoebic encephalitis (BAE) is a serious human disease almost always leading to death. An important step in BAE is amoebae invasion of the bloodstream, followed by their haematogenous spread. Balamuthia mandrillaris entry into the central nervous system most likely occurs at the blood-brain barrier sites. Using human brain microvascular endothelial cells (HBMECs), which constitute the blood-brain barrier, this study determined (i) the ability of B. mandrillaris to bind to HBMECs and (ii) the associated molecular mechanisms. Adhesion assays revealed that B. mandrillaris exhibited greater than 90 % binding to HBMECs in vitro. To determine whether recognition of carbohydrate moieties on the surface of the HBMECs plays a role in B. mandrillaris adherence to the target cells, adhesion assays were performed in the presence of the saccharides mannose, galactose, xylose, glucose and fucose. It was observed that adherence of B. mandrillaris was significantly reduced by galactose, whilst the other saccharides had no effect. Acetone fixation of amoebae, but not of HBMECs, abolished adhesion, suggesting that B. mandrillaris adhesin(s) bind to galactose-containing glycoproteins of HBMECs. B. mandrillaris also bound to microtitre wells coated with galactose-BSA. By affinity chromatography using a galactose-Sepharose column, a galactose-binding protein (GBP) was isolated from detergent extracts of unlabelled amoebae. The isolation of a GBP from cell-surface-biotin-labelled amoebae suggested its membrane association. One-dimensional SDS-PAGE confirmed the proteinaceous nature of the GBP and determined its molecular mass as approximately 100 kDa. This is the first report suggesting the role of a GBP in B. mandrillaris interactions with HBMECs.

Effect of antimicrobial compounds on Balamuthia mandrillaris encystment and human brain microvascular endothelial cell cytopathogenicity

Cycloheximide, ketoconazole, or preexposure of organisms to cytochalasin D prevented Balamuthia mandrillaris-associated cytopathogenicity in human brain microvascular endothelial cells, which constitute the blood-brain barrier. In an assay for inhibition of cyst production, these three agents prevented the production of cysts, suggesting that the biosynthesis of proteins and ergosterol and the polymerization of actin are important in cytopathogenicity and encystment.

The Ameba Balamuthia mandrillaris Feeds by Entering into Mammalian Cells in Culture

Microscopic observations of live cultures of the pathogenic ameba Balamuthia mandrillaris and mammalian cells showed that amebic feeding involved the invasion of the pseudopodia, and/or the whole ameba into the cells. The ameba, recognized by their size and flow of organelles in the cytosol, was seen to extend the tip of a pseudopodium into the cytoplasm of a cell where it moved about leaving visible damage when retracted. In rounded cells, whole amebas were seen to enter into and move around before exiting a cell and then remain quiescent for hours. The invaded mammalian cells retained their turgidity and excluded vital dyes until only their denuded nuclei remained. The cytoplasm of the cells was consumed first, then the nuclei, but not their mitotic chromosomes. The feeding pattern of four isolates of B. mandrillaris, two from humans and two from soil samples, was by amebic invasion into the mammalian cells. The resulting ameba population included cysts, amebas on the surface, and free-floating amebas as individuals or in dense-packed clusters. There was no morphologic indication of a cytopathic change in the mammalian cells before their invasion by the amebas. Feeding by cell invasion is a distinctive feature of B. mandrillaris.

Balamuthia mandrillaris amebic encephalitis

Amebic encephalitis caused by Balamuthia spp is an increasingly recognized chronic granulomatous central nervous system infectious process, which may affect both immunocompetent and immunocompromised individuals. The course of the disease is insidious and fatal in most cases, mainly due to delayed diagnosis, difficulty in isolation and/or identification of the organism, and lack of well-established amebicidal therapeutic regimens. This article reviews the clinicopathologic characteristics of infections caused by Balamuthia mandrillaris compared to other pathogenic free-living amebae and summarizes the latest diagnostic and therapeutic advances in infections caused by Balamuthia spp.

Oral infection of immunocompetent and immunodeficient mice with Balamuthia mandrillaris amebae

Balamuthia mandrillaris is an opportunistic agent of lethal granulomatous amebic encephalitis (GAE). In mice, we have shown that intranasally instilled B. mandrillaris amebae infect the brain via the olfactory nerve pathway. In this study, we raised the question whether this ameba might also reach the brain after an oral/gastrointestinal infection. Immunocompetent (WT) and immunodeficient (RAG) mice received B. mandrillaris amebae by gavage into the esophagus. Mice of both groups became ill and some died (WT 20%, RAG 40%) within 42 days. All orally infected mice revealed B. mandrillaris amebae in the central nervous system. Outwardly intact amebae and/or specific antigen were found widely distributed in various organs and the stool. The data indicate that oral infection with B. mandrillaris leading to GAE is possible. Exit from the gastrointestinal tract and dissemination remains unresolved. Though stool cultures were negative, transmission of this highly pathogenic ameba via stool cannot be ruled out.