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Proctor C, Garner E, Hamilton KA, Ashbolt NJ, Caverly LJ, Falkinham JO, Haas CN, Prevost M, Prevots DR, Pruden A, Raskin L, Stout J, Haig SJ. Tenets of a holistic approach to drinking water-associated pathogen research, management, and communication. WATER RESEARCH 2022; 211:117997. [PMID: 34999316 PMCID: PMC8821414 DOI: 10.1016/j.watres.2021.117997] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 12/13/2021] [Accepted: 12/19/2021] [Indexed: 05/10/2023]
Abstract
In recent years, drinking water-associated pathogens that can cause infections in immunocompromised or otherwise susceptible individuals (henceforth referred to as DWPI), sometimes referred to as opportunistic pathogens or opportunistic premise plumbing pathogens, have received considerable attention. DWPI research has largely been conducted by experts focusing on specific microorganisms or within silos of expertise. The resulting mitigation approaches optimized for a single microorganism may have unintended consequences and trade-offs for other DWPI or other interests (e.g., energy costs and conservation). For example, the ecological and epidemiological issues characteristic of Legionella pneumophila diverge from those relevant for Mycobacterium avium and other nontuberculous mycobacteria. Recent advances in understanding DWPI as part of a complex microbial ecosystem inhabiting drinking water systems continues to reveal additional challenges: namely, how can all microorganisms of concern be managed simultaneously? In order to protect public health, we must take a more holistic approach in all aspects of the field, including basic research, monitoring methods, risk-based mitigation techniques, and policy. A holistic approach will (i) target multiple microorganisms simultaneously, (ii) involve experts across several disciplines, and (iii) communicate results across disciplines and more broadly, proactively addressing source water-to-customer system management.
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Affiliation(s)
- Caitlin Proctor
- Department of Agricultural and Biological Engineering, Division of Environmental and Ecological Engineering, Purdue University, West Lafayette, IN, USA
| | - Emily Garner
- Wadsworth Department of Civil & Environmental Engineering, West Virginia University, Morgantown, WV, USA
| | - Kerry A Hamilton
- School of Sustainable Engineering and the Built Environment and The Biodesign Centre for Environmental Health Engineering, Arizona State University, Tempe, AZ, USA
| | - Nicholas J Ashbolt
- Faculty of Science and Engineering, Southern Cross University, Gold Coast. Queensland, Australia
| | - Lindsay J Caverly
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
| | | | - Charles N Haas
- Department of Civil, Architectural & Environmental Engineering, Drexel University, Philadelphia, PA, USA
| | - Michele Prevost
- Department of Civil, Geological and Mining Engineering, Polytechnique Montreal, Montreal, Quebec, Canada
| | - D Rebecca Prevots
- Epidemiology Unit, Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Amy Pruden
- Department of Civil & Environmental Engineering, Virginia Tech, Blacksburg, VA USA
| | - Lutgarde Raskin
- Department of Civil & Environmental Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Janet Stout
- Department of Civil & Environmental Engineering, University of Pittsburgh, and Special Pathogens Laboratory, Pittsburgh, PA, USA
| | - Sarah-Jane Haig
- Department of Civil & Environmental Engineering, and Department of Environmental & Occupational Health, University of Pittsburgh, Pittsburgh, PA, USA.
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2
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Wu X, Yan G, Han S, Ye Y, Cheng X, Gong H, Yu H. Diagnosing Balamuthia mandrillaris encephalitis via next-generation sequencing in a 13-year-old girl. Emerg Microbes Infect 2021; 9:1379-1387. [PMID: 32552393 PMCID: PMC7473209 DOI: 10.1080/22221751.2020.1775130] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Balamuthia amoebic encephalitis has a subacute-to-chronic course and is almost invariably fatal owing to delayed diagnosis and a lack of effective therapy. Here, we report a 13-year-old girl with cutaneous lesions and multifocal granulomatous encephalitis. The patient underwent a series of tests and was suspected as having tuberculosis. She was treated with various empiric therapies without improvement. She was finally correctly diagnosed via next-generation sequencing of the cerebrospinal fluid. The patient deteriorated rapidly and died 2 months after being diagnosed with Balamuthia mandrillaris encephalitis. This study highlights the important clinical significance of next-generation sequencing, which provides better diagnostic testing for unexplained paediatric encephalitis, especially that caused by rare or emerging pathogens.
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Affiliation(s)
- Xia Wu
- Department of Infectious Diseases, Children's Hospital of Fudan University, Shanghai, People's Republic of China
| | - Gangfeng Yan
- Department of Pediatric Emergency Medicine and Critical Care Medicine, Children's Hospital of Fudan University, Shanghai, People's Republic of China
| | - Shuzhen Han
- Department of Infectious Diseases, Children's Hospital of Fudan University, Shanghai, People's Republic of China
| | - Yingzi Ye
- Department of Infectious Diseases, Children's Hospital of Fudan University, Shanghai, People's Republic of China
| | - Xunjia Cheng
- Department of Medical Microbiology and Parasitology, School of Basic Medical Sciences, Fudan University, Shanghai, People's Republic of China
| | - Hairong Gong
- Department of Pediatric Emergency Medicine and Critical Care Medicine, Children's Hospital of Fudan University, Shanghai, People's Republic of China
| | - Hui Yu
- Department of Infectious Diseases, Children's Hospital of Fudan University, Shanghai, People's Republic of China
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3
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Shehab KW, Aboul-Nasr K, Elliott SP. Balamuthia mandrillaris Granulomatous Amebic Encephalitis With Renal Dissemination in a Previously Healthy Child: Case Report and Review of the Pediatric Literature. J Pediatric Infect Dis Soc 2018; 7:e163-e168. [PMID: 29096002 DOI: 10.1093/jpids/pix089] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Accepted: 09/22/2017] [Indexed: 11/14/2022]
Abstract
Balamuthia mandrillaris is a recently described ameba known to cause a subacute to chronic central nervous system infection called granulomatous amebic encephalitis. Evidence suggests that apparently immunocompetent persons are at risk for disease and show a similar nonspecific presentation to that of immunodeficient persons. However, evidence of hematogenous dissemination, which has been found in immunodeficient patients, has been lacking in immunocompetent patients. Here, we describe a previously healthy patient with B mandrillaris-associated granulomatous amebic encephalitis in whom both central nervous system and renal disease were found during autopsy, which suggests hematogenous dissemination. We also provide a comprehensive review of the pediatric literature on this disease and its clinical presentation in children.
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Affiliation(s)
- Kareem W Shehab
- Department of Pathology, University of Arizona College of Medicine, Tucson
| | - Khalid Aboul-Nasr
- Department of Pathology, University of Arizona College of Medicine, Tucson
| | - Sean P Elliott
- Department of Pediatrics, University of Arizona College of Medicine, Tucson
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Abstract
Pathogenic FLA are ubiquitous protozoans and despite frequent human contact remain a rare cause of often devastating infection with poor prognosis. Given changes in climate, human encroachment into the environment, increasing immunosuppression, and improving diagnostic capacity, it is likely we will see increased cases in the future. Early diagnosis is challenging but crucial to achieving a favourable outcome. It is best facilitated by improved awareness of FLA disease, appropriate clinical suspicion and early diagnostic testing.
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Roy SL, Atkins JT, Gennuso R, Kofos D, Sriram RR, Dorlo TPC, Hayes T, Qvarnstrom Y, Kucerova Z, Guglielmo BJ, Visvesvara GS. Assessment of blood-brain barrier penetration of miltefosine used to treat a fatal case of granulomatous amebic encephalitis possibly caused by an unusual Balamuthia mandrillaris strain. Parasitol Res 2015; 114:4431-9. [PMID: 26329128 DOI: 10.1007/s00436-015-4684-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 08/19/2015] [Indexed: 12/22/2022]
Abstract
Balamuthia mandrillaris, a free-living ameba, causes rare but frequently fatal granulomatous amebic encephalitis (GAE). Few patients have survived after receiving experimental drug combinations, with or without brain lesion excisions. Some GAE survivors have been treated with a multi-drug regimen including miltefosine, an investigational anti-leishmanial agent with in vitro amebacidal activity. Miltefosine dosing for GAE has been based on leishmaniasis dosing because no data exist in humans concerning its pharmacologic distribution in the central nervous system. We describe results of limited cerebrospinal fluid (CSF) and serum drug level testing performed during clinical management of a child with fatal GAE who was treated with a multiple drug regimen including miltefosine. Brain biopsy specimens, CSF, and sera were tested for B. mandrillaris using multiple techniques, including culture, real-time polymerase chain reaction, immunohistochemical techniques, and serology. CSF and serum miltefosine levels were determined using a liquid chromatography method coupled to tandem mass spectrometry. The CSF miltefosine concentration on hospital admission day 12 was 0.4 μg/mL. The serum miltefosine concentration on day 37, about 80 h post-miltefosine treatment, was 15.3 μg/mL. These are the first results confirming some blood-brain barrier penetration by miltefosine in a human, although with low-level CSF accumulation. Further evaluation of brain parenchyma penetration is required to determine optimal miltefosine dosing for Balamuthia GAE, balanced with the drug's toxicity profile. Additionally, the Balamuthia isolate was evaluated by real-time polymerase chain reaction (PCR), demonstrating genetic variability in 18S ribosomal RNA (18S rRNA) sequences and possibly signaling the first identification of multiple Balamuthia strains with varying pathogenicities.
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Affiliation(s)
- Sharon L Roy
- Division of Foodborne, Waterborne and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, 30329, USA.
| | - Jane T Atkins
- Methodist Children's Hospital, San Antonio, TX, 78229, USA
| | | | - Danny Kofos
- Methodist Children's Hospital, San Antonio, TX, 78229, USA
| | - Rama R Sriram
- Division of Foodborne, Waterborne and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, 30329, USA
| | - Thomas P C Dorlo
- Department of Pharmacy and Pharmacology, Slotervaart Hospital-The Netherlands Cancer Institute, 1066 EC, Amsterdam, The Netherlands.,Utrecht Institute for Pharmaceutical Sciences, Utrecht University, PO Box 80082, Utrecht, The Netherlands
| | - Teresa Hayes
- Department of Pathology, Methodist Hospital, San Antonio, TX, 78229, USA
| | - Yvonne Qvarnstrom
- Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, 30329, USA
| | - Zuzana Kucerova
- Division of Foodborne, Waterborne and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, 30329, USA
| | - B Joseph Guglielmo
- Department of Clinical Pharmacy, School of Pharmacy, University of California, San Francisco, San Francisco, CA, 94143, USA
| | - Govinda S Visvesvara
- Division of Foodborne, Waterborne and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, 30329, USA
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Wilson MR, Shanbhag NM, Reid MJ, Singhal NS, Gelfand JM, Sample HA, Benkli B, O'Donovan BD, Ali IKM, Keating MK, Dunnebacke TH, Wood MD, Bollen A, DeRisi JL. Diagnosing Balamuthia mandrillaris Encephalitis With Metagenomic Deep Sequencing. Ann Neurol 2015; 78:722-30. [PMID: 26290222 PMCID: PMC4624031 DOI: 10.1002/ana.24499] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 07/18/2015] [Accepted: 08/02/2015] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Identification of a particular cause of meningoencephalitis can be challenging owing to the myriad bacteria, viruses, fungi, and parasites that can produce overlapping clinical phenotypes, frequently delaying diagnosis and therapy. Metagenomic deep sequencing (MDS) approaches to infectious disease diagnostics are known for their ability to identify unusual or novel viruses and thus are well suited for investigating possible etiologies of meningoencephalitis. METHODS We present the case of a 74-year-old woman with endophthalmitis followed by meningoencephalitis. MDS of her cerebrospinal fluid (CSF) was performed to identify an infectious agent. RESULTS Sequences aligning to Balamuthia mandrillaris ribosomal RNA genes were identified in the CSF by MDS. Polymerase chain reaction subsequently confirmed the presence of B. mandrillaris in CSF, brain tissue, and vitreous fluid from the patient's infected eye. B. mandrillaris serology and immunohistochemistry for free-living amoebas on the brain biopsy tissue were positive. INTERPRETATION The diagnosis was made using MDS after the patient had been hospitalized for several weeks and subjected to costly and invasive testing. MDS is a powerful diagnostic tool with the potential for rapid and unbiased pathogen identification leading to early therapeutic targeting.
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Affiliation(s)
- Michael R Wilson
- Department of Biochemistry and Biophysics, University of California, San Francisco, CA.,Department of Neurology, University of California, San Francisco, CA
| | - Niraj M Shanbhag
- Department of Neurology, University of California, San Francisco, CA
| | - Michael J Reid
- Department of Medicine, Division of Infectious Diseases, University of California, San Francisco, CA
| | - Neel S Singhal
- Department of Neurology, University of California, San Francisco, CA
| | - Jeffrey M Gelfand
- Department of Neurology, University of California, San Francisco, CA
| | - Hannah A Sample
- Department of Neurology, University of California, San Francisco, CA
| | | | - Brian D O'Donovan
- Department of Biochemistry and Biophysics, University of California, San Francisco, CA
| | - Ibne K M Ali
- Free-Living and Intestinal Amebas Laboratory, Centers for Disease Control and Prevention, Atlanta, GA
| | - M Kelly Keating
- Infectious Diseases Pathology Branch, Centers for Disease Control and Prevention, Atlanta, GA
| | - Thelma H Dunnebacke
- California Department of Public Health, Viral and Rickettsial Disease Laboratory, Richmond, CA
| | - Matthew D Wood
- Department of Pathology, Division of Neuropathology, University of California, San Francisco, CA
| | - Andrew Bollen
- Department of Pathology, Division of Neuropathology, University of California, San Francisco, CA
| | - Joseph L DeRisi
- Department of Biochemistry and Biophysics, University of California, San Francisco, CA.,Howard Hughes Medical Institute, Chevy Chase, MD
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Parija SC, Dinoop K, Venugopal H. Management of granulomatous amebic encephalitis: Laboratory diagnosis and treatment. Trop Parasitol 2015; 5:23-8. [PMID: 25709949 PMCID: PMC4326989 DOI: 10.4103/2229-5070.149889] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 01/22/2015] [Indexed: 11/04/2022] Open
Abstract
Granulomatous amebic encephalitis is a life-threatening central nervous system (CNS) infection caused by the free-living amoebae Acanthamoeba spp., Balamuthia mandrillaris and Sappinia pedata. The disease has a subacute to chronic onset affecting commonly the immunocompromised population with high mortality rate. The diagnosis of this disease entity requires high suspicion with appropriate sample collection and testing by the laboratory experts. Radiological investigations are nonspecific and commonly confused with CNS tuberculosis, neurocysticercosis, disseminated encephalomyelitis, viral encephalitis etc., delaying the accurate diagnosis of these cases. Early diagnosis plays a crucial role in the survival of these cases since appropriate management can be initiated. No single drug is effective; hence multiple antibiotics targeting various proteins or receptors are required for successful treatment. A combination of surgical and medical interventions involving multiple specialty experts is required to prevent death and morbidity in survivors.
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Affiliation(s)
- Subhash Chandra Parija
- Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Kp Dinoop
- Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Hrudya Venugopal
- Department of General Medicine, Coimbatore Medical College Hospital, Coimbatore, Tamil Nadu, India
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8
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Acanthamoeba encephalitis: isolation of genotype T1 in mycobacterial liquid culture medium. J Clin Microbiol 2014; 53:735-9. [PMID: 25502534 DOI: 10.1128/jcm.02887-14] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
We report a case of Acanthamoeba encephalitis diagnosed from an antemortem brain biopsy specimen, where the organism was first isolated in mycobacterial liquid medium and first identified by using a sequence generated by a commercial panfungal sequencing assay. We correlate susceptibility results with clinical outcome.
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9
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Kiderlen AF, Radam E, Laube U, Martínez AJ. Resistance to Intranasal Infection with Balamuthia mandrillaris
Amebae is T-Cell Dependent. J Eukaryot Microbiol 2014; 62:26-33. [DOI: 10.1111/jeu.12189] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Revised: 08/19/2014] [Accepted: 08/30/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Albrecht F. Kiderlen
- Division for Mycotic, Parasitic and Mycobacterial Infections; Robert Koch Institute; Nordufer 20 13353 Berlin Germany
| | - Elke Radam
- Division for Mycotic, Parasitic and Mycobacterial Infections; Robert Koch Institute; Nordufer 20 13353 Berlin Germany
| | - Ulrike Laube
- Division for Mycotic, Parasitic and Mycobacterial Infections; Robert Koch Institute; Nordufer 20 13353 Berlin Germany
| | - A. Julio Martínez
- Department of Pathology; Presbyterian Hospital and University of Pittsburgh School of Medicine; Pittsburgh Pennsylvania 15231 USA
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10
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Balamuthia mandrillaris: een beestachtige doodsoorzaak. Crit Care 2014. [DOI: 10.1007/s12426-014-0093-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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11
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Cabello-Vílchez AM, Rodríguez-Zaragoza S, Piñero J, Valladares B, Lorenzo-Morales J. Balamuthia mandrillaris in South America: an emerging potential hidden pathogen in Perú. Exp Parasitol 2014; 145 Suppl:S10-9. [PMID: 24858923 DOI: 10.1016/j.exppara.2014.05.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Revised: 05/07/2014] [Accepted: 05/13/2014] [Indexed: 11/19/2022]
Abstract
Balamuthia mandrillaris is a free living amoeba that can be isolated from soil. It is an emerging pathogen causing skin lesions as well as CNS involvement with a fatal outcome if untreated. Further, infections can sometimes can also appear in peripheral areas such as extremities (usually knee), or trunk. Moreover, it often progresses to an infiltrative lesion that occasionally becomes ulcerated. In countries like Peru, a skin lesion will precede other symptoms. This primary cutaneous lesion can be present for weeks or even months. However, the appearance of neurological disease predicts a poor prognosis. Diagnosis requires a high level of suspicion.
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Affiliation(s)
- Alfonso M Cabello-Vílchez
- Laboratorio de Microbiología Clínica, Instituto de Medicina Tropical "Alexander Von Humboldt" Universidad Peruana Cayetano Heredia, Av. Honorio Delgado N°430, San Martín de Porras, Lima, Peru; University Institute of Tropical Diseases and Public Health of the Canary Islands, University of La Laguna, La Laguna, Tenerife, Canary Islands, Spain.
| | - Salvador Rodríguez-Zaragoza
- Laboratorio de Microbiología de la Unidad de Tecnología de Biología y Prototipos, Facultad de Estudios Superiores Iztacala, UNAM, Mexico City, Mexico
| | - José Piñero
- University Institute of Tropical Diseases and Public Health of the Canary Islands, University of La Laguna, La Laguna, Tenerife, Canary Islands, Spain
| | - Basilio Valladares
- University Institute of Tropical Diseases and Public Health of the Canary Islands, University of La Laguna, La Laguna, Tenerife, Canary Islands, Spain
| | - Jacob Lorenzo-Morales
- University Institute of Tropical Diseases and Public Health of the Canary Islands, University of La Laguna, La Laguna, Tenerife, Canary Islands, Spain
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12
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Bravo FG, Seas C. Balamuthia Mandrillaris Amoebic Encephalitis: An Emerging Parasitic Infection. Curr Infect Dis Rep 2012; 14:391-6. [DOI: 10.1007/s11908-012-0266-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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13
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Balamuthia mandrillaris infection of the skin and central nervous system: an emerging disease of concern to many specialties in medicine. Curr Opin Infect Dis 2011; 24:112-7. [DOI: 10.1097/qco.0b013e3283428d1e] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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14
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Doyle JS, Campbell E, Fuller A, Spelman DW, Cameron R, Malham G, Gin D, Lewin SR. Balamuthia mandrillaris brain abscess successfully treated with complete surgical excision and prolonged combination antimicrobial therapy. J Neurosurg 2011; 114:458-62. [DOI: 10.3171/2010.10.jns10677] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Amoebic encephalitis is an uncommon and usually fatal condition. This case describes successful treatment of a Balamuthia mandrillaris brain abscess using prolonged antimicrobial agents with complete excision. It illustrates the risk of dissemination from cutaneous to cerebral amoebic lesions, potential progression with corticosteroid therapy, and the prospect for curative excision.
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Affiliation(s)
| | | | | | | | | | | | | | - Sharon R. Lewin
- 1Infectious Diseases Unit and
- 6Department of Medicine, Monash University; and
- 7Burnet Institute, Melbourne, Victoria, Australia
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Hodge PJ, Kelers K, Gasser RB, Visvesvara GS, Martig S, Long SN. Another case of canine amoebic meningoencephalitis—the challenges of reaching a rapid diagnosis. Parasitol Res 2010; 108:1069-73. [DOI: 10.1007/s00436-010-2197-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2010] [Accepted: 11/26/2010] [Indexed: 10/18/2022]
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Barratt JLN, Harkness J, Marriott D, Ellis JT, Stark D. Importance of nonenteric protozoan infections in immunocompromised people. Clin Microbiol Rev 2010; 23:795-836. [PMID: 20930074 PMCID: PMC2952979 DOI: 10.1128/cmr.00001-10] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
There are many neglected nonenteric protozoa able to cause serious morbidity and mortality in humans, particularly in the developing world. Diseases caused by certain protozoa are often more severe in the presence of HIV. While information regarding neglected tropical diseases caused by trypanosomatids and Plasmodium is abundant, these protozoa are often not a first consideration in Western countries where they are not endemic. As such, diagnostics may not be available in these regions. Due to global travel and immigration, this has become an increasing problem. Inversely, in certain parts of the world (particularly sub-Saharan Africa), the HIV problem is so severe that diseases like microsporidiosis and toxoplasmosis are common. In Western countries, due to the availability of highly active antiretroviral therapy (HAART), these diseases are infrequently encountered. While free-living amoebae are rarely encountered in a clinical setting, when infections do occur, they are often fatal. Rapid diagnosis and treatment are essential to the survival of patients infected with these organisms. This paper reviews information on the diagnosis and treatment of nonenteric protozoal diseases in immunocompromised people, with a focus on patients infected with HIV. The nonenteric microsporidia, some trypanosomatids, Toxoplasma spp., Neospora spp., some free-living amoebae, Plasmodium spp., and Babesia spp. are discussed.
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Affiliation(s)
- J L N Barratt
- Department of Microbiology, St. Vincent's Hospital, Darlinghurst 2010, NSW, Australia.
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Diagnosis of infections caused by pathogenic free-living amoebae. Interdiscip Perspect Infect Dis 2009; 2009:251406. [PMID: 19657454 PMCID: PMC2719787 DOI: 10.1155/2009/251406] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2009] [Accepted: 06/05/2009] [Indexed: 11/23/2022] Open
Abstract
Naegleria fowleri, Acanthamoeba spp., Balamuthia mandrillaris, and Sappinia sp. are pathogenic free-living amoebae. N. fowleri causes Primary Amoebic Meningoencephalitis, a rapidly fatal disease of the central nervous system, while Acanthamoeba spp. and B. mandrillaris cause chronic granulomatous encephalitis. Acanthamoeba spp. also can cause cutaneous lesions and Amoebic Keratitis, a sight-threatening infection of the cornea that is associated with contact lens use or corneal trauma. Sappinia pedata has been identified as the cause of a nonlethal case of amoebic encephalitis. In view of the potential health consequences due to infection with these amoebae, rapid diagnosis is critical for early treatment. Microscopic examination and culture of biopsy specimens, cerebral spinal fluid (CSF), and corneal scrapings have been used in the clinical laboratory. For amoebic keratitis, confocal microscopy has been used to successfully identify amoebae in corneal tissue. More recently, conventional and real-time PCR assays have been developed that are sensitive and specific for the amoebae. In addition, multiplex PCR assays are available for the rapid identification of these pathogens in biopsy tissue, CSF, and corneal specimens.
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18
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Lupi O, Bartlett BL, Haugen RN, Dy LC, Sethi A, Klaus SN, Machado Pinto J, Bravo F, Tyring SK. Tropical dermatology: Tropical diseases caused by protozoa. J Am Acad Dermatol 2009; 60:897-925; quiz 926-8. [PMID: 19467364 DOI: 10.1016/j.jaad.2009.03.004] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2008] [Revised: 10/05/2008] [Accepted: 03/07/2009] [Indexed: 11/18/2022]
Abstract
UNLABELLED Protozoan infections are very common among tropical countries and have an important impact on public health. Leishmaniasis is the most widely disseminated protozoan infection in the world, while the trypanosomiases are widespread in both Africa and South America. Amebiasis, a less common protozoal infection, is a cause of significant morbidity in some regions. Toxoplasmosis and pneumocystosis (formerly thought to be caused by a protozoan) are worldwide parasitic infections with a very high incidence in immunocompromised patients but are not restricted to them. In the past, most protozoan infections were restricted to specific geographic areas and natural reservoirs. There are cases in which people from other regions may have come in contact with these pathogens. A common situation involves an accidental contamination of a traveler, tourist, soldier, or worker that has contact with a reservoir that contains the infection. Protozoan infections can be transmitted by arthropods, such as sandflies in the case of leishmaniasis or bugs in the case of trypanosomiases. Vertebrates also serve as vectors as in the case of toxoplasmosis and its transmission by domestic cats. The recognition of the clinical symptoms and the dermatologic findings of these diseases, and a knowledge of the geographic distribution of the pathogen, can be critical in making the diagnosis of a protozoan infection. LEARNING OBJECTIVES After completing this learning activity, participants should be able to recognize the significance of protozoan infections worldwide, identify the dermatologic manifestations of protozoan infections, and select the best treatment for the patient with a protozoan infection.
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Affiliation(s)
- Omar Lupi
- Department of Dermatology at Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
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19
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Abstract
Balamuthia mandrillaris is an emerging protozoan parasite, an agent of granulomatous amoebic encephalitis involving the central nervous system, with a case fatality rate of >98%. This review presents our current understanding of Balamuthia infections, their pathogenesis and pathophysiology, and molecular mechanisms associated with the disease, as well as virulence traits of Balamuthia that may be potential targets for therapeutic interventions and/or for the development of preventative measures.
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20
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Fatal amebic encephalitis caused by Balamuthia mandrillaris in an immunocompetent host. Ann Diagn Pathol 2007; 11:440-7. [DOI: 10.1016/j.anndiagpath.2006.04.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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21
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Abstract
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.
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Affiliation(s)
- Maria T Perez
- Department of Pathology, JFK Medical Center, 5301 S. Congress Avenue, Atlantis, FL 33462, USA.
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22
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Valverde J, Arrese JE, Piérard GE. Granulomatous cutaneous centrofacial and meningocerebral amebiasis. Am J Clin Dermatol 2006; 7:267-9. [PMID: 16901188 DOI: 10.2165/00128071-200607040-00009] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
A 7-year-old, otherwise healthy Peruvian boy presented with a 3-month history of an indurated centrofacial plaque. Histologic examination revealed a granuloma containing free-living amebae tentatively identified as Balamuthia mandrillaris. The patient failed to respond to tentative treatment. He was admitted to the intensive care unit 7 months later with neurologic manifestations of granulomatous amebic encephalitis, which proved fatal. The difficulty in diagnosing this rare presentation of cutaneous amebiasis, the challenge of treating the condition, and the morbidity and high mortality associated with cerebral involvement are discussed.
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Affiliation(s)
- Jenny Valverde
- Department of Dermatology, Hospital Regional Docente de Trujillo, University of Trujillo, Trujillo, Peru
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23
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Kiderlen AF, Tata PS, Ozel M, Laube U, Radam E, Schäfer H. Cytopathogenicity of Balamuthia mandrillaris, an Opportunistic Causative Agent of Granulomatous Amebic Encephalitis. J Eukaryot Microbiol 2006; 53:456-63. [PMID: 17123409 DOI: 10.1111/j.1550-7408.2006.00130.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Balamuthia mandrillaris is a free-living ameba and an opportunistic agent of lethal granulomatous amebic encephalitis in humans and other mammals. Balamuthia mandrillaris is highly cytopathic but, in contrast to the related Acanthamoeba, does not feed on bacteria and seems to feed only on eukaryotic cells instead. Most likely, the cytopathogenicity of B. mandrillaris is inseparable from its infectivity and pathogenicity. To better understand the mechanisms of B. mandrillaris cytopathogenicity, an assay for measuring amebic cytolytic activity was adapted that is based on the release of a reporter enzyme by damaged target cells. The ameba is shown to lyse murine mastocytoma cells very efficiently in a time- and dose-related manner. Furthermore, experiments involving semipermeable membranes and phagocytosis inhibitors indicate that the cytolytic activity of B. mandrillaris is essentially cell contact-dependent. Standard and fluorescence light microscopy, as well as scanning and transmission electron microscopy support and extend these findings at the ultrastructural level.
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Affiliation(s)
- Albrecht F Kiderlen
- Cellular Immunology Unit P22, Robert Koch Institute, D-13353 Berlin, Germany.
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24
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Tavares M, Correia da Costa JM, Carpenter SS, Santos LA, Afonso C, Aguiar A, Pereira J, Cardoso AI, Schuster FL, Yagi S, Sriram R, Visvesvara GS. Diagnosis of first case of Balamuthia amoebic encephalitis in Portugal by immunofluorescence and PCR. J Clin Microbiol 2006; 44:2660-3. [PMID: 16825409 PMCID: PMC1489463 DOI: 10.1128/jcm.00479-06] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We report here the first Portuguese case of acute fatal granulomatous encephalitis attributed to Balamuthia mandrillaris, initially thought to be a brain tumor, which had a progressive and fatal outcome. Balamuthia mandrillaris is a free-living amoeba recognized as an uncommon agent of granulomatous encephalitis. Infections have been identified in immunocompromised hosts and in immunocompetent pediatric patients. Balamuthia infections are very rare, with only two reported cases in Europe. The case presented here occurred in a previously healthy boy who died 5 weeks after the onset of the symptoms. No evidence of immunological deficiency was noted, and testing for human immunodeficiency virus antibodies was negative. The symptoms were initially thought to be the result of a tumor, but histopathologic examination showed evidence of amoebic infection. Immunofluorescence staining of brain tissue identified B. mandrillaris as the infectious agent. The diagnosis was confirmed with PCR by detecting Balamuthia DNA in formalin-fixed brain tissue sections. Despite initiation of empirical antimicrobial therapy for balamuthiasis, the patient died 3 weeks after being admitted to the hospital. No source of infection was readily apparent.
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Affiliation(s)
- Marta Tavares
- Department of Pediatrics, Hospital de S. João, Porto, Portugal
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25
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Finnin PJ, Visvesvara GS, Campbell BE, Fry DR, Gasser RB. Multifocal Balamuthia mandrillaris infection in a dog in Australia. Parasitol Res 2006; 100:423-6. [PMID: 17033842 DOI: 10.1007/s00436-006-0302-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2006] [Accepted: 08/07/2006] [Indexed: 10/24/2022]
Abstract
A 6-year-old male golden retriever, with an 8-month history of seizures and a clinical diagnosis of lymphoma in the central nervous system, was (at the owner's request) euthanized after signs of respiratory distress and shock developed. Upon postmortem examination, the diagnoses of meningoencephalitis and pneumonia were made. A histological examination of selected tissues from both the lung and central nervous system revealed a severe, acute, multifocal, amoebic, embolic pneumonia and a severe, chronic, multifocal, nonsuppurative, amoebic meningoencephalitis. Indirect immunofluorescence analysis confirmed the presence of trophozoite and cyst stages of Balamuthia mandrillaris. This is the first report of B. mandrillaris (which is a free-living amoeba) causing fatal, multifocal granulomatous amoebiasis in a dog in Australia.
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Affiliation(s)
- Peter J Finnin
- Department of Veterinary Science, The University of Melbourne, Werribee, Victoria, Australia
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26
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Jayasekera S, Sissons J, Tucker J, Rogers C, Nolder D, Warhurst D, Alsam S, White JML, Higgins EM, Khan NA. Post-mortem culture of Balamuthia mandrillaris from the brain and cerebrospinal fluid of a case of granulomatous amoebic meningoencephalitis, using human brain microvascular endothelial cells. J Med Microbiol 2004; 53:1007-1012. [PMID: 15358823 DOI: 10.1099/jmm.0.45721-0] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The first isolation in the UK of Balamuthia mandrillaris amoebae from a fatal case of granulomatous amoebic meningoencephalitis is reported. Using primary cultures of human brain microvascular endothelial cells (HBMECs), amoebae were isolated from the brain and cerebrospinal fluid (CSF). The cultures showed a cytopathic effect at 20-28 days, but morphologically identifiable B. mandrillaris amoebae were seen in cleared plaques in subcultures at 45 days. The identification of the organism was later confirmed using PCR on Chelex-treated extracts. Serum taken while the patient was still alive reacted strongly with slide antigen prepared from cultures of the post-mortem isolate, and also with those from a baboon B. mandrillaris strain at 1:10,000 in indirect immunofluorescence, but with Acanthamoeba castellanii (Neff) at 1:160, supporting B. mandrillaris to be the causative agent. If the presence of amoebae in the post-mortem CSF reflects the condition in life, PCR studies on CSF and on biopsies of cutaneous lesions may also be a valuable tool. The role of HBMECs in understanding the interactions of B. mandrillaris with the blood-brain barrier is discussed.
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Affiliation(s)
- Samantha Jayasekera
- School of Biological and Chemical Sciences, Birkbeck College University of London, London WC1E 7HX, UK 2Diagnostic Parasitology Laboratory, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK 3Department of Dermatology, King's College Hospital, London, UK
| | - James Sissons
- School of Biological and Chemical Sciences, Birkbeck College University of London, London WC1E 7HX, UK 2Diagnostic Parasitology Laboratory, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK 3Department of Dermatology, King's College Hospital, London, UK
| | - Julie Tucker
- School of Biological and Chemical Sciences, Birkbeck College University of London, London WC1E 7HX, UK 2Diagnostic Parasitology Laboratory, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK 3Department of Dermatology, King's College Hospital, London, UK
| | - Claire Rogers
- School of Biological and Chemical Sciences, Birkbeck College University of London, London WC1E 7HX, UK 2Diagnostic Parasitology Laboratory, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK 3Department of Dermatology, King's College Hospital, London, UK
| | - Debbie Nolder
- School of Biological and Chemical Sciences, Birkbeck College University of London, London WC1E 7HX, UK 2Diagnostic Parasitology Laboratory, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK 3Department of Dermatology, King's College Hospital, London, UK
| | - David Warhurst
- School of Biological and Chemical Sciences, Birkbeck College University of London, London WC1E 7HX, UK 2Diagnostic Parasitology Laboratory, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK 3Department of Dermatology, King's College Hospital, London, UK
| | - Selwa Alsam
- School of Biological and Chemical Sciences, Birkbeck College University of London, London WC1E 7HX, UK 2Diagnostic Parasitology Laboratory, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK 3Department of Dermatology, King's College Hospital, London, UK
| | - Jonathan M L White
- School of Biological and Chemical Sciences, Birkbeck College University of London, London WC1E 7HX, UK 2Diagnostic Parasitology Laboratory, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK 3Department of Dermatology, King's College Hospital, London, UK
| | - E M Higgins
- School of Biological and Chemical Sciences, Birkbeck College University of London, London WC1E 7HX, UK 2Diagnostic Parasitology Laboratory, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK 3Department of Dermatology, King's College Hospital, London, UK
| | - Naveed Ahmed Khan
- School of Biological and Chemical Sciences, Birkbeck College University of London, London WC1E 7HX, UK 2Diagnostic Parasitology Laboratory, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK 3Department of Dermatology, King's College Hospital, London, UK
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27
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Pritzker AS, Kim BK, Agrawal D, Southern PM, Pandya AG. Fatal granulomatous amebic encephalitis caused by Balamuthia mandrillaris presenting as a skin lesion. J Am Acad Dermatol 2004; 50:S38-41. [PMID: 14726864 DOI: 10.1016/s0190-9622(03)02090-5] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Granulomatous amebic encephalitis is an uncommon central nervous system (CNS) infection, usually caused by Acanthamoeba spp., which generally occurs in immunocompromised individuals. Balamuthia mandrillaris is a recently described free-living ameba that occasionally causes fatal CNS disease. The infection might start from a minor, slowly progressive, skin ulceration that can be present for weeks to months before neurologic changes occur. The clinical and histologic presentation is easily confused with many other diseases. Accurate diagnosis requires an awareness of this unusual presentation of amebiasis and identification of the amebic trophozoites in tissue and culture. Special stains are helpful, but immunofluorescence assays or electron microscopy is required to identify the organism as B mandrillaris. We present a fatal case of granulomatous amebic encephalitis that began as a cutaneous infection in an immunocompetent host.
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Affiliation(s)
- Adam S Pritzker
- Department of Dermatology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9190, USA
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28
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Deetz TR, Sawyer MH, Billman G, Schuster FL, Visvesvara GS. Successful Treatment of Balamuthia Amoebic Encephalitis: Presentation of 2 Cases. Clin Infect Dis 2003; 37:1304-12. [PMID: 14583863 DOI: 10.1086/379020] [Citation(s) in RCA: 109] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2003] [Accepted: 07/08/2003] [Indexed: 11/03/2022] Open
Abstract
Case histories are presented of 2 individuals (a 5-year-old girl and 64-year-old man) who developed encephalitis caused by the free-living amoeba Balamuthia mandrillaris. Both individuals survived after diagnosis and initiation of effective antimicrobial therapy. Immunostaining for Balamuthia-specific antibody levels identified the causative agent of the infections. Antimicrobial therapy with flucytosine, pentamidine, fluconazole, sulfadiazine, and a macrolide antibiotic (azithromycin or clarithromycin) was initiated. Phenothiazines (thioridazine and trifluoperazine) were also used. Both patients recovered, and there was no evidence of recrudescence of the disease at 2 and 6 years after onset of symptoms. Awareness of Balamuthia as the causative agent of encephalitis and early initiation of antimicrobial therapy were critical to the recovery of both patients. Although optimal antimicrobial therapy for Balamuthia amoebic encephalitis has yet to be determined, the antimicrobials used in these 2 cases effectively controlled the disease. These 2 individuals are the only known survivors of this otherwise fatal type of amoebic encephalitis.
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Affiliation(s)
- Thomas R Deetz
- Infectious Diseases, Santa Cruz Medical Clinic, Santa Cruz, CA, USA
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29
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Bakardjiev A, Azimi PH, Ashouri N, Ascher DP, Janner D, Schuster FL, Visvesvara GS, Glaser C. Amebic encephalitis caused by Balamuthia mandrillaris: report of four cases. Pediatr Infect Dis J 2003; 22:447-53. [PMID: 12792389 DOI: 10.1097/01.inf.0000066540.18671.f8] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
We report four fatal cases of amebic encephalitis in children caused by the free-living pathogenic ameba Balamuthia mandrillaris. The clinical course ranged from subacute to fulminant. Provisional diagnoses were made either shortly before death or postmortem by an indirect immunofluorescent antibody test. Although the four cases occurred in different geographic locations, their common features may have diagnostic value for recognizing future cases of amebic encephalitis. The cases occurred in children 2 to 7.5 years old who were ostensibly immunocompetent and of Hispanic ethnicity. Three of the four children developed hydrocephalus during their illness. Increased awareness and timely diagnosis of this disease entity might lead to earlier intervention with improved outcome.
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30
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Affiliation(s)
- A J Martínez
- University of Pittsburgh, School of Medicine, Neuropathology Division, PA, USA.
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31
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Knoblock RJ, Townsend JJ, Klatt EC. Pathologic quiz case. Fatal central nervous system lesions in an immunosuppressed patient. Disseminated amebiasis. Arch Pathol Lab Med 2002; 126:1247-9. [PMID: 12385335 DOI: 10.5858/2002-126-1247-pqcfcn] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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32
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Kodet R, Nohýnková E, Tichý M, Soukup J, Visvesvara GS. Amebic encephalitis caused by Balamuthia mandrillaris in a Czech child: description of the first case from Europe. Pathol Res Pract 1998; 194:423-9. [PMID: 9689651 DOI: 10.1016/s0344-0338(98)80033-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
We describe a fatal case of amebic encephalitis caused by Balamuthia mandrillaris in a 3-year-old Czech boy who had never traveled abroad. This is the first such infection reported in Europe. The diagnosis was established by brain biopsy, in which abundant trophozoites and a few round amebic cysts were identified. The presence of multiple nucleoli in some trophozoites suggested the organism to be Balamuthia mandrillaris and this was confirmed by indirect immunofluorescence. The amebae invaded brain tissue, including neurons, and blood vessel walls, causing thrombovasculitis. The tissue reaction was a subacute necrotizing and granulomatous encephalitis (GAE) with an infiltrate of CD4- and CD8-positive T-lymphocytes, B-lymphocytes, plasma cells and macrophages. The child, in whom no underlying immunodeficiency was demonstrated, died after 45 days. The mode of infection was not established. Postmortem examination of the brain revealed massive areas of necrosis and microscopic findings like those in the surgical specimen. In vitro isolation of B. mandrillaris was unsuccessful.
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Affiliation(s)
- R Kodet
- Department of Anatomic Pathology, 2nd Medical School, Prague, Czech Republic
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