Acanthamoeba meningoencephalitis causing secondary hemophagocytic lymphohistiocytosis in an immunocompetent patient: A first case report.

Acanthamoeba is a rare cause of granulomatous amoebic encephalitis (GAE) associated with high mortality. There have been few case reports of Acanthamoeba meningoencephalitis worldwide. Hemophagocytic lymphohistiocytosis (HLH) is a severe hyperinflammatory condition caused by abnormally active macrophages and cytotoxic T lymphocytes; its secondary form is due to infections or malignancies. However, HLH is rather an unknown complication of GAE. We describe an unusual and previously unreported case of Acanthamoeba meningoencephalitis in a young immunocompetent female culminating in secondary HLH.

Lethal outcome of granulomatous acanthamoebic encephalitis in a man who was human immunodeficiency virus-positive: a case report.

BACKGROUND: Acanthamoeba species can cause disseminating infections in immunocompromised individuals. CASE PRESENTATION: Here, we report a case of granulomatous acanthamoebic encephalitis with a lethal outcome in a 54-year-old German man who was human immunodeficiency virus-positive. The diagnosis was based on symptoms of progressive neurological deficits, including sensorimotor paralysis of his right leg and deteriorating alertness. Due to the rapid course and rather late diagnosis of the infection, effective treatment could not be applied and he died 12 days after hospital admission. CONCLUSIONS: To the best of our knowledge, this is the second case of granulomatous acanthamoebic encephalitis reported within Germany. Our case highlights the importance of early diagnosis of granulomatous acanthamoebic encephalitis to prevent fatal outcome.

A case report: primary amoebic meningoencephalitis in a young Zambian adult.

BACKGROUND: Primary amoebic meningoencephalitis (PAM) is a fulminant disease of the brain caused by Naegleria fowleri. Although the disease is rare, the case fatality rate is very high. In this report, we describe the first case of PAM in Zambia. CASE PRESENTATION: The patient presented with sudden onset of seizures and fever on admission. On physical examination he was febrile, comatose and with a stiff neck. Cerebral spinal fluid (CSF) collected on admission did not reveal any organism on microscopy or culture but showed elevated white cell count. A working diagnosis of severe septicemia with acute meningoencephalitis was then made and the patient was started on IV Cephtriaxone (2 g) twice daily. Despite receiving treatment, his condition deteriorated. A second CSF sample collected on day 3 was also negative for bacteria and other organisms. However, a repeat CSF sample collected on day 8 revealed numerous motile organisms that were identified as Naegleria on microscopy and confirmed to be N. fowleri on polymerase chain reaction. The patient died on day 8 of hospital admission after having received one dose of Amphotericin B (50 mg). Features consistent with PAM were detected on autopsy. CONCLUSION: The isolation of N. fowleri in this patient calls for increased awareness among clinical and laboratory staff on suspected PAM cases to promptly diagnose and effectively manage the disease.

Naegleria fowleri: Diagnosis, Pathophysiology of Brain Inflammation, and Antimicrobial Treatments.

Primary amoebic meningoencephalitis (PAM) is a very rare disease with a high mortality rate. PAM is caused by Naegleria fowleri, an amoeba which resides in freshwater lakes and ponds and can survive in inadequately chlorinated pools ( Lopez, C.; Budge, P.; Chen, J., et al. Primary amebic meningoencephalitis: a case report and literature review . Pediatr. Emerg. Care 2012 , 28 , 272 - 276 ). In the past 50 years, there have been over 130 cases of Naegleria induced PAM in the United States with only three known survivors; one survivor was diagnosed and treated at Arkansas Children's Hospital. Successful treatment of PAM started with a rapid diagnosis, extensive antimicrobial therapy including an investigational medication miltefosine, supportive care, an intraventricular shunt, and hypothermia. These treatments address different aspects of the disease process. Increased understanding of the diagnosis and treatment of PAM is important especially for patients who present with meningitis-like findings during the summer months.

Primary Amoebic Meningoencephalitis.

Primary amoebic meningoencephalitis due to free living amoeba, also called 'brain eating amoeba', Naegleria fowleri, was detected in retroviral disease patient of 40 years who has history of using well water. Patient was admitted with severe headache, fever intermittent, nausea, vomiting and slurring of speech. CT scan and MRI scan findings were normal. CSF examination showed increased protein, low sugar and predominant lymphocytes. CSF was negative for cryptococcal antigen but wet mount preparation showed highly motile free living amoeba Naegleria fowleri. Patient was put on Amphotericin B, Metronidazole, Rifampicin in addition to ART and ATT and other supportive medications. His headache was relieved and patient improved and was discharged on request. Earlier eight cases have been reported from India of which four cases survived the acute episode.

An autopsy case of Balamuthia mandrillaris amoebic encephalitis, a rare emerging infectious disease, with a brief review of the cases reported in Japan.

Balamuthia mandrillaris is an amoeba found in fresh water and soil that causes granulomatous amoebic encephalitis. We report herein an autopsy case of B. mandrillaris amoebic encephalitis, which was definitely diagnosed by PCR. An 81-year-old man, who had Sjögren's syndrome, manifested drowsiness 2 months before his death with progressive deterioration. Neuroimaging demonstrated foci of T2- and fluid-attenuated inversion recovery high and T1 low-intensity with irregular post-contrast ring enhancement in the cerebral hemisphere, thalamus and midbrain. Pathologically, multiple hemorrhagic and necrotic lesions were found in the cerebrum, thalamus, midbrain, pons, medulla and cerebellum, which were characterized by liquefactive necrosis, marked edema, hemorrhage and necrotizing vasculitis associated with the perivascular accumulation of amoebic trophozoites, a few cysts, and the infiltration of numerous neutrophils and microglia/macrophages. The trophozoites were ovoid or round, 10-60 µm in diameter, and they showed foamy cytoplasm and a round nucleus with small karyosome in the center. The PCR and immunohistochemistry from paraffin-embedded brain specimens revealed angioinvasive encephalitis due to B. mandrillaris. Human cases of B. mandrillaris brain infection are rare in Japan, with only a few brief reports in the literature.

A new clinical variant of the post-malaria neurological syndrome.

Post-malaria neurological syndrome (PMNS) is an uncommon, monophasic illness that occurs within two months following recovery from Plasmodium falciparum (Pf) malaria. Clinical manifestations of PMNS are variable, but published cases uniformly feature neurological and/or psychiatric symptoms without long tract signs. We describe a case of severe brainstem and spinal cord inflammation with paraplegia and sphincter involvement in a 48 year old woman following recovery from a Pf malarial illness. We propose that this case represents a previously unreported form of PMNS, which has features that distinguish it from acute disseminated encephalomyelitis, and that the recognised clinical spectrum of PMNS should be extended to include brainstem and spinal cord inflammation.

Co-infection of HIV and tropical infectious agents that affect the nervous system.

Tropical infections refer to a group of diseases usually located in regions with a warm climate, particularly affecting developing countries, partly because of the conditions that allow them to thrive. However, due to the increased international travel, infectious agents that were previously limited to tropical regions pose an increasing threat to populations at risk for opportunistic infection (OI), especially those infected with the HIV. Tropical infections can facilitate HIV transmission and accelerate the progression of asymptomatic HIV infection to AIDS. Some have the potential to alter the epidemiology, natural history, and/or response to treatment of the other. The introduction of highly active antiretroviral therapy has provided a huge benefit for the vast majority of patients infected with the HIV, by allowing the immune system to recover, improving the clinical and radiological results and reducing the number of OI. On the other hand, some patients have developed various disorders of immune reconstitution, resulting in either hyper-immune inflammatory response to an exogenous antigen or autoimmunity. A significant proportion of these cases have been reported in immigrants from tropical countries to high-income countries, therefore awareness of these phenomena is needed since clinical presentations are often atypical and pose diagnostic challenges. This article reviews some of the key diagnostic aspects of tropical infections associated with HIV infection.

Balamuthia mandrillaris and Acanthamoeba amebic encephalitis with neurotoxoplasmosis coinfection in a patient with advanced HIV infection.

We describe a patient with advanced HIV infection and Balamuthia mandrillaris and Acanthamoeba amebic encephalitis with Toxoplasma gondii coinfection. A multidisciplinary effort and state-of-the-art diagnostic techniques were required for diagnosis. Our patient is the first reported case of an HIV-infected person with dual Balamuthia mandrillaris and Acanthamoeba amebic encephalitis with neurotoxoplasmosis coinfection.

Hallazgo de acanthamoeba spp en biopsia cerebral de un paciente con adenocarcinoma metastásico / Acanthamoeba spp found in a cerebral biopsy from a patient with metastasic adenocarcinoma

Las amibas de vida libre (AVL) del género Acanthamoeba son parásitos facultativos ampliamente distribuidos en el ambiente, por lo cual el contacto del humano con ellos es frecuente, sin embargo, los reportes de enfermedades producidas por AVL son escasos. La gravedad de éstas justifica su búsqueda, sobre todo cuando la infección es del sistema nervioso central (SNC) y cuando hay compromiso in munológico. En este trabajo se reporta el hallazgo de Acanthamoeba spp en una biopsia cerebral, tomada a un paciente de 44 años de edad con adenocarcinoma. Se exa minó la muestra bajo el protocolo del Laboratorio de Amibiasis, de la Cátedra de Parasitología, Escuela de Bioanálisis, Facultad de Medicina, Universidad Central de Venezuela, para la investigación de AVL y Entamoeba histolytica. Se realizó examen directo y coloraciones especiales, inducción de la flagelación y cultivos a diferentes temperaturas. Se observó crecimiento de Acanthamoeba spp en el medio de Page modificado por Chinchilla y col. (1979), incubado a 37 °C a las 96 horas. La descripción morfológica coincide con la morfología del grupo 3 de Acanthamoeba, según Visvesvara (1991). Se destaca la importancia de la realización del cultivo para el crecimiento e identificación de estos organismos en aquellos laboratorios donde los métodos basados en biología molecular aun no se hayan implementado como parte del diagnóstico y así aplicar el tratamiento oportuno y específico al paciente.

Free-living amoebas (FLA) of genus Acanthamoeba are parasitic facultative organisms whose are widely distributed in the environment, thus the human contact with them is frequent; nevertheless, there are few reports of diseases produced by FLA. The severity of these diseases justifies its re search, mainly when the infection is at central nervous system (CNS) and when there is an immunocompromised host. This work reports the finding of Acanthamoeba spp in a cerebral biopsy from a 44 year-old patient with adenocarcinoma. We followed the protocol established by the Amibiasis Laboratory, Parasitology Chair, School of Bioanalisis, Medicine Faculty, Central University of Venezuela, for the investigation of FLA and Entamoeba histolytica. It wasmade by direct examination of the sample and special stains, flagellation induction and cultures incubated at different temperatures. We observed Acanthamoeba spp growth in biphasic Page media modified by Chinchilla and col. (1979), incubated for 96 hours at 37 °C. The morphologic des cription agrees with the morphology of group 3 of Acanthamoeba, according to Visvesvara (1991). We emphasize the importance of using growth culture for isolation and identification of these organisms in those laboratories where molecular methods has not been implemented yet as part of the diagnosis scheme and thus for applying the opportune and specific treatment to the patient.

Acanthamoeba encephalitis in patient with systemic lupus, India.

We report a fatal case of encephalitis caused by Acanthamoeba in a 24-year-old woman from India with systemic lupus erythematosus. Diagnosis was made by identification of amebas in brain sections by immunofluorescence analysis and confirmed by demonstrating Acanthamoeba mitochondrial 16S rRNA gene DNA in brain tissue sections.

Balamuthia mandrillaris meningoencephalitis in an immunocompetent patient: an unusual clinical course and a favorable outcome.

Balamuthia mandrillaris meningoencephalitis is a rare but often fatal infection; only 2 survivors have been reported to date worldwide. We report the case of an apparently immunocompetent patient (72-year-old woman) who developed several episodes of seizures without prior history of respiratory or skin infections. Magnetic resonance imaging with contrast revealed 2 ring-enhancing lesions, one in the right precentral region and the other in the left posterotemporal region. Open biopsy revealed Balamuthia encephalitis. The patient was treated with combination antibiotics (pentamidine, 300 mg intravenously once a day; sulfadiazine, 1.5 g 4 times a day; fluconazole, 400 mg once a day; and clarithromycin, 500 mg 3 times a day) and was discharged home. There have been no significant neurological sequelae at this writing (6 months after biopsy). We present this case with unusual clinical course to raise awareness of this infectious disease, which may have a more favorable outcome if diagnosed and treated in its early states.

Cerebrospinal acanthamebic granulomas. Case report.

The authors present the case of a previously healthy 26-year-old man who presented with cerebrospinal acanthamebic granulomas, and they review the literature on acanthamebic granulomas of the central nervous system (CNS). The appearance of the lesion on imaging studies suggested the presence of tuberculous granulomas, which are common in India, and antituberculosis treatment was started. Despite surgical excision of a granuloma located in the right temporoparietal region and an intramedullary granuloma at T7-8, the disease progressed and resulted in death. Unlike other cases, this patient was not immunocompromised, had no history of engaging in water activities, and had no ulcers on his body, leaving in question the mode of entry used by the ameba. Acanthamebic granulomas can cause severe infections in healthy patients as well as in sick ones. This disease should be considered in the differential diagnosis when treating infective granulomas of the CNS.

[Neurological effects of American trypanosomyiasis: clinical aspects]. / Neurotripanosomiasis americana: aspectos clínicos de un problema básico.

Trypanosoma cruzi, causative agent of Chagas disease, affects not only cardiac and intestinal structures but also neurological structures. A high prevalence of T. cruzi infection occurs in Colombia, prompting the present study. First, a qualitative metaanalysis was undertaken using the PubMed database, the electronic internet engine Altavista, Colombian journals indexed by Colciencias, and three relevant textbooks. The following key words were used: Trypanosoma, Chagas disease, nervous system, spinal cord, central nervous system, peripheral nervous system, neuromuscular junction, autonomic nervous system, muscle, muscle disorders, neuromuscular disease, neuromuscular disorders, synapticopathies and dysautonomia. The documents analyzed numbered 116 and included original papers, reviews, case reports, editorials, brief communications, conferences and book chapters. At minimum, each document included data involving ELISA testing, indirect immunofluorescense, or parasitemia levels in the clinical, serological or histopathological studies. Polymerase chain reaction (PCR) studies were not included because of the recent introduction of PCR as a confirmatory technique for Chagas disease in Colombia. Chagas disease affects the central, the peripheral and the autonomic nervous system in humans, although its effects on the antonomic system is most commonly investigated in Colombia. Neurological lesions must be evaluated carefully, because patients may be misdiagnosed and treated as carriers of 'idiopathic' diseases. Neurological pathologies poses a serious threat in Colombia due to the prevalence of Chagas disease.

An autopsy case of amebic meningoencephalitis. The first Japanese case caused by Balamuthia mandrillaris.

We report here the first case of amebic meningoencephalitis caused by Balamuthia mandrillaris in a 78-year-old Japanese woman with Sjögren's syndrome. Fourteen days before her death, she presented with high fever and lost consciousness and later developed neck stiffness and abducens palsy. Computed tomography scans of the brain demonstrated multiple low-density areas throughout the brain. Neuropathologically, hemorrhagic and necrotic lesions with many amebic trophozoites were scattered in the brain and spinal cord. Granulomatous lesions were only rarely found. The amebas were identified as Balamuthia mandrillaris based on immunofluorescence assay. Clinicopathologically, our case was thought to be an intermediate between primary amebic meningoencephalitis due to Negleria fowleri and granulomatous amebic encephalitis due to Acanthameba species. Essentially, the case was one of an elderly person with suspected immunodeficiency with fulminant necrotic meningoencephalitis and scanty granulomatous lesions of 14 days course.