Histopathology of primary amebic meningoencephalitis due to Naegleria fowleri. Direct fluorescent antibody stain.
|Classification and external resources|
Naegleriasis, also known as primary amoebic meningoencephalitis (PAM), amebic encephalitis, and naegleria infection, is an infection of the brain by the free-living protist Naegleria fowleri, also known as the "brain-eating amoeba". The term "brain-eating amoeba" has also been applied to Balamuthia mandrillaris, causing some confusion between the two, however Balamuthia mandrillaris is unrelated to Naegleria fowleri, and causes a different disease called granulomatous amoebic encephalitis, and unlike Naegleriasis, which is usually seen in people with normal immune function, granulomatous amoebic encephalitis is usually seen in people with poor immune function such as those with HIV/AIDS or leukemia.
N. fowleri is typically found in warm bodies of fresh water, such as ponds, lakes, rivers, and hot springs. It is also found in soil, poorly maintained municipal water supplies, hot water heaters, near warm-water discharges of industrial plants, and in poorly chlorinated, or unchlorinated swimming pools, in an amoeboid or temporary flagellate stage. There is no evidence of it living in salt water.
Signs and symptoms
Onset symptoms of infection can start from one to seven days after exposure. Initial symptoms include changes in taste and smell, headache, fever, nausea, vomiting, and a stiff neck. Secondary symptoms include confusion, hallucinations, lack of attention, ataxia, and seizures. After the start of symptoms, the disease progresses rapidly over three to seven days, with death occurring usually from seven to fourteen days later, although it can take longer. In 2013, a man in Taiwan died twenty five days after being infected by Naegleria fowleri.
N. fowleri invades the central nervous system via the nose, specifically through the olfactory mucosa and cribriform plate of the nasal tissues. This usually occurs as the result of the introduction of water into the nasal cavity with water that has been contaminated with N. fowleri, during activities like swimming, bathing, or nasal irrigation.
The amoeba follows the olfactory nerve fibers through the cribriform plate of the ethmoid bone into the skull. There, it migrates to the olfactory bulbs and subsequently other regions of the brain, where it feeds on the nerve tissue, resulting in significant necrosis and bleeding.
The organism then begins to consume cells of the brain, piecemeal, by means of an amoebostome, a unique actin-rich, sucking apparatus extended from its cell surface. It then becomes pathogenic, causing primary amoebic meningoencephalitis (PAM or PAME). PAM is a disease affecting the central nervous system. PAM usually occurs in healthy children or young adults with no prior history of immune compromise who have recently been exposed to bodies of fresh water.
Naegleria fowleri propagates in warm, stagnant bodies of freshwater (typically during the summer months), and enters the central nervous system after insufflation of infected water by attaching itself to the olfactory nerve. It then migrates through the cribriform plate and into the olfactory bulbs of the forebrain, where it multiplies itself greatly by feeding on nerve tissue.
N. fowleri can be grown in several kinds of liquid axenic media or on non-nutrient agar plates coated with bacteria. Escherichia coli can be used to overlay the non-nutrient agar plate and a drop of cerebrospinal fluid sediment is added to it. Plates are then incubated at 37 °C and checked daily for clearing of the agar in thin tracks, which indicate the trophozoites have fed on the bacteria. Detection in water is performed by centrifuging a water sample with E. coli added, then applying the pellet to a non-nutrient agar plate. After several days, the plate is microscopically inspected and Naegleria cysts are identified by their morphology. Final confirmation of the species' identity can be performed by various molecular or biochemical methods. Confirmation of Naegleria presence can be done by a so-called flagellation test, where the organism is exposed to a hypotonic environment (distilled water). Naegleria, in contrast to other amoebae, differentiates within two hours into the flagellate state. Pathogenicity can be further confirmed by exposure to high temperature (42 °C): Naegleria fowleri is able to grow at this temperature, but the nonpathogenic Naegleria gruberi is not.
Michael Beach, a recreational waterborne illness specialist for the Centers for Disease Control and Prevention, stated in remarks to the Associated Press that the wearing of nose-clips to prevent insufflation of contaminated water would be an effective protection against contracting PAM, noting that "You'd have to have water going way up in your nose to begin with".
Since its first description in the 1960s, only seven people worldwide have been reported to have survived PAM as of 2015, with three in the United States and one in Mexico. The prognosis remains poor for those who contract PAM, and survival remains less than 1%.
Treatment has often also used combination therapy with multiple other antibiotics in addition to amphotericin such as fluconazole, miconazole, rifampicin and azithromycin. They have shown limited success only when administered early in the course of an infection. Fluconazole is commonly used as it has been shown to have synergistic effects against naegleria when used with amphotericin in-vitro.
While the use of rifampicin has been common, including in all four North American cases of survival, its continued use has been questioned. It only has variable activity in-vitro and it has strong effects on the therapeutic levels of other antibiotics used by inducing cytochrome p450 pathways.
Steroids such as dexamethasone have also been used to try and reduce inflammation of the brain.
In 2013, the two most recent successfully treated cases in the US utilized drug combinations that included the medication miltefosine as well as targeted temperature management. There is currently no data on how well miltefosine is able to reach the central nervous system. The US CDC is currently offering miltefosine to doctors for the treatment of free-living ameobas including naegleria.
Untimely diagnoses remain a very significant impediment to the successful treatment of infection, as most cases have only been discovered post mortem. Infection killed 121 people in the United States from 1937 through 2007.
The disease is rare and highly lethal: there had been fewer than 200 confirmed cases in recorded medical history as of 2004, 300 cases as of 2008. Drug treatment research at Aga Khan University in Pakistan has shown that in-vitro drug susceptibility tests with some FDA approved drugs used for non-infectious diseases have proved to kill Naegleria fowleri with an amoebicidal rate greater than 95%. The same source has also proposed a device for drug delivery via the transcranial route to brain.
This form of nervous system infection by amoeba was first documented in Australia in 1965. In 1966, four cases were reported in the USA. By 1968 the causative organism, previously thought to be a species of Acanthamoeba or Hartmannella, was identified as Naegleria. This same year, occurrence of 16 cases over a period of two years (1963–1965) was reported in Ústí nad Labem, Czechoslovakia. In 1970, the species of amoeba was named N. fowleri.
The number of cases of infection is likely to increase as its range through climate change is increasing. Also, the numbers of reported cases are expected to show an increase, simply because of better informed diagnoses being made both in living patients and also in autopsy findings.
|Costa Rica||1 in 2014 |
|Czechoslovakia||16 from 1962-1965 |
|India||3 from 2001 to 2009 (two infants and one adult) |
|Iran||1 infant in 2012 |
|New Zealand||8 from 1968 to 1979 in geothermal water |
|Pakistan||69 from 2012 to 2014 likely from ablution |
|Taiwan||1 in 2013 from a thermal spring |
|United Kingdom||1 in 1979 in the restored Roman baths in the English city of Bath |
|United States||133 between 1962 and 2015 with most cases in the Southeast U.S.|
|Venezuela||1 in 1998 and 2 in 2006 |
Physicians M. Fowler and R. F. Carter first described human disease caused by amebo-flagellates in Australia in 1965. Their work on amebo-flagellates has provided an example of how a protozoan can effectively live both freely in the environment, and in a human host. Since 1965, more than 144 cases have been confirmed in different countries. In 1966, Fowler termed the infection resulting from N. fowleri, primary amoebic meningoencephalitis (PAM) to distinguish this central nervous system (CNS) invasion from other secondary invasions made by other amoebae such as Entamoeba histolytica. A retrospective study determined the first documented case of PAM possibly occurred in Britain in 1909.
Current research is focused on development of real time PCR diagnostic methods. One method being developed involves monitoring the amplification process in real time with fluorescent-labeled hybridization probes targeting the MpC15 sequence – which is unique to N. fowleri. Another group has multiplexed three real-time PCR reactions as a diagnostic for N. fowleri, as well as Acanthamoeba spp. and Balamuthia mandrillaris. This could prove to be an efficient diagnostic test.
As no effective treatment for PAM has been found, research to develop a therapeutic is searching for what factors, specific to N. fowleri, make it pathogenic; virulence factors may be targeted by drugs. One potential factor in motility of the "amoeba" is the protein coded by Nfa1. When the Nfa1 gene is expressed in non-pathogenic Naegleria gruberi and the amoebae are co-cultivated with target tissue cells, the protein is found to be located on the food cup which is responsible for ingestion of cells during feeding. Following up that research, Nfa1 gene expression knockdown experiments were performed using RNA interference. In these experiments, double-stranded RNA targeting the Nfa1 sequence was introduced and subsequently expression levels of the gene product dramatically decreased. This method could potentially be a technique applicable for knockdown of expression of pathogenicity factors in N. fowleri trophozoites.
- Shadrach, WS; Rydzewski, K; Laube, U; Holland, G; Ozel, M; Kiderlen, AF; Flieger, A (May 2005). "Balamuthia mandrillaris, free-living ameba and opportunistic agent of encephalitis, is a potential host for Legionella pneumophila bacteria.". Applied and environmental microbiology 71 (5): 2244–9. PMID 15870307.
- "The Centers for Disease Control and Prevention, Division of Parasitic Diseases – Naegleria fowleri - Primary Amoebic Meningoencephalitis (PAM) - General Information". Retrieved 2014-05-26.
- "6 die from brain-eating amoeba after swimming". MSNBC. Associated Press. 28 September 2007.
- Cetin N, Blackall D.Naegleria fowleri meningoencephalitis.Blood 2012 Apr 19;119(16):3658.PMID 22645743
- "CDC - 01 This Page Has Moved: CDC Parasites Naegleria". Retrieved 27 July 2015.
- Su MY, Lee MS,et al. A fatal case of Naegleria fowleri meningoencephalitis in Taiwan.Korean J Parasitol. 2013 Apr;51(2):203-6. doi: 10.3347/kjp.2013.51.2.203. Epub 2013 Apr 25. PMID 23710088
- Gautam PL, Sharma S et al. A rare case of survival from primary amebic meningoencephalitis.Indian Crit Care med.2012 Jan;16(1):34-6. doi: 10.4103/0972-5229.94432.PMID 22557831
- Marciano-Cabral, F; John, DT (1983). "Cytopathogenicity of Naegleria fowleri for rat neuroblastoma cell cultures: scanning electron microscopy study". Infection and immunity 40 (3): 1214–7. PMC 348179. PMID 6852919.
- Monsters Inside Me (2010-12-22). "Monsters Inside Me: The Brain-Eating Amoeba : Video : Animal Planet". Animal.discovery.com. Retrieved 2012-09-04.
- Centers for Disease Control and Prevention (CDC) (2008). "Primary amebic meningoencephalitis – Arizona, Florida, and Texas, 2007". MMWR. Morbidity and mortality weekly report 57 (21): 573–7. PMID 18509301.
- Centers for Disease Control and Prevention (CDC) (May 2008). "Primary amebic meningoencephalitis—Arizona, Florida, and Texas, 2007". MMWR Morb. Mortal. Wkly. Rep. 57 (21): 573–7. PMID 18509301.
- Cervantes-Sandoval I, Serrano-Luna Jde J, García-Latorre E, Tsutsumi V, Shibayama M (September 2008). "Characterization of brain inflammation during primary amoebic meningoencephalitis". Parasitol. Int. 57 (3): 307–13. doi:10.1016/j.parint.2008.01.006. PMID 18374627.
- Donald C. Lehman; Mahon, Connie; Manuselis, George (2006). Textbook of Diagnostic Microbiology (3rd ed.). Philadelphia: Saunders. ISBN 1-4160-2581-2.[page needed]
- Pougnard, C.; Catala, P.; Drocourt, J.-L.; Legastelois, S.; Pernin, P.; Pringuez, E.; Lebaron, P. (2002). "Rapid Detection and Enumeration of Naegleria fowleri in Surface Waters by Solid-Phase Cytometry". Applied and Environmental Microbiology 68 (6): 3102–7. doi:10.1128/AEM.68.6.3102-3107.2002. PMC 123984. PMID 12039772.
- "6 die from brain-eating amoeba in lakes", Chris Kahn/Associated Press, 9/28/07
- "Naegleria fowleri — Primary Amebic Meningoencephalitis (PAM) — Amebic Encephalitis". April 23, 2015. Retrieved 17 January 2016.
- Grace, Eddie; Asbill, Scott; Virga, Kris (2015-11-01). "Naegleria fowleri: Pathogenesis, Diagnosis, and Treatment Options". Antimicrobial Agents and Chemotherapy 59 (11): 6677–6681. doi:10.1128/AAC.01293-15. ISSN 0066-4804. PMC 4604384. PMID 26259797.
- Seidel, James S.; Harmatz, Paul; Visvesvara, G. S.; Cohen, Arthur; Edwards, Jack; Turner, Jerrold (1982-02-11). "Successful Treatment of Primary Amebic Meningoencephalitis". New England Journal of Medicine 306 (6): 346–348. doi:10.1056/NEJM198202113060607. ISSN 0028-4793. PMID 7054710.
- Bauman, Robert W. (2009). "Microbial Diseases of the Nervous System and Eyes". Microbiology, With Diseases by Body System (2nd ed.). San Francisco: Pearson Education. p. 617.
- Linam, W. Matthew; Ahmed, Mubbasheer; Cope, Jennifer R.; Chu, Craig; Visvesvara, Govinda S.; Silva, Alexandre J. da; Qvarnstrom, Yvonne; Green, Jerril (2015-03-01). "Successful Treatment of an Adolescent With Naegleria fowleri Primary Amebic Meningoencephalitis". Pediatrics 135 (3): e744–e748. doi:10.1542/peds.2014-2292. ISSN 0031-4005. PMC 4634363. PMID 25667249.
- Kim, J.-H.; Jung, S.-Y.; Lee, Y.-J.; Song, K.-J.; Kwon, D.; Kim, K.; Park, S.; Im, K.-I.; Shin, H.-J. (2008). "Effect of Therapeutic Chemical Agents In Vitro and on Experimental Meningoencephalitis Due to Naegleria fowleri". Antimicrobial Agents and Chemotherapy 52 (11): 4010–6. doi:10.1128/AAC.00197-08. PMC 2573150. PMID 18765686.
- Wiwanitkit V (2004). "Review of clinical presentations in Thai patients with primary amoebic meningoencephalitis". MedGenMed 6 (1): 2. PMC 1140726. PMID 15208515.
- Caruzo G, Cardozo J (October 2008). "Primary amoebic meningoencephalitis: a new case from Venezuela". Trop Doct 38 (4): 256–7. doi:10.1258/td.2008.070426. PMID 18820207.
- Abdul Mannan Baig, Huma Kulsoom, and Naveed Ahmed Khan. Primary amoebic meningoencephalitis: amoebicidal effects of clinically approved drugs against Naegleria fowleri.Journal of Medical Microbiology. 02/2014; doi:10.1099/jmm.0.072306-0
- Abdul M. Baig and Naveed A. Khan. Novel Chemotherapeutic Strategies in the Management of Primary Amoebic Meningoencephalitis Due to Naegleria fowleri. CNS Neuroscience & Therapeutics /01/2014; doi:10.1111/cns.12225
- Fowler, M.; Carter, R. F. (September 1965). "Acute pyogenic meningitis probably due to Acanthamoeba sp.: a preliminary report". British Medical Journal 2 (5464): 740–2. doi:10.1136/bmj.2.5464.734-a. PMC 1846173. PMID 5825411.
- Symmers, W. S. C. (November 1969). "Primary amoebic meningoencephalitis in Britain" (PDF). British Medical Journal 4 (5681): 449–54. doi:10.1136/bmj.4.5681.449. PMC 1630535. PMID 5354833.
- Červa, L.; Novák, K. (April 1968). "Ameobic meningoencephalitis: sixteen fatalities". Science 160 (3823): 92. doi:10.1126/science.160.3823.92. PMID 5642317.
- Gutierrez, Yezid (15 January 2000). "Chapter 6: Free Living Amebae". Diagnostic Pathology of Parasitic Infections with Clinical Correlations (2 ed.). USA: Oxford University Press. pp. 114–115. ISBN 0-19-512143-0.
- Kemble SK, Lynfield R, et al.Fatal Naegleria fowleri infection acquired in Minnesota: possible expanded range of a deadly thermophilic organism. Clin Infect Dis. 2012 Mar;54(6):805-9. doi: 10.1093/cid/cir961. Epub 2012 Jan 11.PMID 22238170
- Kanwal, Farooqi M, Ali S, Ahmed SS.The paradox of primary amoebic meningoencephalitis--a rare disease, but commonly misdiagnosed.J PakMed Assoc2013 May;63(5):667.PMID 22238170
- Reference 38
- "Brain-eating amoeba victim: Sanford boy 'a ray of light'". Retrieved 2014-08-22.
- Ccaronerva, L.; Novak, K. (1968). "Amoebic Meningoencephalitis: Sixteen Fatalities". Science 160 (3823): 92–92. doi:10.1126/science.160.3823.92. PMID 5642317.
- Shenoy S, Wilson G, Prashanth HV, et al.Primary meningoencephalitis by Naegleria fowleri: first reported case from Mangalore, South India. J Clin Microbiol. 2002 Jan;40(1):309-10.PMID 11773141
- Hebbar S, Bairy I, et al.Fatal case of Naegleria fowleri meningo-encephalitis in an infant: case report.Ann Trop Paediatr. 2005 Sep;25(3):223-6.PMID 16156990
- Gupta N, Bhaskar H, et al.Primary amoebic meningoencephalitis: first reported case from Rohtak, North India.National Institute of Communicable Diseases, New Delhi.PMID 20191204
- Movahedi Z, Shokrollahi MR,et al. Primary amoebic meningoencephalitis in an Iranian infant.Case Rep Med. 2012;2012:782854. doi: 10.1155/2012/782854. Epub 2012 Jul 26.PMID 22899941
- Cursons, R; Sleigh, J; Hood, D; Pullon, D (2003). "A case of primary amoebic meningoencephalitis: North Island, New Zealand". The New Zealand medical journal 116 (1187): U712. PMID 14752540.
- "Brain-eating amoeba: need for water chlorination stressed". Retrieved 2012-07-19.
- "‘Brain-eating amoeba’ claims another life in Karachi accessdate = 2014-10-10".
- "Patient who succumbed to Naegleria Fowleri because of doing Ablution". Teeth Maestro Blog. Retrieved 28 Oct 2010.
- "The City of Bath, Somerset, UK". H2G2. Retrieved 2007-11-01.
- Kilvington, Simon; John Beeching (June 1995). "Identification and epidemiological typing of Naegleria fowleri with DNA probes" (PDF). Applied and Environmental Microbiology 61 (6): 2071–2078. PMC 167479. PMID 7793928. Retrieved 2007-10-31.
- "California woman dies from brain-eating amoeba". CBS News. 2 July 2015. Retrieved 5 July 2015.
- Joelving, Frederick (2012-08-28). "CDC strengthens brain-eating amoeba, neti pot link". Reuters. Retrieved 4 January 2013.
- "CDC strengthens brain-eating ameba, neti pot link". Chicago Tribune. 2012-08-28.
- "Naegleria – Frequently Asked Questions (FAQs)". Centers for Disease Control and Prevention. 5 July 2011. Retrieved 2011-08-17.
- Rodríguez R, Méndez O, et al.Central nervous system infection by free-living amebas: report of 3 Venezuelan cases.Rev Neurol. 1998 Jun;26(154):1005-8.PMID 9658480
- Petit F, Vilchez V, et al.Primary amebic meningoencephalitis: two new cases report from Venezuela. Arq Neuropsiquiatr 2006 Dec;64(4):1043-6.PMID 17221024
- Fowler, M; Carter, RF (1965). "Acute pyogenic meningitis probably due to Acanthamoeba sp.: a preliminary report". British Medical Journal 2 (5464): 740–2. doi:10.1136/bmj.2.5464.734-a. PMC 1846173. PMID 5825411.
- Butt, Cecil G. (1966). "Primary Amebic Meningoencephalitis". New England Journal of Medicine 274 (26): 1473–6. doi:10.1056/NEJM196606302742605. PMID 5939846.
- Symmers, WC (1969). "Primary amoebic meningoencephalitis in Britain". British Medical Journal 4 (5681): 449–54. doi:10.1136/bmj.4.5681.449. PMC 1630535. PMID 5354833.
- Maďarová, Lucia; Trnková, Katarína; Feiková, Soňa; Klement, Cyril; Obernauerová, Margita (2010). "A real-time PCR diagnostic method for detection of Naegleria fowleri". Experimental Parasitology 126 (1): 37–41. doi:10.1016/j.exppara.2009.11.001. PMID 19919836.
- Qvarnstrom, Y.; Visvesvara, G. S.; Sriram, R.; Da Silva, A. J. (2006). "Multiplex Real-Time PCR Assay for Simultaneous Detection of Acanthamoeba spp., Balamuthia mandrillaris, and Naegleria fowleri". Journal of Clinical Microbiology 44 (10): 3589–95. doi:10.1128/JCM.00875-06. PMC 1594764. PMID 17021087.
- Song, K; Jeong, S; Park, S; Kim, K; Kwon, M; Im, K; Pak, J; Shin, H (2006). "Naegleria fowleri: Functional expression of the Nfa1 protein in transfected Naegleria gruberi by promoter modification". Experimental Parasitology 112 (2): 115–20. doi:10.1016/j.exppara.2005.10.004. PMID 16321386.
- Jung, S; Kim, J; Lee, Y; Song, K; Kim, K; Park, S; Im, K; Shin, H (2008). "Naegleria fowleri: nfa1 gene knock-down by double-stranded RNAs". Experimental Parasitology 118 (2): 208–13. doi:10.1016/j.exppara.2007.08.008. PMID 17904122.
- Rojas-Hernández S, Rodríguez-Monroy MA, López-Revilla R, Reséndiz-Albor AA, Moreno-Fierros L (2004). "Intranasal coadministration of the Cry1Ac protoxin with amoebal lysates increases protection against Naegleria fowleri meningoencephalitis". Infect. Immun. 72 (8): 4368–75. doi:10.1128/IAI.72.8.4368-4375.2004. PMC 470623. PMID 15271892.
- Naegleria Infection Information Page from the Centers for Disease Control and Prevention
- Naegleria General Information from the website of the Centers for Disease Control and Prevention
- Naegleria from the The Tree of Life Web Project