Naegleriasis
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Naegleriasis, also known as primary amoebic meningoencephalitis (PAM), is an almost invariably fatal infection of the brain by the free-living protozoan Naegleria fowleri. Symptoms include headache, fever, nausea, vomiting, a stiff neck, confusion, hallucinations and seizures.<ref name="cdc.gov-2019" /> Symptoms progress rapidly over around five days with characteristics of both meningitis and encephalitis, making it a type of meningoencephalitis. Death usually results within one to two weeks of symptom onset.<ref name="cdc.gov-2019" /><ref name="mw" />
N. fowleri is typically found in warm bodies of fresh water, such as ponds, lakes, rivers and hot springs. It is found in an amoeboid, temporary flagellate stage or microbial cyst in soil, poorly maintained municipal water supplies, water heaters, near warm-water discharges of industrial plants and in poorly chlorinated or unchlorinated swimming pools. There is no evidence of it living in salt water. As the disease is rare, it is often not considered during diagnosis.Template:Citation needed
Although infection occurs very rarely,<ref name="mw">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> it almost inevitably results in death.<ref>Template:Cite news</ref><ref>One death in September 2018 was the first confirmed case of the infection in the United States since 2016. Template:Cite news)l</ref>
Signs and symptomsEdit
Onset of symptoms begins one to twelve days following exposure (with a median of five).<ref name="cdc.gov-2019">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Initial symptoms include changes in taste and smell, headache, fever, nausea, vomiting, back pain,<ref name="Talaro 2015 p. ">Template:Cite book</ref> and a stiff neck. Secondary symptoms are also meningitis-like including confusion, hallucinations, lack of attention, ataxia, cramp and seizures. After the start of symptoms, the disease progresses rapidly, with death usually occurring anywhere from one to eighteen days later (with a median of five),<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> although it can take longer. In 2013, a man in Taiwan died 25 days after being infected by Naegleria fowleri.<ref>Template:Cite journal</ref>
It affects healthy children or young adults who have recently been exposed to bodies of fresh water.<ref name="MMWR2008">Template:Cite journal</ref> Scientists speculate that lower age groups are at a higher risk of contracting the disease because adolescents have a more underdeveloped and porous cribriform plate, through which the amoeba travels to reach the brain.<ref name="Grace2015rev" />
CauseEdit
N. fowleri invades the central nervous system via the nose, specifically through the olfactory mucosa of the nasal tissues. This usually occurs as the result of the introduction of water that has been contaminated with N. fowleri into the nose during activities such as swimming, bathing or nasal irrigation.<ref name="Safe Ritual Nasal Rinsing">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>
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. The organism then begins to consume cells of the brain, piecemeal through trogocytosis,<ref>Template:Cite journal</ref> by means of an amoebostome, a unique actin-rich sucking apparatus extended from its cell surface.<ref name="Cytopathogenicity">Template:Cite journal</ref> It then becomes pathogenic, causing primary amoebic meningoencephalitis (PAM or PAME).Template:Citation needed
Primary amoebic meningoencephalitis presents symptoms similar to those of relatively common bacterial and viral meningitis. Upon abrupt disease onset, a plethora of symptoms arise. Endogenous cytokines, released in response to the pathogens, affect the thermoregulatory neurons of the hypothalamus causing a rise in body temperature.<ref name="Montgomery">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Additionally, the cytokines may act on the vascular organ of the lamina terminalis, leading to upregulation of Prostaglandin E2 contributing to hyperthermia.<ref>Template:Cite journal</ref> Further, the release of cytokines, exotoxins released by the pathogens and an increase in intracranial pressure stimulate the nociceptors in the meninges<ref name="Montgomery" /> resulting in pain sensations.
The release of cytotoxic molecules in the central nervous system leads to extensive tissue damage and necrosis, such as damage to the olfactory nerve through lysis of nerve cells and demyelination.<ref name="Pugh">Template:Cite journal.</ref> Specifically, the olfactory nerve and bulbs become necrotic and hemorrhagic.<ref name="Fero">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Spinal flexion leads to nuchal rigidity, or stiff neck, due to the stretching of the inflamed meninges.<ref name="Montgomery" /> The increase in intracranial pressure stimulates the area postrema to create nausea sensations which may lead to brain herniation and damage to the reticular formation.<ref name="Montgomery" /> Ultimately, the increase in cerebrospinal fluid from inflammation of the meninges increases intracranial pressure to an extent which leads to the destruction of the central nervous system. Although the exact pathophysiology behind the seizures caused by PAM is unknown, it is speculated that the seizures arise from altered meningeal permeability<ref name="Montgomery" /> caused by increased intracranial pressure.
PathogenesisEdit
Naegleria fowleri propagates in warm, stagnant bodies of fresh water (typically during the summer months), and enters the central nervous system after insufflation of infected water by attaching itself to the olfactory nerve.<ref name="MMWR2008"/> It then migrates through the cribriform plate and into the olfactory bulbs of the forebrain,<ref name="pmid18374627">Template:Cite journal</ref> where it rapidly multiplies by feeding on nerve tissue.
DiagnosisEdit
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.<ref>Template:Cite bookTemplate:Page needed</ref>
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.<ref>Template:Cite journal</ref>
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.Template:Citation needed
PreventionEdit
Michael Beach, a recreational waterborne illness specialist for the Centers for Disease Control and Prevention, stated in remarks to the Associated Press that wearing of nose clips to prevent insufflation of contaminated water would be effective protection against contracting PAM, noting that "You'd have to have water going way up in your nose to begin with".<ref>"6 die from brain-eating amoeba in lakes", Chris Kahn/Associated Press, 9/28/07</ref>
Advice stated in the press release from Taiwan's Centers for Disease Control recommended people prevent fresh water from entering the nostrils and avoid putting their heads down into fresh water or stirring mud in the water with feet. When starting to suffer from fever, headache, nausea, or vomiting subsequent to any kind of exposure to fresh water, even in the belief that no fresh water has traveled through the nostrils, people with such conditions should be carried to hospital quickly and make sure doctors are well-informed about the history of exposure to fresh water.<ref name="衛生福利部疾病管制署 2013">{{#invoke:citation/CS1|citation |CitationClass=web }}Template:PD-notice</ref>
TreatmentEdit
On the basis of laboratory evidence and case reports, heroic doses<ref>Template:Cite book</ref> of amphotericin B have been the traditional mainstay of PAM treatment since the first reported survivor in the United States in 1982.<ref name=Grace2015rev/>
Treatment has often also used combination therapy with multiple other antimicrobials 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.<ref>Template:Cite book</ref>
While the use of rifampicin has been common, including in all four North American cases of survival, its continued use has been questioned.<ref name=Grace2015rev/> It only has variable activity in vitro and it has strong effects on the therapeutic levels of other antimicrobials used by inducing cytochrome p450 pathways.<ref name=Grace2015rev/> Fluconazole is commonly used as it has been shown to have synergistic effects against naegleria when used with amphotericin in vitro.<ref name="Grace2015rev"/>
In 2013–2016, three successfully treated cases in the United States utilized the medication miltefosine.<ref name="CDC2015Tx" /> In one of the cases, a 12-year-old female, was given miltefosine and targeted temperature management to manage cerebral edema which is secondary to the infection. She survived with no neurological damage. The targeted temperature management coupled with early diagnosis and the medication has been attributed with her survival. On the other hand, another survivor, an 8-year-old male, was diagnosed several days after symptoms appeared and was not treated with targeted temperature management although he was administered miltefosine. He suffered apparent permanent neurological damage.<ref name=CDC2015Tx/> In 2016, a 16-year-old male also survived PAM. He was treated with the same protocols as of the 12-year-old female in 2013. He recovered with a near-complete neurological recovery; however, the patient has mentioned difficulties with learning post-recovery.<ref name=CDC2015Tx/><ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Template:As of the U.S. CDC offered miltefosine to doctors for the treatment of diseases caused by free-living amoebas including Naegleria,<ref name="CDC2015Tx" /> despite a lack of any data on how well the drug reaches the central nervous system.<ref name=Grace2015rev/>
In 2018, a 10-year-old girl in the Spanish city of Toledo became the first person to contract the disease in Spain, and was successfully treated using intravenous and intrathecal amphotericin B.<ref>Template:Cite news</ref>
A 2023 study on mice has shown that treatment that included a derivative of the drug acoziborole known as AN3057 significantly prolonged survival and showed a 28% recovery rate without relapse.<ref>Template:Cite journal</ref><ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>
PrognosisEdit
Template:Update section Since its first description in the 1960s, only nine people worldwide have been reported to have survived PAM out of 450 cases diagnosed, implying a fatality rate of about 98.5%.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref><ref name="MMWR2008" /> The survivors include four in the United States, one in Mexico and one in Spain. One of the US survivors had brain damage that is likely permanent, but there are two documented surviving cases in the United States who made a full recovery with no neurological damage; they were both treated with the same protocols.
There is also a fourth survivor in the United States. However, he had a different strain.Template:Clarify<ref name="CDC2015Tx">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref><ref name="Grace2015rev">Template:Cite journal</ref>
EpidemiologyEdit
The disease is rare and highly lethal: there had only been 381 cases Template:As of<ref name="pmid18820207">Template:Cite journal</ref> 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 (digoxin and procyclidine were shown to be most effective of the drugs studied) have proved to kill Naegleria fowleri with an amoebicidal rate greater than 95%.<ref>Template:Cite journal</ref> The same source has also proposed a device for drug delivery via the transcranial route to the brain.<ref>Template:Cite journal</ref>
In the US, the most common states with cases reported of PAM from N. fowleri are the southern states, with Texas and Florida having the highest prevalence. The most commonly affected age group is 5–14-year olds (those who play in water).<ref>"Number of Case-Reports of Primary Amebic Meningoencephalitis Caused by Naegleria Fowleri (N=133) by State of Exposure*— United States, 1962–2014". CDC.gov, CDC, www.cdc.gov/parasites/naegleria/pdf/naegleria-state-map-2014.pdf.</ref> The number of cases of infection could increase due to climate change, which was posited as the reason for three cases in Minnesota in 2010, 2012, and 2015.<ref name="ReferenceA">Template:Cite journal</ref><ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>
Template:As of the numbers of reported cases were expected to increase simply because of better-informed diagnoses being made both in ongoing cases and in autopsy findings.<ref>Template:Cite journal</ref>
HistoryEdit
In 1899, Franz Schardinger first discovered and documented an amoeba he called Amoeba gruberi that could transform into a flagellate.<ref>Template:Cite journal</ref> The genus Naegleria was established by Alexis Alexeieff in 1912, who grouped the flagellate amoeba. He coined the term Naegleria after Kurt Nägler, who researched amoebae.<ref>Template:Cite journal</ref> It was not until 1965 that doctors Malcolm Fowler and Rodney F. Carter in Adelaide, Australia, reported the first four-human cases of amoebic meningoencephalitis. These cases involved four Australian children, one in 1961 and the rest in 1965, all of whom had succumbed to the illness.<ref name="pmid5825411">Template:Cite journal</ref><ref name="pmid5354833">Template:Cite journal</ref><ref>Template:Cite journal</ref> 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.<ref name=NEJM1966/>
In 1966, Butt 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.<ref name=NEJM1966>Template:Cite journal</ref> A retrospective study determined the first documented case of PAM possibly occurred in Britain in 1909.<ref name="pmid5354833"/> In 1966, four cases were reported in the US. By 1968 the causative organism, previously thought to be a species of Hartmannella, was identified as a novel species of Naegleria. This same year, occurrence of sixteen cases over a period of three years (1962–1965) was reported in Ústí nad Labem, Czechoslovakia.<ref>Template:Cite journal</ref> In 1970, Carter named the species of amoeba N. fowleri, after Malcolm Fowler.<ref>Template:Cite book</ref><ref>Template:Cite journal</ref>
Society and cultureEdit
Naegleria fowleri is also known as the "brain-eating amoeba". This common name has also been applied to Balamuthia mandrillaris, causing some confusion between the two; Balamuthia mandrillaris is unrelated to Naegleria fowleri, and causes a different disease called granulomatous amoebic encephalitis. 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.<ref>Template:Cite journal</ref>
Naegleriasis was the topic in Season 2 of the medical mystery drama House, M.D. in the two-part episode titled "Euphoria".<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref><ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> It is also the topic of the episode "39 Differences" of season 6 of The Good Doctor.Template:Citation needed
ResearchEdit
The U.S. National Institutes of Health budgeted $800,000 for research on the disease in 2016.<ref>Template:Cite news</ref> Phenothiazines have been tested in vitro and in animal models of PAM.<ref>Template:Cite journal</ref> Improving case detection through increased awareness, reporting, and information about cases might enable earlier detection of infections, provide insight into the human or environmental determinants of infection, and allow improved assessment of treatment effectiveness.<ref name="MMWR2008"/>
See alsoEdit
- Balamuthia mandrillaris – unrelated pathogenic organism that shares the same common name as N. fowleri