Critical Masses MIDG October 2015 Myra Hardy, Jeremy Carr, Tony He, Nigel Curtis
Case 2 16yo F 2 weeks focal seizures Intermittent left hemiparesis and sensory symptoms Headache PMHX: Asthma on Seretide Eczema Hayfever IUTD including typhoid and hep A SHx: Lives in urban regional centre in Victoria Pet guinea pigs and rabbits Bats fly over house but no direct contact Travel: School trip to Chang Mai, Thailand, 5 months prior Assisted in building projects Washed elephants in fresh water Ate cooked insects from market Well during travel
Case 2
What Jeremy saw in the lab wet prep of CSF
In the textbooks Images from Hardy Diagnostics ATCC (American type Culture Collection)
Geimsa Stain Centrifuged CSF
Granulomatous amoebic encephalitis GAE Primary amoebic meningoencephalitis PAM
Free living amoeba (FLA) Epidemiology PAM Rapid Immunocompetent GAE Subacute Immunocompromised Olfactory entry Olfactory, respiratory, skin entry Skin lesions, keratitis CSF PMN pleocytosis CSF lymphocytic pleocytosis
Naegleria fowleri Trophozoite 6-15 µm diameter, in CSF and brain tissue A large nucleolus visible in the centre of the nucleus No peripheral chromatin Presence of feeding tracks Rounded pseudopodia (lobopodia) Cyst and flagellate form not in CSF or brain Clinical Invades via nose / olfactory nerve Invariably fatal, some survivors (7) Images from Centres for Disease Control and Prevention (CDC) & Visvesvara 2011
Acanthomoeba Spp. Trophozoite 25-40 µm Acanthopodia prickly/spindles A large nucleolus visible in the centre of the nucleus Presence of feeding tracks May resemble macrophages Cyst 13-20 µm round, double walled - food deprivation, desiccation, temp change Usually only seen in brain biopsy, rare in CSF Clinical Amoebic keratitis Amoebic encephalitis (sub-acute) Images from Centres for Disease Control and Prevention (CDC) & Visvesvara 2011 Trop Parasitol 2014 Jul-Dec 4(2) 115-118
Amoebic keratitis Eye trauma Contact lenses improper maintenance Acanthomoeba proliferate in ophthalmic solutions or in lens cases Localised infections, vision threatening Amoebic spread to CNS not reported Abelson et al Review of Ophthalmology 2008 Acanthamoeba: A Dangerous Pathogen. An in-depth look at the organism, how it causes keratitis and how patients can avoid infection.
Balamuthia mandrillaris Trophozoite 15-60 µm Irregular branching structure, long slender pseudopodia One nucleus, > 1 nucleolus Cyst 13-30 µm, 3 walls oval or round - food deprivation, desiccation, temp change Usually only seen in brain biopsy, rare in CSF Clinical Amoebic encephalitis (sub-acute) Images from Centres for Disease Control and Prevention (CDC) & Visvesvara 2011 Skin Lesions
Diagnostic flow chart Tissue sample Brain Cornea Skin Bx CSF sample Lymphocyte predominant Low glucose Keep at room temperature Geimsa stain (Low g spin) Histopathology Enflagellation (Naegleria) Culture Non-nutrient agar + E. coli (Acanthamoeba,Naeglaria only) Tissue culture Monkey, human lung (All FLA including Balamuthia)
Culture techniques Acanthamoeba - endosymbiotic bacteria Pathogenic - Legionella spp., M. avium, L. monocytogenes, B. pseudomallei, V. cholera Non-nutrient agar supplemented with E. coli or non-mucoid strains of K. pneumoniae or Enterobacter spp. mucoid capsules impede phagocytosis by amoebas and leads to bacterial overgrowth up to 7 days to grow
NNA + E. coli culture 10x mag
Treatment Empirical treatment commenced CDC Balamuthia guideline adopted Miltefosine Flucytosine Fluconazole Sulfadiazine Pentamidine Azithromycin Day 7 Much improved CSF WCC 9: Lymph 8 Neut 1 Glucose 4.8 Protein 0.11
Further results CDC Free Living Amoeba Division PCR positive for Acanthomoeba spp. Azithromycin stopped Continued: Miltefosine Flucytosine Fluconazole Sulfadiazine Pentamidine
Infectious Diseases Society of America (2008) Acanthamoeba spp. encephalitis treatment regimen Category III level recommendation for either 1. TMP/SMX + rifampicin + ketoconazole 1. Successfully treated: 58% (7/12) 2. Fatal: 20% (2/10) 2. Fluconazole + sulfadiazine + pyrimethamine 1. Successfully treated: 8% (1/12) 2. Fatal: 10% (1/10) Miltefosine
CDC (2015) Acanthamoeba spp. Balamuthia mandrillaris Naegleria fowleri FLA: CDC Treatment Recommendations Pentamidine (IV) - 4mg/kg given once per day Sulfadiazine (oral) 200mg/kg/day Flucytosine (oral) 37.5mg/kg every 6 hours (total 150mg/kg/day) Fluconazole (oral or IV) 12mg/kg/day up to 400mg/day Miltefosine (oral) Paediatric cases: 2.5mg/kg/day (up to 100mg daily) <45kg BW: 100mg daily >45kg BW: 150mg daily Pentamidine (IV) - 4mg/kg given once per day Sulfadiazine (oral) 200mg/kg/day Flucytosine (oral) 37.5mg/kg every 6 hours (total 150mg/kg/day) Fluconazole (oral or IV) 12mg/kg/day up to 400mg/day Azithromycin (oral) 20mg/kg given once per day Clarithromycin (oral) 14mg/kg/day as an alternative Miltefosine (oral) Paediatric cases: 2.5mg/kg/day (up to 100mg daily) <45kg BW: 100mg daily >45kg BW: 150mg daily Amphotericin B (14 day IV course) First 3 days: 1.5mg/kg/day in 2 divided doses Following 11 days: 1mg/kg/day once daily Amphotericin B (10 day intra-thecal course) First 2 days: 1.5mg once daily Following 8 days: 1mg/day every other day Azithromycin 10mg/kg/day once daily, IV/PO, max 500mg/day 28 day course Fluconazole 10mg/kg/day once daily, IV/PO, max 600mg/day 28 day course Rifampin 10mg/kg/day once daily, IV/PO, max 600mg/day 28 days Miltefosine (oral) Paediatric cases: 2.5mg/kg/day (up to 100mg daily) <45kg BW: 100mg daily >45kg BW: 150mg daily 28 days Dexamethasone 0.6mg/kg/day in 4 divided doses, IV, max 0.6mg/kg/day 4 days
Miltefosine Alkylphosphocholine drug Antineoplastic and antiparasitic activity Used to treat leishmaniasis Mechanism of action unknown Inhibit the metabolism of phospholipids in cell membranes of parasites Cope JR, Roy SL, Yoder JS, Beach MJ. Improved treatment of granulomatous amebic encephalitis and other infections caused by Balamuthia mandrillarisand Acanthamoeba species [Poster]. Presented at Council of State and Territorial Epidemiologists' Annual Conference, Pasadena, CA, June 9 13, 2013.
New changes on MRI Uncontrolled disease on singe agent therapy? PRES - Posterior reversible encephalopathy syndrome? Inflammatory response?
Peru experience Carlos Seas from Cayetano University in Lima: 1 case of acanthamoeba miltefosine, voriconazole, albendazole Dozens of cases of Balamuthia: 60% success with miltefosine, albendazole and fluconazole New lesions on imaging common and hypothesised to represent dying parasites Monitoring: Monthly MRI Treatment duration: >6months after resolution of changes on MRI
Progress
Conclusions: Amoebic Encephalitis Rare disease and rarely seen in CSF Brain biopsy often required for diagnosis Travel history may trigger consideration of AE, but may be acquired locally Cerebral mass lesions Wet prep quick and easy! QUESTIONS?
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