Increased Patient Survival: for Treatment of Free-living Ameba Infections Caused by and Balamuthia Jennifer R. Cope, Sharon L. Roy, Jonathan S. Yoder, Michael J. Beach

BACKGROUND RESULTS CONCLUSIONS Granulomatous amebic encephalitis (GAE) Acanthamoeba Comparing survival in patients who received miltefosine with patients who did not receive miltefosine . Subacute to chronic central nervous system infection . Photomicrograph of Acanthamoeba trophozoite . Number of B. mandrillaris and Acanthamoeba spp. infections . Caused by the free-living amebae (FLA) Balamuthia mandrillaris and N Received Did Not Receive P- treated with a miltefosine-containing regimen is small. Acanthamoeba spp. Miltefosine Miltefosine value . Miltefosine-containing treatment regimen does offer a survival . Often fatal advantage for these often fatal infections. Survived/Total (%) Survived/Total (%) . CDC should provide drug to clinicians for FLA infections under an Symptoms of GAE Non-keratitis expanded access IND until it becomes commercially available in the . Personality and behavioral . Photophobia Acanthamoeba 63 5/7 (71) 9/56 (16) 0.005 United States. changes . Seizures infections (1955–2012) . Depressed mental status . Cranial nerve dysfunction . Fever . Visual Loss Balamuthia infections Brain imaging (1974–2012) 60 6/14 (43) 6/46 (13) 0.05 . Single or multiple ring-enhancing lesions CDC’s Fr ee-living Ameba Program Other infections Balamuthia mandrillaris Activities include: . Disseminated . Providing 24/7 diagnostic services and clinical guidance to health . (AK) . Photomicrograph of Balamuthia mandrillaris trophozoite professionals Age and gender of patients who received miltefosine Treatment . Tracking, investigating, and reporting infections and disease outbreaks . Ineffective . Leading CDC health promotion and communication activities . Investigational drug miltefosine has in Median age in years Gender vitro activity against FLA (range) (% male) . Testing the efficacy of promising drugs against the ameba in the laboratory setting . Given since 2009 under FDA compassionate use for FLA infections . Developing new methods for detection of FLA in clinical and Acanthamoeba environmental samples Magnetic resonance imaging (MRI) of miltefosine patients 53 (2–64) 71.4 patient with Balamuthia GAE (n=7) For more information on Acanthamoeba and Balamuthia For 24/7 diagnostic assistance, specimen collection infections, visit: Balamuthia guidance, shipping instructions, and treatment http://www.cdc.gov/parasites/acanthamoeba/ miltefosine patients 24 (4–67) 66.7 recommendations, please contact the CDC Emergency http://www.cdc.gov/parasites/balamuthia/ (n=9) Operations Center at 770-488-7100. Miltefosine Selected References: . Alkylphosphocholine drug with antineoplastic and . Centers for Disease Control and Prevention. Balamuthia mandrillaris . Martinez DY, Seas C, Bravo F, et al. Successful treatment of Balamuthia activity transmitted through organ transplantation --- Mississippi, 2009. MMWR. mandrillaris amoeb ic infection with extensive neurological and cutaneous Morbidity and mortality weekly report. 2010; 59(36):1165-1170. involvement. Clinical Infectious Diseases. 2010;51(2):E7 -E11. . Used to treat leishmaniasis . Cary LC, Maul E, Potter C, et al. Balamuthia mandrillaris . Web ster D, Umar I, Ko ly v a s G, et al. Treatment of granulomatous amoebic . Mechanism of action unknown, but can inhibit the meningoencephalitis: survival of a p ediatric patient. Pediatrics. Mar encep halitis with voriconazole and miltefosine in an immunocompetent metabolism of phospholipids in cell membranes of parasites 2010;125(3):E699-E703. soldier. American Journal of Tropical Medicine and Hygiene. 2012;87(4):715-718. M ETHODS . Aichelb urg AC, Walochnik J, Assadian O, et al. Successful treatment . Maritschnegg P, Sovinz P, La c kn e r H, et al. Granulomatous ameb ic Acknowledgements and Contact Information . Not currently licensed in the U.S. for any indication of disseminated Acanthamoeba sp infection with miltefosine. Emerging encep halitis in a child with acute lymp hob lastic leukemia successfully treated . Reviewed the literature and case reports submitted to CDC . Structure of miltefosine (below) Inf ect ious Diseases. 2008;14(11):1743-1746. with multimodal antimicrob ial therapy and hyperbaric oxygen. Journal of Dr. Govinda Visvesvara, Ch ie f, Free-living Ameba Laboratory . Determined treatment regimens, including miltefosine use, and mortality for . Bravo FG, Alvarez PJ, Gotuzzo E. Balamuthia mandrillaris infection of Clinical Microbiology. 2011;49(1):446-448. For more information, contact : case patients with B. mandrillaris infection and non-keratitis Acanthamoeba the skin and central nervous system: an emerging disease of concern to many sp ecialties in medicine. Current Opinion in Infectious Diseases. Jennifer Cope, MD, MPH spp. infection 2011;24(2):112-117. [email protected] . Analyzed proportions using Fisher’s exact test 404-718-4878

National Center for Emerging and Zoonotic Infectious Diseases E-mail: [email protected] | Web: www.cdc.gov Division of Foodborne, Waterborne and Environmental Diseases The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.