Critical Masses
MIDG October 2015 Myra Hardy, Jeremy Carr, Tony He, Nigel Curtis Case 2
16yo F Travel: 2 weeks focal seizures School trip to Chang Mai, Thailand, 5 months prior Intermittent left hemiparesis and sensory Assisted in building projects symptoms Washed elephants in fresh water Ate cooked insects from market Headache Well during travel 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 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 Primary amoebic meningoencephalitis GAE PAM Free living amoeba (FLA) Epidemiology
PAM GAE Rapid Subacute
Immunocompetent 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 Images from Centres for Disease Control and Prevention (CDC) & Visvesvara 2011 Invariably fatal, some survivors (7) 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 CSF sample Geimsa stain Brain Cornea Skin Lymphocyte predominant Bx Low glucose (Low g spin) Keep at room temperature
Histopathology
Enflagellation Culture (Naegleria) 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 Day 7 CDC Balamuthia guideline adopted Much improved Miltefosine CSF Flucytosine WCC 9: Lymph 8 Neut 1 Glucose 4.8 Fluconazole Protein 0.11 Sulfadiazine Pentamidine Azithromycin 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:• Pentamidine CDC(IV) Treatment - 4mg/kg given once Recommendationsper • Pentamidine (IV) - 4mg/kg given once per • Amphotericin B (14 day IV course) day day • First 3 days: 1.5mg/kg/day in 2 divided • Sulfadiazine (oral) – 200mg/kg/day • Sulfadiazine (oral) – 200mg/kg/day doses • Flucytosine (oral) – 37.5mg/kg every 6 hours • Flucytosine (oral) – 37.5mg/kg every 6 hours • Following 11 days: 1mg/kg/day once (total 150mg/kg/day) (total 150mg/kg/day) daily • Fluconazole (oral or IV) – 12mg/kg/day up to • Fluconazole (oral or IV) – 12mg/kg/day up to • Amphotericin B (10 day intra-thecal course) 400mg/day 400mg/day • First 2 days: 1.5mg once daily • Miltefosine (oral) • Azithromycin (oral) – 20mg/kg given once • Following 8 days: 1mg/day every other • Paediatric cases: 2.5mg/kg/day (up to per day day 100mg daily) • Clarithromycin (oral) – 14mg/kg/day as • Azithromycin – 10mg/kg/day once daily, • <45kg BW: 100mg daily an alternative IV/PO, max 500mg/day • >45kg BW: 150mg daily • Miltefosine (oral) • 28 day course • Paediatric cases: 2.5mg/kg/day (up to • Fluconazole – 10mg/kg/day once daily, 100mg daily) IV/PO, max 600mg/day • <45kg BW: 100mg daily • 28 day course • >45kg BW: 150mg daily • 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? References
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