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A Case of Naegleria Fowleri Related Primary Amoebic Meningoencephalitis in China Diagnosed by Next-Generation Sequencing

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A Case of Naegleria Fowleri Related Primary Amoebic Meningoencephalitis in China Diagnosed by Next-Generation Sequencing A case of Naegleria fowleri related primary amoebic meningoencephalitis in China diagnosed by next-generation sequencing Wang, Qiang; Li, Jianming; Ji, Jingkai; Yang, Liuqing; Chen, Li; Zhou, Rongrong; Yang, Yang; Zheng, Haixia; Yuan, Jing; Li, Liqiang; Bi, Yuhai; Gao, George F.; Ma, Jinmin; Liu, Yingxia Published in: BMC Infectious Diseases DOI: 10.1186/s12879-018-3261-z Publication date: 2018 Document version Publisher's PDF, also known as Version of record Document license: CC BY Citation for published version (APA): Wang, Q., Li, J., Ji, J., Yang, L., Chen, L., Zhou, R., Yang, Y., Zheng, H., Yuan, J., Li, L., Bi, Y., Gao, G. F., Ma, J., & Liu, Y. (2018). A case of Naegleria fowleri related primary amoebic meningoencephalitis in China diagnosed by next-generation sequencing. BMC Infectious Diseases, 18, [349]. https://doi.org/10.1186/s12879- 018-3261-z Download date: 28. Sep. 2021 Wang et al. BMC Infectious Diseases (2018) 18:349 https://doi.org/10.1186/s12879-018-3261-z CASEREPORT Open Access A case of Naegleria fowleri related primary amoebic meningoencephalitis in China diagnosed by next-generation sequencing Qiang Wang1,2†, Jianming Li1†, Jingkai Ji3,6†, Liuqing Yang1, Li Chen1, Rongrong Zhou1, Yang Yang1,2, Haixia Zheng1, Jing Yuan1, Liqiang Li3,6, Yuhai Bi1,2, George F. Gao1,2,4,5, Jinmin Ma3,6,7* and Yingxia Liu1,5* Abstract Background: Primary amoebic meningoencephalitis (PAM), caused by Naegleria fowleri, is a rare protozoan infectious disease in China. A fatality rate of over 95% had been reported due to extremely rapid disease progression in the USA and other countries. Rapid and precise identification of the causative agent is very important to clinicians for guiding their choices for administering countermeasures in the clinic. In this report, we applied the next-generation sequencing (NGS) method to rapidly show that N. fowleri was the causative agent of a fatal case involving a 42-year-old man with severe PAM disease, the first reported in mainland China. Case presentation: A 42-year old male in a deep coma was admitted to Shenzhen Third People’s Hospital, a special medical care unit with expertise in infectious diseases. Increased intracranial pressure was detected. The cerebrospinal fluid (CSF) sample was found to be red and cloudy with increased leukocyte and protein levels. While bacterial cultures with CSF were negative, N. fowleri was determined to be the causative agent with NGS. Amphotericin B (AmB), a drug with anti-amoeba activity, was used immediately, but the treatment came too late and the patient died 2 days after the NGS confirmation. Conclusion: In this paper, we reported a case of PAM disease for the first time in mainland China. NGS was used for rapid diagnosis and provided guidance for prescribing medications. However, the patient died due to a late admission amid advanced PAM disease. Early detection of N. fowleri is necessary in order to select effective drug treatments and control the disease progression. Despite the negative survival outcome, NGS was shown to be a promising method of rapid and precise identification of N. fowleri. Keywords: Naegleria fowleri, Primary amoebic meningoencephalitis, Amoeba, Next-generation sequencing Background in contact with contaminated water. N. fowleri is com- Primary amoebic meningoencephalitis (PAM) is an acute monly known as a “brain-eating amoeba” because of its and rapidly fatal disease of the central nervous system, induction of severe encephalitis in the brain upon infec- caused by infection with Naegleria fowleri, a thermo- tion, with a fatality rate of over 95% [3]. There are over philic free-living amoeba found in warm freshwater such 40 species of Naegleria, but only N. fowleri infections re- as lakes, ponds, rivers and hot springs [1]. Contaminated sults in PAM [1]. PAM has a rapid, acute disease pro- tap water could also be a source of infection [2]. N. fow- gression, with an incubation period varying from 2 to leri usually infects people through the nose cavity when 15 days, and death typically occurring 3–7 days after the onset of symptoms [1]. N. fowleri has been reported worldwide including America, Australia, Thailand, Hong * Correspondence: [email protected]; [email protected] †Qiang Wang, Jianming Li and Jingkai Ji contributed equally to this work. Kong and Taiwan [4], and about 300 cases in total have 3BGI-Shenzhen, Shenzhen 518083, China been reported in 50 years since the first case was re- 1 Shenzhen Key Laboratory of Pathogen and Immunity, State Key Discipline ported in 1965 [3]. Prompt diagnosis is important in of Infectious Disease, Shenzhen Third People’s Hospital, 29 Bulan Rd, Shenzhen 518112, China order to start treatment as soon as possible. However, Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Wang et al. BMC Infectious Diseases (2018) 18:349 Page 2 of 5 prompt diagnosis is not easy for those who had no ex- perience in treatment of N. fowleri infection and PAM is often misdiagnosed because no distinctive differences in diagnosis exist to distinguish PAM from bacterial men- ingoencephalitis [5]. In this study, we report using the next generation sequencing (NGS) method for prompt diagnosis of a N. fowleri-related infection, the first case in mainland China. Case presentation On 20th August 2016, a 42-year-old man with a fever (38.4 °C) was admitted to a local hospital in Hangzhou City, China. He lived in Shenzhen City, but was visiting Hangzhou at the time. His disease began with a head- ache 1 day earlier. Upon admission, blood tests showed a leukocytosis of 10.48 × 109/L (80% neutrophils). On the night of admission, a lumbar puncture showed high levels of white blood cells (WBCs, 1170 cells/ μL, 83% neutrophils), a protein concentration of 3.0 g/L and a glucose concentration of 1.0 mmol/L in the cerebro- Fig. 1 Computed tomography scan of the patient brain with primary amoebic meningoencephalitis spinal fluid (CSF) sample. He was treated with 2.0 g of the antimicrobial ceftriaxone and his situation was not improved. precipitate was used for nucleic acid extraction using the One day later, the patient’s speech became incoherent QIAamp DNA Mini Kit (Qiagen), following manufac- and he experienced dyspnea. He was transferred to the turer instructions. NGS was performed on the newly de- intensive care unit and endotracheal intubation was ap- veloped BGISEQ-500 platform [6]. The sequencing plied. He was administered combined therapy compris- detection identified 65,658 (out of 246,938,950) sequence ing of antibiotics (meropenem and linezolid) and an reads (0.0266%) uniquely corresponding to the N. fowleri anti-inflammatory drug (dexamethasone). During the genome (Fig. 2b)[7], and these reads covered a high per- night, the patient was found in a coma with dilated bilat- centage of the genome (Fig. 2a). When the reads from eral pupils. Computed tomography scans of his brain il- the human host were excluded, N. fowleri reads were lustrated hydrocephalus, cerebral edema and foggy brain comprised the most of any microbial species, accounting ventricles. Ventricle puncture for external CSF drainage for 0.3689% of total microbial reads and unknown or un- was performed to reduce intracranial pressure. Four days classified reads (Fig. 2c), and more than the total reads after admission, microbial culture results of the CSF of bacterium or fungi (Additional file 1). A 1.6-kb con- samples were negative for bacteria and fungi. sensus sequence of the 18S ribosomal RNA of N. fowleri On 31th August, the patient was taken back to Shen- was assembled (GenBank accession no.KY062165) and zhen at the request of his family, and transferred to found to be 99.99% identical to a reference N. fowleri se- Shenzhen Third People’s Hospital, the key institute for quence (GenBank accession no. U80059). N. fowleri in- handling infectious disease cases. At the time of admis- fection was confirmed by PCR (Fig. 3) using the specific sion, he was already in a deep coma and unresponsive primers NFITS-FW (TGAAAACCTTTTTTCCATTTA to simple cues. A blood test showed a leukocytosis of CA) and NFITS-RV (AATAAAAGATTGACCATTTGA 14.72 × 109 /L (93.3% neutrophils). The CSF appeared AA) covering the 5.8S ribosomal DNA and internal tran- light red in color and was mixed with cloudy debris. scribed spacer 2 [4]. Therefore, all these results indicate The WBC count in the CSF had increased substantially that the patient was infected with N. fowleri. In addition, to 52,860 cells/ μL (79% lymphocytes), whereas the pro- patient history collected from family members showed tein level had increased to 49.96 g/L and the glucose that the man was splashed by lake water when he concentration was 0.11 mmol/L. Computed tomog- attended the Water-Splashing Festival in Shenzhen ap- raphy scans showed severe brain swelling. The shape of proximately 1 weeks before symptoms onset, which may the cerebral ventricles had become twisted and almost be the source of infection. Anti-amoebic drugs including disappeared (Fig. 1). amphotericin B (AmB) at 50 mg/day and fluconazole His CSF sample was immediately sent for pathogen 0.4 g/day were immediately administered.
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