2013 PARASITOLOGY WORKSHOP Lynnegarcia2@verizon.net

1. 2013 PARASITOLOGY WORKSHOPLynnegarcia2@verizon.net LYNNE S. GARCIA, MS, FAAM, CLS, BLM Diagnostic Medical Parasitology Workshop 2013 UPDATE – PART 3 FREE-LIVING AMEBAE SPONSORED BY MEDICAL CHEMICAL CORPORATION www.med-chem.com

2. 2 PATHOGENIC FREE-LIVING AMEBAE

3. PATHOGENIC FREE-LIVING AMEBAE: Naegleria fowleri • Environment Wet environments, domestic water sources, power plant cooling water, well water Isolated in Arctic and sub-Antarctic regions (often associated with warmer temperatures) • Infected Groups Usually healthy immunocompetent individuals • Survival Only 7 out of approximately 300 prior to 2002; death within about a week; no development of immune response • Therapy often ineffective; amphotericin B • Can occur – northern latitudes – climate change/warm 3

4. PATHOGENIC FREE-LIVING AMEBAENaegleria fowleri • History of water exposure – springs Enter through olfactory epithelium Headache, nausea, vomiting, confusion, fever, seizures, coma Primary Amebic Meningoencephalitis – rapid, fatal • Hemorrhagic necrosis of brain Brain biopsy, CSF wet mounts, culture IFA, PCR • Rare, but almost always fatal; symptoms mimic bacterial meningitis, death usually 3-7 days • Clinical history critical = clinical suspicion • Incubation = days; 111 cases (1962-2008) US 4

5. Naegleria fowleri - AmeboflagellatePrimary Amebic Meningoencephalitis (PAM) • 9-year-old male: headache, vomiting, lethargy, neck pain, unable to stand or walk • CSF trophozoite and flagellate forms (2 flagella, water) • Aggressive treatment with amphotericin B, rifampin • Symptoms began 1 week after swimming in man-made lake (Texas) 5

6. Naegleria fowleriPrimary Amebic Meningoencephalitis (PAM) • 10-year-old male developed PAM 1 week after swimming in irrigation canal • Admitted 9 h after severe headache, vomiting, fever, ataxic gait, confusion, seizures • CSF trophozoites seen • Aggressive treatment with amphotericin B, fluconazole, rifampin • By 3rd day conscious, discharged on day 23; only 9 cured cases reported 6

7. Naegleria fowleriPrimary Amebic Meningoencephalitis (PAM) • 7-year-old male developed PAM 10-12 days after swimming in warm fresh water lake • Admitted after severe headache, vomiting, fever, ataxic gait, confusion, seizures; antibiotics begun • Transferred to another hospital, diagnosed correctly • CSF purulent, trophozoites seen; aggressive treatment with amphotericin B and tetracycline • Patient died week later; distilled water test demonstrated flagellated stage – confirmed N. fowleri 7

8. Naegleria fowleriPrimary Amebic Meningoencephalitis (PAM) 8 • 6-month-old male developed PAM • High index of suspicion: patients appear to have pyogenic meningitis, but CSF shows no bacteria (“false positive” Gram stain) • Critical CSF wet mount performed for early detection • Patient died – another fatal case in infant from India • 20+ year old dies 2011 after using tap water in neti pot to rinse out nose and sinuses (Louisiana)

9. Naegleria fowleri(PAM) • 10-year-old male developed PAM (water reservoir); died during 3rd hospital day • 23-year-old male with PAM died on 2nd hospital day; second case - Venezuela • Prevention: nose plugs, no digging in sediment Direct immunofluorescence on brain tissue. 9

10. PATHOGENIC FREE-LIVING AMEBAE: Acanthamoeba • Environment Soil, air, fresh water, salt water, sewage Washing the face in pond water, sand/dust in eye, inhalation, traumatic injection, entry through existing wounds or lesions • Disseminated Infections Skin, brain, bones Rhinosinusitis, keratitis, otitis, vasculitis, endophthalmitis reported in HIV infected persons Skin lesions present in absence of CNS involvement • Immunocompromised AIDS, lung, kidney, or liver transplants 10

11. PATHOGENIC FREE-LIVING AMEBAEAcanthamoeba • Granulomatous Amebic Encephalitis Chronic, slowly progressive, CNS (involve lungs) Confusion, headache, stiff neck, irritability Focal necrosis, brain biopsy, culture, IFA, PCR • Keratitis Corneal disease, non-healing corneal ulcers Blurred vision, inflammation, pain, photophobia, blindness Corneal scrapings or biopsy, culture, Calcofluor white • Cutaneous lesions, sinusitis Most common in AIDS, immunosuppressed (transplants) Slowly progressive – weeks to months 11

12. Acanthamoeba keratitis2005-2007 • 2006, Illinois Dept of Public Health investigating possible increase over 3 years in ophthalmology center • January, 2007, CDC began retrospective survey of 22 ophthalmology centers nationwide • Data from 13 centers demonstrated increase in culture-confirmed cases • Increases begun in 2004 – associated with soft contact lens wearers using Complete MoisturePlus cleaning solution; voluntary recall begun. 12

13. Acanthamoeba keratitisafter LASIK • 20-year-old woman developed pain, redness, decreased vision, and corneal infiltrate in right eye 15 days after LASIK; NO contact lenses used postoperatively. • 3 months later, large corneal infiltrate with multiple satellite lesions in right eye • Culture positive for Acanthamoeba cysts; growth • 2 months after therapy with topical polyhexamethylene biguanide, chlorhexidine, atropine sulfate, and oral itraconazole – infiltrate resolved 13

14. Disseminated Acanthamoeba Renal Transplant Recipient • 36-year-old female renal transplant recipient; on immunosuppressives for 4 years • Autopsy showed CNS with chronic granulomatous encephalitis • Predominant perivascular infiltrate of amebic cysts, trophozoites, inflammatory cells • Both lungs and pancreas also showed infiltration with Acanthamoeba 14

15. Disseminated Acanthamoeba Cryoglobulinemia Patient • 66-year-old female with therapy-refractive cryoglobulinemia treated with rituximab, plasmapheresis, and steroids • Fatal case of granulomatous amebic encephalitis (GAE) • Unusually rapid course, probably due to rituximab – also seen in patients with Lupus • Cause of GAE, keratitis, pulmonary lesions, cutaneous lesions, and sinusitis 15

16. PATHOGENIC FREE-LIVING AMEBAE (1990) Balamuthia mandrillaris – 100 cases • Possible history of water exposure (Peru skin plaque) Similar to disease caused by Acanthamoeba (GAE) Headache, nausea, vomiting, confusion, fever, seizures, coma – dissemination from cutaneous lesions Granulomatous Amebic Meningoencephalitis – more chronic, typically fatal; unknown incubation period • Inflammatory response, amebae surrounded by macrophages, lymphocytes, neutrophils • CSF wet mounts, bacterial overlay culture NOT effective, IFA, PCR • Rare, but almost always fatal – some cures; prolonged treatment 16

17. Balamuthia mandrillarisBalamuthia Amebic Encephalitis (BAE) • 23-year-old male: acute meningoencephalitis, inflammation of nasal ulcer • 6 months before motorcycle accident (fell into swamp – nose wound); died on day 13 after therapy • Brain sections numerous trophozoites, rare cysts • First reported case in Southeast Asia (2004) 17

18. Balamuthia mandrillarisClinical Findings • Can be found in immunocompromised or immunocompetent patients; prognosis poor • Clinical course slow; CNS symptoms weeks prior to diagnosis and treatment – transplant cases • Does not cause keratitis – cutaneous lesions • Susceptibility increased in cancers, diabetes, drug abuse, alcoholism, organ transplantation, HIV • Symptoms include fever, headache, nausea, vomiting, stiff neck, focal neurological signs, changes in personality and mental status, seizures, sleepiness • North/South America; none yet in Africa 18

19. DIAGNOSIS - TISSUEAmebic Meningoencephalitis • Naegleria:Primary Amebic Meningoencephalitis • No cysts present; neutrophilic inflammation • Acanthamoeba, Balamuthia:Granulomatous Amebic Encephalitis + cutaneous lesions • Cysts present; granulomatous inflammation • Balamuthia: Amebic Meningoencephalitis + skin plaques (face, knee) • Diagnostic Options • PCR simultaneous detection of all three • (High specificity within 5 h); also PCR from paraffin specimens 19

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22. PATHOGENIC FREE-LIVING AMEBAEAGAR PLATE CULTURE 22

23. PATHOGENIC FREE-LIVING AMEBAE Sappinia diploidea, S. pedata • Very few cases: Amebic Meningoencephalitis • 38-year-old male: visual disturbances, headache, seizure • Brain image: solitary mass left temporal lobe (tumor); central necrotic and hemorrhagic inflammation (acute, chronic inflammatory cells without granulomas or eosinophils) • Trophozoites have double nuclei; cysts in host unknown • Prognosis after surgical excision, medical treatment was favorable 23

24. THANKS – QUESTIONS ?? 24