Naegleria fowleri primary amebic meningoencephalitis (PAM) Acanthamoeba spp. granulomatous amebic encephalitis (GAE)

1. Pathogenic Free-Living Amebae • Naegleria fowleri • primary amebic meningoencephalitis (PAM) • Acanthamoeba spp. • granulomatous amebic encephalitis (GAE) • granulomatous skin and lung lesions (primarily immunocompromised) • amebic keratitis • Balamuthia mandrillaris • GAE + granulomatous skin and lung lesions (primarily healthy) • Sappinia diplidea • single case report (encephalitis)

2. Naegleria Life Cycle low nutrients desiccation Cyst = dormant form

3. Naegleria fowleri • ubiquitous genus found in fresh water lakes and ponds • PAM first recognized by Fowler (1965) • initially thought to be Acanthamoeba • Naegleria fowleri is only species associated with PAM • ~ 200 documented cases worldwide • 81 in U.S. • 14 cases from same lake in Virginia • 16 cases from same stream feed pool in Czech Republic

4. Primary Amebic Meningoencephalitis (PAM) • 1-14 days incubation period • symptoms usually within a few days after swimming in warm still waters • infection believed to be introduced through nasal cavity and olfactory bulbs • symptoms include headache, lethargy, disorientation, coma • rapid clinical course, death in 4-5 days after onset of symptoms • trophozoites can be detected in spinal fluid, but diagnosis is usually at autopsy • 4 known survivors treated with Amphotericin B

5. in vitro culture brain section “lobopodia”

6. Acanthamoeba life cycle

8. Acanthamoeba • ubiqutous ameba of the soil and water • Culbertson (1958) fortuitously produced disease in mice (culture contaminant) • human cases first reported in the early 70's • 73 cases worldwide of GAE as of 1991 • 39 in U.S. • majority of patients are chronically ill, immunocompromised, or debilitated with other diseases • also produces amebic keratitis and skin and lung lesions

9. Acanthamoeba Meningoencephalitis • portal of entry unknown, possibly respiratory tract (inhalation of cysts) or wounds in skin • presumed hematogenous dissemination to the CNS • infection associated with debilitation or immunosuppression • onset is insidious with headache, personality changes, slight fever • progresses to coma and death in weeks to months • amebas not yet detected in spinal fluid • trophozoites and sometimes cysts detectable in histological examination • no human cures documented

11. Amebic Keratitis • predisposing factors • ocular trauma • contact lens (contaminated cleaning solutions) • symptoms • ocular pain • corneal lesions (refractory to usual treatments) • diagnosis • demonstration of amebas in corneal scrapings • treatment • difficult, limited success • corneal grafts often required

12. Balamuthia mandrillaris • first report in mandrill baboon (1990) • genus/species named 1993 • morphology similar to Acanthamoeba • 18S rRNA: related to Acanthamoeba, but independent genus • many Acanthamoeba GAE cases retrospectively assigned to Balamuthia • ~100 cases as of 2003 • 3 survivors (extensive treatment with multiple drugs)

13. Source of Balamuthia • initially eluded detection in soil samples • slow growing, feed on other amebas • Schuster et al (2003) J. Clin. Micro. 41, 3175 • ameba successfully grown from soil samples associated with a fatal case • potted plant next to TV • child played with dirt while watching TV

14. Recavarren-Arce et al (Human Path. 30:269, 1999) • 10 autopsies (1985-97) of Balamuthia cases in Peru • all healthy and all died within days or weeks of neurological symptoms • primary lesions: 8 nasal, 3 dermal • questioned hematogenous dissemination in both Acanthamoeba and Balamuthia • no intravascular ameba (this study and literature) • perivascular infiltration frequently observed • propose perivascular route from primary mucosal lesion

15. Red Tides • ‘blooms’ of dinoflagellates • phyto- and zooplankton • usually monospecific • rapid population increase • nutrients, lack of grazing, sunlight, etc • long cyst survival in some species • Increasing Incidence • better monitoring (seafood, aquaculture) • coastal pollution/nutrients • agricultural wastes/fertilizers • long distance shipping

16. Potential Impact of Red Tides • deplete oxygen  dead zones • produce toxins  fish kills • dinoflagellate toxins pass up the food chain and consumed by humans • ciguatera • shellfish poisoning

17. Ciguatera Fish Poisoning • known in tropics for centuries • herbivorous fish ingest toxic dino-flagellates while feeding on seaweed • fish, such as barracuda, grouper, jack and snapper, accumulate the toxin • initial symptoms within 6 hours of meal • nausea, vomiting, diarrhea • numbness and tingling around the mouth • can also have neurological and cardiovascular manifestations • usually self-limiting, clears in a few days

18. diagnosis is based on recent dietary history and symptoms • generally a full recovery within days • PSP, some respiratory distress • ASP, serious in elderly • a variety of symptoms are observed • specific toxin • dose

19. Shellfish Poisoning Symptoms

20. Pfiesteria piscicida • effects observed in late 1980’s (named 1996) • fisherman and swimmers complaining of rashes, lesions, respiratory and neurological problems • massive fish kills in east coast estuaries • complex life cycle (at least 24 morphological forms) • Human Exposure to Pfiesteria Aerosols • narcosis/disorientation • respiratory distress/asthma-like • stomach cramping/nausea/vomiting • eye irritation/blurred vision • erratic heart beat (weeks) • sudden rages/personality changes • short term memory loss

21. Pfiesteria Toxins • culture filtrates induce open ulcerative sores, hemorrhaging and death in fish • at least two toxins • heat-stable, water-soluble toxin (fish become moribund within seconds and die within minutes) • lipophilic compound (causes the epidermis to slough off) Why produce toxins?

22. Pfiesteria Toxins • culture filtrates induce open ulcerative sores, hemorrhaging and death in fish • at least two toxins • heat-stable, water-soluble toxin (fish become moribund within seconds and die within minutes) • lipophilic compound (causes the epidermis to slough off) Why produce toxins? • accidental chemical affinity • self-defense (zooplankton, grazers) • ambush-predator life style