Naegleria fowleri (Primary amebic meningoencephalitis)

Summary of Naegleria fowleri (Primary amebic meningoencephalitis)

Naegleria fowleri is an amoeba that can be pathogenic, causing a fulminant brain infection known as primary amoebic meningoencephalitis. This microorganism is typically found in bodies of warm freshwater, such as ponds, lakes, rivers, and hot springs, and may gain access to the central nervous system through the cribriform plate. Amoebas can be seen on spinal fluid analysis. Amphotericin B, though not typically effective, is the treatment of choice.

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Naegleria fowleri (Primary amebic meningoencephalitis)

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Chapter 64 Central Nervous System Infections TREATMENT MEDICATIONS ▪ Current treatment regimes uncertain (based on in vitro studies, case reports) ▫ Antifungal, antiparasitic agents in combination ▫ Empiric antifungal regime: miltefosine, ﬂuconazole, pentamidine isethionate +/- trimethoprim-sulfamethoxazole, metronidazole, macrolide antibiotic SURGERY ▪ Single cerebral lesions ▫ Surgical resection NAEGLERIA FOWLERI (PRIMARY AMEBIC MENINGOENCEPHALITIS) osmosis.org/learn/naegleria_fowleri PATHOLOGY & CAUSES ▪ Thermophilic, free-living ameba, found in bodies of warm (stagnant), freshwater TYPES ▪ Life cycle, three forms 1. Cyst ▫ Immotile, dormant, survival phase ▫ Smooth, single-layered cell wall with single nucleus, naturally resistant to environmental factors ▫ Formation of cysts induced by unfavorable conditions such as food shortage, overcrowding, desiccation, accumulation of waste products, cold temperatures (< 10° celsius) 2. Trophozoite (ameboid) ▫ Feeding, reproductive, infective phase ▫ Transformation into trophozoites occurs around 25° celsius ▫ Reproduction occurs via binary ﬁssion (single cell divides into two offspring), optimal temperature 42° celsius 3. Biﬂagellate (two ﬂagella) ▫ Mobile, infective phase ▫ Pear-shaped body with two ﬂagella ▫ Flagellate phase occurs when ameba encounters change in ﬂuid ionic concentration → allows movement to suitable environment ▪ In human tissues Naegleria fowleri exists as ameboid trophozoite; ﬂagellate form may be found in CSF/during initial nasal insufﬂation Primary amoebic meningoencephalitis ▪ AKA naegleriasis ▪ Rare infection, fatality rate > 95% ▪ Mechanism of entry ▫ Insufﬂated into sinuses during waterbased activities → attaches to olfactory epithelium → follows olfactory axon through cribiform plate → migration to olfactory bulbs → spread throughout brain → diffuse meningoencephalitis ▪ In tissues, Naegleria fowleri feeds via two mechanisms; feeding on neurological tissue → necrosis, bleeding ▫ Phagocytosis of red, white blood cells ▫ Piecemeal consumption of astrocytes, neurons via amoebostome (actin-rich sucking apparatus extended from cell surface) OSMOSIS.ORG 355

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Naegleria fowleri (Primary amebic meningoencephalitis)

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Diagnosis of Naegleria fowleri is via visualization of in spinal fluid.

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A 23-year-old woman is brought to the emergency department by her mother due to rapid deterioration over the past two days. She initially had a high fever but has now developed seizures, hallucinations, and is profusely vomiting. Her medical history is noncontributory, and examination shows a loss of coordination and a stiff neck. She is a diver and has been swimming in a nearby lake in the past week. A lumbar puncture is performed and shows amoebas in her cerebrospinal fluid. Which of the following is the most appropriate pharmacotherapy for this patient?

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