A Reminder About Naegleria

Photo  Credit Florida DOH

 

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Last week a small news item appeared out of Baton Rouge, LA regarding a pair of municipal employees who apparently falsified records and failed to check the local water supply for adequate levels of chlorine designed to keep Naegleria fowleri in check. 

 

An amoeba that, when ingested through the nose, can cause a fatal brain infection.  

 

2 plead guilty in failure to test St. John water sites for deadly amoeba

THE ASSOCIATED PRESS  
May 12, 2015 - 6:50 pm EDT

 BATON ROUGE, Louisiana — Two former employees of a south Louisiana water system have pleaded guilty to covering up their failure to properly collect and test water samples from sites where a dangerous type of amoeba was found.

(Continue . . . )

 

Long time readers will recall that in 2013 we saw a 4 year-old infected in Louisiana through contact with the municipal water supply. Subsequently we saw the St. Bernard Parish Water Supply Tests Positive For Naegleria Fowleri, which prompted an increase in chlorination.

 

Prior to that, in 2011, 2 people in Louisiana became infected through the introduction of tap water into their sinuses using a neti pot. These incidents caused the Louisiana Health Department to recommend that people `use distilled, sterile or previously boiled water to make up the irrigation solution’ (see Neti Pots & Naegleria Fowleri).

Photo Credit FDA

 

While extraordinarily rare in the United States, every year Pakistan reports a dozen or more infections from this `killer amoeba’ , as chlorination of their water supplies is often inadequate, and for many, nasal ablutions are part of their daily ritual.

 

Even though it is unlikely to lurk in most modern municipal water supplies, the advice to boil water for use in neti pots is prudent given the almost universal fatal outcome from infection.

 

As rare as it is, it is more common for people to acquire this infection while swimming in warm, usually stagnant fresh water lakes and ponds. After introduction of this Free Living Amoeba (FLA) into the nasal passages, it makes a direct bee line to the brain, where is causes PAM (Primary Amebic Meningoencephalitis). 

 

Up until recently, there was little that could be done for someone infected, and the illness was almost always fatal. 

 

Last summer the CDC held a COCA Call On Naegleria Fowleri & Cryptosporidium for clinicians, with guidance on a new investigational drug called miltefosine, which – for the first time on record -  was used to successfully treat a victim of  PAM or Primary amebic meningoencephalitis last summer (see MMWR: CDC Imports Investigational Drug For Amoebic Infections).

 

While progress, this remains a largely fatal infection.

 

Naegleria infection happen almost anywhere, but in the United States is most common in the warmer southern states. Every year the State of Florida issues warnings to people on how to avoid this rare, but deadly, parasite.  This from last summer’s campaign.

 

FOR IMMEDIATE RELEASE         Contact: Communications Office

June 4, 2014                  (850) 245-4111

THE FLORIDA DEPARTMENT OF HEALTH REMINDS RESIDENTS OF THE DANGERS OF NAEGLERIA FOWLERI

TALLAHASSEE -The Florida Department of Health cautions those who swim frequently in Florida’s lakes, rivers and ponds during warm temperatures about the possible presence of  Naegleria fowleri. Contact with this amoeba is rare, but the organism targets a person’s brain and usually results in death. Adverse health effects on humans can be prevented by avoiding nasal contact with the waters, since the amoeba enters through the nasal passages. Though there are only 34 reported casesin Florida since 1962, Naegleria fowlerican cause Primary Amebic Meningoencephalitis(PAM) disease which usually leads to death once infected.  As a precaution, health officials recommend the following:

• Avoid water-related activities in bodies of warm freshwater, hot springs and thermally polluted water such as water around power plants.
• Avoid water-related activities in warm freshwater during periods of high water temperature and low water levels.
• Hold the nose shut or use nose clips when taking part in water-related activities in bodies of warm freshwater such as lakes, rivers, or hot springs.
• Avoid digging in or stirring up the sediment while taking part in water-related activities in  shallow, warm freshwater areas.
• Please note exposure to the amoeba may also occur when using neti pots to rinse your sinuses of cold/allergy-related congestion or conducting religious rituals with tap water.
• Use only boiled and cooled, distilled, or sterile water for making sinus rinse solutions for neti pots or performing ritual ablutions.

If you experience any of these symptoms after swimming in any warm body of water, contact your health care provider immediately:headache, fever, nausea, disorientation, vomiting, stiff neck, seizures, loss of balance, or hallucinations. It is essential to seek medical attention right away, as PAM usually becomes fatal within five days of exposure.

Remember, this disease is rare and effective prevention strategies can allow for a safe and relaxing summer swim season.

 

For more information on the Naegleria parasite, you can also visit the CDC’s Naegleria webpage.

Kansas DHE Reports Naegleria Fowleri Fatality

L & R: Trophozoites of N. fowleri in brain tissue, stained with H&E.

Center: Ameboflagellate trophozoite of N. fowleri. Credit: DPDx

 

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Of the many and varied infections reported in North America each year, Naegleria Fowleri is among the rarest, and almost certainly one of the deadliest, that we know of.  Sometimes called the `brain eating amoeba’ in the media, this parasite lurks in warm, often stagnant fresh water, and is usually responsible for 2 or 3 infections every summer.

 

Just last month the CDC held a COCA Call On Naegleria Fowleri & Cryptosporidium for clinicians, with guidance on a new investigational drug called miltefosine, which – for the first time on record -  was used to successfully treat a victim of  PAM or Primary amebic meningoencephalitis last summer (see MMWR: CDC Imports Investigational Drug For Amoebic Infections).

 

Although infections usually occur while swimming in warm, freshwater lakes and streams, last year we saw a 4 year-old infected in Louisiana, through contact with the municipal water supply. Subsequently we saw the St. Bernard Parish Water Supply Tests Positive For Naegleria Fowleri, which prompted an increase in chlorination.

 

Also, in 2011 we saw a new wrinkle when 2 people in Louisiana became infected through the introduction of tap water into their sinuses using a neti pot. These incidents caused the Louisiana Health Department to recommend that people `use distilled, sterile or previously boiled water to make up the irrigation solution’ (see Neti Pots & Naegleria Fowleri).

Photo Credit FDA

 

The bottom line is that after introduction of this Free Living Amoeba (FLA) into the nasal passages, it makes a direct bee line to the brain, usually with tragic results. Yesterday, the State of Kansas announced the death of a 9 year-old girl (see local media report) from PAM, although the exact route of exposure is uncertain.

FOR IMMEDIATE RELEASE

July 11, 2014

KDHE Office of Communications
communications@kdheks.gov, 785-296-0461

Fatal Primary Amoebic Meningoencephalitis (PAM) Case Reported

TOPEKA, Kan. - Kansas Department of Health and Environment has been notified of a fatal case of primary amoebic meningoencephalitis (PAM) caused by Naegleria fowleri, a free-living amoeba found in freshwater, in a resident of Johnson County. The investigation indicates there were several potential fresh water exposures in Kansas, so the actual source of the infection cannot be determined.

Initial laboratory examination has identified the presence of Naegleria fowleri in a specimen from the patient, and additional laboratory testing by the U.S. Centers for Disease Control and Prevention is pending. This is the second known case of PAM caused by Naegleria fowleri in Kansas. The first case occurred in 2011.

Naegleri fowleri can be found in freshwater environments around the world, but infection causing PAM is extremely rare. From 1962 to 2013, there have been 132 cases reported in the United States, with 34 of those cases occurring from 2004 to 2013. Most cases have occurred in southern-tier states. The risk of infection is very low, but increases during the summer months when water temperatures rise and more people participate in water-related activities. The infection typically occurs when the amoeba enters the body through the nose while the person is swimming underwater or diving and travels to the brain.

“We are very saddened to learn of this unfortunate circumstance, and our thoughts and prayers are with the family and friends during this difficult time,” said Robert Moser, MD, KDHE Secretary and State Health Officer, “It is important for the public to know that infections like these are extremely rare and there are precautions one can take to lower their risk – such as nose plugs.”

Symptoms usually appear about five days after infection, but can range between one and seven days, and include headache, fever, nausea and vomiting, stiff neck, confusion, lack of attention to people and surroundings, loss of balance and bodily control, seizures, and hallucinations. This infection cannot be spread from person to person or contracted from a properly maintained swimming pool.

Though the risk of infection is extremely low, the following precautions might decrease the possibility of infection:

• Hold your nose shut, use nose clips, or keep your head above water when taking part in water-related activities in bodies of warm freshwater.
• Avoid putting your head under the water in hot springs and other untreated thermal waters.
• Avoid water-related activities in warm freshwater during periods of high water temperature.
• Avoid digging in, or stirring up, the sediment while taking part in water-related activities in shallow, warm freshwater areas.

There is no known way to control the occurrence of Naeglaria fowleri in freshwater lakes and rivers.

For more information on healthy swimming visit the CDC website at http://www.cdc.gov/healthyswimming/.

 

Naegleria infection happen almost anywhere, but in the United States is most common in the warmer southern states. Every year the State of Florida issues warnings to people on how to avoid this rare, but deadly, parasite.  Here the Florida Department of Health offers some additional common sense safety advice on how to avoid this parasite.

Photo Credit – Florida DOH

For more information on the Naegleria parasite, you can also visit the CDC’s Naegleria webpage.

MMWR: CDC Imports Investigational Drug For Amoebic Infections

L & R: Trophozoites of N. fowleri in brain tissue, stained with H&E. Center: Ameboflagellate trophozoite of N. fowleri. Credit: DPDx

 

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Amoebic infections by Naegleria fowleri resulting in PAM (Primary Amebic Meningoencephalitis) or by Acanthamoeba and Balamuthia mandrillaris producing GAE (Granulomatous amoebic encephalitis) are fortunately exceedingly rare, but for the unlucky few who are infected, survival is rare.

 

The CDC only reports one survivor of Naegleria fowleri out of 128 cases diagnosed in the United States (cite) over the past 50 years.

 

Survival from GAE is very rare as well, and those few who do survive usually experience significant neurological impairment.

 

This summer, we’ve already seen a couple of Naegleria infections linked to swimming in freshwater lakes reported in the United States (see Florida Reports Naegleria fowleri Infection, Naegleria fowleri Shuts Water Park), and last year, we saw two cases in Louisiana linked to nasal irrigation using tap water (see FDA Advice On Safe Use Of Neti Pots).

 

Until recently, treatment options have been limited to supportive care, but now the CDC is making available a drug (Miltefosine)– currently used outside of the U.S. to treat visceral and cutaneous leishmaniasis – to victims of FLA (Free Living Amoebic) in the United States.

 

While there’s not a lot of history of using this drug to treat these infections, the CDC believes there is enough evidence that it provides a `survival advantage’ to have imported the drug for this use.

Here is the CDC MMWR release from yesterday:

 

 

Investigational Drug Available Directly from CDC for the Treatment of Infections with Free-Living Amebae

Weekly

August 23, 2013 / 62(33);666-666

Infections caused by free-living amebae (FLA) are severe and life-threatening. These infections include primary amebic meningoencephalitis (PAM) caused by Naegleria fowleri* and granulomatous amebic encephalitis caused by Balamuthia mandrillaris† and Acanthamoeba species.§ Although several drugs have in vitro activity against FLA, mortality from these infections remains >90% despite treatment with combinations of drugs.

 

Miltefosine is a drug used to treat leishmaniasis and also has shown in vitro activity against FLA (1), but as an investigational drug, it has not been readily available in the United States. With CDC assistance, however, miltefosine has been administered since 2009 for FLA infections as single-patient emergency use with permission from the Food and Drug Administration. Although the number of B. mandrillaris and Acanthamoeba species infections treated with a miltefosine-containing regimen is small, it appears that a miltefosine-containing treatment regimen does offer a survival advantage for patients with these often fatal infections (2). Miltefosine has not been used successfully to treat a Naegleria infection, but the length of time it has taken to import miltefosine from abroad has made timely treatment of fulminant Naegleria infections difficult.

 

CDC now has an expanded access investigational new drug (IND) protocol in effect with the Food and Drug Administration to make miltefosine available directly from CDC for treatment of FLA in the United States. The expanded access IND use of miltefosine for treatment of FLA is partly supported by 26 case reports of FLA infection in which miltefosine was part of the treatment regimen (Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, CDC, unpublished data, 2013). Miltefosine generally is well-tolerated, with gastrointestinal symptoms the most commonly reported adverse effects. Clinicians who suspect they have a patient with FLA infection who could benefit from treatment with miltefosine should contact CDC to consult with an FLA expert. For diagnostic assistance, specimen collection guidance, specimen shipping instructions, and treatment recommendations, clinicians should contact the CDC Emergency Operations Center at 770-488-7100.

Reported by

Corresponding contributor: Jennifer R. Cope, Div of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, CDC, jcope@cdc.gov, 404-718-4878.

The Return Of Naegleria fowleri

L & R: Trophozoites of N. fowleri in brain tissue, stained with H&E. Center: Ameboflagellate trophozoite of N. fowleri. Credit: DPDx

 

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While it is exceedingly rare, each summer we hear of one or two fatal cases of PAM (Primary Amoebic Meningoencephalitis) here in the United States caused by an infection usually acquired while swimming in warm lakes and streams.

 

Tragically, an 8-year old boy from South Carolina has become the latest victim (see Amoeba kills Sumter youth –The State).

 

Blake Driggers reportedly fell ill a week after swimming in Lake Marion and was rushed to the hospital by his family.

 

Roughly a week later he died. With no effective treatment, survival with this infection is very rare. 

 

Last year, in Sometimes It’s Zebras I wrote about this usually fatal form of meningitis caused by the Naegleria fowleri parasite.

 

N. flowleri is an amoeba, which can often be found in the silt at the bottom of warm water lakes and streams. If absorbed through the nostrils - it can make a beeline towards the brain.

 

Although usually only a danger to swimmers, last year we saw a new wrinkle when 2 people in Louisiana became infected through the introduction of tap water into their sinuses using a neti pot.

 

Photo Credit – Wikipedia Commons

These incidents caused the Louisiana Health Department to recommend that people `use distilled, sterile or previously boiled water to make up the irrigation solution’ (see Neti Pots & Naegleria Fowleri).

 

While it made a lot of headlines, this was not the first time that nasal irrigation has been linked to PAM. Several years ago N. fowleri contaminated tap water in Karachi, Pakistan may have caused 13 cases over 18 months.

 

According to the CDC’s FAQ on Naegleria, we average 2 to 4 infections each year in the United States with this parasite.  They list the common sources of the amoeba as:

Where is Naegleria fowleri found?

Naegleria fowleri is found around the world. In the United States, the majority of infections have been caused by Naegleria fowleri from freshwater located in southern-tier states (2). The ameba can be found in:

• Bodies of warm freshwater, such as lakes and rivers
• Geothermal (naturally hot) water, such as hot springs
• Warm water discharge from industrial plants
• Geothermal (naturally hot) drinking water sources
• Soil
• Swimming pools that are poorly maintained, minimally-chlorinated, and/or un-chlorinated
• Water heaters with temperatures less than 47°C (3, 4)

Naegleria fowleri is not found in salt water, like the ocean.

 

Since millions of people swim in waters where this amoeba naturally occur (or are otherwise exposed) and only a small handful of infections result, the odds of acquiring this infection are extraordinarily low.

 

But the Florida Department of Health has some common sense safety advice on how to avoid this parasite.

 

Photo Credit – Florida DOH

For more information on the Naegleria parasite, you can visit the CDC’s Naegleria webpage.

 

UPDATE:

While I was writing this blog, Ronan Kelly and Alert over at FluTrackers were posting on a recent spate of deaths due to Naegleria – once again in Karachi, Pakistan.

 

The number of deaths being reported varies depending on the source, but the media is reporting between 3 and 8 fatalities over the past couple of weeks. 

 

You can follow the media reports in this thread.