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Primary amebic meningoencephalitis is a fulminating, hemorrhagic, necrotizing meningoencephalitis that occurs in healthy children and young adults and is rapidly fatal It is caused by free-living amebas, most commonly Naegleria fowleri, but also Balamuthia mandrillaris and Acanthamoeba species N fowleri is a thermophilic organism found in fresh and polluted warm lake water, domestic water supplies, swimming pools, thermal water, and sewers Most patients give a history of exposure to warm fresh water The incubation period varies from 2 to 15 days Early symptoms include headache, fever, stiff neck, and lethargy, often associated with rhinitis and pharyngitis Vomiting, disorientation, and other signs of meningoencephalitis develop within 1 or 2 days, followed by coma and then death within 7 10 days No distinctive clinical features distinguish the infection from acute bacterial meningoencephalitis CSF shows hundred to thousands of leukocytes and erythrocytes per cubic millimeter Protein is usually elevated, and glucose is normal or moderately reduced A fresh wet mount of the CSF may show motile trophozoites Staining with Giemsa or Wright stain will identify the trophozoites Species identification is based on morphology and immunologic methods Primary amebic

Prevention requires safe water supplies; sanitary disposal of human feces; adequate cooking of foods; protection of foods

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meningoencephalitis is nearly always fatal Amphotericin B appears to be the drug of choice; one survivor was treated with intravenous and intrathecal amphotericin B, intravenous miconazole, and oral rifampin

Vargas-Zepeda J et al Successful treatment of Naegleria fowleri meningoencephalitis by using intravenous amphotericin B, fluconazole and rifampicin Arch Med Res 2005 Jan Feb; 36(1):83 6 [PMID: 15900627]

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Acanthamoeba species and B mandrillaris can cause an encephalitis that is more chronic in nature than primary amebic meningoencephalitis Neurologic disease may be preceded by skin lesions, including ulcers and nodules After an uncertain incubation period neurologic symptoms develop slowly, with headache, meningismus, nausea, vomiting, lethargy, and low-grade fevers progressing over weeks to months to focal neurologic findings, mental status abnormalities, and eventually coma and death CT and MRI show single or multiple nonspecific lesions Lumbar puncture is dangerous due to increased intracranial pressure CSF shows a lymphocytic pleocytosis with elevated protein; amebas are not typically seen Diagnosis can be made by biopsy of skin or brain lesions Information on the treatment of granulomatous amebic encephalitis is limited Some patients have been successfully treated with various combinations of flucytosine, pentamidine, fluconazole or itraconazole, sulfadiazine, trimethoprim-sulfamethoxazole, and azithromycin

COCCIDIOSIS (CRYPTOSPORIDIOSIS, ISOSPORIASIS, CYCLOSPORIASIS, SARCOCYSTOSIS) & MICROSPORIDIOSIS General Considerations

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The causes of coccidiosis are Cryptosporidium species (C parvum, C hominis, and others); Isospora belli; Cyclospora cayetanensis; and Sarcocystis species Microsporidiosis is caused by at least 14 species, most commonly Enterocytozoon bieneusi and Encephalitozoon intestinalis These infections occur worldwide, particularly in the tropics and in regions where hygiene is poor They are causes of endemic childhood gastroenteritis (particularly in malnourished children in developing countries); institutional and community outbreaks of diarrhea; traveler s diarrhea; and acute and chronic diarrhea in immunosuppressed patients, in particular those with AIDS They are all notable for the potential to cause prolonged diarrhea, often lasting for a number of weeks Clustering occurs in households, day care centers, and among sexual partners The infectious agents are oocysts (coccidiosis) or spores (microsporidiosis) transmitted from person to person or by contaminated drinking or swimming water or food Ingested oocysts release sporozoites that invade and multiply in enterocytes, primarily in the small bowel Coccidian oocysts and microsporidian cysts can remain viable in the environment for years I belli and C cayetanensis appear to infect only humans C cayetanensis has caused a number of food-borne outbreaks in the United States in recent years, most commonly associated with imported fresh produce Sarcocystis infects many species; humans are intermediate hosts (infected by ingestion of fecal sporocysts) for some species but definitive hosts for Sarcocystis bovihominis and Sarcocystis suihominis (infected by ingestion of tissue cysts in undercooked beef and pork, respectively) Cryptosporidiosis is a zoonosis (C parvum principally infects cattle), but most human infections are acquired from humans, in particular with C hominus Cryptosporidia are highly infectious and readily transmitted in day care settings and households They have caused large community outbreaks due to contaminated water supplies (causing ~400,000 illnesses in Milwaukee in 1993) and are the leading cause of recreational water associated outbreaks of gastroenteritis Of note, coccidia and microsporidians will generally be missed on routine evaluations of stool for ova and parasites, as they require special staining techniques for identification.

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