Abstract
Introduction: Primary amoebic meningoencephalitis (PAM) is a rare disease caused by the free-living amoeba Naegleria fowleri. Infection occurs by insufflation of water containing amoebae into the nasal cavity, and is usually associated with bathing in freshwater. Nasal irrigation is a more rarely reported route of infection.Case presentation: A fatal case of PAM in a previously healthy Norwegian woman, acquired during a holiday trip to Thailand, is described. Clinical findings were consistent with rapidly progressing meningoencephalitis. The cause of infection was discovered by chance, owing to the unexpected detection of N. fowleri DNA by a PCR assay targeting fungi. A conclusive diagnosis was established based on sequencing of N. fowleri DNA from brain biopsies, supported by histopathological findings. Nasal irrigation using contaminated tap water is suspected as the source of infection.Conclusion: The clinical presentation of PAM is very similar to severe bacterial meningitis. This case is a reminder that when standard investigations fail to identify a cause of infection in severe meningoencephalitis, it is of crucial importance to continue a broad search for a conclusive diagnosis. PAM should be considered as a diagnosis in patients with symptoms of severe meningoencephalitis returning from endemic areas.
Highlights
Primary amoebic meningoencephalitis (PAM) is a rare disease caused by the free-living amoeba Naegleria fowleri
The patient presented with typical symptoms and signs of PAM, initially mimicking bacterial meningitis, with rapid progression to loss of consciousness, increased intracerebral pressure, herniation and death
The incubation period of PAM is generally short (Capewell et al, 2015; Visvesvara et al, 2007), suggesting that the infection was most likely acquired from tap water in the apartment at Jomtien Beach, as the patient had stayed at this location for the last 12 days before symptom onset
Summary
Primary amoebic meningoencephalitis (PAM) is a rare disease caused by the free-living amoeba Naegleria fowleri. She presented with rapid onset of nausea and vomiting associated with fever and exhaustion, and had been complaining of fatigue for two days. Sequencing of amplicons obtained by subsequent conventional PCR using the primers NAEGL-FOR1, NAEGL-SHORT-REV1 and NAEGL-REV1 (Table 1) confirmed the presence of DNA belonging to N. fowleri. The group rented a privately owned apartment at Jomtien Beach south of Pattaya, connected to a municipal water supply They stayed two nights at a hotel on the island of Koh Chang, returning two weeks before the end of the trip (12 days before the onset of symptoms). Tap water was heated by continuous-flow water heaters
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