| Identifier |
walsh_2018_s2_c3 |
| Title |
A Sad Story - Slides |
| Creator |
Jason Peragallo |
| Affiliation |
(JP) Emory University, Atlanta, Georgia |
| Subject |
Meningo-encephalitis, 6th nerve palsy, Infectious, Increased intracranial pressure, Nystagmus |
| Description |
Our patient was diagnosed initially with aseptic meningitis. However his clinical condition deteriorated over the course of two weeks. Evaluations for more common infectious causes of his meningitis were negative. A wet prep of his CSF revealed only white blood cells. His CSF was sent to the CDC, and PCR was positive for Balamuthia mandrillaris, negative for Naegleria and Acanthomoeba. He was started on pentamidine, sulfadiazine, flucytosine, fluconazole,azithromycin, and miltefosine. Three days later, the patient was found to have cessation of all cerebral and brainstem function, and care was withdrawn. The family elected not to proceed with autopsy. Balamuthia mandrillaris is a free-living amoeba that can produce rare but frequently fatal granulomatous ameobic encephalitis. The organism has been isolated from soil, and infection is thought to occur through inhalation of cysts or through broken skin. Prodromal symptoms can last weeks to months, and most cases are fatal. Miltefosine, a drug approved for the treatment of leshmaniasis, has shown promise in treating granulomatous ameobic encephalitis. |
| History |
A healthy 6-year-old boy had a two-week history of progressive headaches associated with nausea and vomiting. An ER diagnosed allergic rhinitis, treated with augmentin and steroids, however his symptoms worsened. At a second ER he was febrile to 103F. A classmate was recently diagnosed with Erlichiosis, and our patient was given; doxycycline. Brain MRI with and without contrast was normal. CBC was normal. A lumbar puncture revealed 286; WBC (75%lymphs) , 1 RBC, protein 65, glucose 24, negative gram stain. He was diagnosed with aseptic meningitis. Blood culture, CSF culture, CMV, EBV, Arbovirus, RMSF, Erlichia chaffeensis, Bartonella, and West Nile virus were; negative. He developed binocular horizontal diplopia. Neuro-ophthalmology was consulted. Afferent visual function was normal, extraocular motility was full, he had horizontal gaze-evoked nystagmus, an alternating; esotropia, and mild bilateral disc edema. Diagnosis was mild sixth nerve palsy from elevated ICP in the setting of; meningitis. Neurologic examination was otherwise unremarkable. Head CT showed mild communicating; hydrocephalus. Repeat LP showed opening pressure 33cmH2O, WBC 366 (60% lymphs), 4 RBC, protein 180, glucose 4, negative Cryptococcus, VDRL, HIV, HSV, TB by PCR. IV ceftriaxone and acyclovir were initiated. MRI; brain and spine revealed leptomeningeal enhancement and hydrocephalus. His sixth nerve palsies worsened. He developed bowel and bladder incontinence, and clincally deteriorated. Rifampin, isoniazide, pyrazinamide, and; ethambutol were initiated, with vancomycin and steroids. A right EVD was placed for hydrocephalus. Quantiferon Gold, urine and blood histoplasma antigen were negative. He began complaining of vision loss. Repeat head CT revealed dilation of the left lateral ventricle, and a left EVD was placed. He was intubated and sedated. Amphotericin was added. At this point the patient was covered for bacterial, viral, TB, and fungal meningitis. His mother noted he was exposed to well water and frequently played outside in the dirt. |
| Disease/Diagnosis |
Balamuthia mandrillaris granulomatous amebic encephalitis |
| Date |
2018-05 |
| References |
1) Rowen JL, Doerr CA, Vogel H, Baker CJ. Balamuthia mandrillaris: a newly recognized agent for amebic meningoencephalitis. Pediatr Infect Dis J 1995;14:705-10. 2) Ong TYY, Khan NA, Siddiqui R. Brain-eating amoebae: Prediliction sites in the brain and disease outcome. J Clin Microbiol 2017;55:1989-97. 3) Roy SL, Atkins JT, Gennuso R, Kofos D, Sriram RR, et al. Assessment of blood-brain barrier penetration of miltefosine used to treat a fatal case of granulomatous amebic encephalitis possibly caused by an unusual Balamuthia mandrillaris strain. Parasitol Res 2015;114:4431-39. 4) Matin A, Siddiqui R, Jayasekara S, Khan NA. Increasing importance of Balamuthia mandrillaris. Clin Microbiol Rev 2008;21:435-8. 5) Moriarty P, Burke C, McCrossin D, Campbell R, Cherian S, et al. Balamuthia mandrillaris encephalitis: Survival of a child with severe meningoencephailitis and review of the literature. J Pediatr Infect Dis Soc 2014;3:e4-9. |
| Language |
eng |
| Format |
application/pdf |
| Format Creation |
Microsoft PowerPoint |
| Type |
Text |
| Source |
2018 North American Neuro-Ophthalmology Society Annual Meeting |
| Relation is Part of |
NANOS Annual Meeting 2018 |
| Collection |
Neuro-Ophthalmology Virtual Education Library: Walsh Session Annual Meeting Archives: https://novel.utah.edu/Walsh/ |
| Publisher |
North American Neuro-Ophthalmology Society |
| Holding Institution |
Spencer S. Eccles Health Sciences Library, University of Utah |
| Rights Management |
Copyright 2018. For further information regarding the rights to this collection, please visit: https://NOVEL.utah.edu/about/copyright |
| ARK |
ark:/87278/s689596d |
| Setname |
ehsl_novel_fbw |
| ID |
1326599 |
| Reference URL |
https://collections.lib.utah.edu/ark:/87278/s689596d |
