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 ~  Abstract
 ~ Introduction
 ~ Case Report
 ~ Discussion
 ~  References
 ~  Article Figures

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  Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 33  |  Issue : 2  |  Page : 298-300
 

Emergence of balamuthia mandrillaris meningoencephalitis in India


1 Department of Medical Parasitology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
3 Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission02-Aug-2014
Date of Acceptance20-Jan-2015
Date of Web Publication10-Apr-2015

Correspondence Address:
B D Radotra
Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0255-0857.154887

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 ~ Abstract 

We report two cases of fatal chronic meningoencephalitis caused by Balamuthia mandrillaris in immunocompetent men. Diagnosis of amoebic meningoencephalitis was made ante-mortem in one case and postmortem in another by histopathological examination and confirmed by demonstration of B. mandrillaris deoxyribonucleic acid (DNA) by polymerase chain reaction (PCR).


Keywords: Balamuthia mandrillaris, free living amebae, meningoencephalitis, molecular diagnosis


How to cite this article:
Khurana S, Hallur V, Goyal M K, Sehgal R, Radotra B D. Emergence of balamuthia mandrillaris meningoencephalitis in India. Indian J Med Microbiol 2015;33:298-300

How to cite this URL:
Khurana S, Hallur V, Goyal M K, Sehgal R, Radotra B D. Emergence of balamuthia mandrillaris meningoencephalitis in India. Indian J Med Microbiol [serial online] 2015 [cited 2018 Nov 20];33:298-300. Available from: http://www.ijmm.org/text.asp?2015/33/2/298/154887



 ~ Introduction Top


Pathogenic free-living amoebae including Acanthamoeba spp., Naegleria fowleri and Balamuthia mandrillaris cause infection of central nervous system (CNS) and have a mortality rate of greater than 95%. [1] These infections have been described in both immunocompetent and immunocompromised individuals. [1],[2],[3],[4] The main predisposing factors are skin lesions, diabetes mellitus, liver cirrhosis, antineoplastic therapy and human immunodeficiency virus (HIV). [1],[4] While N. fowleri causes primary amoebic meningoencephalitis that is rapidly fatal, Acanthamoeba and B. mandrillaris cause encephalitis which has a subacute or chronic and insidious course. [2],[3] Infection usually manifests clinically as progressive headache, fever, abnormalities of higher mental functions, hemiparesis, cranial nerve palsies, seizures. [4] As a result of such varied manifestations, it is often confused with other infectious conditions like tuberculosis, abscesses, toxoplasmosis or non-infectious conditions like malignancy. [5] Hence, a majority of the cases are diagnosed postmortem at autopsy by identification of amoebic trophozoites or cysts on histopathology and confirmed by immunofluorescence or polymerase chain reaction (PCR). [1],[3],[6] However, ante-mortem diagnosis by histopathological examination and culture plays a very important role. It is difficult to grow Balamuthia in vitro, thus molecular tests play a very important role.

Here, we report two cases of granulomatous amoebic encephalitis (GAE), one of which was diagnosed ante-mortem and one postmortem by using PCR that targeted the 16s region of B. mandrillaris, followed by sequencing. [7],[8] Very few cases of amoebic encephalitis have been reported from India. [9] The consent for the same was obtained by the parents of the subjects.


 ~ Case Report Top


Case 1

An 18-year-old previously healthy male was referred to Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India on 3 January 2013 with a history of headache and vomiting for a month, weakness of right upper limb and slurring of speech for 20 days, fever and altered sensorium for 5 days. He was apparently healthy a month prior to developing severe holocranial headache, not relieved on medication, present throughout the day and associated with projectile vomiting. He then developed gradually progressive weakness in the right upper limb which progressed to involve the right lower limb and slurring of speech. A contrast enhanced computed scan (CECT) in a previous hospital (14 December 2012) revealed the presence of focal cerebritis with leptomeningitis in the left parietal (3.1 × 2.9 cm) and right parafalcine region (1.3 × 0.8 cm). Subsequently, lumbar puncture performed on 18 December 2012 revealed lymphocytosis (20 cells/μl), elevated protein (132 mg/dL), normal glucose (71 mg/dL) and adenosine deaminase (ADA) (2.17 U) and the patient was started on antitubercular treatment (ATT, i.e. isoniazid + rifampicin + ethionamide + pyrazinamide × 3 times a week). Following an initial improvement, he developed fever with altered sensorium and was referred to PGIMER. Apart from correlating the findings of the previous scan, a magnetic resonance imaging (MRI) scan done at admission suggested multiple ill-defined heterogenous intra-axial mass lesions in the left cerebellum, bilateral frontoparietal, left temporal and occipital lobes. Repeat cerebrospinal fluid (CSF) examination done on 3 January 2013 had similar findings as the previous one and was negative for cryptococcal antigen, bacterial culture and tuberculosis (TB) PCR. Following this intravenous (i.v) ceftriaxone and vancomycin were added to the pre-existing regimen. However, the patient deteriorated further and succumbed to his illness on 5 January 2013. Autopsy of the brain showed multiple variable-sized haemorrhagic and necrotic lesions and granulomas with trophozoites in large numbers in frontal and parietal lobes, insula, corpus callosum and left cerebellum [Figure 1] and [Figure 2]. PCR on these sections was positive for Balamuthia mandrillaris and negative for Acanthamoeba spp [Figure 3].
Figure 1: Gross examination of brain on coronal slicing on autopsy showing extensive haemorrhagic and necrotic lesions in both cerebral hemispheres

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Figure 2: Perivascular collection of amoebic trophozoites (approximately 25 μm with prominent nucleus) in the brain parenchyma amidst neutrophilic infiltrate (original magnification × 40, Haematoxylin and Eosin stain)

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Figure 3: Agarose gel showing band at 1075bp for Balamuthia by PCR amplification (Booton et al., 2003). Lane 1:1 Kbp ladder; Lane 2: Sample of Patient 1 positive for Balamuthia; Lane 3 and 4: Acanthamoeba control; Lane 5 and 6: Samples of patient 2 positive for Balamuthia; Lane 7 and 8: Negative controls (Milli Q water)

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Case 2

An 18-year-old previously healthy male presented to PGIMER on 1 May 2013 with history of headache for diplopia for 15 days, fever and vomiting for 1 week. He was apparently healthy 1 month prior to developing progressive holocranial throbbing headache, which was more severe in the morning and associated with head banging. The patient had raised intracranial pressure at admission, thus lumbar puncture was not performed. The computed tomography (CT) scan demonstrated the presence of oedema in the right and left high parafalcine regions suggesting cerebritis phase of TB. The patient was started on ATT. Two weeks later, he developed binocular diplopia, continuous fever and projectile vomiting. MRI scan showed presence of ill-defined lesions of varying sizes and intensity in the left parafalcine, left high frontoparietal region, left parietooccipital and right high parietal region, the largest measuring 6.2 × 4.7 cm. These lesions were thought to be granulomatous in nature. Because of the increasing size and number of the lesions and appearance of new symptoms, debulking and biopsy of the intracerebral mass was performed which showed necrosis, granulomatous inflammation, amoebae and cysts. PCR on the fixed sections was positive for Balamuthia only. It was sequenced and had 100% identity with B. mandrillaris isolate V 433. The sequences were submitted to Genbank with accession numbers KF246746. The patient was then started on albendazole, amphotericin and clarithromycin. However, the patient continued to deteriorate and succumbed to his illness.

Outcome and follow-up

Both the patients succumbed to the illness; and in one case, diagnosis of Balamuthia meningoencephalitis was made postmortem.


 ~ Discussion Top


, we present two cases of Balamuthia mandrillaris GAE which were diagnosed by PCR. There is only one report from India prior to our report [9] though approximately 200 cases are reported worldwide. [1],[6],[7],[8] Diagnosis and treatment of GAE due to B. mandrillaris is particularly challenging because of the rarity of the disease, lack of awareness among both the clinicians and laboratory physicians and an inability to distinguish it clinically from neurotuberculosis, tuberculoma neurocysticercosis, other non-infectious aetiologies and from Acanthamoeba spp. on histopathology and inability to grow in culture medium. In such cases, early diagnosis by molecular methods should be recommended. We performed PCR using primers targeting 16s deoxyribonucleic acid (DNA) that yields a product of 1075bp of Balamuthia and 950bp of Acanthamoeba and followed it up with sequencing that gave 100% homology with B. mandrillaris.[7],[8] Balamuthia has been found in other organs including the kidneys, adrenal glands and lungs. [10] However, we did not find Balamuthia in organs other than brain in case 2, while case 1 was partial brain autopsy. The occurrence of two cases within a span of few months in immunocompetent individuals at our centre indicates the presence of this rare agent in this country and a need for increased awareness among both clinicians and laboratory physicians for adequate and timely diagnosis and management of patients.

 
 ~ References Top

1.
Matin A, Siddiqui R, Jayasekera S, Khan NA. Increasing importance of Balamuthia mandrillaris. Clin Microbiol Rev 2008;21:435-48.  Back to cited text no. 1
    
2.
Khurana S, Mewara A, Verma S, Totadri SK. Central nervous system infection with Acanthamoeba in a malnourished child. BMJ Case Rep 2012;2012.  Back to cited text no. 2
    
3.
Trabelsi H, Dendana F, Sellami A, Sellami H, Cheikhrouhou F, Neji S, et al. Pathogenic free-living amoebae: Epidemiology and clinical review. Pathol Biol (Paris) 2012;60:399-405.  Back to cited text no. 3
    
4.
Schuster FL, Visvesvara GS. Free-living amoebae as opportunistic and non-opportunistic pathogens of humans and animals. Int J Parasitol 2004;34:1001-27.  Back to cited text no. 4
    
5.
Intalapaporn P, Suankratay C, Shuangshoti S, Phantumchinda K, Keelawat S, Wilde H. Balamuthia mandrillaris meningoencephalitis: The first case in southeast Asia. Am J Trop Med Hyg 2004;70:666-9.  Back to cited text no. 5
    
6.
Lobo SA, Patil K, Jain S, Marks S, Visvesvara GS, Tenner M, et al. Diagnostic challenges in Balamuthia mandrillaris infections. Parasitol Res 2013;112:4015-9.  Back to cited text no. 6
[PUBMED]    
7.
Booton GC, Carmichael JR, Visvesvara GS, Byers TJ, Fuerst PA. Identification of Balamuthia mandrillaris by PCR assay using the mitochondrial 16S rRNA gene as a target. J Clin Microbiol 2003;41:453-5.  Back to cited text no. 7
    
8.
Ledee DR1, Booton GC, Awwad MH, Sharma S, Aggarwal RK, Niszl IA, et al. Advantages of using mitochondrial 16S rDNA sequences to classify clinical isolates of Acanthamoeba. Invest Ophthalmol Vis Sci 2003;44:1142-9.  Back to cited text no. 8
[PUBMED]    
9.
Prasad K, Bhatia R, Srivastava MV, Pardasani V, Garg A, Rishi A. Fatal subacute necrotising brainstem encephalitis in a young man due to a rare parasitic (Balamuthia) infection. Pract Neurol 2008;8:112-7.  Back to cited text no. 9
    
10.
Visvesvara GS, Martinez AJ, Schuster FL, Leitch GJ, Wallace SV, Sawyer TK, et al. Leptomyxid ameba, a new agent of amebic meningoencephalitis in humans and animals. J Clin Microbiol 1990;28:2750-6.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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