Neurosurgical intervention in the diagnosis and treatment of Balamuthia mandrillaris encephalitis

Report of 3 cases

Restricted access

The authors describe the unique presentation of Balamuthia mandrillaris encephalitis in a kidney donor and two recipients. All three patients suffered acute clinical deterioration, with radiological or clinical evidence of intracranial hypertension. Brain autopsy in the donor and an urgent brain biopsy in a recipient established the diagnosis. Firsttier therapy, with mannitol and CSF drainage, successfully treated the intracranial hypertension in both recipients, while administration of a combination of antiamebic drugs was associated with survival in the second recipient. For both recipients, neurosurgical management played a critical role in the rapid diagnosis and treatment of Balamuthia mandrillaris encephalitis.

Abbreviations used in this paper: EVD = external ventricular drain; GOS = Glasgow Outcome Scale; ICP = intracranial pressure; PCR = polymerase chain reaction; WBC = white blood cell count.

Article Information

Address correspondence to: William Hanigan, M.D., Department of Neurosurgery, University of Mississippi Medical Center, 2500 North State Street, Jackson, Mississippi 39216. email: whanigan@umc.edu.

Please include this information when citing this paper: published online May 27, 2011; DOI: 10.3171/2011.4.JNS102057.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    A, B, and C: Axial T2-weighted, FLAIR, and T1-weighted postcontrast MR images obtained in the kidney donor showing cortical/subcortical signal changes, with nodular enhancement.

  • View in gallery

    Axial FLAIR and T1-weighted postcontrast MR images obtained in the first kidney recipient (A and B) and the second kidney recipient (C and D). Images demonstrate cortical/subcortical enhancing lesions bilaterally, some of which show ring enhancement. There is mild leptomeningeal enhancement noted (D).

  • View in gallery

    Balamuthia mandrillaris in patient specimens. A: Brain autopsy specimen acquired in the kidney donor. The organisms appeared as scattered cells with cytoplasmic vacuoles loosely clustered around the thin-walled blood vessel. PAS, original magnification × 200. B: Brain biopsy obtained in a kidney recipient. Amebae are in dense aggregates, again arranged around a capillary. PAS, original magnification × 100. C: Closer view of the image in B showing the prominent vacuoles and nucleosomes in the amebae. PAS, original magnification × 400. D: Brain autopsy specimen obtained in a kidney donor. Perivascular amebae labeled by an antibody to Acanthamoeba/Balamuthia, original magnification × 100. (A subsequent PCR assay amplified antigens specific for Balamuthia mandrillaris.)

  • View in gallery

    Axial FLAIR (A) and postcontrast T1-weighted (B) images demonstrating ring-enhancing lesions, with surrounding vasogenic edema.

References

  • 1

    Anzil APRao CWrzolek MAVisvesvara GSSher JHKozlowski PB: Amebic meningoencephalitis in a patient with AIDS caused by a newly recognized opportunistic pathogen. Leptomyxid ameba. Arch Pathol Lab Med 115:21251991

    • Search Google Scholar
    • Export Citation
  • 2

    Bakardjiev AAzimi PHAshouri NAscher DPJanner DSchuster FL: Amebic encephalitis caused by Balamuthia mandrillaris: report of four cases. Pediatr Infect Dis J 22:4474532003

    • Search Google Scholar
    • Export Citation
  • 3

    Cary LCMaul EPotter CWong PNelson PTGiven C II: Balamuthia mandrillaris meningoencephalitis: survival of a pediatric patient. Pediatrics 125:e699e7032010

    • Search Google Scholar
    • Export Citation
  • 4

    Centers for Disease Control and Prevention (CDC): Balamuthia amebic encephalitis—California, 1999–2007. MMWR Morb Mortal Wkly Rep 57:7687712008

    • Search Google Scholar
    • Export Citation
  • 5

    Centers for Disease Control and Prevention (CDC): Balamuthia mandrillaris transmitted through organ transplantation—Mississippi, 2009. MMWR Morb Mortal Wkly Rep 59:116511702010

    • Search Google Scholar
    • Export Citation
  • 6

    Deetz TRSawyer MHBillman GSchuster FLVisvesvara GS: Successful treatment of Balamuthia amoebic encephalitis: presentation of 2 cases. Clin Infect Dis 37:130413122003

    • Search Google Scholar
    • Export Citation
  • 7

    Denney CFIragui VJUber-Zak LDKarpinski NCZiegler EJVisvesvara GS: Amebic meningoencephalitis caused by Balamuthi mandrillaris: case report and review. Clin Infect Dis 25:135413581997

    • Search Google Scholar
    • Export Citation
  • 8

    Duke BJTyson RWDeBiasi RFreeman JEWinston KR: Balamuthia mandrillaris meningoencephalitis presenting with acute hydrocephalus. Pediatr Neurosurg 26:1071111997

    • Search Google Scholar
    • Export Citation
  • 9

    Griesemer DABarton LLReese CMJohnson PCGabrielsen JABTalwar D: Amebic meningoencephalitis caused by Balamuthia mandrillaris. Pediatr Neurol 10:2492541994

    • Search Google Scholar
    • Export Citation
  • 10

    Healy JF: Balamuthia amebic encephalitis: radiographic and pathologic findings. AJNR Am J Neuroradiol 23:4864892002

  • 11

    Jung SSchelper RLVisvesvara GSChang HT: Balamuthia mandrillaris meningoencephalitis in an immunocompetent patient: an unusual clinical course and a favorable outcome. Arch Pathol Lab Med 128:4664682004

    • Search Google Scholar
    • Export Citation
  • 12

    Kansagra APMenon JPYarbrough CKUrbaniak KWaters JDBorys E: Balamuthia mandrillaris meningoencephalitis in an immunocompromised patient. Case report. J Neurosurg 111:3013052009

    • Search Google Scholar
    • Export Citation
  • 13

    Katz JDRopper AHAdelman LWorthington MWade P: A case of Balamuthia mandrillaris meningoencephalitis. Arch Neurol 57:121012122000

    • Search Google Scholar
    • Export Citation
  • 14

    Kiderlen AFRadam ELewin A: Detection of Balamuthia mandrillaris DNA by real-time PCR targeting the RNase P gene. BMC Microbiol 8:2102008

    • Search Google Scholar
    • Export Citation
  • 15

    Kodet RNohýnková ETichý MSoukup JVisvesvara GS: Amebic encephalitis caused by Balamuthia mandrillaris in a Czech child: description of the first case from Europe. Pathol Res Pract 194:4234291998

    • Search Google Scholar
    • Export Citation
  • 16

    Krogh D: William Balamuth, Zoology: Berkley. University of California: In Memoriam 1985 (http://content.cdlib.org/view?docId=hb4d5nb20m&brand=calisphere&doc.view=entire_text) [Accessed May 3 2011]

    • Search Google Scholar
    • Export Citation
  • 17

    Lowichik ARollins NDelgado RVisvesvara GSBurns DK: Leptomyxid amebic meningoencephalitis mimicking brain stem glioma. AJNR Am J Neuroradiol 16:4 Suppl9269291995

    • Search Google Scholar
    • Export Citation
  • 18

    Martínez AJVisvesvara GS: Balamuthia mandrillaris infection. J Med Microbiol 50:2052072001

  • 19

    Martínez DYSeas CBravo FLegua PRamos CCabello AM: Successful treatment of Balamuthia mandrillaris amoebic infection with extensive neurological and cutaneous involvement. Clin Infect Dis 51:e7e112010

    • Search Google Scholar
    • Export Citation
  • 20

    Matin ASiddiqui RJayasekera SKhan NA: Increasing importance of Balamuthia mandrillaris. Clin Microbiol Rev 21:4354482008

  • 21

    Seas RCBravo PF: [Amebic granulomatosis encephalitis due to Balamuthia mandrillaris: fatal disease increasingly recognized in Latin America.]. Rev Chilena Infectol 23:1971992006. (Span)

    • Search Google Scholar
    • Export Citation
  • 22

    Taratuto ALMonges JAcefe JCMeli FParedes AMartinez AJ: Leptomyxid amoeba encephalitis: report of the first case in Argentina. Trans R Soc Trop Med Hyg 85:771991

    • Search Google Scholar
    • Export Citation
  • 23

    Visvesvara GSMartinez AJSchuster FLLeitch GJWallace SVSawyer TK: Leptomyxid ameba, a new agent of amebic meningoencephalitis in humans and animals. J Clin Microbiol 28:275027561990

    • Search Google Scholar
    • Export Citation
  • 24

    Visvesvara GSMoura HSchuster FL: Pathogenic and opportunistic free-living amoebae: Acanthamoeba spp., Balamuthia mandrillaris, Naegleria fowleri, and Sappinia diploidea. FEMS Immunol Med Microbiol 50:1262007

    • Search Google Scholar
    • Export Citation

TrendMD

Cited By

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 201 201 10
Full Text Views 143 112 1
PDF Downloads 62 42 2
EPUB Downloads 0 0 0

PubMed

Google Scholar