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Fatal Balamuthia mandrillaris Encephalitis
Binoy Yohannan1, Mark Feldman1
1Department of Internal Medicine, Texas Health Presbyterian Hospital Dallas, Dallas 75231, USA.
Abstract:
Balamuthia mandrillaris is a rare cause of granulomatous meningoencephalitis associated with high mortality. We report a 69-year-old Caucasian female who presented with a 3-day history of worsening confusion and difficulty with speech. On admission, she was disoriented and had expressive dysphasia. Motor examination revealed a right arm pronator drift. Cerebellar examination showed slowing of finger-nose testing on the left. She was HIV-negative, but the absolute CD4 count was low. Neuroimaging showed three cavitary, peripherally enhancing brain lesions, involving the right frontal lobe, the left basal ganglia, and the left cerebellar hemisphere. She underwent right frontal craniotomy with removal of tan, creamy, partially liquefied necrotic material from the brain, consistent with granulomatous amoebic encephalitis on tissue staining. Immunohistochemical studies and PCR tests confirmed infection with Balamuthia mandrillaris. She was started on pentamidine, sulfadiazine, azithromycin, fluconazole, flucytosine, and miltefosine. The postoperative course was complicated by an ischemic stroke, and she died a few weeks later.
Insights
Balamuthia mandrillaris, a rare cause of granulomatous meningoencephalitis, led to fatal outcomes in a 69-year-old woman. This case highlights the challenges in diagnosing and treating this severe amoebic brain infection.
Area of Science:
- Neurology
- Infectious Diseases
- Pathology
Background:
- Balamuthia mandrillaris is a rare protozoan pathogen causing granulomatous meningoencephalitis (GAM), a severe central nervous system infection with high mortality.
- GAM typically affects immunocompromised individuals, but can also occur in immunocompetent hosts.
Observation:
- A 69-year-old female presented with acute confusion, expressive dysphasia, and focal neurological deficits.
- Neuroimaging revealed multiple peripherally enhancing cavitary brain lesions.
- Tissue analysis confirmed Balamuthia mandrillaris infection consistent with granulomatous amoebic encephalitis.
Findings:
- Immunohistochemistry and PCR confirmed Balamuthia mandrillaris infection.
- The patient received a multi-drug regimen including pentamidine, sulfadiazine, azithromycin, fluconazole, flucytosine, and miltefosine.
- Despite treatment, the patient experienced an ischemic stroke and succumbed to the infection.
Implications:
- This case underscores the diagnostic challenges and poor prognosis associated with Balamuthia mandrillaris encephalitis.
- Early recognition and aggressive multi-agent therapy are crucial, though outcomes remain grim.
- Further research into novel therapeutic strategies is warranted for this devastating infection.
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