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Mark Bello
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Brain-Eating Amoeba Lurk in Lakes. Should You Worry?

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Earlier this month, an 11-year-old Florida boy died after he was infected by a brain-eating amoeba while on vacation in Costa Rico.  Now, a 9-year-old Kansas girl has suffered the same fate after swimming in several local lakes. Both children died from amoebic meningoencephalitis (PAM) caused by Naegleria fowleri.

Although rare, people die every summer from this brain-eating amoeba, usually a healthy, young person. The parasite doesn’t even like humans; it only attacks people when it is forced up the nose.  These parasites are commonly found in warm freshwater, including lakes, rivers and hot springs, especially in Florida and Texas.

According to the CDC, when the amoeba becomes lodged into a person’s nose and starts looking for food, it ends up in the brain and begins quickly eating at neurons. The amoeba multiplies and the brain will swell, creating immense pressure until the brain stops working. The initial symptoms are exactly the same as bacterial meningitis and typically start within two to five days after the amoeba enters the nose.  Symptoms include headache, fever, nausea, vomiting, and neck stiffness. Later symptoms include confusion, inattention to surroundings, and loss of balance, seizures and hallucinations. Death occurs within three to seven days after symptoms appear.

There is no effective treatment at the moment; the best course of action is prevention.  Because the nose is the pathway of the amoeba, most infections occur from diving, water skiing, or performing water sports in which water is forced into the nose.  This does not mean you should avoid swimming.  Doctors and the CDC recommend wearing nose clips, holding your nose when under water, or not putting your head under water at allAnother good tip is to avoid stirring up a lot of sediment in shallow, warm water.

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  1. George Meredith MD says:
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    Another tragic summertime preteen or teen swimming/diving ethmoid sinus, frontal sinus, cribiform plate infection with secondary meningitis and then death…usually in teenage boys because of the rapid changes in their frontoethmoid air cell pneumatization.

    Sadly history repeats itself. Caution: pre teens and especially teens, as they are in the process of pneumatizing their ethmoid and frontal sinuses, are particularly vulnerable to diving/water pressure related infections. They are at a vulnerable state in anatomic development. The ethmoid and frontal sinuses, because of their delicate connections with the nasal passages, at this point in development, are vulnerable to (especially fresh and brackish) water pressure obstruction, swelling and then secondary infection of these delicate air cell systems. Alternatively or in combination with the above, the cribiform plate, with its multiple, needle like perforations represents another portal of (fresh) water entry into the epidural space.

    There are only thin sheets of bone, the fovea ethmoidalis and the posterior wall of the frontal air cell system, that separate these two paired, critically placed sinuses and the frontal lobe of the brain. Remember high dose IV penicillin, no longer available in the United States, is one of the few antibiotics that can cross the blood brain barrier. And was once the drug of choice, along with high dose IV corticosteroids, in these situations.

    High index of suspicion, careful medical history, detailed ENT exam in a dark examination room, use of a brilliant headlight and two rounds of intranasal cotton pledget topical vasoconstriction, liberal use of sinus/frontal lobe CAT scans, are essential if these cases are to be managed successfully.

    Once an infection starts, immediate, aggressive treatment is imperative. This consists of corticosteroids intravenously combined with (used to be very high dose intravenous penicillin treatment)….combined with high dose antibiotic treatment. That’s before the FDA took IV Penicillin off the market in the US because of “cleanliness issues” at the production plants (translated since there is no money in high dose IV Penicillin therapy anymore, we will buckle to the Pharmaceutical industry and take the stuff off the American market).

    Consider: typically, no single organism is the cause of these life threatening infections. Generally, both gram positive bacteria from the nasal vault and gram negative bacteria from the fresh or even brackish water will be proliferating in the epidural and subdural spaces…along with the amoebic (parasite). Therapy should be tailored accordingly. Accordingly, it is imperative that an effective high dose intravenous antibiotic treatment program be initiated post haste. Don’t wait for culture and sensitivity results prior to beginning the high dose IV antibiotics. Consider: very high dose IV penicillin, in countries where it is still available, is effective against both gram negative as well as gram positive organisms. To verify this, simply increase the concentration of penicillin, tenfold, on the culture and sensitivity disks on the culture plates.

    And don’t forget the high dose intravenous corticosteroids. The steroids reduce the interstitial edema in the nasal vault, in the paranasal sinuses and in the epidural and subdural spaces. Reducing the interstitial edema allows the IV antibiotics to more efficiently pass into the tissue spaces that need to be sterilized. Don’t forget the steroids!

    Given these facts, it is imperative that these, mostly, teenage boys are promptly placed in the hands of a knowledgeable otolaryngologist, working with a likewise knowledgeable neurosurgeon. Forget the children’s hospital, the infectious disease expert, the CDC, the often spurious nasal and epidural space and blood cultures. What these kids need is prompt, aggressive treatment….high dose IV steroids and antibiotics and then, external ethmoidectomy and frontal sinus trephine with Silastic tube insertion, if early sufficient progress is not forthcoming.

    Advanced cases like this are relatively rare. Perhaps not even once in the practice career of the young family doctor, pediatrician, and emergency room doctor. It is much more important that these patients be promptly placed in the right hands, early on, and that aggressive treatment as outlined above be begun forthwith. Once the cat is out of the bag, all the infectious disease consultations, blood cultures, CDC consults, children’s’ hospitals…once the cat is out of the bag none of the usual practice routines will be of any benefit.

    George Meredith MD
    Virginia Beach