Primary amebic meningoencephalitis

PAM je akutna infektivna bolest uzrokovana Neglerijom fowleri i karakterizirana je nekrotizirajućom, hemoragijskom upalom mozga i moždanih ovojnica. N. fowleri je ameba koja živi u slatkim vodama, a čovjek se može zaraziti udisanjem kontaminirane vode prilikom plivanja ili ispiranjem nosnih puteva neprokuhanom ili nefiltriranom vodovodnom vodom. Do sada je prijavljeno više od četiristo slučajeva zaraze N. fowleri diljem svijeta, od čega je samo desetak preživjelih. Od PAM-a obolijevaju uglavnom djeca i mladi u vrućim ljetnim mjesecima. N. fowleri putem olfaktornih živaca i bulbusa prodire u moždano tkivo gdje izaziva upalu s predominantno prisutnim neutrofilima, makrofagima i malobrojnim eozinofilima. Klinički simptomi su neraspoznatljivi od simptoma bakterijskog ili virusnog meningoencefalitisa i uključuju jaku glavobolju, visoku vrućicu, ukočenost vrata i mučninu i povraćanje. Kasnije se javljaju i razdražljivost, fotofobija, diplopija, letargija, konfuzija, a povećanje IKT-a dovodi do konvulzivnih napada, hernijacije mozga, kome i naposljetku smrti. Dijagnostika se zasniva na pronalasku pokretnih trofozoita u nativnom razmazu CSL-a pod svjetlosnim mikroskopom i potvrdi dijagnoze PCR-om i pronalaskom DNA N. fowleri. Liječi se kombiniranom antimikrobnom terapijom koja uključuje amfotericin B koji djeluje sinergistički s azitromicinom i mikonazolom. Terapiji se mogu pridodati i kotrimazol, itrakonazol, flukonazol i ketokonazol, kloramfenikol i miltefozin. Povišeni IKT potrebno je agresivno snižavati lijekovima, a po potrebi i kirurškom intervencijom. U prevenciji PAM-a preporuča se adekvatno kloriranje bazena, nadzor slatkih voda ljeti u područjima u kojima je dokazano postojanje N. fowleri, te oprez svakog pojedinca pri kupanju u prirodnim vodama i pri ispiranju nazalnih puteva bilo u terapijske ili religijske svrhe.PAM is an acute infective disease caused by Naegleria fowleri and characterized by a necrotic, hemorrhaging inflammation of the brain and leptomeninges. N. fowleri is an ameba that lives in natural freshwater and infects humans via the inhalation of contaminated water during swimming or by rinsing nasal passages with unboiled or unfiltered tap water. To this date, there have been more than four hundred reported cases of N. fowleri worldwide, of which there are only a dozen survivors. PAM targets mostly children and young adults during hot summer months. N. fowleri invades the brain tissue via the olfactory nerves and bulbs, where it causes inflammation with predominance of neutrophils, macrophages and few eosinophils. Clinical symptoms are unrecognizable from symptoms of bacterial or viral meningoencephalitis, such as headache, high fever, nuchal rigidity, vomiting and nausea. Agitation, photophobia, diplopy, lethargy and confusion occur in later stages, while the rise of ICP leads to convulsions, brain herniation, coma and, finally, death. The diagnosis is based on the detection of motile trophozoites in the sample of wet-mount CSF under a light microscope and the confirmation of the diagnosis via PCR and the detection of N. fowleri DNA. Treatment is based on multimodal antimicrobial therapy that includes amphotericin B which shows synergistic activity with azithromycin and miconazole. Clotrimazole, itraconazole, fluconazole and ketoconazole, chloramphenicol and miltefosine can also be included in the therapy. Elevated ICP should be aggressively treated by medication and, if needed, by surgical intervention. Prevention of PAM requires adequate pool chlorination, monitoring of freshwater inhabited by N. fowleri and caution of every individual while swimming in freshwater or rinsing nasal passages in therapeutic or religious purposes