Indiana University Infectious Diseases Fellowship
1 Mar,
16 tweets, 6 min read
#idboardreview 60 M sarcoidosis w/ 2wks x fever, unsteady gait, fluctuating arm weakness/dysarthria, horizontal diplopia. CSF 200wbc 90%lymph, shock on vanc,cefepime,amp, ampho, rapid inc brain edema➡️death. Diagnosis? #medEd #idmedEd #idtwitter 
#acanthamoeba rapidly progressive meningoencephalitis & uncontrollable cerebral edema, resulting in death from increased intracranial pressure w/in few days after presentation & no response to broad-spectrum abx, antiviral, antifungal, and immune-modulation therapies
#acanthamoeba Ddx neurosarcoidosis: 5% of pt sarcoidosis have neurosarcoidosis & even smaller% have primary neurosarcoidosis. Acute neurosarcoidosis w/hypothalamic pituitary failure could cause rapid progression to death, but not w/ rapid cerebral edema as in this case
#acanthamoeba DDx Noninfectious meningoencephalitis: acute multiple sclerosis, Marburg’s variant MS, Schilder’s disease, tumor-like (tumefactive) demyelination. Mostly in childhood. Abscence of blood in CSF argues against it and rapid progression to death is very unusual
#acanthamoeba ddx Various autoimmune (paraneoplastic or benign) conditions presence of antibodies to voltage-gated potassium channels, LGI1, Caspr2, NMDA receptor occasionally cause meningoencephalitis but rapid progression makes it unlikely
#acanthamoeba ddx Castleman’s disease HHV8 produces a more chronic illness. EBV lymphoproliferative disorders as lymphomatoid granulomatosis do not progress at the rapid rate seen in this case.
#acanthamoeba ddx HSV most common cause of viral encephalitis, but it produces limbic encephalitis, and most of the arboviruses have a predisposition for the basal ganglia
Four amebas are #ambeic #encephalitis: Acanthamoeba culbertsoni, Naegleria fowleri, Balamuthia mandrillaris, and Sappinia pedata
#ambeic #encephalitis risk factors exposure to freshwater lakes, ponds and rivers, hot springs, thermally polluted water, warm groundwater, inadequately treated swimming pools, sewage, soil, dental irrigation water, household water (neti pots, handheld showerheads, or nozzles)
#acanthamoeba encephalitis Diagnosis: actively moving amebas on wet smears of CSF samples; a Giemsa or trichrome stain may be able to identify the characteristic nuclear morphologic features. PCR
ambeic encephalitis balamuthia generally chronic/subacute illness in IC pts, naegleria is more common in younger pts w/ water exposure. Acanthamoeba can cause acute, subacute, chronic but likely severe in this case due to immunosuppression
#acanthamoeba GAE should be treated with combination of antimicrobial agents including pentamidine, azole, sulfonamide, miltefosine and flucytosine. No efficacious regimen is not known
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