Primary amebic meningoencephalitis deaths associated with sinus irrigation using contaminated tap water.
BACKGROUND
Naegleria fowleri is a climate-sensitive, thermophilic ameba found in the environment, including warm, freshwater lakes and rivers. Primary amebic meningoencephalitis (PAM), which is almost universally fatal, occurs when N. fowleri-containing water enters the nose, typically during swimming, and N. fowleri migrates to the brain via the olfactory nerve. In 2011, 2 adults died in Louisiana hospitals of infectious meningoencephalitis after brief illnesses.


METHODS
Clinical and environmental testing and case investigations were initiated to determine the cause of death and to identify the exposures.


RESULTS
Both patients had diagnoses of PAM. Their only reported water exposures were tap water used for household activities, including regular sinus irrigation with neti pots. Water samples, tap swab samples, and neti pots were collected from both households and tested; N. fowleri were identified in water samples from both homes.


CONCLUSIONS
These are the first reported PAM cases in the United States associated with the presence of N. fowleri in household plumbing served by treated municipal water supplies and the first reports of PAM potentially associated with the use of a nasal irrigation device. These cases occurred in the context of an expanding geographic range for PAM beyond southern tier states with recent case reports from Minnesota, Kansas, and Virginia. These infections introduce an additional consideration for physicians recommending nasal irrigation and demonstrate the importance of using appropriate water (distilled, boiled, filtered) for nasal irrigation. Furthermore, the changing epidemiology of PAM highlights the importance of raising awareness about this disease among physicians treating persons showing meningitislike symptoms.
National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention,1600 Clifton Road, Atlanta, GA 30329, USA. jey9@cdc.gov
Jonathan S
JS
Yoder
Susanne
S
Straif-Bourgeois
Sharon L
SL
Roy
Thomas A
TA
Moore
Govinda S
GS
Visvesvara
Raoult C
RC
Ratard
Vincent R
VR
Hill
Jon D
JD
Wilson
Andrea J
AJ
Linscott
Ron
R
Crager
Natalia A
NA
Kozak
Rama
R
Sriram
Jothikumar
J
Narayanan
Bonnie
B
Mull
Amy M
AM
Kahler
Chandra
C
Schneeberger
Alexandre J
AJ
da Silva
Mahendra
M
Poudel
Katherine L
KL
Baumgarten
Lihua
L
Xiao
Michael J
MJ
Beach
D000328:Adult; D000562:Amebiasis / Q000139:chemically induced* / Q000401:mortality*; D020808:Central Nervous System Protozoal Infections / Q000139:chemically induced* / Q000401:mortality*; D005260:Female; D006801:Humans; D008145:Louisiana; D008297:Male; D008875:Middle Aged; D016848:Naegleria fowleri / Q000302:isolation & purification* / Q000472:pathogenicity; D010254:Paranasal Sinus Diseases / Q000150:complications* / Q000628:therapy*; D007507:Therapeutic Irrigation / Q000009:adverse effects*