title: Fatal primary amoebic meningoencephalitis in a Norwegian tourist returning from Thailand.
abstract: BACKGROUND
  Primary amoebic meningoencephalitis (PAM) is a rare disease caused by the free-living amoebaNaegleria fowleri. Infection occurs by insufflation of water containing amoebae into the nasal cavity, and is usually associated with bathing in freshwater. Nasal irrigation is a more rarely reported route of infection.
  
  
  METHODS
  A fatal case of PAM in a previously healthy Norwegian woman, acquired during a holiday trip to Thailand, is described. Clinical findings were consistent with rapidly progressing meningoencephalitis. The cause of infection was discovered by chance, owing to the unexpected detection ofN. fowleriDNA by a PCR assay targeting fungi. A conclusive diagnosis was established based on sequencing ofN. fowleriDNA from brain biopsies, supported by histopathological findings. Nasal irrigation using contaminated tap water is suspected as the source of infection.
  
  
  CONCLUSIONS
  The clinical presentation of PAM is very similar to severe bacterial meningitis. This case is a reminder that when standard investigations fail to identify a cause of infection in severe meningoencephalitis, it is of crucial importance to continue a broad search for a conclusive diagnosis. PAM should be considered as a diagnosis in patients with symptoms of severe meningoencephalitis returning from endemic areas.
authors.affiliation: Department of Microbiology, Oslo University Hospital - Ullevaal, Oslo, Norway.
authors.forename: Tore Taksdal
authors.initials: TT
authors.lastname: Stubhaug
authors.affiliation: Department of Infectious Diseases, Oslo University Hospital - Ullevaal, Oslo, Norway.
authors.forename: Olaug Marie
authors.initials: OM
authors.lastname: Reiakvam
authors.affiliation: Department of Microbiology and Infection Control, Statens Serum Institut, Copenhagen, Denmark.
authors.forename: Christen Rune
authors.initials: CR
authors.lastname: Stensvold
authors.affiliation: Department of Microbiology, Oslo University Hospital - Ullevaal, Oslo, Norway.
authors.forename: Nils Olav
authors.initials: NO
authors.lastname: Hermansen
authors.affiliation: Department of Microbiology, Oslo University Hospital - Ullevaal, Oslo, Norway.
authors.forename: Mona
authors.initials: M
authors.lastname: Holberg-Petersen
authors.affiliation: Department of Pathology, Oslo University Hospital - Rikshospitalet, Oslo, Norway.
authors.forename: Ellen-Ann
authors.initials: EA
authors.lastname: Antal
authors.affiliation: Department of Anaesthesiology, Oslo University Hospital - Ullevaal, Oslo, Norway.
authors.forename: Knut
authors.initials: K
authors.lastname: Gaustad
authors.affiliation: Department of Anaesthesiology, Oslo University Hospital - Ullevaal, Oslo, Norway.
authors.forename: Ingrid Schage
authors.initials: IS
authors.lastname: Førde
authors.affiliation: Department of Infectious Diseases, Oslo University Hospital - Ullevaal, Oslo, Norway.
authors.forename: Bernt
authors.initials: B
authors.lastname: Heger
keywords: Naegleria fowleri; free-living amoebae; meningitis; meningoencephalitis; nasal irrigation; primary amoebic meningoencephalitis; travel medicine