Case report

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Case report

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• ?? 941031

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Present illness

• A previously healthy 10-year-old boy was seen in
  July in the emergency department suffering from
  fever and a severe headache of several days'
  duration. He had vomited several times and
  complained of nausea and a runny nose.

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• The weather had been very hot, and the child had
  spent much of the summer swimming in a local
  pond. On exami-nation, the emergency room
  physician noted neck stiffness and performed a
  lumbar puncture.

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Lab finding

• Cerebrospinal fluid (CSF) was collected and sent
  to the laboratory for cell count, glucose and
  protein levels, bacterial culture, and a request
  to "rule out an amebic infection."

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Lab finding

• The white blood cell count of the CSF was
  25,000 per mm3, with neutrophils pre-dominating.
  A small number of red blood cells were also
  present. The glucose level was decreased (lt5
  mg/dl), and the protein level was markedly
  elevated (600 mg/dl).

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• The Gram stain of the CSF showed many white blood
  cells but no bacteria. A wet mount microscopic
  examination revealed motile amebic trophozoites.
  A trichrome stain was made and revealed an
  ameboid form.

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• A diagnosis of meningoencephalitis was made. The
  child was admitted to the pedia-tric intensive
  care unit but died on the fourth day of
  hospitalization.

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Question 1

• Which ameba is likely to be responsible for the
  child's symptoms? What is the name of this
  infection?

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• ??????(Naegleria fowleri) ???????,?????????cyst???
  ???,?????????cyst?Acute(??)????????????????,?????,
  ????,????,?????????.???PAM(primary amoebic
  meningo-meninginitis)

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Question 2

• What is the correlation between a "hot summer"
  and the child's illness?

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• ???????????C????
• The means of determining whether a person has PAM
  are as follows
• Clinical signs and symptoms
• History of swimming in hot or warm water
• Isolation of the amebas

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Question 3

• What are the stages in the life cycle of this
  parasite?

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Naegleria.Flagellate
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Naegleria.Trophozoite
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Question 4

• How is the diagnosis of this infection made in
  the laboratory?

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wet mount microscopic examination

• The direct wet mount is used primarily to detect
  motile protozoan trophozoites. These organisms
  are very pale and transparent, two
  characteristics that require the use of low light
  intensity. Protozoan organisms in a saline
  preparation will usually appear as refractile
  objects. If suspicious objects are seen on high
  dry power, allow at least 15 s to detect motility
  of slowly moving protozoa.

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• Heat applied by placing a hot penny on the edge
  of a slide may enhance the motility of trophic
  protozoa. Tapping on the coverslip can also
  stimulate the fluid to move objects will roll
  over, thus providing a better view of the
  parasite or artifact. After the wet preparation
  has been thoroughly checked for trophic amebae, a
  drop of iodine can be placed at the edge of the
  coverslip or a new wet mount can be prepared with
  iodine alone.

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• A weak iodine solution is recommended too strong
  a solution may obscure the organisms. The color
  should resemble "strong tea." Several types of
  iodine are available D'Antoni's will be
  discussed here. Gram's iodine used in bacterial
  work is not recommended for staining parasitic
  organisms.

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TRICHROME STAIN

• The trichrome technique of Wheatley for fecal
  specimens is a modification of Gomori's original
  staining procedure for tissue. It is a rapid,
  simple procedure which produces uniformly well
  stained smears of the intestinal protozoa, human
  cells, yeast cells, and artifact material in
  about 45 min or less.

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TRICHROME STAIN

• The specimen usually consists of fresh stool
  smeared on a microscope slide that is immediately
  fixed in Schaudinn's fixative or PVA-preserved
  stool smeared on a slide and allowed to air dry.
  Although SAF- and MIF-preserved specimens can be
  stained with trichrome, there are other stains
  which are recommended for better overall results.
  

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Question 5

• How is this infection transmitted?

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Question 6

•   
• Which other ameba resembles this parasite and may
  cause a similar type of infection?

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• Acanthamoeba spp.
• ????(Acanthamoeba)????

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Question 7

• How can these two amebae be distinguished?

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• ??????(Naegleria fowleri) ??????????
• ??????(Naegleria fowleri) ???????,?????????cyst???
  ???,?????????cyst?

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• ????(Acanthamoeba) ????????
• ?chronic(??)??,?????,?????????,??????.??GAE(granul
  omatous amoebic encephalitis)???????.
• ????????,?????

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Question 8

• Which other infectious disease might be confused
  with this illness?

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Bacterial meningoencephalitis

• Chills and fever
• Headache
• Nausea and vomiting
• Back pain
• Neck stiffness
• Prostration
• Sharp shrill cry (meningeal cry in children)
• Clouded, stupor or coma
• Convulsive seizure

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• Acute ill-looking
• Conscious change (confused, stuporour, or
  semicomatose)
• Fever (may be occasionally normal at the onset)
• Rapid pulse respiratory rate
• Neck rigidity (positive Kernig and Brudzinski
  signs, but may be absent in newborn, elderly, or
  comatous patient)
• IICP
• Decreased DTR (but occasionally increased)

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Kernigs sign

• ?????,??????,??????????,????????(??),????????????
  ??????????????,?????,??????,??????,??????????Kerni
  ng sign??????,????????????????????,??????????????
  (???????)??????????????(??????)

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Brudzinskis sign

• ???????????????,??????????,????????????,??????????
  ?????????????,?????????,??????????????,???????????
  ?

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Bacterial meningitis in different age group
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CSF STUDY
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Question 9

• Is this infection treatable?

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• Successful outcomes are reported with high-dose
  systemic and intrathecal amphotericin B.
• Survival is reported with intrathecal and
  systemic amphotericin B and miconazole, as well
  as rifampin and sulfisoxazole.

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• At present there is no satisfactory treatment for
  PAM. (Amphotericin B)
• PAM carries a mortality rate of approximately
  95, and patients usually die within 72 hours.
  Rarely, individuals survive after early
  recognition and aggressive therapy.
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Reference

• ????????M100???
• ???????M100???
• http//www.emedicine.com/med/topic1582.htm

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Thanks for your attention !!!