In July 2018, the International Journal of Infectious Diseases presented a disturbing report: a 69-year-old woman had a sinus infection, so she was told to rinse her nostrils out using a neti pot after a round of medication didn’t work. A year later, she was dead. The culprit? A brain eating amoeba known as Balamuthia mandrillaris, that lives in freshwater and soil.
The woman, who remains anonymous, developed a rash on the bridge of her nose and raw skin at the opening of her nostrils after rinsing them out for a month. She was prescribed an antibiotic ointment, which provided no symptomatic relief, unfortunately.
Over the next year, the woman returned to her dermatologist time and time again, and even had the nasal sore biopsied three separate times; her dermatologist and pathologists were baffled, unable to provide any definitive diagnosis but instead doling out differential diagnoses of rosacea on a few separate occasions, as well as suggesting other issues such as infection and an inflammatory disease called sarcoidosis.
About a year after the nasal rash first turned up, the woman went to the hospital seeking treatment for a seizure. During the episode, she was conscious but the left side of her body trembled and she lost cognition. Follow up physical exams showed nothing particularly notable aside from a bit of weakness in her left arm. But then the doctors performed a CT scan.
The CT scan showed a 1.5cm ring-enhancing lesion on the brain’s right motor cortex, which is an area of the brain involved in goal-oriented movement. Specialists took the CT to be indicative of a possible primary high-grade tumour, since a systemic CT scan showed no signs of metastasis. They rushed the woman to the operating room, where a surgeon biopsied the lesion; results were consistent with necrosis–premature cell death–and potential high-grade glioma. However, the histopathology was unusual, so samples were sent to Johns Hopkins in Baltimore for further testing.
The woman was then sent home two days post-op after an uneventful hospital stay, and given anticonvulsants to manage any other potential symptoms. Four days later, she returned, complaining of numbness in her left leg and arm. A CT scan showed that the biopsied area had swollen, and she was readmitted to the hospital the following week in an altered mental state. MRI and CT scans showed that the mass had grown, suggesting potential fluid accumulation or hemorrhage. Despite being treated with steroids, her condition continued to worsen. When doctors scanned the woman’s brain again several days later, they saw new multifocal ring-enhancing lesions in five other parts of her brain.
Finally, 19 days after her first operation, the consulting neuropathologist from Hopkins got back to the woman’s team, suggesting a possible amoebic infection as being the culprit. The woman’s medical team took samples of the lesions again, and sure enough, histopathological evaluation returned with clear evidence of amoebic infection and incredibly concerning necrosis. She was given strong anti-amoebic therapy, but it was too late: she continued to get worse, and eventually became comatose after a little more than a week. It was then that her family decided to withdraw life support. After her death, the Center for Disease Control and Prevention performed analyses that specifically tested for Balamuthia on tissue samples from both the brain abscess and nasal lesion; it was determined that B. mandrillaris was the definitive causative agent in this patient’s unfortunate case.
So how was the woman exposed to the dangerous amoeba in the first place? It was because she forgot to adhere to a major part of her physician’s instructions: only use saline or sterile water with a neti pot. She used non-sterile tap water that had only been filtered through a Brita pitcher for an entire month, giving herself plenty of opportunities for exposure. If she had used the neti pot as her doctor had directed, she could have avoided this terribly drawn out, ultimately lethal ordeal.