Publication

Abstract : Case 1 was an 18-year-old college student who presented with complaints of fever, headache, and vomiting of 2 days duration. On the day of admission, he had altered sensorium in the form of increasing drowsiness. The patient had visited a water park a few days before symptom onset. On examination, signs of meningeal irritation were seen in the form of neck stiffness. Magnetic resonance imaging of the brain showed features suggestive of meningoencephalitis predominantly involving the right basifrontal lobe. Cerebrospinal fluid (CSF) sent for biochemical parameters showed glucose of 1.4 mg/dl and protein of 826.2 mg/dl. Microscopy of the CSF showed neutrophilic pleocytosis with multiple 10–16-μm unicellular, sluggishly motile ciliated structures, which gave an initial impression of the flagellate form of Naegleria fowleri (Figure 1A) . As the patient gave a history of swimming in a water park just before the onset of his symptoms and the brain imaging showed rapidly progressing meningoencephalitis, treatment with amphotericin B and rifampin was started in addition to the empirical antibiotics and steroids. The CSF was cultured for free-living amoebae on non-nutrient agar with overlay of Escherichia coli; CSF microscopy images were sent to the US Centers for Disease Control and Prevention in Atlanta, USA, for a second opinion. The structures were diagnosed as ciliated ependymal cells. Multiplex PCR for CSF pathogens (Xcyton, Bangalore, India) was positive for Streptococcus pneumoniae. Blood cultures grew S. pneumoniae. The patient's condition deteriorated rapidly and he died of cardiac arrest on day 12 of admission.