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a young patient with Balamuthia encephalitis with a combination regimen of miltefosine, fluconazole, and albendazole.
Case report. A 21-year-old woman presented in August
2006 with a long-term history of cutaneous lesions on her right
knee. Four years before admission, she had noticed several
papular, erythematous, and painless lesions that had appeared
2 weeks after a fall in front of her house. The lesions coalesced
to form a violaceus and indurate plaque covering the entire
right knee. Empirical therapy was started at another institution
with topical antifungal creams that contained fluconazole and
clotrimazole plus topical steroids, which were administered for
almost 1 year, followed by a combination of oral fluconazole
(150 mg per day for 45 days) and subsequent addition of
clarithromycin (1500 mg per day) and trimethoprim-sulfamethoxazole (TMP-SMX; 320 mg/1600 mg per day) for 8
months, without improvement.
The patient was born in Lima, Peru, and has resided there
for her entire life. She denied travel or specific occupational
exposure, including gardening and swimming in brackish, fresh,
or sea water. She noticed enlargement of the lesion on the right
knee and the appearance of 3 new papular lesions2 of them
around the plaque on the right knee, and the third on the left
thighin February 2006. Both lesions subsequently evolved
into violaceus plaques. She was first seen at our institution 4
months later, where a skin biopsy of the lesion on the right
knee was performed (Figure 1A). Histopathologic examination
revealed a dense inflammatory infiltrate of the dermis composed of lymphocytes, plasma cells, and ill-defined granulomas,
with great number of multinucleated giant cells located inside
and outside the granulomas. A microorganism with a nucleus
that has a large, central karyosome and a vacuolated cytoplasm,
compatible with an amoebic trophozoite, was observed (Figure
1B). In addition, B. mandrillaris was isolated from a skin sample
cultivated in an axenic culture prepared with monkey kidney
cells [7]. Polymerase chain reaction of a skin sample also yielded
positive results for B. mandrillaris (the amplification was performed using the primer mitochondrial 16S rRNA gene from
B. mandrillaris as a target) [9]. A skin biopsy sample was sent
to the Public Health Department of California (Sacramento)
and to the Centers for Disease Control and Prevention (Atlanta,
GA), where B. mandrillaris infection was confirmed by immunohistochemical staining in September 2006. A brain computed tomograph, without contrast enhancement, yielded normal findings at this time. Empirical therapy was started with
itraconazole (200 mg per day), and albendazole (400 mg per
day).
Figure. 1. A, Cutaneous lesion on the right knee observed in February 2006 showing an indurated and violaceous plaque covering the entire knee
with 2 papular lesions. B, Skin biopsy specimen showing a dense inflammatory infiltrate of the dermis with granulomas (hematoxylin and eoisin stain).
An amoebic trophozoite is observed, with a nucleus that has a large, central karyosome and vacuolated cytoplasm. C, Fluid-attenuated inversion
recovery (FLAIR) magnetic resonance image (MRI) obtained 7 days after the onset of neurologic symptoms (June 2007) showing hypersignal in the
left temporal lobe. D, Axial gadolinium-enhanced T1-weighted sequence (June 2007) showing a ring-enhancing lesion in the left temporal lobe. E,
Follow-up of the left knee lesion 1 week after the patient had commenced treatment with miltefosine, albendazole, and fluconazole. The lesions
abruptly changed, developing a scaly and crusty surface. F, Axial gadolinium-enhanced MRI obtained 5 months after the start of treatment, showing
significant improvement on the neurological lesions without evidence of contrast enhancing. G, Gadolinium-enhanced MRI image 4 months after
completion of treatment, showing the disappearance of the brain lesions. H, Follow-up of the healed left knee lesions (May 2008).
72
35
10
21
Region
Type of lesion(s)
Treatment regimen
NA
California
New York
California
California
2.4 years
6 months
3 months
3 years
18 months
30 months, including 12
without therapy and
no recurrence
Duration of follow-up
5 years
Outcome
Performing all activities of daily living,
with good communication skills
NOTE. CNS, central nervous system (confirmed by MRI); MRI, magnetic resonance imaging; NA, not available; PR, present report; TMP-SMX, trimethoprim-sulfamethoxazole.
64
Age,
Patient years Sex
Table. 1. Demographic Characteristics, Clinical Data, and Therapeutic Regimens for 7 Survivors of Balamuthia mandrillaris Infection
PR
[4]
[4]
[8]
[6]
[5]
[5]
Reference
redia) for his advice in this case and permanent inspiration. Sadly, Dr
Cabrera passed away on 25 May 2009.
Potential conflicts of interest. C.S. has received recent research funding
from Schering-Plough and has served on the speakers bureau for Pfizer.
All other authors: no conflicts.
7.
8.
References
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