Cure of Acanthamoeba cerebral abscess in a liver transplant patient

Abstract

Acanthamoeba-related cerebral abscess and encephalitis are rare but usually fatal, being caused by free-living amoebic infections usually occurring in immunocompromised patients. In patients receiving transplants, a literature review showed that the infection is universally fatal. The diagnosis is often missed despite appropriate investigations including lumbar puncture, computerized tomography, and brain biopsy. We present the first reported liver transplant patient with Acanthamoeba cerebral abscess. The diagnosis was made in brain tissue removed at decompressive frontal lobectomy. He was successfully treated with a 3-month course of co-trimoxazole and rifampicin. There was no recurrence of the disease after 11 years of follow-up. Liver Transpl 14:308-312, 2008 Central nervous system (CNS) infections by free-living amoebae, including Acanthamoeba species, Balamuthia mandrillaris, and Naegleria fowleri, have been recognized only in recent decades. The first two amoebae cause chronic granulomatous encephalitis, whereas the last one causes acute fulminant meningitis. Acanthamoeba-related infection is usually limited to immunocompromized patients, although infection in healthy children has been reported.1 Unfortunately, most of the infections are fatal and are diagnosed at autopsy. 2,3 We report the first case of successfully treated Acanthamoeba cerebral infection following liver transplantation. CASE REPORTA 41-year-old male had liver transplantation with a cadaveric donor graft in our hospital in September 1994 for end-stage alcoholic liver cirrhosis. He had a previous history of abdominal tuberculosis in 1986 and was an insulin-dependent diabetic. He recovered well after the operation and was given maintenance immunosuppression of cyclosporine, azathioprine, and prednisolone. He received fluconazole and acyclovir prophylaxis, which he continued for 6 weeks after discharge, which took place 3 weeks after the operation. At 3 months after transplantation, his prednisolone was tailed off completely. He developed depression and resumed drinking alcohol about 9 months after transplantation without affecting his graft function. He was followed up by a psychiatrist specializing in alcohol and substance abuse. Azathioprine was also stopped at the same time because of neutropenia, which subsequently recovered fully.At 14 months after transplantation, the patient was admitted as an emergency because of pyrexia, sore throat, and green sputum for 2 days. Physical examination was normal apart from the abdominal scar of his surgery. Chest X-ray showed elevated right hemidiaphragm but was otherwise normal. Cytomegalovirus polymerase chain reaction in blood was positive. Otherwise, no positive culture or serological positivity for bacteria or viruses was obtained. Ganciclovir was started on day 4 of admission. However, the patient continued to have a high unremitting fever. On day 6, Abbreviations: CNS, central nervous system; CT, computerized tomography.

Importance of Nonenteric Protozoan Infections in Immunocompromised People

“…In lung transplant recipients, infections involving the skin, lungs, and brain as well as sinusitis and widely disseminated disease have been reported (176,411,571,580). Acanthamoeba has also been reported to cause disease in kidney and liver transplant recipients (215,536). An unusual case of Acanthamoeba infection was reported for a patient who was severely IC (CD4 ϩ cell count of 182 cells/mm 3 ) due to an infection with Mycobacterium tuberculosis (594).…”

“…A broad range of drugs have been used to treat Acanthamoeba infections but with various successes. Drugs that show some anti-Acanthamoeba activity include propamidine isethionate, polyhexamethylene biguanide, itraconazole, clotrimazole, pentamidine isethionate, amphotericin B, flucytosine, chlorhexidine gluconate, hydroxystilbamidine, paromomycin, cotrimoxazole, rifampin, polymyxin, sulfadiazine, trimethoprimsulfamethoxazole, azithromycin, dibromopropamidine, hexamidine, and ketoconazole (215,377,401,411,579). In one study, propamidine proved to be the most effective anti-Acanthamoeba agent against 19 corneal isolates (357).…”

“…Despite the broad range of drugs trialed, the most effective treatment for acanthamoebiasis remains undefined, and many drug treatments have shown various efficacies (215,320,323,377,571,594). To date, there is no proven regimen for the treatment of Acanthamoeba infection (233).…”

Amebic meningoencephalitides and keratitis: challenges in diagnosis and treatment*

“…A few patients have recovered after a combination of multiple drugs including fluconazole, itraconazole, ketoconazole, pentamidine isethionate, trimethoprim-sulfamethoxazole (co-trimoxazole), sulfadiazine, and 5-fluorocytosine (flucytosine), but the outlook for most patients remains hopeless especially because of HIV/AIDS and other opportunistic infections [2, 14,15]. Recently, however, several patients recovered after treatment with a combination of drugs partly because of early diagnosis [16][17][18][19][20][21]. Treatment of cutaneous infections without spreading to CNS has fared better.…”

Treatment of Granulomatous Amoebic Encephalitis with Voriconazole and Miltefosine in an Immunocompetent Soldier

“…[4][5][6] Where intracerebral lesions are observed, surgical resection is generally required. [7][8][9][10] We report the successful treatment of a 38-year-old Canadian soldier with surgical debulking combined with voriconazole and miltefosine.…”