Rare or­gan­isms kill woman who rinsed her si­nuses with tap wa­ter


SEAT­TLE — When a 69-yearold Seat­tle woman un­der­went brain surgery ear­lier this year at Swedish Med­i­cal Cen­ter, her doc­tors were stumped.

Last Jan­uary, the woman was ad­mit­ted to the hos­pi­tal’s emer­gency depart­ment af­ter suf­fer­ing a seizure. Doc­tors took a CT scan of her brain to de­ter­mine the cause, finding what they ini­tially thought was a tu­mor. But an ex­am­i­na­tion of tis­sue taken from her brain dur­ing surgery a day later showed she was up against a much dead­lier at­tack, one that had been un­der­way for about a year and was lit­er­ally eat­ing her alive.

“When I op­er­ated on this lady, a sec­tion of her brain about the size of a golf ball was bloody mush,” Dr. Charles Cobbs, neu­ro­sur­geon at Swedish, said in a phone in­ter­view. “There were these amoeba all over the place just eat­ing brain cells. We didn’t have any clue what was go­ing on, but when we got the ac­tual tis­sue we could see it was the amoeba.”

The woman died a month later from the rare or­gan­isms that en­tered her brain af­ter be­ing in­jected into her nasal cav­ity by way of a neti pot, a teapot-shaped prod­uct used to rinse out the si­nuses and nasal cav­ity, ac­cord­ing to a case study re­cently pub­lished in the In­ter­na­tional Jour­nal of In­fec­tious Dis­eases.

The study was au­thored by Swedish doc­tors and re­searchers who worked on her case, in­clud­ing Cobbs. The pub­li­ca­tion doesn’t iden­tify the vic­tim.

Most cases fa­tal

The woman’s in­fec­tion is the sec­ond ever re­ported in Seat­tle — the first came in 2013 — but the first fa­tal­ity to be caused by it. In 1990, re­searchers first be­came aware that this type of amoeba can cause dis­ease in peo­ple, ac­cord­ing to a study pub­lished in Clin­i­cal In­fec­tious Dis­eases in Novem­ber. That re­port found there have been 109 cases of the amoeba re­ported in the U.S. be­tween 1974 and 2016. Ninety per­cent of those cases were fa­tal.

Amoe­bas are sin­gle-celled or­gan­isms, some of which can cause dis­ease. Since they thrive in warm soil and wa­ter, some lo­cal

‘It’s such an in­cred­i­bly un­com­mon dis­ease it was not on any­one’s radar that this ini­tial nose sore would be re­lated to her brain.’ Mem­ber of team that pro­duced study

doc­tors are grow­ing con­cerned that the woman’s deadly in­fec­tion could be among other south­ern­hemi­sphere dis­eases that may be­come spread north­ward to­ward the Pa­cific North­west amid warm­ing tem­per­a­tures. The or­gan­isms are com­monly found in South Amer­ica and Cen­tral Amer­ica, but may now have a bet­ter chance of sur­vival in other, usu­ally cooler places, such as Wash­ing­ton.

“I think we are go­ing to see a lot more in­fec­tions that we see south (move) north, as we have a warm­ing of our en­vi­ron­ment,” said Cyn­thia Ma­ree, a Swedish in­fec­tious­dis­ease doc­tor who co-au­thored the case study about the woman’s con­di­tion. “Con­sid­er­ing the mor­tal­ity as­so­ci­ated with this in­fec­tion, my hope was that I was wrong. But my fear was that I was right.”

Use ster­il­ized wa­ter

In the case of the Seat­tle woman, she likely be­came in­fected with the amoe­bas from her tap wa­ter, ac­cord­ing to the re­searchers. Rather than fill­ing her neti pot with sa­line or ster­ile wa­ter, she used tap wa­ter fil­tered through a store-bought wa­ter fil­ter. She then shot the con­tam­i­nated wa­ter far up her nasal cav­ity to­ward ol­fac­tory nerves in the up­per part of her nasal cav­ity, caus­ing the brain-eat­ing in­fec­tion called gran­u­lo­ma­tous amoe­bic en­cephali­tis (GAE).

Re­searchers are also “lim­ited in our un­der­stand­ing” of the fac­tors that in­crease the like­li­hood of con­tract­ing the dis­ease, which may in­clude a com­pro­mised im­mune sys­tem, ge­net­ics, and en­vi­ron­men­tal fac­tors, Keenan Piper, a mem­ber of the Swedish team that pro­duced the study.

Amoe­bas may be found in fresh-wa­ter sources around Puget Sound such as wells, but aren’t present in city-treated wa­ter, ac­cord­ing to Liz Cole­man, a spokes­woman for the En­vi­ron­men­tal Pub­lic Health divi­sion of the state’s Depart­ment of Health. The re­searchers weren’t able to test the woman’s tap wa­ter, but peo­ple can­not be in­fected by sim­ply swal­low­ing wa­ter con­tam­i­nated with the amoe­bas, ac­cord­ing to Cobbs.

Af­ter con­tract­ing the amoe­bas, the woman de­vel­oped a red sore on her nose. For about a year, the sore was mis­di­ag­nosed and be­ing treated as a com­mon, treat­able skin con­di­tion known as rosacea, the study said. Cobbs said this was likely the first symp­tom of the amoeba, but its rar­ity makes the amoeba dif­fi­cult to quickly di­ag­nose.

“It’s such an in­cred­i­bly un­com­mon dis­ease it was not on any­one’s radar that this ini­tial nose sore would be re­lated to her brain,” Piper said.

The woman’s in­fec­tion is the first to be linked to im­proper nasal lavage, ac­cord­ing to Piper. Al­though the risk of in­fec­tion to the brain is ex­tremely low, peo­ple who use neti pots or other nasal-ir­ri­ga­tion de­vices can nearly elim­i­nate it by fol­low­ing di­rec­tions printed on the de­vices, in­clud­ing us­ing only sa­line or ster­il­ized wa­ter, Ma­ree said.

Slow-act­ing amoeba

Three types of amoe­bas have been iden­ti­fied as caus­ing fa­tal brain in­fec­tions, ac­cord­ing to Jen­nifer Cope, an epi­demi­ol­o­gist with the Cen­ters for Dis­ease Control and Preven­tion’s unit that fo­cuses on food­borne, wa­ter­borne and en­vi­ron­men­tal dis­eases.

While in­fec­tions re­main rare, the Seat­tle woman died from the least-known of them all: Bala­muthia man­drillaris. That’s a type of amoeba that moves more slowly and can take weeks or months to cause death. The other slow-act­ing amoeba is called Acan­thamoeba spp.

Nae­g­le­ria fow­leri is the most doc­u­mented, Cope said, be­cause it acts quickly, caus­ing an in­fec­tion that leads to death in just a few days. New Jersey health of­fi­cials linked a man’s death to N. fow­leri in Oc­to­ber. He was be­lieved to have got­ten in­fected while surf­ing in an in­door wa­ter park in Texas. N. fow­leri is present in Puget Sound wa­ters and other fresh­wa­ter sources, Ma­ree said. She wasn’t im­me­di­ately aware of any other lo­cal cases of in­fec­tion.

Cope said all three amoeba types have sim­i­lar rates of preva­lence, but Bala­muthia man­drillaris is the least-rec­og­nized among the med­i­cal com­mu­nity be­cause it is rarely doc­u­mented, pro­vid­ing lim­ited op­por­tu­nity for re­search.

It is thought the amoe­bas are pri­mar­ily soil-based, but the “ex­act en­vi­ron­men­tal niche is re­ally un­known,” Cope said in an email.

“From my un­der­stand­ing it’s ev­ery­where. There are molds and fungi that can kill you if it in­fects your brain. MRSA (a treat­able bac­te­rial in­fec­tion) is ev­ery­where, but we don’t have a mech­a­nism of in­ject­ing it into our brain,” Cobbs said. “It’s al­ways go­ing to be an up­hill bat­tle be­cause peo­ple learn by see­ing things over and over again, but I don’t think that there are go­ing to be an in­crease in cases in the fu­ture. At least I hope not.”

Keenan Piper

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