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From the Centers for Disease Control and Prevention
January 19, 2011

Notes From the Field: Transplant-Transmitted Balamuthia mandrillaris—Arizona, 2010

JAMA. 2011;305(3):249. doi:

MMWR. 2010;59:1182

On August 23, 2010, CDC was notified regarding two organ transplant recipients in Arizona who had encephalitis with multiple ring-enhancing lesions revealed by cerebral magnetic resonance imaging. The common organ donor, a Hispanic male landscaper aged 27 years, had died in Arizona from a presumed stroke on July 21. He had a large skin lesion for approximately 6 months on his back that he had attributed to an insect bite. The ill recipients, a male liver recipient aged 56 years, and a male recipient of a kidney and pancreas aged 24 years, received organ transplants on July 22. In addition, two other recipients received organs from this donor: an adult male heart recipient received his transplant in California on July 22, and an adult male kidney recipient received his transplant in Utah on July 23.

On August 8, the liver recipient had onset of diplopia and difficulty walking; he was hospitalized on August 9 and died on August 17. The kidney-pancreas recipient had onset of headache, nausea, and vomiting on August 15 and was hospitalized the same day. A brain biopsy, performed on August 23, demonstrated amebic encephalitis on histopathologic examination; empiric therapy was initiated on August 24. On August 26, Balamuthiamandrillaris antigens were identified in the brain biopsy from the kidney-pancreas recipient and in postmortem brain and liver tissue from the liver recipient, using immunohistochemical staining. B.mandrillaris DNA was detected in the brain tissue from both patients by real-time polymerase chain reaction on August 27. The kidney-pancreas recipient died on August 30. The heart and kidney recipients, who have been asymptomatic, were placed on preemptive therapy on August 26.

This is the second confirmed cluster of transplant-transmitted Balamuthia granulomatous amebic encephalitis (GAE). The first occurred in 2009 in two recipients of kidneys from a common donor.1Balamuthia GAE is a rare and frequently fatal disease caused by B. mandrillaris, a free-living ameba found in soil.2,3 Persons of Hispanic ethnicity might be disproportionately affected.2,3 Patients can have skin lesions months to years before having encephalitis symptoms. No optimal treatment has been identified; among patients treated with combination antimicrobial therapy, few have survived.13 Amebic encephalitis might be more common than previously thought and underdiagnosed among organ donors with encephalitis of uncertain etiology or other neurologic conditions.*

Reported by:

Arizona Dept of Health Svcs. Div of Healthcare Quality Promotion, Div of High-Consequence Pathogens and Pathology, Div of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases; Div of Parasitic Diseases and Malaria, Center for Global Health; C Mbaeyi, BDS, EIS Officer, CDC.

*Additional information available at http://www.cdc.gov/balamuthia.

References
1.
Centers for Disease Control and Prevention (CDC).  Balamuthia mandrillaris transmitted through organ transplantation—Mississippi, 2009.  MMWR. 2010;59(36):1165-1170PubMed
2.
Schuster FL, Visvesvara GS. Balamuthia mandrillaris. In: Khan NA, ed. Emerging protozoan pathogens. London, England: Taylor and Francis Group; 2008:71-118
3.
Schuster FL, Yagi S, Gavali S,  et al.  Under the radar: balamuthia amebic encephalitis.  Clin Infect Dis. 2009;48(7):879-887PubMedArticle
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