Conclusions
As the clinical and epidemiologic history demonstrate, our patient contracted PAM caused by N. fowleri 10 days after swimming and diving in polluted river water in Italy during the unusually hot summer. He displayed characteristic, though not strictly specific, clinical features of PAM (1,2): 1) hyperacute clinical course; 2) unrelenting signs and symptoms of meningitis and encephalitis, the latter confirmed by CT imaging; 3) high levels of peripheral leukocyte count, mainly polymorphonuclear leukocytes; 4) cloudy CSF with leukocytes, hyperproteinosis, low glucose level, and absence of bacteria and fungi; 5) rapid worsening of disease, leading to death within a week. Gross pathologic and histologic findings confirmed the clinical suspicion.
None of the patient?s friends and relatives who swam in the same water hole on the same day became ill. Nasal swabs from all of them were negative for amebas, which confirms that fatal N. fowleri infection is rare.
Previous epidemiologic studies, conducted in Italy on warm water and thermal mud, failed to isolate N. fowleri, although they isolated strains of two other Naegleria species, N. italica and N. australiensis, which are experimentally pathogenic to mice (8?11). Therefore, we initially hypothesized that this case could be caused by one of these species; however, N. fowleri was identified by IIF analysis, and PCR confirmed it as genotype I.
This case is the first diagnosed occurrence of PAM in Italy. Few clinicians and microbiologists in Italy are aware of the disease and the potential danger presented by other free-living, pathogenic species of amebas, such as Acanthamoeba and Balamuthia. Consequently, other cases may have gone undiagnosed.
We emphasize that environmental conditions, in particular, the unusually hot summer of 2003 in Italy and other European countries, have strongly contributed to increasing the surface temperature of natural, open-air basins, such as rivers, lakes, and ponds. According to the forecast by a United Nations scientific advisory panel, global temperature will rise 0.8?C?3.5?C by the year 2100 if production of greenhouse gases is not reduced. An increase in surface temperature will create ideal niches for the thermophilic N. fowleri (1,2). Persons who bathe, swim, or dive in pools or freshwater natural basins will increase their chances of coming into contact with N. fowleri and contracting PAM.
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