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Little is known about the prevalence of Balamuthia mandrillaris amoebae and Balamuthia amoebic encephalitis in Africa. As an approach, relative concentrations of amoebae-binding serum antibodies (Ab) were assessed by flow cytometry using formaldehyde-fixed B. mandrillaris, Acanthamoeba lenticulata 72-2 and Acanthamoeba castellanii 1BU amoebae for specific Ab capture (B.m.-Ab, A.l.-Ab, A.c.-Ab). One hundred and ninety-two sera from West African (Côte d'Ivoire) donors aged 11-95years (mean 38 a; 51% males), and living in villages surrounded by rainforest near the Liberian border, were tested and related to reference sera from Berlin. While B.m.-Ab tended to increase with donor age, A.l.-Ab and A.c.-Ab did not. Accordingly, B.m.-Ab correlated only weakly with A.l.-Ab or A.c.-Ab. Of the nine individuals with the highest B.m.-Ab concentrations, most were elderly (mean 58 a), male (78%), and professed intensive outdoor activity (hunting, farming). Only three of these sera also showed elevated A.l.-Ab, and none elevated A.c.-Ab.

Pathogenic free-living amoebae, such as Acanthamoeba species, Balamuthia mandrillaris, and Naegleria fowleri, are known to cause infections of the central nervous system in human and other animals. In 2001, a case of human encephalitis was reported that was caused by another amoeba with morphological features suggestive of Sappinia. The amoeba originally identified as Sappinia diploidea was identified, most likely as S. pedata, by use of newly developed real-time polymerase chain reaction assays. This amoeba had previously been found only in environmental sources, such as soil and tree bark. The results illustrate the potential for other free-living amoebae, which are not normally associated with human disease, to cause occasional infections.

Eosinophilic meningitis can be the result of noninfectious causes and infectious agents. Among the infectious agents, Angiostrongylus cantonensis and Gnathostoma spinigerum are the most common. Although angiostrongyliasis and gnathostomiasis are not common in the United States, international travel and immigration make these diseases clinically relevant. Both A. cantonensis and G. spinigerum infection can present as severe CNS compromise. Diagnoses of both infections can be challenging and are often clinical because of a paucity of serological assays readily available in the United States. Furthermore, there are conflicting recommendations about treatment for angiostrongyliasis and gnathostomiasis. To further explore the emerging nature of these helminthic infections, a case description and review of A. cantonensis and G. spinigerum infections are presented. The clinical severity of eosinophilic meningitis and diagnosis of these infections are highlighted.

SUMMARY Balantidium coli is a cosmopolitan parasitic-opportunistic pathogen that can be found throughout the world. Pigs are its reservoir hosts, and humans become infected through direct or indirect contact with pigs. In rural areas and in some developing countries where pig and human fecal matter contaminates the water supply, there is a greater likelihood that balantidiosis may develop in humans. The infection may be subclinical in humans, as it mostly is in pigs, or may develop as a fulminant infection with bloody and mucus-containing diarrhea; this can lead to perforation of the colon. The disease responds to treatment with tetracycline or metronidazole. Balantidiosis is a disease that need never exist given access to clean water and a public health infrastructure that monitors the water supply and tracks infections. Its spread can be limited by sanitary measures and personal hygiene, but it is a disease that will be around as long as there are pigs. Immunocompromised individuals have developed balantidiosis without any direct contact with pigs, perhaps with rats or contaminated produce as a possible source of infection. For the clinician, balanatidiosis should be included in the differential diagnosis for persistent diarrhea in travelers to or from Southeast Asia, the Western Pacific islands, rural South America, or communities where close contact with domestic swine occurs. Warming of the earth's surface may provide a more favorable environment, even in the now-temperate areas of the world, for survival of trophic and cystic stages of Balantidium, and its prevalence may increase. Effective sanitation and uncontaminated water are the most useful weapons against infection. Fortunately, balantidiosis responds to antimicrobial therapy, and there have been no reports of resistance to the drugs of choice.

Background. Balamuthia mandrillaris and Acanthamoeba species are 2 free-living amoebae responsible for granulomatous amoebic encephalitis in humans and animals. We have screened serum samples from hospitalized patients with encephalitis for antibodies against these 2 amoebae as a means of detecting a disease with few defining symptoms and a poor prognosis. Methods. Indirect immunofluorescence antibody (IFA) staining of serum samples from patients with encephalitis was conducted over a period of 6 years to detect amoeba antibodies. More than 250 serum samples from patients hospitalized with encephalitis were screened. Most of the samples were from patients in California and were screened as part of the California Encephalitis Project, with a small number of specimens from other states. Results. During the course of the study, 7 cases of Balamuthia encephalitis were detected; all cases were detected in Hispanic individuals, and all cases were fatal. Examination of hematoxylin-eosin-stained and immunostained sections of brain tissue obtained at biopsy or autopsy for amoebae confirmed balamuthiasis in all serum samples with positive IFA results. One case of Acanthamoeba encephalitis was detected in an immunocompromised individual with a normal antibody titer by identification of amoebae in immunostained brain tissue obtained at autopsy. Conclusions. IFA can be successfully used in screening for balamuthiasis and acanthamoebiasis in patients whose clinical presentation, laboratory results, and neuroimaging findings are suggestive of amoebic encephalitis. Ideally, this can lead to an earlier definitive diagnosis and earlier start of antimicrobial therapy. Without IFA staining, the balamuthiasis cases in our study would have been diagnosed as neurocysticercosis, tumor, tuberculosis, or viral encephalitis or would have been undiagnosed.

Naegleria dunnebackei n. sp., a new species of the free-living amoeboflagellate Naegleria, is described in this report. The organism was isolated from a water sample taken from drinking troughs associated with cases of primary amoebic meningoencephalitis in cattle at a ranch in southern California. The isolate grew at, but not above 37 degrees C, and did not kill young mice upon intranasal inoculation suggesting that it was not pathogenic. The new species combines morphological features of non-pathogenic Naegleria gruberi and pathogenic Naegleria fowleri. The trophic amoeba resembled other members of the genus, with a prominent vesicular nucleus and mitochondria with discoidal cristae; a Golgi apparatus was not observed by electron microscopy. The cyst stage had pores in the wall typical of those seen in pathogenic N. fowleri. Upon suspension in distilled water, amoebae transformed into temporary, non-feeding flagellates, mostly with two anterior flagella but occasionally with four. The rationale for its description as a new species was based upon sequencing of the 5.8S rDNA and internal transcribed spacers of the amoeba, which is similar to but not identical to that of Naegleria gallica, differing from that organism's DNA by six base pairs. Virus-like elements were found in the cytoplasm of trophic amoebae, often in association with crystalloids, and may be the cause of lysis of amoebae in culture.

Balamuthia mandrillaris is a free-living ameba that causes granulomatous amebic encephalitis in both immunocompromised and immunocompetent individuals. Because of a lack of pathognomonic symptoms and the difficulty in recognizing amebas in biopsied tissues, most cases are not diagnosed or effectively treated, leading to a >95% mortality. We report here on five cases of balamuthiasis that were diagnosed by indirect immunofluorescence (IIF) staining of serum for anti- Balamuthia antibodies (titer ≥ 1:128) and confirmed by IIF of unstained brain tissue sections and/or detection of amebas in hematoxylin-eosin-stained slides. Additionally, we have used the PCR for the detection of mitochondrial 16S rRNA gene DNA from the ameba in clinical specimens such as brain tissue and cerebrospinal fluid (CSF) from individuals with Balamuthia encephalitis. Balamuthia DNA was successfully detected by the PCR in clinical samples from all five individuals. It was detected in brain tissue from three cases, in CSF from three cases, and in one of two samples of lung tissue from two individuals, but not in two samples of kidney tissue tested. One sample of unfixed brain tissue was culture positive for Balamuthia . In order to test the sensitivity of the PCR for detection of Balamuthia DNA, CSF specimens from two individuals negative for amebic infection were spiked with Balamuthia amebas. We found that it was possible to detect Balamuthia DNA in the PCR mixtures containing mitochondrial DNA from 1 to as little as 0.2 ameba per reaction mixture. A single Balamuthia ameba contains multiple mitochondrial targets; thus, 0.2 ameba represents multiple targets for amplification and is not equivalent to 0.2 of an ameba as a target.

Granulomatous amebic encephalitis (GAE), an infection of immunocompromised hosts, is almost uniformly fatal. A case of GAE in a patient who failed to mount a serologic response to Acanthamoeba polyphaga is presented. Although Acanthamoeba polyphaga that is sensitive to multiple antimicrobials grew from brain tissue, an inability to make a premortem diagnosis precluded therapy.

Balamuthia mandrillarisamoebas are recognized as a causative agent of granulomatous amoebic encephalitis, a disease that is usually fatal. They were first recognized when isolated from the brain of a mandrill baboon that died in the San Diego Zoo Wild Life Animal Park. Subsequently, the amoebas have been found in a variety of animals, including humans (young and old, immunocompromised and immunocompetent persons), in countries around the world. Until recently, the amoebas had not been recovered from the environment and their free-living status was in question. The recovery of aBalamuthiaamoeba from a soil sample taken from a plant at the home of a child from California, USA, who died ofBalamuthiaamoebic encephalitis, was reported previously. In a continued investigation, a second amoeba was isolated from soil that was obtained from an outdoor potted plant in a spatially unrelated location. A comparison of these two environmental amoebas that were isolated from different soils with the amoeba that was obtained from the child's clinical specimen is reported here. Included are the isolation procedure for the amoebas, their growth requirements, their immunological response to anti-Balamuthiaserum, their sensitivity to a selection of antimicrobials and sequence analysis of their 16S rRNA gene. The evidence is consistent that the amoebas isolated from both soil samples and the clinical isolate obtained from the Californian child areB. mandrillaris.

Knowledge that free-living amoebae are capable of causing human disease dates back some 50 years, prior to which time they were regarded as harmless soil organisms or, at most, commensals of mammals. First Naegleria fowleri, then Acanthamoeba spp. and Balamuthia mandrillaris, and finally Sappinia diploidea have been recognised as etiologic agents of encephalitis; Acanthamoeba spp. are also responsible for amoebic keratitis. Some of the infections are opportunistic, occurring mainly in immunocompromised hosts (Acanthamoeba and Balamuthia encephalitides), while others are non-opportunistic (Acanthamoeba keratitis, Naegleria meningoencephalitis, and cases of Balamuthia encephalitis occurring in immunocompetent humans). The amoebae have a cosmopolitan distribution in soil and water, providing multiple opportunities for contacts with humans and animals, as evidenced by antibody titers in surveyed human populations. Although, the numbers of infections caused by these amoebae are low in comparison to other protozoal parasitoses (trypanosomiasis, toxoplasmosis, malaria, etc.), the difficulty in diagnosing them, the challenge of finding optimal antimicrobial treatments and the morbidity and relatively high mortality associated with, in particular, the encephalitides have been a cause for concern for clinical and laboratory personnel and parasitologists. This review presents information about the individual amoebae: their morphologies and life-cycles, laboratory cultivation, ecology, epidemiology, nature of the infections and appropriate antimicrobial therapies, the immune response, and molecular diagnostic procedures that have been developed for identification of the amoebae in the environment and in clinical specimens.

This report describes the first isolation of the ameba Balamuthia mandrillaris from an environmental soil sample associated with a fatal case of amebic encephalitis in a northern California child. Isolation of the ameba into culture from autopsied brain tissue confirmed the presence of Balamuthia . In trying to locate a possible source of infection, soil and water samples from the child's home and play areas were examined for the presence of Balamuthia . The environmental samples (plated onto nonnutrient agar with Escherichia coli as a food source) contained, in addition to the ameba, a variety of soil organisms, including other amebas, ciliates, fungi, and nematodes, as contaminants. Presumptive Balamuthia amebas were recognized only after cultures had been kept for several weeks, after they had burrowed into the agar. These were transferred through a succession of nonnutrient agar plates to eliminate fungal and other contaminants. In subsequent transfers, axenic Naegleria amebas and, later, tissue cultures (monkey kidney cells) served as the food source. Finally, the amebas were transferred to cell-free axenic medium. In vitro, the Balamuthia isolate is a slow-growing organism with a generation time of ∼30 h and produces populations of ∼2 × 10 5 amebas per ml. It was confirmed as Balamuthia by indirect immunofluorescence staining with rabbit anti- Balamuthia serum and human anti- Balamuthia antibody-containing serum from the amebic encephalitis patient. The environmental isolate is similar in its antimicrobial sensitivities and identical in its 16S ribosomal DNA sequences to the Balamuthia isolate from the deceased patient.

SUMMARY Free-living amebas are widely distributed in soil and water, particularly members of the genera Acanthamoeba and Naegleria . Since the early 1960s, they have been recognized as opportunistic human pathogens, capable of causing infections of the central nervous system (CNS) in both immunocompetent and immunocompromised hosts. Naegleria is the causal agent of a fulminant CNS condition, primary amebic meningoencephalitis; Acanthamoeba is responsible for a more chronic and insidious infection of the CNS termed granulomatous amebic encephalitis, as well as amebic keratitis. Balamuthia sp. has been recognized in the past decade as another ameba implicated in CNS infections. Cultivation of these organisms in vitro provides the basis for a better understanding of the biology of these amebas, as well as an important means of isolating and identifying them from clinical samples. Naegleria and Acanthamoeba can be cultured axenically in cell-free media or on tissue culture cells as feeder layers and in cultures with bacteria as a food source. Balamuthia , which has yet to be isolated from the environment, will not grow on bacteria. Instead, it requires tissue culture cells as feeder layers or an enriched cell-free medium. The recent identification of another ameba, Sappinia diploidea , suggests that other free-living forms may also be involved as causal agents of human infections.

SUMMARY Cultivation of both human and non-human species of Plasmodium spp., the causal agent of malaria, has been a major research success, leading to a greater understanding of the parasite. Efforts at cultivating the organisms in vitro are complicated by the parasites' alternating between a human host and an arthropod vector, each having its own set of physiological, metabolic, and nutritional parameters. Life cycle stages of the four species that infect humans have been established in vitro. Of these four, P. falciparum remains the only species for which all stages have been cultured in vitro; different degrees of success have been achieved with the other human Plasmodium spp. The life cycle includes the exoerythrocytic stage (within liver cells), the erythrocytic stage (within erythrocytes or precursor reticulocytes), and the sporogonic stage (within the vector). Culture media generally consist of a basic tissue culture medium (e.g., minimal essential medium or RPMI 1640) to which serum and erythrocytes are added. Most of the efforts have been directed toward the stage found in the erythrocyte. This stage has been cultivated in petri plates or other growth vessels in a candle jar to generate elevated CO 2 levels or in a more controlled CO 2 atmosphere. Later developments have employed continuous-flow systems to reduce the labor-intensive nature of medium changing. The exoerythrocytic and sporogonic life cycle stages have also been cultivated in vitro. A number of avian, rodent, and simian malarial parasites have also been established in vitro. Although cultivation is of great help in understanding the biology of Plasmodium , it does not lend itself to use for diagnostic purposes.

Balamuthia mandrillaris and several species of Acanthamoeba are pathogenic “opportunistic” free-living amebas which cause granulomatous encephalitis (GAE) in humans and animals. The granulomatous component is negligible or absent, particularly in immunocompromised individuals. GAE is an “opportunistic” infection, usually seen in debilitated, malnourished individuals, in patients undergoing immunosuppressive therapy for organ transplants, and in Acquired Immunodeficiency Syndrome (AIDS). From around the world 156 cases of GAE have been reported from 1956 through October 1, 1995, 59 (26 in the USA) of them caused by B. mandrillaris , at least seven of them in AIDS patients. The present study was designed to compare and contrast the susceptibility of infection, the rate of infectivity and the histopathological changes within the CNS between the mutant, severe combined immunodeficient mice (SCID) infected with B. mandrillaris and the normal immunocompetent BALB-C mice. The SCID mouse is severely deficient in B and T lymphocytes, therefore lacking immunoglobulin and cell-mediated immunity. This mouse is also prone to develop early T cell lymphomas. One thousand amebic trophozoites and cysts of B. mandrillaris were intranasally and intraperitoneally inoculated in both strains of mice. Seventy percent of the intranasally inoculated SCID mice died due to CNS infection. Amebic trophozoites and cysts were found within CNS parenchyma without inflammatory response. Death occurred from 2 to 4 weeks after inoculation. By contrast only 10 percent of the intranasally inoculated BALB-C mice died with CNS infection showing the characteristic features of GAE. None of the intraperitoneally inoculated mice developed amebic infection. The SCID and BALB-C mice are logical models to study the structural alterations within the CNS of B. mandrillaris infection. This animal model recapitulates with excellent degree of fidelity several aspects of the pathogenesis and histopathological features of free-living amebic infection in human beings.

We recently reported the isolation of a leptomyxid ameba from the brain of a mandrill baboon that died of meningoencephalitis. Based on light and electron microscopic studies, animal pathogenicity tests, and immunofluorescence patterns, we conclude that our isolate differs fundamentally from the other two amebas (Leptomyxa and Gephyramoeba) included in the Order Leptomyxida. We therefore created a new genus, Balamuthia, to accommodate our isolate and described it as Balamuthia mandrillaris to reflect the origin of the type species. Briefly, B. mandrillaris is a pathogenic ameba that causes amebic encephalitis in humans and animals. It has trophic and cyst stages in its life cycle, and is uninucleate with a large vesicular nucleus and a central nucleolus. Mature cysts have a tripartite wall consisting of an outer loose ectocyst, an inner endocyst and a middle mesocyst. Unlike Acanthamoeba and Naegleria, the other two amebas that cause amebic encephalitis in humans, Balamuthia will not grow on agar plates seeded with enteric bacteria. However, Balamuthia grows on a variety of mammalian cell cultures and kills mice following intranasal or intraperitoneal inoculation. Based on immunofluorescence testing, 35 cases of amebic encephalitis in humans and three in other animals have been identified worldwide as being caused by Balamuthia.

Background. We present data from 9 years (1999–2008) of tests for Balamuthia mandrillaris, an agent of amebic encephalitis that were conducted as part of the California Encephalitis Project. Methods. Specimens obtained from patients with encephalitis were sent to the California Encephalitis Project for diagnostic testing; a subset of these specimens were tested for Balamuthia species. Tests included indirect immunofluorescent staining of sections for amebae, fluorescent antibody staining and enzyme-linked immunosorbent assay for serum titers, and polymerase chain reaction for Balamuthia 16S mitochondrial DNA. Cerebrospinal fluid (CSF) samples obtained from patients with diverse types of encephalitis were also tested for a broad range of cytokines. Results. Of 13500 cases referred to the California Encephalitis Project, 10 were found to be amebic encephalitis on the basis of serologic and CSF tests and examination of stained tissue sections. Most of these cases would have been described as “encephalitis of unknown origin” if it were not for the California Encephalitis Project. Nine of the 10 patients were male; ages ranged from 1.5 to 72 years. All patients had abnormal neuroimaging findings and abnormal CSF composition. The more common symptoms at presentation included headache, seizures, cranial nerve palsies, and lethargy. CSF specimens from patients with Balamuthia infection had significant elevations in the levels of cytokines IL-6 and IL-8, compared with specimens obtained from persons with viral or noninfectious encephalitides. Conclusions. Balamuthiasis is difficult to diagnose, and it is likely that cases go unrecognized because clinicians and laboratorians are unfamiliar with the disease. Alerting the medical community to this disease may lead to earlier diagnosis and improve the chances of survival. Granulomatous amebic encephalitis due to the freeliving ameba Balamuthia mandrillaris (BAE) is an often-unrecognized disease. B. mandrillaris has caused, with little attention, 1125 cases of BAE since 1975, as determined on the basis of unpublished laboratory results and published reports in the biomedical literature [2]. Relatively few clinicians are familiar with the disease, and diagnosis is frequently made postmortem. Only ∼60 cases of BAE have been diagnosed in the

We report the development of an enzyme-linked immunosorbent assay (ELISA) for detecting antibodies to Balamuthia mandrillaris, a free-living ameba that is an etiologic agent of granulomatous amebic encephalitis (GAE). As part of the California Encephalitis Project (CEP), we have tested serum and cerebrospinal fluid (CSF) samples from a subgroup of 130 hospitalized encephalitis patients (out of approximately 430 samples) over a 16-month period. Case criteria were based on clinical, laboratory, and occupational/recreational histories. All serum samples initially underwent screening by immunofluorescent antibody (IFA) staining with results ranging from no detectable ameba antibodies to titers of 1:256. In addition to the 130 samples tested prospectively, sera and/or CSF from 11 previously confirmed cases of balamuthiasis, six healthy individuals, and earlier CEP submissions with high IFA antibody titers were also tested retrospectively. Among the 130 samples, two cases of balamuthiasis were identified by ELISA and confirmed by the polymerase chain reaction (PCR). The availability of sera from human and animal cases and from varied geographic areas allowed comparisons of serologic similarities of the different Balamuthia strains and human sera. All sera, whether from human or other mammals, reacted with all strains of Balamuthia, as they did with Balamuthia amebae from different geographic areas. Enzyme-linked immunosorbent assay results were consistent with the IFA results. Differences between readings were likely due to cross-reactivity between Balamuthia antigens and unidentified antibodies in serum.

Granulomatous amoebic encephalitis (GAE) is a usually fatal disease caused by the free-living amoebae Balamuthia mandrillaris and Acanthamoeba spp. The intent of this study was to determine if the polymerase chain reaction (PCR) could be used retrospectively to detect amoeba mitochondrial 16S ribosomal ribonucleic acid gene deoxyribonucleic acid (DNA) in confirmed archival tissue sections from GAE cases stored in our laboratories for 1 to 34 years. The DNA was extracted from deparaffinized sections, and appropriate primer sets for each of the two amoebae were used for DNA detection. Indirect immunofluorescent staining (IIF) of tissue sections was used as the standard for identification of amoebae against which the PCR results were compared. Sixty slides from a total of 56 cases were processed by PCR for amoeba 16S DNA. In 28 (47%) slides, there was agreement between the IIF and PCR results. In 41 of the slides (52%), no DNA was detected after PCR. In one slide (1%), the PCR and IIF results did not agree. While PCR supported IIF findings in about half of the slides, there are significant limitations in amoeba DNA identifications in formalin-fixed brain tissues. Degradation of amoeba DNA because of formalin fixation was probably a factor in limiting valid results.

Among the many genera of free-living amoebae that exist in nature, members of only four genera have an association with human disease: Acanthamoeba spp., Balamuthia mandrillaris, Naegleria fowleri and Sappinia diploidea. Acanthamoeba spp. and B. mandrillaris are opportunistic pathogens causing infections of the central nervous system, lungs, sinuses and skin, mostly in immunocompromised humans. Balamuthia is also associated with disease in immunocompetent children, and Acanthamoeba spp. cause a sight-threatening infection, Acanthamoeba keratitis, mostly in contact-lens wearers. Of more than 30 species of Naegleria, only one species, N. fowleri, causes an acute and fulminating meningoencephalitis in immunocompetent children and young adults. In addition to human infections, Acanthamoeba, Balamuthia and Naegleria can cause central nervous system infections in animals. Because only one human case of encephalitis caused by Sappinia diploidea is known, generalizations about the organism as an agent of disease are premature. In this review we summarize what is known of these free-living amoebae, focusing on their biology, ecology, types of disease and diagnostic methods. We also discuss the clinical profiles, mechanisms of pathogenesis, pathophysiology, immunology, antimicrobial sensitivity and molecular characteristics of these amoebae.

We report here the first Portuguese case of acute fatal granulomatous encephalitis attributed to Balamuthia mandrillaris , initially thought to be a brain tumor, which had a progressive and fatal outcome. Balamuthia mandrillaris is a free-living amoeba recognized as an uncommon agent of granulomatous encephalitis. Infections have been identified in immunocompromised hosts and in immunocompetent pediatric patients. Balamuthia infections are very rare, with only two reported cases in Europe. The case presented here occurred in a previously healthy boy who died 5 weeks after the onset of the symptoms. No evidence of immunological deficiency was noted, and testing for human immunodeficiency virus antibodies was negative. The symptoms were initially thought to be the result of a tumor, but histopathologic examination showed evidence of amoebic infection. Immunofluorescence staining of brain tissue identified B. mandrillaris as the infectious agent. The diagnosis was confirmed with PCR by detecting Balamuthia DNA in formalin-fixed brain tissue sections. Despite initiation of empirical antimicrobial therapy for balamuthiasis, the patient died 3 weeks after being admitted to the hospital. No source of infection was readily apparent.

Background. Encephalitis is a complex syndrome, and its etiology is often not identified. The California Encephalitis Project was initiated in 1998 to identify the causes and further describe the clinical and epidemiologic characteristics of encephalitis. Methods. A standardized report form was used to collect demographic and clinical data. Serum, cerebrospinal fluid, and respiratory specimens were obtained prospectively and were tested for the presence of herpesviruses, arboviruses, enteroviruses, measles, respiratory viruses, Chlamydia species, and Mycoplasma pneumoniae. The association between an identified infection and encephalitis was defined using predetermined, organism-specific criteria for confirmed, probable, or possible causes. Results. From 1998 through 2005, a total of 1570 patients were enrolled. Given the large number of patients, subgroups of patients with similar clinical characteristics and laboratory findings were identified. Ten clinical profiles were described. A confirmed or probable etiologic agent was identified for 16% of cases of encephalitis: 69% of these agents were viral; 20%, bacterial; 7%, prion; 3%, parasitic; and 1%, fungal. An additional 13% of cases had a possible etiology identified. Many of the agents classified as possible causes are suspected but have not yet been definitively demonstrated to cause encephalitis; these agents include M. pneumoniae (n = 96), influenza virus (n = 22), adenovirus (n = 14), Chlamydia species (n = 10), and human metapneumovirus (n = 4). A noninfectious etiology was identified for 8% of cases, and no etiology was found for 63% of cases. Conclusions. Although the etiology of encephalitis remains unknown in most cases, the recognition of discrete clinical profiles among patients with encephalitis should help focus our efforts toward understanding the etiology, pathogenesis, course, and management of this complex syndrome.

The anticancer agent miltefosine and the antifungal drug voriconazole were tested in vitro against Balamuthia mandrillaris, Acanthamoeba spp., and Naegleria fowleri. All three amebas are etiologic agents of chronic (Balamuthia, Acanthamoeba) or fulminant (Naegleria) encephalitides in humans and animals and, in the case of Acanthamoeba, amebic keratitis. Balamuthia exposed to40 microm concentrations of miltefosine survived, while concentrations ofor=40 microM were generally amebacidal, with variation in sensitivity between strains. At amebastatic drug concentrations, recovery from drug effects could take as long as 2 weeks. Acanthamoeba spp. recovered from exposure to 40 microM, but not 80 microM miltefosin. Attempts to define more narrowly the minimal inhibitory (MIC) and minimal amebacidal concentrations (MAC) for Balamuthia and Acanthamoeba were difficult due to persistence of non-proliferating trophic amebas in the medium. For N. fowleri, 40 and 55 microM were the MIC and MAC, respectively, with no trophic amebas seen at the MAC. Voriconazole had little or no inhibitory effect on Balamuthia at concentrations up to 40 microg/ml, but had a strong inhibitory effect upon Acanthamoeba spp. and N. fowleri at all drug concentrations through 40 microg/ml. Following transfer to drug-free medium, Acanthamoeba polyphaga recovered within a period of 2 weeks; N. fowleri amebas recovered from exposure to 1 microg/ml, but not from higher concentrations. All testing was done on trophic amebas; drug sensitivities of cysts were not examined. Miltefosine and voriconazole are potentially useful drugs for treatment of free-living amebic infections, though sensitivities differ between genera, species, and strains.

The roles free-living amebae and the parasitic protozoa Entamoeba histolytica and Balantidium coli play as agents of waterborne zoonotic diseases are examined. The free-living soil and water amebae Naegleria fowleri, Acanthamoeba spp., and Balamuthia mandrillaris are recognized etiologic agents of mostly fatal amebic encephalitides in humans and other animals, with immunocompromised and immunocompetent hosts among the victims. Acanthamoeba spp. are also agents of amebic keratitis. Infection is through the respiratory tract, breaks in the skin, or by uptake of water into the nostrils, with spread to the central nervous system. E. histolytica and B. coli are parasitic protozoa that cause amebic dysentery and balantidiasis, respectively. Both intestinal infections are spread via a fecal-oral route, with cysts as the infective stage. Although the amebic encephalitides can be acquired by contact with water, they are not, strictly speaking, waterborne diseases and are not transmitted to humans from animals. Non-human primates and swine are reservoirs for E. histolytica and B. coli, and the diseases they cause are acquired from cysts, usually in sewage-contaminated water. Amebic dysentery and balantidiasis are examples of zoonotic waterborne infections, though human-to-human transmission can occur. The epidemiology of the diseases is examined, as are diagnostic procedures, anti-microbial interventions, and the influence of globalization, climate change, and technological advances on their spread.

This review focuses on free-living amoebae, widely distributed in soil and water, causing opportunistic and non-opportunistic infections in humans: Acanthamoeba spp., Balamuthia mandrillaris, Naegleria fowleri, and Sappinia diploidea. Diseases include primary amoebic meningoencephalitis (N. fowleri), granulomatous amoebic encephalitis, cutaneous and nasopharyngeal infections (Acanthamoeba spp., Balamuthia mandrillaris, S. diploidea), and amoebic keratitis (Acanthamoeba spp). Acanthamoeba, Balamuthia, and Naegleria have been repeatedly isolated; S. diploidea has been reported only once, from a brain infection. Antimicrobial therapy for these infections is generally empirical and patient recovery often problematic. N. fowleri is highly sensitive to the antifungal agent amphotericin B, but delay in diagnosis and the fulminant nature of the disease result in few survivors. Encephalitis and other infections caused by Acanthamoeba and Balamuthia have been treated, more or less successfully, with antimicrobial combinations including sterol-targeting azoles (clotrimazole, miconazole, ketoconazole, fluconazole, itraconazole), pentamidine isethionate, 5-fluorocytosine, and sulfadiazine. The use of drug combinations addresses resistance patterns that may exist or develop during treatment, ensuring that at least one of the drugs may be effective against the amoebae. Favorable drug interactions (additive or synergistic) are another potential benefit. In vitro drug testing of clinical isolates points up strain and species differences in sensitivity, so that no single drug can be assumed effective against all amoebae. Another complication is risk of activation of dormant cysts that form in situ in Acanthamoeba and Balamuthia infections, and which can lead to patient relapse following apparently effective treatment. This is particularly true in Acanthamoeba keratitis, a non-opportunistic infection of the cornea, which responds well to treatment with chlorhexidine gluconate and polyhexamethylene biguanide, in combination with propamidine isothionate (Brolene), hexamidine (Desomodine), or neomycin. Acanthamoeba spp. may also be carriers of endosymbiotic bacteria (Legionella and Legionella-like pathogens) and have been implicated in outbreaks of pneumonias in debilitated hosts. As with other infectious diseases, recovery is dependent not only on antimicrobial therapy, but also on patient's immune status, infective dose and virulence of the ameba strain, and on how early the disease is diagnosed and drug therapy initiated.

An amoeba was isolated from the intestines of several moribund pink-tongued skinks (lizards), Hemisphaeriodon gerrardi. Unusual features of this isolate were its ability to grow at temperatures ofor = 37 degrees C, and its inability to use Escherichia coli as a food source or to grow axenically on a variety of enriched culture media suitable for other soil amoeba isolates. Growth was abundant, however, on tissue culture cells, with amoebae clearing cell monolayers in approximately 48 h at 37 degrees C. Trophozoites had a vahlkampfiid-like morphology, moving by means of an anterior eruptive pseudopod. Cysts, round to slightly ovoid and lacking exit pores, were formed in culture. Tests for enflagellation of trophic amoebae were negative. Indirect immunofluorescence staining was negative for Naegleria fowleri and Willaertia sp. The isolate was sensitive to azithromycin, but not to amphotericin B, pentamidine isethionate, fluconazole, 5-fluorocytosine, and sulfadiazine. Phylogenetic analysis based on the PCR-amplified small subunit ribosomal DNA, identified the organism as Paravahlkampfia ustiana, an amoeba not previously isolated from either poikilothermic or homeothermic hosts. No evidence of pathology was seen in stained sections of lizard intestine, suggesting that the ameba was part of the normal fauna of the lizard gut. Its diet in the lizard intestine is unknown and the organism may have unusual growth requirements. Thus, P. ustiana joins other soil amoebae that have been isolated from mammals, amphibia, fish, and reptiles, which have the potential of becoming opportunistic pathogens.

We report four fatal cases of amebic encephalitis in children caused by the free-living pathogenic ameba Balamuthia mandrillaris. The clinical course ranged from subacute to fulminant. Provisional diagnoses were made either shortly before death or postmortem by an indirect immunofluorescent antibody test. Although the four cases occurred in different geographic locations, their common features may have diagnostic value for recognizing future cases of amebic encephalitis. The cases occurred in children 2 to 7.5 years old who were ostensibly immunocompetent and of Hispanic ethnicity. Three of the four children developed hydrocephalus during their illness. Increased awareness and timely diagnosis of this disease entity might lead to earlier intervention with improved outcome.

Case histories are presented of 2 individuals (a 5-year-old girl and 64-year-old man) who developed encephalitis caused by the free-living amoeba Balamuthia mandrillaris. Both individuals survived after diagnosis and initiation of effective antimicrobial therapy. Immunostaining for Balamuthia-specific antibody levels identified the causative agent of the infections. Antimicrobial therapy with flucytosine, pentamidine, fluconazole, sulfadiazine, and a macrolide antibiotic (azithromycin or clarithromycin) was initiated. Phenothiazines (thioridazine and trifluoperazine) were also used. Both patients recovered, and there was no evidence of recrudescence of the disease at 2 and 6 years after onset of symptoms. Awareness of Balamuthia as the causative agent of encephalitis and early initiation of antimicrobial therapy were critical to the recovery of both patients. Although optimal antimicrobial therapy for Balamuthia amoebic encephalitis has yet to be determined, the antimicrobials used in these 2 cases effectively controlled the disease. These 2 individuals are the only known survivors of this otherwise fatal type of amoebic encephalitis.

SUMMARY The hemoflagellates, Trypanosoma spp. and Leishmania spp., are causal agents of a number of parasitic diseases having a major impact on humans and domestic animals over vast areas of the globe. Among the diseases are some of the most pernicious and deadly of human afflictions: African sleeping sickness, Chagas' disease, kala-azar, and Oriental sore. The organisms have complex, pleomorphic life cycles typically involving a vertebrate and an invertebrate host, the latter serving as a vector. In the vertebrate host, they are primarily blood and tissue parasites. In their transition from one host to another, the hemoflagellates undergo morphological, physiological, and biochemical changes that facilitate their growth and subsequent transmission. A major goal in the study of the hemoflagellates has been the cultivation in vitro of both vertebrate and invertebrate stages of the organisms. The first types of media used in their cultivation, and still useful for establishment of cultures, were undefined and contained a complex of ingredients. These gave way to semidefined formulations which included tissue culture media as a base and, as a next step, addition of tissue culture cells as a feeder layer to promote parasite growth. More recently developed media are completely defined, having replaced the feeder cells with various supplements. Serum, a sometimes-variable component of the media, can be replaced by various serum substitutes. This review focuses on the hemoflagellates that infect humans, describing stages in the development of media leading to the fully defined formulations that are now available for the cultivation of many of these organisms.

SUMMARY Babesia and its close relatives are members of a group of organisms called piroplasms, a name which comes from their pear-shaped outlines. Long associated with blood diseases of cattle and other mammals, members of the genus Babesia have been recognized since the 1950s as infectious agents in humans. Species of this protozoan blood parasite that have routinely been isolated from mice ( B. microti ) or cattle ( B. divergens ) have also been isolated from humans. In addition to these familiar species, new isolates that resist being placed in existing taxonomic categories are the basis for rethinking their phylogenetic relationships based on sequencing data. The parasite represents a threat to the safety of the blood supply in that blood from asymptomatic humans can transmit Babesia to blood recipients. Such transmissions have occurred. The development of methods for cultivation of these organisms represents a significant opportunity to study their biology and disease potential. In addition, in vitro cultivation has provided a basis for studying immune responses of mammals to these infectious agents, with the hope of ultimately producing attenuated strains that could be used for immunizing of cattle and, perhaps, humans who live in areas of endemicity. The microaerophilous stationary phase culture technique, which uses a tissue culture medium base supplemented with appropriate serum and erythrocytes, has made it possible to obtain large numbers of parasitized erythrocytes for studying the biology of this parasite.

In 1958, Clyde G. Culbertson predicted the occurrence in humans of infection by free-living amebas (6). A few years later, Rodney F. Carter and Malcolm Fowler, in Adelaide, Australia, reported the first human cases of primary amebic meningoencephalitis (PAM) caused by Naegleria fowleri [2, 91. Since then, hundreds of cases of infection caused by Acanthamoeba spp. and Naegleria fowleri have been published all over the world [20]. During the last 10 years, another opportunistic ameba, B. mandrillaris has been added to the list of pathogenic, opportunistic free-living amebas [ I , 3-5, 7, 8, 10-12, 15-27

Free-living amebae of the genus Acanthamoeba are causal agents of granulomatous amebic encephalitis in humans, almost exclusively in immunocompromised hosts. The prognosis is poor, and the mortality is high. Because the symptoms are nonspecific, diagnosis can be difficult and is often made

We examined the effects of the macrolide antimicrobial agent azithromycin and phenothiazine compounds against clinical isolates of Acanthamoeba spp. and Balamuthia mandrillaris, opportunistic pathogens of human beings and other animals. Acanthamoeba growth was inhibited in vitro at 1, 5, and 10 micrograms/ml of azithromycin, but not the macrolides, erythromycin, and clarithromycin. In experiments attempting to simulate in vivo conditions, azithromycin protected monolayers of rat glioma cells from destruction by Acanthamoeba at a concentration of 0.1 microgram/ml, and delayed destruction at concentrations of 0.001 and 0.01 microgram/ml. We concluded that the minimal inhibitory concentration of azithromycin was 0.1 microgram/ml. Our results, however, suggested that the drug was amebastatic but not amebicidal, since ameba growth eventually resumed after drug removal. The phenothiazines (chlorpromazine, chlorprothixene, and triflupromazine) inhibited Acanthamoeba growth by 70-90% at 5 and 10 micrograms/ml, but some of these compounds were toxic for rat glioma cells at 10 micrograms/ml. Azithromycin was not very effective against B. mandrillaris in an in vitro setting, but was amebastatic in tissue culture monolayers at concentrations of 0.1 microgram/ml and higher. Balamuthia amebas showed in vitro sensitivity to phenothiazines. Ameba growth was inhibited 30-45% at 5 micrograms/ml in vitro, but completely at 5 micrograms/ml in the rat glioma model. In spite of their potential as antiamebic drugs in Balamuthia infections, toxicity of phenothiazines limits their use in clinical settings.

A visual assay slide chamber was used in conjunction with time-lapse videomicroscopy to analyze chemotactic behavior of axenically grown Acanthamoeba castellanii. Data were collected and analyzed as vector scatter diagrams and cell tracks. Amebas responded to a variety of bacterial products or potential bacterial products by moving actively toward the attractant. Responses to the chemotactic peptide formyl-methionyl-leucyl-phenylalanine (fMLP), lipopolysaccharide, and lipid A were statistically significant (Por = 0.03), as was the response to fMLP benzylamide (Por = 0.05). Significant responses to cyclic AMP, lipoteichoic acid, and N-acetyl glucosamine were also found. Chemotactic peptide antagonists, mannose, mannosylated bovine serum albumin, and N-acetyl muramic acid all yielded nonsignificant responses (P0.05). There was no single optimal concentration for response to any of the attractants tested, and amebas responded equally over the range of concentrations tested. Pretreatment of amebas with chemotactic peptides, bacterial products, and bacteria reduced the directional response to attractants. Amebas that had been grown in the presence of bacteria appeared more responsive to chemotactic peptides. Treatment of amebas with trypsin reduced the response of cells to chemotactic peptides, though sensitivity was restored within a couple of hours. This suggests the ameba membrane may have receptors, sensitive to these bacterial substances, which are different from the mannose receptors involved in binding bacteria to the membrane during phagocytosis. The rate of movement was relatively constant (ca. 0.40 microns/s), indicating that the locomotor response to these signals is a taxis, or possibly a klinokinesis, but not an orthokinesis. Studies of the population diffusion rate in the absence of signals indicate that the basic population motility follows the pattern of a Levy walk, rather than the more familiar Gaussian diffusion. This suggests that the usual mathematical models of ameboid dispersion may need to be modified.

Investigation into the recent death of a young California child from amebic encephalitis revealed antibodies in the serum and amebas from brain specimens identified as Balamuthia mandrillaris [1]. Amebas of this group had been isolated from a mandrill baboon at the San Diego Wildlife Park [6]. At first classified as leptomyxid amebas because of their size and morphology, their pathogenicity, growth at elevated temperature, and live cells as food source were sufficient to designate these as separate organisms; they were given the name of Balamuthia mandrillaris in honor of the late Dr. William Balamuth [7]. These amebas have been found in some 90 human cases of encephalitis. The cases have occurred worldwide and antibodies to them can be identified in the serum [4]. Earlier attempts to recover the amebas from environmental samples that may have been implicated in the encephalitis cases had not been successful; nevertheless, a group of 18 soil and water samples from the home and play areas of the California child were collected. From one of them, amebas identified as Balamuthia (RP-5) were recovered [3]. A second group of soil samples was collected from a separate location unrelated to any known disease. From these, another ameba (OK-1) was isolated and when compared with the known amebas, it, too, is a Balamuthia ameba. The isolation of these two soil amebas and their comparison to the ameba (SAm) from the California child is presented here.

A clinical isolate of Acunthamoeba polyphagu, associated with Acunthamoebu keratitis, was used for in vitro evaluation of antiamebic activity of selected azole compounds. Those antimicrobials tested included clotrimazole, bifonazole, fluconazole, itraconazole, and ketoconazole. The drugs were tested at varying concentrations on axenic trophic amebas and MgC12,-induced cysts. On the basis of their effects on the two stages in the ameba life-cycle, clotrimazole and bifonazole were the more promising of the azoles screened but, at concentrations tested, were amebastatic rather than amebicidal. Other strains of A. polyphaga and species of Acunthamoebu were used for comparing variation in response to these and other antimicrobial agents.

The life-cycle of the amoeboflagellate Tetramitus rostratus includes amoeboid, cyst, and flagellate stages. The ultrastructure of these three stages is illustrated, with particular emphasis on flagellate morphology. Amoeba morphology is typical of that of limax amoebas. Cysts, forming from trophic amoebas, are enclosed by a wall made up of two layers: ectocyst (ca. 70 nm), and endocyst (200 nm). The wall apparently forms from precursor material present in vesicles in the pre-cyst stage cytoplasm. Flagellate morphology is characterized by a well-defined top-shaped profile, maintained by microtubules under the plasma membrane. The flagellar apparatus or mastigont consists of four flagella, their basal bodies, sheaves of microtubules associated with two of the basal bodies, and several rhizoplasts (periodicity 20 nm). A deep, microtubule-supported, ventral invagination appears to function as a gullet. A small number of mitotic stages observed in amoeboid and flagellate individuals suggests similarity in the division process in both stages: intranuclear mitotic apparatus, nucleolus persisting through mitosis, no centrioles or basal bodies functioning as centrioles, difficulty in resolving chromosomes. The text compares ultrastructures of several amoeboflagellate organisms and evaluates the phylogenetic significance of those features common to different species. On the basis of this study, Tetramitus most closely resembles Naegleria spp.

Naegleria gruberi is an amoeboflagellate found in soil; mitosis is restricted to the amoeboid phase of its life-cycle. Ultrastructural examination of mitotic stages has confirmed some aspects of karyokinesis reported in earlier light-microscopic studies and expanded on other features of nuclear division described in electron-microscopic studies of Naegleria The nuclear envelope remained intact throughout division, the nucleolus persisted, and centrioles were not found Chromosomes were indistinguishable at the ultrastructural level, nor was any evidence detected of sites of microtubular attachment to possible chromosomes. An interzonal body, formed during separation in two of the nucleolus, was not an invariable feature of mitosis. The same was true of the polar caps, which appeared to be little more than the ends of the mitotic spindle. It is suggested that, in line with comparable situations in other protists, expansion of the nuclear envelope is chiefly responsible for separation of the nucleus into two daughter nuclei.

SYNOPSIS. The schizont stage of 3 strains of the testate marine ameba, Trichosphaerium sp., was examined in the transmission electron microscope. The cytoplasm of this multinucleate organism contained the usual organelles; the test was covered by spicules. Pseudopodial types included broad ectoplasmic lobopods that assisted in locomotion, and thin dactylopods that probably had a sensory function. Nuclear division, observed in one of the strains, was characterized by an intact nuclear envelope (at least through anaphase), and the absence of centrioles. Nuclei in an ameba divided synchronously. An unusual intranuclear body of unknown function was found in another of the strains examined.

SYNOPSIS. Axenic and monobacterial cultures of Naegleria gruberi were utilized to study the ultrastructure of encysting amoebae, mature cysts, and excystation stages. Encystation is characterized by an increase in cytoplasmic density due to dehydration. The mitochondria appear to be undergong division and are found closely associated with elements of the endoplasmic reticulum. Numerous vacuoles (or droplets) of low electron density occur in proximity to the nucleus and scattered throughout the cytoplasm. These are thought to contain the material which gives rise to the cyst wall. Other types of vacuoles are described. The mature cyst wall is double, consisting of an inner thick component (200–450 mμ) and an outer thin component (25 mμ). Both elements of the cyst wall show an affinity for osmium. The two layers are separated by a space filled with a spongy network but join at the region of the cyst pore. The pores (about 600 mμ at maximum diameter) are closed by a plug of electron-transparent material. At excystation, the amoeba cytoplasm becomes highly alveolar. The plug sealing the pore in the wall dissolves and the amoeba leaves the cyst.