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St. Thomas Fatality from Rare Amoebic Disease

A St. Thomas man’s death from a very rare brain infection in 2012 was the first and only V.I. case ever, and the first U.S. case linked to religious nasal rinsing, according to a recent Centers for Disease Control and Prevention field report.

According to the report: "Notes from the Field: Primary Amebic Meningoencephalitis Associated with Ritual Nasal Rinsing," a 47-year-old man passed away on St. Thomas from primary amoebic meningoencephalitis, a form of swelling of the brain that is almost universally fatal.

Dr. Tai Hunte, a territorial infectious disease specialist with the V.I. Health Department, was the lead researcher on the report.

A warm freshwater amoeba called Naegleria fowleri causes the illness when it enters the nose and migrates to the brain. The patient’s only reported freshwater exposures were the use of tap water for daily household activities and for ablution, a ritual cleansing that he practiced several times a day in preparation for Islamic prayer. Ablution can include nasal rinsing.

The patient visited the emergency room Nov. 16, 2012, with a headache, was treated for a headache and was sent home, according to the report. The next day, he was brought by ambulance to the hospital suffering with fever, confusion, agitation and a severe headache.

Tests of his spinal fluid were consistent with bacterial meningitis and doctors started giving antibiotics. On Nov. 18, 2012, the patient showed fixed pupils and other signs of serious neurological problems. A second spinal fluid test found parasitic amoebas in their feeding stage, called trophozoites. Testing by the CDC of his DNA confirmed that it was N. Fowleri.

One of the factors that make this disease rare is it requires contaminated water to get deep up the nose, so it would not normally be transmitted by drinking or even bathing in contaminated water. Swimming in warm lake and river water is one major vector for infection, as is nasal rinsing, according to the CDC.

Islam has several washing rituals performed before prayers and other activities, including nasal ablution or rinsing out the nose with fresh, clean water. And in some parts of the world this ritual is an established vector for transmitting the rare but deadly illness.

In December of 2012, the V.I. Department of Health and CDC investigated the patient’s home and mosque to try to find the likely source of infection. The patient’s roommate said he performed ablution, including nasal rinsing, at home and at the mosque. The mosque showed no signs of the amoeba and had chlorinated water. But samples from the patient’s shower head and hot water heaters showed N. Fowleri, and there was no chlorine in his well-water.

According to Hunte, of 31 people in the United States infected with N. Fowleri from 2003-2012, three were infected after performing nasal rinsing with contaminated tap water, making nasal rinsing an uncommon cause of this already rare infection. Of those three cases in 10 years, two were from rinsing with a neti pot or other similar device for sinus relief. The St. Thomas death is the third case and first to result from ritual ablution.

Researchers determined ritual ablution was the vector by process of elimination, Hunte said recently.

"No additional risk factors were identified after thorough history taking and interviews were performed. Thus this risk factor is the likely, plausible cause of his infection," Hunte told the Source in an email.

While the risk of infection is very small, it can be reduced further by only using sterile water for nasal rinsing and avoiding swimming in warm, fresh water. Rinsing water can be treated by boiling or a small amount of chlorine bleach.

Additional information regarding Primary Amebic Meningoencephalitis and ablution is available at http://www.cdc.gov/parasites/naegleria/ritual-ablution.html.

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