Prevalence of Acanthamoeba spp. and other free-living amoebae in household water, Ohio, USA--1990-1992

Acanthamoeba Infection and Nasal Rinsing, United States, 1994-2022

We describe 10 patients with nonkeratitis Acanthamoeba infection who reported performing nasal rinsing before becoming ill. All were immunocompromised, 7 had chronic sinusitis, and many used tap water for nasal rinsing. Immunocompromised persons should be educated about safe nasal rinsing to prevent free-living ameba infections.

Challenges and advances in the medical treatment of granulomatous amebic encephalitis

Granulomatous amebic encephalitis, caused by the free-living amebae Balamuthia mandrillaris or Acanthamoeba species, is a rare and deadly infectious syndrome with a current mortality rate of >90%. Much work remains to define the optimal treatment for these infections. Here, we provide a comprehensive overview of the supporting evidence behind antimicrobials currently recommended by the Centers for Disease Control and Prevention (CDC) with updated statistics on survival rates and medication usage from the CDC Free-Living Ameba Database. We also discuss promising treatments, especially the emerging therapeutic agent nitroxoline, and provide recommendations for the next steps in this area.

Identification and genotyping of Acanthamoeba spp. in the water resources of western Iran

Background

Acanthamoeba spp. is opportunistic amoeba that resides in water, soil, and air. Some pathogenic genotypes of the genus of Acanthamoeba can cause granulomatous amoebic encephalitis (GAE) in people with a defective immune system. The parasite can also cause Acanthamoeba keratitis (AK) among contact lens users. This study was conducted to isolate and identify the Acanthamoeba genotypes in water resources in Lorestan province, western Iran.

Methods

Collected 72 water samples from surface and groundwater (springs and aqueducts) in Lorestan province. Samples were filtered and cultured in non-nutrient 1.5% agar medium covered with Escherichia coli (E. coli) at 25 °C. DNA extraction was done and the PCR reaction was performed to detect the Acanthamoeba spp. The positive PCR products were sequenced to determine the genotypes of Acanthamoeba.

Results

Out of 72 examined water samples, 23.61% were positive for Acanthamoeba sp. by PCR. From PCR-positive samples, 8 (47.05%) samples were T4 genotypes and others were other Acanthamoeba genotypes (T1-T23). Therefore, approximately half of the genotypes belong to the pathogenic T4 genotype.

Conclusions

The water examined samples in western provinces of Iran have the potential risk factor for public health. Therefore, the efforts of healthcare providers are needed to identify, train, and prevention from human infections.

Amebic encephalitis and meningoencephalitis: an update on epidemiology, diagnostic methods, and treatment

PURPOSE OF REVIEW

Free-living amebae (FLA) including Naegleria fowleri , Balamuthia mandrillaris , and Acanthamoeba species can cause rare, yet severe infections that are nearly always fatal. This review describes recent developments in epidemiology, diagnosis, and treatment of amebic meningoencephalitis.

RECENT FINDINGS

Despite similarities among the three pathogenic FLA, there are notable variations in disease presentations, routes of transmission, populations at risk, and outcomes for each. Recently, molecular diagnostic tools have been used to diagnose a greater number of FLA infections. Treatment regimens for FLA have historically relied on survivor reports; more data is needed about novel treatments, including nitroxoline.

SUMMARY

Research to identify new drugs and guide treatment regimens for amebic meningoencephalitis is lacking. However, improved diagnostic capabilities may lead to earlier diagnoses, allowing earlier treatment initiation and improved outcomes. Public health practitioners should continue to prioritize increasing awareness and providing education to clinicians, laboratorians, and the public about amebic infections.

The Epidemiology and Clinical Features of Non-Keratitis Acanthamoeba Infections in the United States, 1956-2020

Background

Acanthamoeba is a free-living ameba that can cause severe disease affecting the central nervous system, skin, sinuses, and other organs, particularly in immunocompromised individuals. These rare but severe infections are often fatal, yet incompletely described.

Methods

Cases included were either reported to the Centers for Disease Control and Prevention (CDC) Free-Living Ameba program or published in scientific literature. Characteristics of all patients in the United States with laboratory-confirmed non-keratitis Acanthamoeba infections were described using descriptive statistics, and associations with survival were determined using χ² and Fisher exact tests.

Results

Of 173 patients identified, 71% were male and the median age was 44 years (range, 0-87 years). Of these, 26 (15%) survived. Most patients (88%) had at least 1 immunocompromising condition, most commonly human immunodeficiency virus (39%), cancer (28%), and solid organ or hematopoietic stem cell transplant (28%). Granulomatous amebic encephalitis (GAE) was the most common disease presentation (71%). Skin (46%), sinuses (29%), lungs (13%), and bone (6%) were also involved. Nearly half of patients (47%) had involvement of >1 organ system. Survival was less frequent among those with GAE (3%, P < .001) compared with cutaneous disease, rhinosinusitis, or multiorgan disease not including GAE. Of 7 who received the currently recommended treatment regimen, 5 (71%) survived.

Conclusions

Non-keratitis Acanthamoeba infections occur primarily in immunocompromised individuals and are usually fatal. Survival may be associated with disease presentation and treatment. Providers who care for at-risk patients should be aware of the various disease manifestations to improve early recognition and treatment.

Molecular screening and characterization of Legionella pneumophila associated free-living amoebae in domestic and hospital water systems

Free-living amoebae are ubiquitous in the environment and cause both opportunistic and non-opportunistic infections in humans. Some genera of amoebae are natural reservoirs of opportunistic plumbing pathogens, such as Legionella pneumophila. In this study, the presence of free-living amoebae and Legionella was investigated in 140 water and biofilm samples collected from Australian domestic (n = 68) and hospital water systems (n = 72). Each sample was screened in parallel using molecular and culture-based methods. Direct quantitative polymerase chain reaction (qPCR) assays showed that 41% samples were positive for Legionella, 33% for L. pneumophila, 11% for Acanthamoeba, and 55% for Vermamoeba vermiformis gene markers. Only 7% of samples contained culturable L. pneumophila serogroup (sg)1, L. pneumophila sg2-14, and non-pneumophila Legionella. In total, 69% of samples were positive for free-living amoebae using any method. Standard culturing found that 41% of the samples were positive for amoeba (either Acanthamoeba, Allovahlkampfia, Stenamoeba, or V. vermiformis). V. vermiformis showed the highest overall frequency of occurrence. Acanthamoeba and V. vermiformis isolates demonstrated high thermotolerance and osmotolerance and strong broad spectrum bacteriogenic activity against Gram-negative and Gram-positive bacteria. Importantly, all Legionella positive samples were also positive for amoeba, and this co-occurrence was statistically significant (p < 0.05). According to qPCR and fluorescence in situ hybridization, V. vermiformis and Allovahlkampfia harboured intracellular L. pneumophila. To our knowledge, this is the first time Allovahlkampfia and Stenamoeba have been demonstrated as hosts of L. pneumophila in potable water. These results demonstrate the importance of amoebae in engineered water systems, both as a pathogen and as a reservoir of Legionella. The high frequency of gymnamoebae detected in this study from Australian engineered water systems identifies an issue of significant public health concern. Future water management protocols should incorporate treatments strategies to control amoebae to reduce the risk to end users.

Isolation and morphological and molecular characterization of waterborne free-living amoebae: Evidence of potentially pathogenic Acanthamoeba and Vahlkampfiidae in Assiut, Upper Egypt

Free-living amoebae (FLA) are gaining attention due to the increasing number of related grave central nervous system (CNS) and sight-threatening eye infections and their role as Trojan horses for many bacteria and viruses. This study was conducted in Assiut City, Egypt to detect the presence of FLA in different water sources using morphological and molecular approaches and determine their potential pathogenicity. A total of 188 water samples (100 tap, 80 tank, and 8 swimming pool samples) were collected, cultivated on non-nutrient agar seeded with Escherichia coli, and inspected for FLA. Thermo- and osmo-tolerance assays were performed to determine their pathogenicity. Polymerase chain reaction and sequence analysis were performed to confirm the identification and analyze the genotype. Overall, 52 samples (27.7%) were positive for FLA. Of these, 20.7% were identified as Acanthamoeba, 1.6% as Vahlkampfiidae, and 5.3% as mixed Acanthamoeba and Vahlkampfiidae. Seven species of Acanthamoeba were recognized, of which A. triangularis, A. polyphaga, A. lenticulata, and A. culbertsoni are thermo- and osmo-tolerant, and A. astronyxis, A. comandoni, and A. echinulata are non-thermo- and non-osmo-tolerant. The phylogeny analysis revealed T4 and T7 genotypes. Among Vahlkampfiids, 61.5% were identified as thermo- and osmo-tolerant Vahlkampfia, and 30.8% were identified as non-pathogenic Naegleria. One isolate (7.7%) was identified as potentially pathogenic Allovahlkampfia, as confirmed by sequencing. This is the first report documenting the occurrence and phylogeny of waterborne FLA (Acanthamoeba/Vahlkampfiidae) in Assiut, Egypt. The presence of potentially pathogenic FLA highlights the possible health hazards and the need for preventive measures.

Prevalence of opportunistic pathogens in a school building plumbing during periods of low water use and a transition to normal use

The spread of opportunistic pathogens via building water supply and plumbing is of public health concern. This study was conducted to better understand microbial water quality changes in a LEED-certified school building during low water use (Summer) and normal water use (Autumn). The copper plumbed building contained water saving devices, a hot water recirculation system, and received chloraminated drinking water from a public water system. Three separate sampling events were conducted during the summer break inside the building and another three sampling events were conducted after the school returned to session. Using quantitative PCR, Legionella spp. were detected in all water samples, followed by Mycobacterium spp. (99%). Mycobacterium avium (75%) and Acanthamoeba spp. (17.5%) throughout the building water system. Legionella pneumophila and Naegleria fowleri were not detected in any of the samples. The mean concentrations of Legionella spp., Mycobacterium spp., Mycobacterium avium, and Acanthamoeba spp. detected in water samples were 3.9, 5.7, 4.7, and 2.8 log₁₀ gene copies per 100 ml, respectively. There was a statistically significantly difference in the mean concentrations of Legionella spp., Mycobacterium spp. and M. avium gene markers in water samples between school breaks and when school was in session. Cultivable Legionella were also detected in water samples collected during periods of low water use. This study highlights the need for routine proactive water quality testing in school buildings to determine the extent of drinking water quality problems associated with plumbing and direct action to remediate microbial colonization.

Molecular characterization and phylogenetic analysis of FLA from different water sources in Egypt

Free-living amoebae (FLA) are protozoa ubiquitously found in nature. In addition to their natural distribution, some species have been documented as pathogenic to humans. The main aim of the current study was the molecular identification, sequencing and phylogenetic analysis of morphologically detected FLA in water sources in El-Qalyubia, Egypt. A total of 96 water samples were collected from different water sources. Each water sample was filtrated and cultured on non-nutrient agar (NNA). Morphologically positive FLA were subjected to PCR, PCR products were sequenced and the obtained sequences were phylogenetically analysed. FLA were found in 41 water samples examined (42.7%). Nile water and groundwater were the sources with the highest prevalence rates (83.3 and 62.5%, respectively). Naegleria italica was first identified in Egypt from the waters of the Nile. In addition, Vahlkampfia spp. and Hartmannella spp. were also detected. However, other FLA species, including Acanthamoeba spp. and the pathogenic Naegleria fowleri, previously reported in Egypt, were not included in this study. The recent identification of these FLA in the Egyptian waters related to human populations indicates the need for more phylogenetic studies using larger sample sizes to investigate their potential threat to human health.

Co-Existence of Free-Living Amoebae and Potential Human Pathogenic Bacteria Isolated from Rural Household Water Storage Containers

Simple Summary

In many households in rural communities, water needed for drinking and cooking is fetched from rivers, fountains, or boreholes shared by the community. The water is then stored in various storage containers for several days without treatment and exposed to several conditions that could potentially contaminate the water and cause diseases. If the storage containers are not regularly and properly cleaned, biofilms can form inside the containers. Several microorganisms can be found inside the biofilm that can potentially cause diseases in humans. One such group of organisms is called free-living amoebae, which graze on the bacteria found inside the biofilm. Several of these potentially harmful bacteria have adapted and can survive inside these free-living amoebae and potentially cause diseases when ingested by humans.

Abstract

This study investigated the co-existence of potential human pathogenic bacteria and free-living amoebae in samples collected from stored water in rural households in South Africa using borehole water as a primary water source. Over a period of 5 months, a total of 398 stored water and 392 biofilm samples were collected and assessed. Free-living amoebae were identified microscopically in 92.0% of the water samples and 89.8% of the biofilm samples. A further molecular identification using 18S rRNA sequencing identified Vermamoeba vermiformis, Entamoeba spp., Stenamoeba spp., Flamella spp., and Acanthamoeba spp. including Acanthamoeba genotype T4, which is known to be potentially harmful to humans. Targeted potential pathogenic bacteria were isolated from the water samples using standard culture methods and identified using 16S rRNA sequencing. Mycobacterium spp., Pseudomonas spp., Enterobacter spp., and other emerging opportunistic pathogens such as Stenotrophomonas maltophilia were identified. The results showed the importance of further studies to assess the health risk of free-living amoebae and potential human pathogenic bacteria to people living in rural communities who have no other option than to store water in their homes due to water shortages.

Intracellular Behaviour of Legionella Non-pneumophila Strains within Three Amoeba Strains, Including Willaertia magna C2c Maky

Legionellosis, an often-lethal pneumonia, is generally associated with contamination by Legionella pneumophila. This bacterium can persist in the environment and resist chemical treatment when it is internalized by amoebae. In addition, there is increasing medical proof that other Legionella species can be causative agents of Legionellosis. The objective of this study was to evaluate whether Legionella non-pneumophila (Lnp) strains were able to use the machinery of amoeba to multiply, or whether amoebae were able to limit their proliferation. Seven strains belonging to the species L. longbeachae, L. anisa, L. bozemanae, L. taurinensis, and L. dumoffii were cocultured with three amoebae, Acanthamoeba castellanii, Willaertia magna T5(S)44, and Willaertia magna C2c Maky, at two temperatures, 22 and 37 °C. We found that at 22 °C, all amoebae were able to phagocytose the seven Lnp strains and to avoid intracellular development, except for L. longbeachae, which was able to multiply inside W. magna T5(S)44. At 37 °C, four Lnp strains were able to hijack the machinery of one or two amoebae and to use it to proliferate, but none were able to multiply inside W. magna C2c Maky.

Molecular Identification of Pathogenic Free-Living Amoeba from Household Biofilm Samples in Iran: A Risk Factor for Acanthamoeba Keratitis

Free-living amoeba (FLA) are ubiquitously distributed in the environment. However, they are also the causative agents of opportunistic infections in humans and other animals. A biofilm comprises any syntrophic consortium of microorganisms in which cells stick to each other and often also to a surface. Moreover, FLA have been detected in various biofilms around the world. Therefore, the present study aimed to check for presence of FLA in samples from household biofilms in Iran and to characterize them at the molecular level. A total of 69 biofilm samples collected from showerheads, kitchen areas, and bathroom sinks were analyzed. Positive samples for FLA were characterized at the morphological and molecular levels. Furthermore, the results of morphology analysis indicated that 26.08% (18/69) of biofilm samples were positive for Acanthamoeba spp., Vermamoeba genus, and Vahlkampfiids. According to sequence analysis, five strains of Acanthamoeba isolates related to the T4 genotype and two strains belonged to the T2 genotype. In addition, the pathogenic potential of Acanthamoeba-positive isolates was conducted using the tolerance ability test. The results of BLASTn of Vermamoeba sequences were similar to what was expected for Vermamoeba vermiformis. The above-mentioned reasons revealed that the relative high contamination of household biofilm samples with FLA may pose a risk for people using soft contact lenses and for patients with traumatic cataract. Our finding proposes that filtration should be performed in shower heads and indicates the need to monitor people at increased risk of Acanthamoeba keratitis.

The role of Acanthamoeba spp. in biofilm communities: a systematic review

Acanthamoeba spp. have always caused disease in immunosuppressed patients, but since 1986, they have become a worldwide public health issue by causing infection in healthy contact lens wearers. Amoebae of the Acanthamoeba genus are broadly distributed in nature, living either freely or as parasites, and are frequently associated with biofilms throughout the environment. These biofilms provide the parasite with protection against external aggression, thus favoring its increased pathogeny. This review aims to assess observational studies on the association between Acanthamoeba spp. and biofilms, opening potential lines of research on this severe ocular infection. A systematic literature search was conducted in May 2020 in the following databases: PubMed Central^®/Medline, LILACS, The Cochrane Library, and EMBASE^®. The studies were selected following the inclusion and exclusion criteria specifically defined for this review. Electronic research recovered 353 publications in the literature. However, none of the studies met the inclusion criterion of biofilm-producing Acanthamoeba spp., inferring that the parasite does not produce biofilms. Nonetheless, 78 studies were classified as potentially included regarding any association of Acanthamoeba spp. and biofilms. These studies were allocated across six different locations (hospital, aquatic, ophthalmic and dental environments, biofilms produced by bacteria, and other places). Acanthamoeba species use biofilms produced by other microorganisms for their benefit, in addition to them providing protection to and facilitating the dissemination of pathogens residing in them.

Acanthamoeba sclerokeratitis in a cat

CASE DESCRIPTION

A 12-year-old neutered male domestic shorthair cat with chronic anterior uveitis and secondary glaucoma of the right eye was examined for persistent blepharospasm 2 weeks after corneal debridement and grid keratotomy for nonhealing superficial ulcerative keratitis.

CLINICAL FINDINGS

Examination of the right eye revealed a central superficial corneal ulcer associated with corneal epithelial and subepithelial infiltrates and mild aqueous flare. Structures consistent with amoeboid cysts and trophozoites were detected in the cornea by in vivo confocal microscopy. Suppurative keratitis was identified cytologically. An Acanthamoeba spp was isolated through culture and identified by a PCR assay of corneal specimens.

TREATMENT AND OUTCOME

Symptomatic and antiamoebic (polyhexamethylene biguanide 0.02% ophthalmic solution) treatments were instituted. Over the following 6 weeks, the cat lost vision in the affected eye and lesions progressed to nonulcerative stromal keratitis associated with a dense paracentral corneal stroma ring infiltrate and anterior lens luxation. The globe was enucleated, and lymphoplasmacytic sclerokeratitis, anterior uveitis, and retinal detachment were noted. Acanthamoeba organisms were detected within the corneal stroma and anterior sclera with histologic and immunohistochemical stains. The amoebae were classified to the Acanthamoeba T4 genotype by DNA sequencing. The cat had no medical problems attributed to Acanthamoeba infection over 36 months after enucleation, until the cat was lost to follow-up.

CLINICAL RELEVANCE

Naturally acquired Acanthamoeba sclerokeratitis is described in a cat for the first time. Acanthamoeba infection should be considered for cats with superficial corneal disease refractory to appropriate treatments and especially occurring after ocular trauma, including keratotomy.

Nosocomial Infections: Do Not Forget the Parasites!

Nosocomial infections (NIs) pose an increasing threat to public health. The majority of NIs are bacterial, fungal, and viral infections; however, parasites also play a considerable role in NIs, particularly in our increasingly complex healthcare environment with a growing proportion of immunocompromised patients. Moreover, parasitic infections acquired via blood transfusion or organ transplantation are more likely to have severe or fatal disease outcomes compared with the normal route of infection. Many of these infections are preventable and most are treatable, but as the awareness for parasitic NIs is low, diagnosis and treatment are often delayed, resulting not only in higher health care costs but, importantly, also in prolonged courses of disease for the patients. For this article, we searched online databases and printed literature to give an overview of the causative agents of parasitic NIs, including the possible routes of infection and the diseases caused. Our review covers a broad spectrum of cases, ranging from widely known parasitic NIs, like blood transfusion malaria or water-borne cryptosporidiosis, to less well-known NIs, such as the transmission of Strongyloides stercoralis by solid organ transplantation or nosocomial myiasis. In addition, emerging NIs, such as babesiosis by blood transfusion or person-to-person transmitted scabies, are described.

Molecular characterization and phylogenetic analysis of Acanthamoeba isolates in tap water of Beni-Suef, Egypt

The genus Acanthamoeba is a free-living amoeba widely distributed in various aquatic environments. It is an etiologic cause of amoebic encephalitis and keratitis particularly for immunocompromised individuals. The purpose of the present study was to investigate Acanthamoeba species prevalence in household and hospital potable water in Beni-Suef governorate, Egypt, and to employ sequencing methods to identify positive Acanthamoeba species isolates and their potential health risks. Sixty tap water samples (30 household and 30 governmental and private hospital settings) collected from Beni-Suef governorate, Egypt were filtered, cultured on non-nutrient agar, identified by morphotyping keys after staining with Giemsa stain and then confirmed by PCR using Acanthamoeba specific primers. Twenty positive samples were successfully genetically characterized and phylogenetically analyzed to identify Acanthamoeba species. The total detection rate for Acanthamoeba was 48/60 (80%); Acanthamoeba contamination in water collected from domestic houses was higher than in hospitals; 27/30 (90%) versus 21/30 (70%) with statistical significant value (P value = 0.05). Sequencing of 20 positive isolates revealed Acanthamoeba T4 in 65% and T2 in 35%. To our knowledge, this is the first research that documents the occurrence and phylogeny of Acanthamoeba species in Beni-Suef, Egypt. The presence of a higher percentage of Acanthamoeba species in tap water, in particular T4, highlights the potential health hazards for immunocompromised individuals and emphasizes the urgent need for the implementation of effective filtration and disinfection measures.

Influences of model structure and calibration data size on predicting chlorine residuals in water storage tanks

This study evaluated the influences of model structure and calibration data size on the modelling performance for the prediction of chlorine residuals in household drinking water storage tanks. The tank models, which consisted of two modules, i.e., hydraulic mixing and water quality modelling processes, were evaluated under identical calibration conditions. The hydraulic mixing modelling processes investigated included the continuously stirred tank reactor (CSTR) and multi-compartment (MC) methods, and the water quality modelling processes included first order (FO), single-reactant second order (SRSO), and variable reaction rate coefficients (VRRC) second order chlorine decay kinetics. Different combinations of these hydraulic mixing and water quality methods formed six tank models. Results show that by applying the same calibration datasets, the tank models that included the MC method for modelling the hydraulic mixing provided better predictions compared to the CSTR method. In terms of water quality modelling, VRRC kinetics showed better predictive abilities compared to FO and SRSO kinetics. It was also found that the overall tank model performance could be substantially improved when a proper method was chosen for the simulation of hydraulic mixing, i.e., the accuracy of the hydraulic mixing modelling plays a critical role in the accuracy of the tank model. Advances in water quality modelling improve the calibration process, i.e., the size of the datasets used for calibration could be reduced when a suitable kinetics method was applied. Although the accuracies of all six models increased with increasing calibration dataset size, the tank model that consisted of the MC and VRRC methods was the most suitable of the tank models as it could satisfactorily predict chlorine residuals in household tanks by using invariant parameters calibrated against the minimum dataset size.

Water Exposure is a Common Risk Behavior Among Soft and Gas-Permeable Contact Lens Wearers

PURPOSE

To understand soft contact lens (SCL) and gas-permeable (GP) lens wearers' behaviors and knowledge regarding exposure of lenses to water.

METHODS

The Contact Lens Risk Survey (CLRS) and health behavior questions were completed online by a convenience sample of 1056 SCL and 85 GP lens wearers aged 20 to 76 years. Participants were asked about exposing their lenses to water and their understanding of risks associated with these behaviors. Chi-square analyses examined relationships between patient behaviors and perceptions.

RESULTS

GP lens wearers were more likely than SCL wearers to ever rinse or store lenses in water (rinsing: 91% GP, 31% SCL, P < 0.001; storing: 33% GP, 15% SCL P < 0.001). Among SCL wearers, men were more likely to store (24% vs. 13%, P = 0.003) or rinse (41% vs. 29%, P = 0.012) their lenses in water. Showering while wearing lenses was more common in SCL wearers (86%) than GP lens wearers (67%) (P < 0.0001). Swimming while wearing lenses was reported by 62% of SCL wearers and 48% of GP lens wearers (P = 0.027). Wearers who rinsed (SCL; P < 0.0001, GP; P = 0.11) or stored lenses in water (SCL; P < 0.0001, GP P = 0.007) reported that this behavior had little or no effect on their infection risk, compared with those who did not. Both SCL (P < 0.0001) and GP lens wearers (P < 0.0001) perceived that distilled water was safer than tap water for storing or rinsing lenses.

CONCLUSIONS

Despite previously published evidence of Acanthamoeba keratitis' association with water exposure, most SCL, and nearly all GP lens wearers, regularly expose their lenses to water, with many unaware of the risk.

Acanthamoeba granulomatous amoebic encephalitis after pediatric hematopoietic stem cell transplant

Acanthamoeba encephalitis is a rare, often fatal condition, particularly after HSCT, with 9 reported cases to date in the world literature. Our case was originally diagnosed with ALL at age 3 years, and after several relapses underwent HSCT at age 9 years. At 17 years of age, he was diagnosed with secondary AML for which he underwent a second allogeneic HSCT. He presented with acute-onset worsening neurological deficits on day +226 after the second transplant and a post-mortem diagnosis of Acanthamoeba encephalitis was established, with the aid of the CDC.

Differential expression of virulence genes in Legionella pneumophila growing in Acanthamoeba and human monocytes

Legionella pneumophila, the causative agent of Legionnaires’ disease, is widely distributed throughout natural and artificial water systems and can replicate in macrophages and amoebae. Amoebae are the natural hosts of L. pneumophila, whereas macrophages are incidentally infected. The life cycle of L. pneumophila comprises a replicative phase within the Legionella-containing vacuole (LCV) and a transmissive phase during which bacterial cells become motile and are released via killing of the host. Although the host death mechanisms induced by L. pneumophila have been studied, the expression patterns of related L. pneumophila genes have not been reported. The present study compared the expression patterns of host cell death-associated genes in L. pneumophila grown in the human monocytic cell line THP-1 and Acanthamoeba castellanii. Notably, when L. pneumophila was grown in THP-1, expression of the gene flaA, which is involved in the induction of pyroptosis, was downregulated during the course of infection. In contrast, sdhA associated indirectly with host death, was upregulated. Expression of the genes vipD and sidF, which are involved in the induction and suppression of apoptosis, changed by less than 2-fold. Notably, a lower percentage of pyroptotic cells was observed among infected THP-1 cells relative to uninfected cells, and the latter exhibited stronger expression of caspase-1. A different pattern was observed when L. pneumophila was grown in A. castellanii: flaA and vipD were activated, whereas sdhA and sidF were downregulated during the later stage of replication. The percentage of non-viable (annexin-V⁺ PI⁺ or annexin-V⁺PI⁻) A. castellanii organisms increased with Legionella infection, and the expression of metacaspase-1, which is involved in encystation was up-regulated at late infection time. In summary, L. pneumophila can multiply intracellularly in both amoebae and macrophages to induce cell death and secondary infection, and this characteristic is essential for its survival in water and the lungs. The gene expression profiles observed in this study indicated the increased cytotoxicity of L. pneumophila in A. castellanii, suggesting an increased adaptation of Legionella to this host.

Methodological approaches for monitoring opportunistic pathogens in premise plumbing: A review

Opportunistic premise (i.e., building) plumbing pathogens (OPPPs, e.g., Legionella pneumophila, Mycobacterium avium complex, Pseudomonas aeruginosa, Acanthamoeba, and Naegleria fowleri) are a significant and growing source of disease. Because OPPPs establish and grow as part of the native drinking water microbiota, they do not correspond to fecal indicators, presenting a major challenge to standard drinking water monitoring practices. Further, different OPPPs present distinct requirements for sampling, preservation, and analysis, creating an impediment to their parallel detection. The aim of this critical review is to evaluate the state of the science of monitoring OPPPs and identify a path forward for their parallel detection and quantification in a manner commensurate with the need for reliable data that is informative to risk assessment and mitigation. Water and biofilm sampling procedures, as well as factors influencing sample representativeness and detection sensitivity, are critically evaluated with respect to the five representative bacterial and amoebal OPPPs noted above. Available culturing and molecular approaches are discussed in terms of their advantages, limitations, and applicability. Knowledge gaps and research needs towards standardized approaches are identified.

Detection of Acanthamoeba spp. in water samples collected from natural water reservoirs, sewages, and pharmaceutical factory drains using LAMP and PCR in China

Various species of amoebas belonging to the genus Acanthamoeba are widely distributed in many parts of the world. Some strains of these protozoans may exist as parasites and pose risks to human health as causative agents of serious human diseases. Currently in China there is a lack of information about the distribution of Acanthamoeba strains in the environment. Accordingly, 261 environmental water samples taken from rivers, sewage, and pharmaceutical factory drains were collected in Qinghai Province, China. The material was filtered and then analysed with both LAMP and PCR assays. Of the samples examined, Acanthamoeba DNA was found in 32 (14.68%) samples with the use of LAMP; in 13 of these samples, DNA from this amoeba was also detected using PCR. Sequencing of selected positive samples confirmed that the PCR products were fragments of the Acanthamoeba 18S rRNA gene and that isolates represent the T4 genotype, known as the most common strain related to AK cases. The results indicate that surface water, as well as water taken from sewage and pharmaceutical drains, may be a source of acanthamoebic strains potentially pathogenic for humans in China. It has been also demonstrated that LAMP assays is more sensitive than PCR and can be regarded as useful tool for screening the environment for Acanthamoeba spp.

Acanthamoeba Keratitis among Rigid Gas Permeable Contact Lens Wearers in the United States, 2005 through 2011

PURPOSE

To describe the clinical presentation and outcomes of Acanthamoeba keratitis (AK) in rigid gas permeable (RGP) contact lens wearers and to identify modifiable risk factors.

DESIGN

Case-control investigation.

PARTICIPANTS

Patients were RGP contact lens-wearing United States residents with a diagnosis of AK from 2005 through 2011. Controls were RGP contact lens wearers with no history of AK who were at least 12 years of age.

METHODS

Patients were identified during 2 multistate AK outbreak investigations. Controls from the first investigation in 2007 were identified using a reverse address directory. In the second investigation, controls were recruited from participating ophthalmology and optometry practices. Patients and controls were interviewed by phone using a standardized questionnaire. Odds ratios (ORs) and Fisher exact P values were calculated to assess risk factors associated with infection.

MAIN OUTCOME MEASURES

Acanthamoeba keratitis, a rare eye disease primarily affecting contact lens wearers, is caused by free-living amebae, Acanthamoeba species.

RESULTS

We identified 37 patients in the 2 investigations, 10 (27%) from the 2007 investigation and 27 (73%) from 2011. There were 17 healthy controls, 9 (53%) from 2007 and 8 (47%) from 2011. Among patients, 9 (24%) wore RGP lenses for orthokeratology or therapeutic indication; no controls wore RGP lenses for these indications. Significant risk factors for AK were wearing lenses for orthokeratology (OR, undefined; P = 0.02), sleeping while wearing lenses (OR, 8.00; P = 0.04), storing lenses in tap water (OR, 16.00; P = 0.001), and topping off contact lens solution in the case (OR, 4.80; P = 0.01). After stratifying by use of RGP lenses for orthokeratology, storing lenses in tap water and topping off remained significant exposures.

CONCLUSIONS

Nearly one quarter of patients were orthokeratology wearers. Using tap water to store RGP lenses and topping off solution in the lens case were modifiable risk behaviors identified in RGP wearers who wore lenses for both orthokeratology and nonorthokeratology indications. Rigid gas permeable wearers should avoid exposing their lenses to tap water and should empty their cases and use fresh lens solution each time they take out their lenses.

Occurrence and genetic characterisation of Acanthamoeba spp. from environmental and domestic water sources in Queen Elizabeth Protected Area, Uganda

Background

Acanthamoeba is an emerging potentially pathogenic amoeba that has been receiving increasing attention worldwide as a reservoir and potential vector for the transmission of pathogenic bacteria. It is also associated with brain cell damage, keratitis and skin irritation in humans. Its effects are more severe in immunocompromised individuals. This study provides for the first time in Uganda, information on the prevalence and genotypes of Acanthamoeba in environmental and domestic (tap) water.

Methods

A total of 324 environmental and 84 tap water samples were collected between November 2013 and September 2014. The samples were centrifuged, cultured (Non-Nutrient agar seeded with gram-negative bacteria) and observed under a microscope. After confirmation of Acanthamoeba, genomic DNA was extracted for PCR assays by chemical lysis and purification with phenol/chloroform/isoamyl alcohol. Samples that showed the strongest positive bands (400–600 bp) were subjected to cycle sequencing.

Results

Among environmental and tap water samples, 107 (33 %) and 36 (42.9 %) tested positive for Acanthamoeba spp., respectively. Prevalence of Acanthamoeba from specific environmental locations was as follows; Kazinga channel banks (60.7 %), Fish landing sites (50 %), River Kyambura (39.6 %) and Kazinga mid channel (5.3 %). There was a significant difference (p = 0.001) in the prevalence of Acanthamoeba between sampling sites. The mean (Mean ± SE) occurrence of the organism was higher in Kazinga channel banks (3.44 ± 0.49) and Fish landing sites (3.08 ± 0.53). Correlation between in situ parameters and Acanthamoeba was insignificant except for the Dissolved Oxygen (mg/ML) which was negatively correlated (r = −0.231, p = 0.001) to Acanthamoeba. Six distinct partial Acanthamoeba T-genotype groups T1, T2, T4, T5, T6 and T11 were obtained. Ultimately, Acanthamoeba spp., Acanthamoeba hatchetti and Acanthamoeba polyphaga were isolated in the current study.

Conclusions

There was a high prevalence of Acanthamoeba in communal piped tap and environmental water used by communities, indicating poor environmental and domestic water quality.

Emerging Threats for Human Health in Poland: Pathogenic Isolates from Drug Resistant Acanthamoeba Keratitis Monitored in terms of Their In Vitro Dynamics and Temperature Adaptability

Amphizoic amoebae generate a serious human health threat due to their pathogenic potential as facultative parasites, causative agents of vision-threatening Acanthamoeba keratitis (AK). Recently, AK incidences have been reported with increasing frequency worldwide, particularly in contact lens wearers. In our study, severe cases of AK in Poland and respective pathogenic isolates were assessed at clinical, morphological, and molecular levels. Misdiagnoses and the unsuccessful treatment in other ophthalmic units delayed suitable therapy, and resistance to applied chemicals resulted in severe courses and treatment difficulties. Molecular assessment indicated that all sequenced pathogenic corneal isolates deriving from Polish patients with AK examined by us showed 98–100% homology with Acanthamoeba genotype T4, the most prevalent genotype in this human ocular infection worldwide. In vitro assays revealed that the pathogenic strains are able to grow at elevated temperature and have a wide adaptive capability. This study is our subsequent in vitro investigation on pathogenic Acanthamoeba strains of AK originating from Polish patients. Further investigations designed to foster a better understanding of the factors leading to an increase of AK observed in the past years in Poland may help to prevent or at least better cope with future cases.

Genotypic characterization of amoeba isolated from Acanthamoeba keratitis in Poland

Free-living amoebae belonging to the genus Acanthamoeba are the causative factor of many diseases. Among others, they cause Acanthamoeba keratitis (AK), a condition that usually occurs in contact lens wearers, though it is also observed in non-wearers. The number of diagnosed cases of AK increased more than eightfold during 8 years in the USA, and a proportional increase in frequency also occurred in Poland and Europe. Cases of AK are usually diagnosed late, and their therapy is difficult and rarely successful. AK is an uncommon diagnosis in Poland. The increased number of positive cases observed in our laboratory may reflect the growing at-risk population of contact lens wearers. Acanthamoeba as a genus of facultative human parasites is currently classified into 17 genotypes. Isolates belonging to seven genotypes were found to be associated with AK. One genotype in particular, T4, was found to be overrepresented in human disease. The main finding of our study is that in Poland, AK is almost always associated with the T4 genotype.

Microbial dose response modeling: past, present, and future

The understanding of the risk to humans from exposure to pathogens has been firmly put into a risk assessment framework. A key element of applying this approach is the understanding of the relationship between dose and response for particular pathogens. This understanding has progressed from early use of threshold concepts ("minimal infectious dose") thru multiple generations of models. Generation 1 models describe probability of response to exposed dose. Generation 2 models incorporate host factors (e.g., age) and/or pathogen factors (e.g., particle size of inhaled agents). Generation 3 models describe the rate at which effects develop, i.e. the epidemic curve. These (generation 1 through three models) have been developed and used in multiple contexts. Beyond Generation 3 lies an opportunity for the deep incorporation of in vivo physiological responses and the coupling of the individual host dynamics to the dynamics of spread of contagious diseases in the population. This would enable more direct extrapolation from controlled dosing studies to estimate population level effects. There remain also needs to understand broader categories of infectious agents, including pathogenic amoebae and fungi. More advanced models need to be validated against well-characterized human outbreak data.

Surveillance and evaluation of the infection risk of free-living amoebae and Legionella in different aquatic environments

Free-living amoebae (FLA) are ubiquitous in various aquatic environments. Several amoebae species are pathogenic and host other pathogens such as Legionella, but the presence of FLA and its parasites as well as the related infection risk are not well known. In this study, the presence of pathogenic FLA and Legionella in various water bodies was investigated. Water samples were collected from a river, intake areas of drinking water treatment plants, and recreational hot spring complexes in central and southern Taiwan. A total of 140 water samples were tested for the presence of Acanthamoeba spp., Naegleria spp., Vermamoeba vermiformis, and Legionella. In addition, phylogenetic characteristics and water quality parameters were also assessed. The pathogenic genotypes of FLA included Acanthamoeba T4 and Naegleria australiensis, and both were abundant in the hot spring water. In contrast, Legionella pneumophila was detected in different aquatic environments. Among the FLA assessed, V. vermiformis was most likely to coexist with Legionella spp. The total bacteria level was associated with the presence of FLA and Legionella especially in hot spring water. Taken together, FLA contamination in recreational hot springs and drinking water source warrants more attention on potential legionellosis and amoebae infections.

Application of TaqMan qPCR for the detection and monitoring of Naegleria species in reservoirs used as a source for drinking water

Naegleria spp. can be found in the natural aquatic environments. Naegleria fowleri can cause fatal infections in the central nervous system in humans and animals, and the most important source of infection is through direct water contact. In this study, PCR of 5.8S ribosomal RNA (rRNA) gene and internal transcribed spacer (ITS) region was performed in order to identify Naegleria isolates and quantify the Naegleria spp. by TaqMan real-time quantitative PCR in reservoir water samples. The occurrence of Naegleria spp. was investigated in 57 water samples from reservoirs with culture and PCR positive in 2 of them (3.5%), respectively. The total detection rate was 7.0% (4/ 57) for Naegleria spp. The identified species included Naegleria spp., Naegleria canariensis, and Naegleria clarki. N. fowleri was not found in Taiwan's reservoirs used for drinking purposes. The concentrations of Naegleria spp. in detected positive reservoir water samples were in the range of 599 and 3.1 × 10(3) cells/L. The presence or absence of Naegleria spp. within the reservoir water samples showed significant difference with the levels of water temperature. The presence of Naegleria spp. in reservoirs considered a potential public health threat if pathogenic species exist in reservoirs.

Free-living amoebae (FLA) co-occurring with legionellae in industrial waters

Legionella pneumophila is known as the causative agent of Legionnaires’ disease and free-living amoebae (FLA) can serve as vehicles for legionellae. The aim of this study was to screen industrial waters for the occurrence of FLA and their co-occurrence with legionellae. A total of 201 water samples, including 129 cooling waters and 72 process waters, and 30 cooling lubricants were included in the study. Treated waters were screened periodically, pre and post treatment. Altogether, 72.6% of the water samples were positive for FLA, acanthamoebae being most prevalent (in 23.9% of the samples) followed by Vermamoeba vermiformis (19.4%). Only one cooling lubricant was positive (Acanthamoeba genotype T4). Legionella spp. were detected in 34.8% of the water samples and in 15% in high concentrations (>1000 CFU/100 ml). Altogether, 81.4% of the Legionella-positive samples were positive for FLA by standard methods. By applying a highly sensitive nested PCR to a representative set of random samples it was revealed that Legionella spp. always co-occurred with Acanthamoeba spp. Although the addition of disinfectants did influence amoebal density and diversity, treated waters showed no difference concerning FLA in the interphases of disinfection. It appears that FLA can re-colonize treated waters within a short period of time.

The first genotype determination of Acanthamoeba potential threat to human health, isolated from natural water reservoirs in Poland

Different species of amoebae belonging to the genus Acanthamoeba are widely distributed in many parts of the world and known as free-living organisms. Some strains of the protozoans may exist as parasites and cause risk to human health as causative agents of serious human diseases. Currently, in Poland, there is no sufficient information about the distribution of Acanthamoeba strains and their genotypes in the environment. Therefore, 20 environmental surface water samples were collected from different sites located at five water reservoirs in Gdynia, Sopot, and Gdańsk (northern Poland). The material was cultured to obtain Acanthamoeba isolates that were then specifically analyzed with both PCR and real-time PCR assays. Of the 20 samples examined, Acanthamoeba DNA was found in 13 samples tested with the use of real-time PCR; in 10 of them, DNA of the amoeba was also detected using PCR technique. The comparison with sequences available in the GenBank confirmed that the PCR products are fragments of Acanthamoeba 18S rRNA gene and that isolates represent T4 genotype, known as the most common strains related to AK cases. This is the first investigation in Poland describing Acanthamoeba detection in environmental water samples with molecular techniques and genotyping. The results indicate that surface water in Poland may be a source of acanthamoebic strains potentially pathogenic for humans.

Distribution of sequence-based types of legionella pneumophila serogroup 1 strains isolated from cooling towers, hot springs, and potable water systems in China

Legionella pneumophila serogroup 1 causes Legionnaires' disease. Water systems contaminated with Legionella are the implicated sources of Legionnaires' disease. This study analyzed L. pneumophila serogroup 1 strains in China using sequence-based typing. Strains were isolated from cooling towers (n = 96), hot springs (n = 42), and potable water systems (n = 26). Isolates from cooling towers, hot springs, and potable water systems were divided into 25 sequence types (STs; index of discrimination [IOD], 0.711), 19 STs (IOD, 0.934), and 3 STs (IOD, 0.151), respectively. The genetic variation among the potable water isolates was lower than that among cooling tower and hot spring isolates. ST1 was the predominant type, accounting for 49.4% of analyzed strains (n = 81), followed by ST154. With the exception of two strains, all potable water isolates (92.3%) belonged to ST1. In contrast, 53.1% (51/96) and only 14.3% (6/42) of cooling tower and hot spring, respectively, isolates belonged to ST1. There were differences in the distributions of clone groups among the water sources. The comparisons among L. pneumophila strains isolated in China, Japan, and South Korea revealed that similar clones (ST1 complex and ST154 complex) exist in these countries. In conclusion, in China, STs had several unique allelic profiles, and ST1 was the most prevalent sequence type of environmental L. pneumophila serogroup 1 isolates, similar to its prevalence in Japan and South Korea.

Rickettsiae, protozoa, and opisthokonta/metazoa

Rhizobiales (formerly named Rickettsiales) cause in rare instances meningitis and meningovasculitis, respectively. In case of history of exposure, infection by Rhizobiales needs to be considered since both diagnosis and therapy may be extremely difficult and pathogen-specific. The same applies to protozoa; in this chapter, Babesia species, free-living amoebae and Entamoeba histolytica infection, including severe meningitis and brain abscess, infection by Trypanosoma species (South American and African trypanosomiasis) are discussed with respect to history, epidemiology, clinical signs, and symptoms as well as differential diagnosis and therapy. Parasitic flatworms and roundworms, potentially able to invade the central nervous system, trematodes (flukes), cestodes (in particular, Cysticercus cellulosae), but also nematodes (in particular, Strongyloides spp. in the immunocompromised) are of worldwide importance. In contrast, filarial worms, Toxocara spp., Trichinella spp., Gnathostoma and Angiostrongylus spp. are seen only in certain geographically confined areas. Even more regionally confined are infestations of the central nervous system by metazoa, in particular, tongue worms (=arthropods) or larvae of flies (=maggots). The aim of this chapter is (1) to alert the neurologist to these infections, and (2) to enable the attending emergency neurologist to take a knowledgeable history, with an emphasis on epidemiology, clinical signs, and symptoms as well as therapeutic management possibilities.

Hartmannella vermiformis inhibition of Legionella pneumophila cultivability

Hartmannella vermiformis and Acanthamoeba polyphaga are frequently isolated from drinking water and permissive to Legionella pneumophila parasitization. In this study, extracellular factor(s) produced by H. vermiformis and A. polyphaga were assessed for their effects on cultivability of L. pneumophila. Page's amoeba saline (PAS) was used as an encystment medium for H. vermiformis and A. polyphaga monolayers, and the culture supernatants (HvS and ApS, respectively) were assessed against L. pneumophila growth. Compared to PAS and ApS, HvS significantly inhibited L. pneumophila strain Philadelphia-1 (Ph-1) cultivability by 3 log(10) colony forming unit (CFU) mL(-1) after 3 days of exposure compared to <0.5 log(10) CFU mL(-1) reduction of strain Lp02 (P < 0.001). Flow cytometric analysis revealed changes in the percentage and cultivability of three bacterial subpopulations: intact/slightly damaged membrane (ISM), undefined membrane status (UD), and mixed type (MT). After 3 days of HvS exposure, the MT subpopulation decreased significantly (31.6 vs 67.2 %, respectively, P < 0.001), while the ISM and UD subpopulations increased (+26.7 and +6.9 %, respectively) with the ISM subpopulation appearing as viable but nonculturable (VBNC) cells. HvS was separated into two fractions based on molecular weight, with more than 99 % of the L. pneumophila inhibition arising from the <5 kDa fraction (P < 0.001). Liquid chromatography indicated the inhibitory molecule(s) are likely polar and elute from a Novapak C18 column between 6 and 15 min. These results demonstrate that H. vermiformis is capable of extracellular modulation of L. pneumophila cultivability and probably promote the VBNC state for this bacterium.

Fulminant and fatal encephalitis caused by Acanthamoeba in a kidney transplant recipient: case report and literature review

Acanthamoeba is the most common cause of granulomatous amebic encephalitis, a typically fatal condition that is classically described as indolent and slowly progressive. We report a case of Acanthamoeba encephalitis in a kidney transplant recipient that progressed to death within 3 days of symptom onset and was diagnosed at autopsy. We also review clinical characteristics, treatments, and outcomes of all published cases of Acanthamoeba encephalitis in solid organ transplant (SOT) recipients. Ten cases were identified, and the infection was fatal in 9 of these cases. In 6 patients, Acanthamoeba presented in a fulminant manner and death occurred within 2 weeks after the onset of neurologic symptoms. These acute presentations are likely related to immunodeficiencies associated with solid organ transplantation that result in an inability to control Acanthamoeba proliferation. Skin lesions may predate neurologic involvement and provide an opportunity for early diagnosis and treatment. Acanthamoeba is an under-recognized cause of encephalitis in SOT recipients and often presents in a fulminant manner in this population. Increased awareness of this disease and its clinical manifestations is essential to attain an early diagnosis and provide the best chance of cure.

Eukaryotic diversity in premise drinking water using 18S rDNA sequencing: implications for health risks

The goal of this study was to characterize microbial eukaryotes over a 12-month period to provide insight into the occurrence of potential bacterial predators and hosts in premise plumbing. Nearly 6,300 partial 18S rRNA gene sequences from 24 hot (36.9-39.0 °C) and cold (6.8-29.1 °C) drinking water samples were analyzed and classified into major eukaryotic groups. Each major group, consisting of free-living amoebae (FLA)/protozoa, algae, copepods, dinoflagellates, fungi, nematodes, and unique uncultured eukaryotic sequences, showed limited diversity dominated by a few distinct populations, which may be characteristic of oligotrophic environments. Changes in the relative abundance of predators such as nematodes, copepods, and FLA appear to be related to temperature and seasonal changes in water quality. Sequences nearly identical to FLA such as Hartmannella vermiformis, Echinamoeba thermarmum, Pseudoparamoeba pagei, Protacanthamoeba bohemica, Platyamoeba sp., and Vannella sp. were obtained. In addition to FLA, various copepods, rotifers, and nematodes have been reported to internalize viral and bacterial pathogens within drinking water systems thus potentially serving as transport hosts; implications of which are discussed further. Increasing the knowledge of eukaryotic occurrence and their relationship with potential pathogens should aid in assessing microbial risk associated with various eukaryotic organisms in drinking water.

Density of environmental Acanthamoeba and their responses to superheating disinfection

Exposure to viable Acanthamoeba may cause fatal encephalitis and blinding keratitis in humans. Quantification of environmental Acanthamoeba by a reliable analytical assay is essential to assess the risk of human exposure and efficacy of control measures (e.g., superheating). Two DNA binding dyes (ethidium monoazide (EMA) and propidium monoazide) coupled with real-time quantitative PCR (qPCR) were tested for the ability in selectively quantifying viable Acanthamoeba castellanii. This newly developed qPCR assay was applied to determine the density of environmental Acanthamoeba and disinfection efficacy of superheating. Results showed qPCR with 2.3 μg/mL EMA performed optimal with a great linearity (R (2) = 0.98) and a wide range of detection (5-1.5 × 10(5) cells). EMA-qPCR analyses on water samples collected from cooling towers, eyewash stations, irrigated farmlands, and various wastewater treatment stages further showed viable Acanthamoeba density from nondetectable level to 6.3 × 10(5) cells/L. Superheating A. castellanii at 75-95 °C for 20 min revealed significant reductions in both EMA-qPCR and qPCR detectable Acanthamoeba target sequences with an adverse association between heating temperature and qPCR-determined DNA quantity (r = -0.76 to -0.93, p < 0.0001). Moreover, A. castellanii trophozoites were more sensitive to superheat stress than the cells being encysted for 6 and 13 d (p < 0.05). This is the first study to quantify environmental Acanthamoeba and characterize their responses to superheating by EMA-qPCR. The quantitative data provided in this study facilitate to understand better the relative risk for human exposed to viable Acanthamoeba and the efficacy of superheating against Acanthamoeba.

Co-isolation of Vahlkampfia and acanthamoeba in acanthamoeba-like keratitis in a Spanish population

PURPOSE

To report the co-isolation incidence of Acanthamoeba and Vahlkampfia in amoebic keratitis from a tertiary care institution in Madrid, Spain.

METHODS

In this retrospective case series, 7 eyes of 7 consecutive patients with culture-proven or polymerase chain reaction-positive Acanthamoeba keratitis were seen at a tertiary care institution from January 2010 to April 2011, and their charts were reviewed.

RESULTS

Two of 7 patients showed mixed Acanthamoeba and Vahlkampfia keratitis. Good clinical response to the treatment was strongly correlated with early diagnosis, whereas delayed diagnosis resulted in poor response to the treatment in single or mixed infection.

CONCLUSIONS

Co-isolation of Vahlkampfia and Acanthamoeba in Acanthamoeba-like keratitis has recently been detected in our population. This finding should raise awareness of the existence of other amoeba different from Acanthamoeba causing keratitis. There are not enough cases yet to determine the impact of mixed amoebic keratitis in the prognosis of this disease.

Isolation and identification of free-living amoebae from tap water in Sivas, Turkey

The present work focuses on a local survey of free-living amoebae (FLA) that cause opportunistic and nonopportunistic infections in humans. Determining the prevalence of FLA in water sources can shine a light on the need to prevent FLA related illnesses. A total of 150 samples of tap water were collected from six districts of Sivas province. The samples were filtered and seeded on nonnutrient agar containing Escherichia coli spread. Thirty-three (22%) out of 150 samples were found to be positive for FLA. The FLA were identified by morphology and by PCR using 18S rDNA gene. The morphological analysis and partial sequencing of the 18S rDNA gene revealed the presence of three different species, Acanthamoeba castellanii, Acanthamoeba polyphaga, and Hartmannella vermiformis. Naegleria fowleri, Balamuthia mandrillaris, or Sappinia sp. was not isolated during the study. All A. castellanii and A. polyphaga sequence types were found to be genotype T4 that contains most of the pathogenic Acanthamoeba strains. The results indicated the occurrence and distribution of FLA species in tap water in these localities of Sivas, Turkey. Furthermore, the presence of temperature tolerant Acanthamoeba genotype T4 in tap water in the region must be taken into account for health risks.

Preferential colonization and release of Legionella pneumophila from mature drinking water biofilms grown on copper versus unplasticized polyvinylchloride coupons

Legionella occurrence in premise drinking water (DW) systems contributes to legionellosis outbreaks, especially in the presence of suitable protozoan hosts. This study examined L. pneumophila behavior within DW biofilms grown on copper (Cu) and unplasticized polyvinylchloride (uPVC) surfaces in the presence of Acanthamoeba polyphaga. One year-old DW biofilms were established within six CDC biofilm reactors: three each containing Cu or uPVC coupons. Biofilms were then inoculated with L. pneumophila (uPVC-Lp and Cu-Lp), or L. pneumophila and A. polyphaga (uPVC-Lp/Ap and Cu-Lp/Ap) and compared to sterile water inoculated controls (uPVC- and Cu-Control) over a 4 month period. L. pneumophila appeared more persistent by qPCR within Cu biofilms in the presence of A. polyphaga compared to uPVC biofilms with or without A. polyphaga, but maintained their cultivability in uPVC biofilms compared to Cu biofilms. Also, persistent shedding of L. pneumophila cells (assayed by qPCR) in the effluent water implied colonization of L. pneumophila within Cu-coupon reactors compared to no detection from uPVC-coupon reactor effluent 14 days after inoculation. Hence, L. pneumophila appeared to colonize Cu surfaces more effectively and may be shed from the biofilms at a greater frequency and duration compared to L. pneumophila colonized uPVC surfaces with host amoebae playing a role in L. pneumophila persistence within Cu biofilms.

Cooccurrence of free-living amoebae and nontuberculous Mycobacteria in hospital water networks, and preferential growth of Mycobacterium avium in Acanthamoeba lenticulata

The incidence of lung and other diseases due to nontuberculous mycobacteria (NTM) is increasing. NTM sources include potable water, especially in households where NTM populate pipes, taps, and showerheads. NTM share habitats with free-living amoebae (FLA) and can grow in FLA as parasites or as endosymbionts. FLA containing NTM may form cysts that protect mycobacteria from disinfectants and antibiotics. We first assessed the presence of FLA and NTM in water and biofilm samples collected from a hospital, confirming the high prevalence of NTM and FLA in potable water systems, particularly in biofilms. Acanthamoeba spp. (genotype T4) were mainly recovered (8/17), followed by Hartmannella vermiformis (7/17) as well as one isolate closely related to the genus Flamella and one isolate only distantly related to previously described species. Concerning mycobacteria, Mycobacterium gordonae was the most frequently found isolate (9/17), followed by Mycobacterium peregrinum (4/17), Mycobacterium chelonae (2/17), Mycobacterium mucogenicum (1/17), and Mycobacterium avium (1/17). The propensity of Mycobacterium avium hospital isolate H87 and M. avium collection strain 104 to survive and replicate within various FLA was also evaluated, demonstrating survival of both strains in all amoebal species tested but high replication rates only in Acanthamoeba lenticulata. As A. lenticulata was frequently recovered from environmental samples, including drinking water samples, these results could have important consequences for the ecology of M. avium in drinking water networks and the epidemiology of disease due to this species.

Quantitative detection and identification of Naegleria spp. in various environmental water samples using real-time quantitative PCR assay

Naegleria spp. is a free-living amoeba that can be found in various aquatic environments. There are some Naegleria spp. that can cause fatal infections in animals and humans, and the most important source of infection is through direct water contact. In this study, a real-time quantitative PCR was developed to detect and quantify the Naegleria spp. in various environmental water samples. The water samples were taken from rivershed, water treatment plants, and thermal spring recreation areas. The total detection rate was 4.0% (7/176) for Naegleria spp. The percentages of samples containing Naegleria spp. from river water, raw drinking water, and thermal spring water were 0% (0/100), 10.7% (3/28) and 8.3% (4/48), respectively. The concentration of Naegleria spp. in detected positive raw drinking water and thermal spring water samples was in the range of 3.9-12.6 and 1.1-24.2 cells/L, respectively. The identified species included Naegleria australiensis, Naegleria lovaniensis, and Naegleria spitzbergeniensis. The presence of Naegleria spp. in various aquatic environments is considered a potential public health threat.

Acanthamoeba keratitis: an emerging disease gathering importance worldwide?

Acanthamoeba keratitis (AK) is increasingly being recognized as a severe sight-threatening ocular infection worldwide. Although contact lens wear is the leading risk factor for AK, Acanthamoeba parasites are also an important cause of keratitis in non-contact lens wearers. Diagnosis of AK is challenging, and the available treatments are lengthy and not fully effective against all strains. The pathogenesis of Acanthamoeba is still under study, and the identification of the key factors involved in this process should be useful for the development of fully effective therapies. This review focuses on recent developments on AK pathogenesis and diagnosis as well as novel strategies for the evaluation of anti-amoebic agents that could be applied in the near future against these pathogens.