Man contracts ‘brain-eating ameba’ via ritual nasal rinsing in US Virgin Islands: Case study

Many people perform ritual nasal rinsing. This practice is included in Yogic, Ayurvedic, and Islamic traditions. Within the Islamic faith, ritual nasal rinsing is included in a cleansing process called “wudu” or “ablution.” It is usually performed several times a day in preparation for prayer, according to the Centers for Disease Control and Prevention.

Naegleri fowleri Image/CDC

Almost exactly one year ago, a man from the US Virgin Islands died from primary amebic meningoencephalitis (PAM) after contracting the free-living thermophilic ameba, Naegleria fowleri. This was the first case and death due to the “brain-eating ameba” in the US territory, according to a Morbidity and Mortality Weekly Report (MMWR) last week.

It is reported that the 47-year-old man had fresh water exposure using tap water for ablution, a ritual cleansing that he practiced several times a day in preparation for Islamic prayer, which can include nasal rinsing.

According to the “Notes from the Field”:

On November 16, 2012, the patient had visited the emergency department with a headache; he was treated symptomatically and released. The following day, the patient returned to the emergency department by ambulance with fever, confusion, agitation, and a severe headache, for which he was admitted.

Cerebrospinal fluid (CSF) studies were consistent with bacterial meningitis, and antibiotics were started. On November 18, neurologic findings included fixed nonresponsive pupils, no response in the upper or lower extremities, muted plantar responses, and no response to verbal commands. Microscopic examination of the CSF obtained from a second lumbar puncture revealed motile amebic trophozoites.

CSF specimens sent to CDC for confirmatory testing were positive for N. fowleri by real-time polymerase chain reaction testing. On the morning of November 21, the patient was pronounced brain dead based on neurologic criteria.

An environmental investigation into the water supply at the man’s home and the mosque he attended was performed to determine the presence of the deadly parasite.

The findings included:

His household water sources were untreated groundwater from a well and untreated rainwater from a cistern; both sources were connected to the home’s plumbing system. No municipal water was piped into the home. The mosque water supply was desalinated and chlorinated municipal water. None of three samples from the mosque yielded N. fowleri; however, three of 17 samples from the patient’s home yielded N. fowleri. Water samples taken from the showerhead and the hot water heater along with the showerhead itself were positive for N. fowleri. None of the positive household water samples had detectable levels of free chlorine.

This suggests the source of his exposure to be the home.

Although there has been two documented cases of N. fowleri  due to the use of neti pots in the US, this is the first case likely due to ablution.

There has been documented cases of PAM due to ablution in other parts of the globe.

LISTEN: CDC Expert, Dr. Jennifer Cope Talks Parasitic Meningitis And Naegleria Fowleri

The CDC recommends taking one of the following actions to help prevent getting infected with this deadly parasite during ritual nasal rinsing:

• Boil: Use water that has been previously boiled for 1 minute and left to cool.
  • At elevations above 6,500 feet, boil for 3 minutes.
• Filter: Use a filter designed to remove some water-loving germs.
  • The label may read “NSF 53” or “NSF 58.”
  • Filter labels that read “absolute pore size of 1 micron or smaller” are also effective.
• Buy: Use water with a label specifying that it contains distilled or sterile water.
• Disinfect: Learn how to disinfect your water to ensure it is safe from Naegleria.
  • Chlorine bleach used at the right level and time will work as a disinfectant against this germ.

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