A 14-year-old boy came to Dr Susmita Banerjee, a Paediatric Nephrologist at The Calcutta Medical Research Institute (CMRI) with complaints of headache and vomiting. The boy’s history was same as that of any other healthy teenager, active and filled with a lot of

sport. He was involved with lots of sports and was especially fond of swimming. The boy was complaining of mild neck stiffness and his initial symptoms suggested meningitis. Dr Banerjee recommended admission at The Calcutta Medical Research Institute. However further investigations made her rule out meningitis considering that there wasn’t any other symptom apart from neck stiffness like malaise or fever that may have raised some doubt.

The CMRI team of doctors were all involved in this case when the lumbar puncture report showed abnormal readings. Cell counts were high and CSF protein count was alarmingly high. The doctors started to question how these readings were possible in an active child with only a days fever. Medical intuitions having been raised, Dr Banerjee went back to the family to find out more about the child’s whereabouts in the days before the fever. The feedback revealed a distinct history of the child’s love for swimming. This triggered Dr Banerjee to dig deeper and ask for a rare test that is never called for. She decided to test for PAM or Primary Amoebic Meningitis. PAM is an extremely rare kind of meningitis associated with swimming in freshwater lakes, rivers and pools.

A free-living microscopic amoeba called Naegleria fowleri, sometimes referred to as the brain-eating amoeba, causes this rare and devastating infection. This amoeba enters the body through the nose, makes its way to the brain and causes Primary Amoebic Meningitis. In the brain, it feeds on nerve tissues and multiplies itself causing necrosis and bleeding. PAM, across the world, is one of the rarest kinds of meningitis reported.

Cases of PAM are few and therefore research on the infection is also rare. PAM is associated with fatality in 95-98% of cases. In the USA, only 135 cases have been recorded in the last two decades and only 4 have survived. 4 cases of survival have been reported in Indian literature. When the test reports came back, amoeba was found floating in the CSF sample. The CMRI team had a diagnosis within 24 hours of the patient being admitted. However, there still remained the daunting, exacting and complicated task of treatment.

Dr Banerjee immediately consulted Dr Bibhuti Saha, who heads the Tropical Medicine Unit of the state. They went through the literature available on this rare infection. They soon found that because of the rare nature of the bacteria, there was not much clarity on which drugs would work best going by the survival cases around the world. A number of drugs had been tried and the same drug had different effects on different individuals. The main medicine, amphotericin B, which is a very toxic drug was administered and soon the child went into kidney failure (which is a known side effect). The CMRI team now needed to act very fast. They immediately stopped administering the drug and decided to try three other drugs that had been mentioned in the PAM medical literature. One of these was Miltifocin, a new drug that is not yet available in the market. CMRI immediately contacted the Department of Health and Family (Swasthya Bhavan), Government of West Bengal, for the drug. The Directorate of Health provided quick and speedy delivery of the drug, which was being used in another health scheme on the field. As soon as it was procured, the drug was administered. It was administered along with the other two recommended drugs for a total of 14 days. Gradually his kidney stabilised and urine output improved. Over two to three weeks he gradually recovered under the close monitoring of the team of specialists at CMRI. After being discharged when he had come back for a check-up he showed no signs of kidney problems and has now fully recovered.

He is also gradually getting back to his love— sports.

Dr Susmita Banerjee

MBBS, DCH, MSC, MRCPI, FRCPCH, FIAP