New PAM case reported in woman in district
The woman has a history of bathing in a stream in her neighbourhood and a test of her cerebrospinal fluid has confirmed amoebic encephalitis.
The anxiety surrounding the seemingly increasing incidence of primary amoebic meningoencephalitis (PAM) in the district was heightened again on Monday as a new case of PAM was reported in a 24-year-old woman from Navayikulam.
According to the Health department, the woman has a history of bathing in a stream in her neighbourhood and a test of her cerebrospinal fluid has confirmed amoebic encephalitis.
With this new case, the total number of people undergoing treatment for PAM in Thiruvananthapuram Government Medical College hospital has gone up to nine. This includes the cluster of five confirmed cases and two suspected cases from Athiyannur panchayat in Neyyattinkara; one case from Mannammoola and the new case from Navayikulam. The index case from the PAM cluster at Neyyattinkara, had died earlier on July 23.
So far seven confirmed cases of PAM, two probable PAM cases and one PAM death have been reported from the district.
Health officials maintain that PAM is a rare disease and that its incidence is indeed sporadic.
“Kavinkulam PAM cluster in Neyyatatinkara is an entirely different story because the patients from this cluster are united by a common risky behaviour that led to the direct introduction of the amoeba into nasal mucosa. But the other two instances of PAM are indeed sporadic events — a theory we are wont to re-examine only if more than one case is reported from a water body,” a senior Health official said
He pointed out that pro-active case-finding by clinicians — checking for the presence of amoeba in CSF samples whenever acute encephalitis syndrome is encountered — has thrown up more cases.
However, going by the fact that more cases are being reported from multiple locations , one should naturally assume that amoeba is present in most water bodies except in chlorinated water and that the increased environmental heat and other aquatic factors may be aiding the increase in its concentration.
The focus of the Health department is thus on creating IEC campaigns for the public, by narrowing down the possible risks.
“The patient from Mannammoola has no contact with ponds but while examining patient history, we were told that in his house, water from the well is pumped into the overhead tank and then re-directed to the pipe system. The overhead tank has not been cleaned in ages and it is possible that the water harbours amoeba. The patient also has the past history of a head injury, hence it is possible that the cribriform plate may not be intact, aiding the quick entry of amoeba into the brain,” he said..
(Cribriform plate is located at the base of the skull and acts as a barrier between the nasal cavity and the brain. The amoeba which enters the nasal cavity, crosses the cribriform plate to reach the brain and create inflammation)
All persons in this patient’s household have been warned to report to the MCH if at all they develop any symptoms such as headache or difficulty in turning the neck.
Each new case of PAM seems to be throwing up new learnings and the IEC message disseminated by the Health department on Monday specified that using water from uncleaned overhead tanks may be dangerous.
Also, persons who have had head injuries or nasal surgery in the past should absolutely stay away from entering stagnant water bodies. Under no circumstances should one snort water into the nose while washing face or when swimming in ponds . Those in the habit of sinus irrigation (rinsing the sinus )should use sterilised water for the same and not tap water
Patients currently undergoing treatment for PAM at MCH are clinically stable now. They are being treated with a cocktail of drugs, primarily amphotericin and miltefosin, the latter is believed to have shown promising results in previous PAM cases. The treatment duration is 28 days, only after which can the prognosis be made.
The current directive to all clinicians is to take a close look at the CSF for the presence of amoeba in all cases of meningoencephalitis, irrespective of whether the patient has had a direct or indirect contact with water bodies. This is because early diagnosis and treatment might be life-saving, in an infection which is almost always fatal, a learning which has been unique to Kerala.
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