PMC7275226_01
CAT scan on admission showing (a) axial, (b) sagittal, (c) post hemicraniectomy within 12 hrs. of admission. Note, there is diffuse sulcal effacement in (a), possibly reflecting hypoxic-ischemic encephalopathy Vs meningitis.
CRICC2020-9235794.002.jpg
PMC7275226_01_CRICC2020-9235794.002.jpg
fig2
A computerized tomography (CT) scan of the brain showed no evidence of acute intracranial infarction or hemorrhage; however, there was sulcal effacement concerning for hypoxic/ischemic encephalopathy versus meningitis (Figure 2).
Naegleria trophozoites were rapidly identified by their large, round- to pear-shaped cells with a prominent, dark nucleus, and scattered vacuoles. Images of Naegleria fowleri on Giemsa Wright-stained CSF slides (1000x, oil immersion). Black arrowheads point to Naegleria trophozoites with a background of mostly RBC and some neutrophils.
CRICC2020-9235794.003.jpg
PMC7275226_01_CRICC2020-9235794.003.jpg
fig3
We sent samples to the CDC, which confirmed the diagnosis of Naegleria fowleri (Figure 3).
MRI post 72 hours of admission. After uncomplicated wide bilateral craniectomies. (a) The sagittal view showing transtentorial herniation with stretching and obliteration of the fourth ventricle. (b) Note on the axial view showing diffuse swelling with loss of gray white junctions and absence of ventricular space.
CRICC2020-9235794.004.jpg
PMC7275226_01_CRICC2020-9235794.004.jpg
fig4
Despite the bilateral craniectomies and other interventions, the patient's ICP remained elevated, and he started to demonstrate signs of brain death with MRI revealing transtentorial herniation without uncal or subfalcine herniation (Figure 4).