Balamuthia mandrillaris

# Overveiw
Balamuthia mandrillaris is a free-living leptomyxid amoeba which is known to cause disease in humans, especially the deadly neurological condition known as primary amoebic meningoencephalitis. Balamuthia has not been definitively isolated in nature, but it is believed to be distributed throughout the temperate regions of the world. This is supported somewhat by the presence of antibodies to Balamuthia present in healthy individuals.

# Morphology
Balamuthia mandrillaris is a free-living, heterotrophic amoeba, consisting of a standard complement of organelles surrounded by a three-layered cell wall, and with an abnormally large, vesicular nucleus. On average, a Balamuthia trophozoite is approximately 30-120 m across. The cysts fall approximately in this range as well. 

# Life Cycle
Balamuthias life cycle consists of a cystic stage and a trophozoite stage, both of which are infectious, and both of which can be identified as inclusions into the brain tissue on microscopic examination of brain biopsies performed on infected individuals.
- Balamuthia mandrillaris has been isolated from the environment and has also been isolated from autopsy specimens of infected humans and animals.
- B. mandrillaris has only two stages, cysts and trophozoites, in its life cycle.
- No flagellated stage exists as part of the life cycle. The trophozoites replicate by mitosis (nuclear membrane does not remain intact).
- The trophozoites are the infective forms, although both cysts and trophozoites gain entry into the body through various means.
- Entry can occur through the nasal passages to the lower respiratory tract, or ulcerated or broken skin.
- When B. mandrillaris enters the respiratory system or through the skin, it can invade the central nervous system by hematogenous dissemination causing granulomatous amoebic encephalitis (GAE) or disseminated disease, or skin lesions in individuals who are immune competent as well as those with compromised immune systems.
- B. mandrillaris cysts and trophozoites are found in tissue.

# Pathology
Balamuthia mandrillaris enters the body through the lower respiratory tract or through open wounds. Upon introduction, the amoebas  may form a skin lesion, or migrate to the brain. Once in the brain, Balamuthia causes a condition known as granulomatous amoebic encephalitis (GAE), which is usually fatal. The symptoms of infection by Balamuthia are unclear, as a very few patients have presented with the disease thus far. Balamuthia-induced GAE can cause focal paralysis, seizures, and brainstem symptoms such as facial paralysis, difficulty swallowing, and double vision.
Balamuthia is also known to cause a variety of non-neurological symptoms, and often causes skin lesions, through which the amoeba may enter the bloodstream and migrate to the brain. Many patients experiencing this particular syndrome report a skin lesion (sometimes similar to those caused by Staphylococcus aureus or other bacteria), which does not respond well to dermatologic treatment. The lesion is usually localised and very slow to heal, if at all. In some presentations, the lesion may be mistaken for certain forms of skin cancer. Balamuthia lesions on the face may also lead to amebic keratitis, and usually results in facial swelling.
Balamuthia encephalitis is an extremely deadly disease, and as of 2003, only two recoveries had been reported, both with lasting brain damage.

# Culturing and Identification
Balamuthia is most easily identifiable in a brain biopsy performed on an individual suffering from Balamuthia meningoencephalitis. The amoeba may also, however, be identified in a standard culture performed on agar plate. Identification by this method is, however, used primarily for confirmation of an existing diagnosis, as the amoebas are very slow to begin multiplying within the agar.  From this point, Balamuthia may be transferred to tissue cultures, commonly composed of cultured kidney cells taken from primates.
Culture on agar may be expedited by coating the surface of the agar with a layer of bacteria, on which the amoebas may feed.

# Treatment
Balamuthia infection has only been successfully treated in two cases. Both were treated with a cocktail of antibiotics and antiparasitics, although it is unclear if any or all of these medications played a part in treatment. Both victims suffered permanent neurological deficits as a result of their infection.

## Antimicrobial Regimen
- 1. Granulomatous Amebic Encephalitis
- Preferred regimen (1): Pentamidine AND Flucytosine AND Fluconazole AND Sulfadiazine AND (Azithromycin OR Clarithromycin)
- Preferred regimen (2): Pentamidine AND Albendazole AND (Itraconazole OR Fluconazole) AND Miltefosine

# Other Pathogenic Amoebas
- Acanthamoeba spp.
- Naegleria fowleri

# Related Amoebas
- Gephyramoeba spp.