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Nasal irrigation can kill you

Robin Wulffson MD's picture
nasal irrigation, Naegleria fowleri, primary amebic meningoencephalitis, PAM

Some people use tap water for nasal irrigation. A new study has reported that the practice could be fatal because it could expose an individual to a microscopic organism, which could produce a fatal brain infection. Researchers affiliated with the Centers for Disease Control and Prevention (CDC) published their findings online on August 23 in the journal Clinical Infectious Diseases.

The organism implicated in the fatal infections is Naegleria fowleri, which is a climate-sensitive, thermophilic (heat-loving) ameba, which is present in the environment, including warm, freshwater lakes and rivers. When this organism enters the nose, it can cause primary amebic meningoencephalitis (PAM), which is almost universally fatal. When water containing N. fowleri enters the nose, it migrates to the brain via the olfactory nerve (the nerve that transmits sense of smell to the brain). Past cases of PAM have occurred in swimmers; however, in 2011, two died in Louisiana hospitals of the disease after brief illnesses.

The first case occurred in a 28-year-old man from southern Louisiana who became ill in June 2011. He had a 24-hour history of a severe occipital headache (back of head) that radiated down his neck, neck stiffness, back pain, and intermittent vomiting. When he presented at the emergency department, he had a fever ((38.5° C; 101.3° F); he was confused, disoriented, and combative. He was intubated for breathing assistance. Despite neurological critical care, he died two days later.

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The second case occurred in 51-year-old woman admitted to the hospital with a three-day history of altered mental status, nausea, vomiting, poor appetite, listlessness, fatigue, and high fever. Her temperature was 38.6° C (101.5° F); she was lethargic, with neck stiffness, and thyromegaly (enlarged thyroid gland). Tests for specific viral, bacterial, and fungal organisms as well as the bacterial culture were negative. She died four days after admission.

The two patients underwent clinical and environmental testing; furthermore, case investigations were initiated to determine the cause of death and to identify the exposures. Both patients received a diagnosis of PAM. Their only reported water exposures were tap water used for household activities, including regular sinus irrigation with neti pots. (A neti pot is a small vessel with a spout, which facilitates instilling water into the nasal cavity.) Water samples, tap swab samples, and neti pots were collected from both households and tested; N. fowleri were identified in water samples from both homes.

The authors concluded that these two cases are the first reported PAM cases in the United States associated with the presence of N. fowleri in household plumbing served by treated municipal water supplies; furthermore, it marks the first report of PAM potentially associated with the use of a nasal irrigation device. In addition, these cases occurred in the context of an expanding geographic range for PAM beyond southern tier states with recent case reports from Minnesota, Kansas, and Virginia. They note that these infections introduce an additional consideration for physicians recommending nasal irrigation and demonstrate the importance of using appropriate water (distilled, boiled, filtered) for nasal irrigation. Furthermore, the changing epidemiology of PAM highlights the importance of raising awareness about this disease among physicians treating persons showing meningitis-like symptoms.

Reference: Clinical Infectious Diseases

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I boil filtered water for 5 minutes; adding 1/2 t sodium bicarb and 2t non-iodized salt to the boil. I then keep it in a sanitized jar in a dark cabinet and make a new batch at least 2X a week.