An 85-year old lady originally from Gujurat presented to the emergency department with sudden onset left sided weakness and slurred speech. Stroke was suspected. Computed tomography (CT) of the head showed bilateral multiple cortical and subcortical hypodense lesions; magnetic resonance imaging revealed that these lesions were ring enhancing with oedema. Lumbar puncture found an opening pressure of 22cm HO, 98% lymphocytes (60x106/L) in the cerebrospinal fluid with a normal glucose (6.1mg/L) and high protein (0.66 mg/L). Cerebrospinal fluid culture, PCR and cytology were all negative. The patient was started on empirical therapy for tuberculous meningitis. A subsequent CT chest, abdomen and pelvis however did not find any other significant pathology.

Unfortunately, soon after her investigations, the woman rapidly deteriorated. A joint medical decision was made to shift focus of treatment to palliative care. After death, post-mortem found multiple irregular haemorrhagic solid lesions with dark brown edges. Histopathology confirmed extensive areas of necrosis, within which there were multiple amoebic trophozoites and cysts. A diagnosis of amoebic (it may be) meningo-encephalitis was made. These were thought to be free-living amoebae.

Free-living amoebae are ubiquitous to the environment, and exposure is common. The incidence of amoebic encephalitis however is rare and usually occurs in immunocompromised patients. Portal of entry, especially in cases where the cerebrospinal fluid protein is only mildly raised or normal, is thought to be through the nose or eyes (for example, Acanthamoeba keratitis from contact lenses). Clinicians should consider this as a differential diagnosis for any patient with multiple brain abscesses.

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