Successful Multimodal Management of Acanthamoeba-Associated Granulomatous Amebic Encephalitis in an Immunocompetent Child: Clinical Analysis With Structured Review of Published Pediatric Cases

Abstract

Objectives: To describe the diagnostic pathway, multimodal therapeutic approach, and long-term outcome of an immunocompetent child with Acanthamoeba-associated granulomatous amebic encephalitis, and to place the case in the context of previously published immunocompetent pediatric cases through a structured literature review. Methods: A 4-year-old child from Tbilisi, Georgia, presented with intractable seizures and intermittent fever. Despite broad-spectrum antibiotics, symptoms persisted. After excision of the lesions, pathological, microbiological, and molecular analyses were performed. Acanthamoeba-like microorganisms were identified during microscopic examination of Kinyoun-stained smears and confirmed by polymerase chain reaction (PCR). The patient received prolonged combination antimicrobial therapy, including miltefosine, and was followed for 3 years. A structured PubMed and Scopus-based review was also performed, covering publications from 1990 to 2025. Duplicates were removed manually. Two authors independently screened titles, abstracts, and full texts, and disagreements were resolved by consensus. Results: The index patient had multiple supratentorial lesions with marked edema, diffusion restriction, and blood products. Staged surgical resection provided diagnostic tissue and decompression; Kinyounstained smears showed Acanthamoeba-like organisms, and PCR confirmed Acanthamoeba spp. After prolonged combination therapy including miltefosine, the patient achieved sustained clinical and radiological recovery at 3 years. The review identified 14 previously published cases, including the present patient; 15 immunocompetent pediatric cases were analyzed. Median age was 9 years (range, 1-17), with 10 boys and 5 girls. Nine patients survived and six died, yielding a fatality rate of 40%. Conclusions: Acanthamoeba-associated GAE should be considered in immunocompetent children with unexplained multifocal intracranial lesions, seizures, and fever when routine investigations are nondiagnostic. Early surgical tissue sampling, fresh-smear microscopy, PCR confirmation, lesion-directed decompression when indicated, and prolonged targeted therapy, including miltefosine, may contribute to survival in selected pediatric patients. (c) 2026 The Authors. Published by Elsevier Ltd on behalf of International Society for Infectious Diseases. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)