235.3 🩺 內科專科考前版

235.3.0.1 1⃣ Naegleria Climate Change

  • Range expanding north (USA: previously mostly Gulf states + Florida + Texas)
  • 2018+: Minnesota, Indiana, Nebraska, Kansas cases
  • 2024 climate adaptation + public health awareness
  • Warm summer + warm freshwater = risk

235.3.0.2 2⃣ Neti Pot Outbreaks

  • Louisiana 2011 + 2024+ cases
  • Tap water containing Naegleria
  • Use boiled (1 min) or distilled water only
  • FDA + CDC warnings

235.3.0.3 3⃣ PAM Treatment Protocol (CDC)

  • Amphotericin B IV 0.5 mg/kg/d AND intrathecal 1.5 mg/d
  • Miltefosine 50 mg PO bid
  • Azithromycin 500 mg/d
  • Fluconazole 10 mg/kg/d
  • Rifampin 10 mg/kg/d
  • Dexamethasone
  • Therapeutic hypothermia (selective)
  • ICU + ventilator + ICP monitoring
  • CDC consultation for current protocol

235.3.0.4 4⃣ Acanthamoeba Keratitis Misdiagnosis

  • Often initially diagnosed as HSV keratitis
  • Failure to respond to acyclovir → reconsider
  • Confocal microscopy increasingly available
  • High index of suspicion + early ophthalmology consultation

235.3.0.5 5⃣ Balamuthia in Hispanic Populations USA

  • Slight predilection (mechanism unclear — possibly genetic or soil exposure)
  • Increased awareness in 2010s+
  • Early recognition + biopsy

235.3.0.6 6⃣ Corneal Transplant for Acanthamoeba Keratitis

  • Penetrating keratoplasty for severe / refractory
  • Recurrence in graft possible
  • Pre-transplant aggressive antimicrobial
  • Long-term immunosuppression considerations

235.3.0.7 7⃣ Miltefosine Acquisition

  • CDC stockpile + compassionate use
  • Not commercially available in many countries
  • 24/7 emergency request
  • Rapid shipping for suspected cases

235.3.0.8 8⃣ 健保 / Taiwan

  • 眕芋 endemic; sporadic cases
  • 通報 mandatory
  • 健保 amphotericin + supportive
  • Miltefosine through specialty channels

235.3.0.9 9⃣ Diagnostic Challenges

  • Free-living amebae often misdiagnosed or diagnosed post-mortem
  • Awareness + high index of suspicion critical
  • PCR + biopsy for definitive
  • Reference labs (CDC) for confirmation

235.3.0.10 10. Future

  • Earlier diagnostics (PCR availability, biomarkers)
  • New treatment combinations
  • Miltefosine alternatives
  • Public awareness campaigns