Fatal Case of Splash Pad-Associated Naegleria fowleri Meningoencephalitis - Pulaski County, Arkansas, September 2023

Abstract

A fatal case of primary amebic meningoencephalitis (PAM), an infection caused by Naegleria fowleri, was diagnosed in Arkansas in a young child in September 2023. A public health investigation was completed, with epidemiologic, laboratory, and environmental data suggesting that a splash pad (an interactive water play venue that sprays or jets water on users and has little or no standing water) with inadequately disinfected water was the most likely site of the patient's N. fowleri exposure. This case is the third occurrence of splash pad-associated PAM reported in the United States; all three cases involved inadequately disinfected water. PAM should be considered in patients with acute meningoencephalitis and a history of recent possible exposure to fresh water, including treated recreational water (e.g., in splash pads or pools), via the nasal passages. Proper design, construction, operation, and management of splash pads can help prevent illnesses, including N. fowleri infections. Increased awareness, collaboration, and communication among clinicians, hospitals, laboratories, CDC, health departments, the aquatics sector, and the public can help support N. fowleri infection identification, treatment, prevention, and control efforts.

FIGURE 1

Wright-Giemsa stained (x1,000 magnification) cerebrospinal fluid cytospin slide images from a patient with fatal primary amebic meningoencephalitis, demonstrating numerous Naegleria fowleri trophozoites seen as extracellular single forms (A) or clusters (B), with a predominantly neutrophilic background inflammatory response including neutrophils phagocytizing N. fowleri microorganisms (C) — Pulaski County, Arkansas, September 2023 Photos/Jeanette M. Ramos, Arkansas Children’s Hospital Department of Pathology

FIGURE 2

Schematic representation of splash pad water system — Pulaski County, Arkansas, September 2023 * Includes a recirculating system and a separate water feature pump, which pulled water from an underground tank when users activated the splash pad and directed it through a manifold piping system to a series of laminar nozzles that sprayed water up from the deck. After the water fell onto the splash pad, it flowed down a sloped surface into a return drain lining the perimeter and was plumbed back into the tank. A recirculating pump then pulled water from this tank and sent it through a sand filter and, subsequently, calcium hypochlorite tablets and sodium bisulfate tablets were added by a chlorinator and dry acid feeder, respectively. The water was then returned to the tank until being recirculated again, or until a user activated the splash pad again. The splash pad water source was municipal potable water; in addition, water was also occasionally pumped via hose directly from the pool into the splash pad tank. Overflow outlet piping drained from the splash pad tank to a storm drain and helped prevent the tank from flooding.