Scott Webb (Host): Naegleria fowleri is also known as the brain-eating amoeba. And though it's not terribly common, folks in South Carolina need to know how to avoid it and how to spot the signs and symptoms.

I'm joined today by Dr. Anna-Kathryn Burch. She's a Division Director of Pediatric Infectious Diseases; Medical Director, Pediatric Antimicrobial Stewardship Program; and Associate Professor with Prisma Health Children's Hospital-Midlands.

 This is Flourish, the podcast brought to you by PRISMA Health. I'm Scott Webb. Doctor, it's nice to have you here today. We're going to do kind of a summer safety spotlight and get to the truth about Naegleria fowleri and what is that, right? That's not something I say out loud very often. So, what is that? What is Naegleria fowleri, and why is it called the brain-eating amoeba?

Dr. Anna-Kathryn Burch: Naegleria fowleri is an amoeba that lives very commonly, especially in the Southeast, in fresh water. So, fresh water, you usually think of lakes or rivers, but that can also be ponds and hot springs as well. The reason why it's called brain-eating amoeba is because if the amoeba reaches the brain, and we'll talk about that a little bit later on, but if there is an actual infection in the brain, this particular amoeba infects the brain, makes the brain swell, and it basically kills the brain.

Host: Yeah, that sounds horrible. And I know this isn't terribly common. But as you say it, it happens in fresh water in the southeast primarily. What are the ways that folks are exposed to this, Doctor? Is it from drinking contaminated water, contact with sand in warm areas, or is it really only through the nose?

Dr. Anna-Kathryn Burch: So actually, a lot of us who frequent, the lakes, rivers, those kind of things are exposed to this particular amoeba. And it's not harmful to us as long as we don't get it in our nose. So, the problem is, if under pressure, so a large amount of water at one time going up the nose, enough pressure to actually cross over the nose into the brain, that's where the infection can occur if the amoeba actually makes it to the brain. So if we are just regular splashing around having a good time in the lakes or rivers, it's not an issue. It's not an issue if you drink some of the lake water or river water. When the issue comes is when you have enough pressure of the water to get up to the nose, into the brain.

Host: Ah, it's so interesting. It makes me wonder, like, what precautions can we take, right? Is it really just keeping our heads out of the water? Like, how do we do that? How do we avoid being exposed to Naegleria fowleri?

Dr. Anna-Kathryn Burch: Well, obviously, and unfortunately, the easiest way to avoid it is to stay out of fresh water.

Host: Just don't go in the water, right?

Dr. Anna-Kathryn Burch: That's correct. But you know, we're all from South Carolina. A lot of us are from the South and we love our water. We like to go. It gets hot. You know, it's a way that we can enjoy the summers without dying in the heat.

So, ways that you can avoid this particular amoeba: number one, kind of staying away, especially in the really, really hot parts of the summer when we're getting these 100-degree heat waves. You can just keep your head above water. You can stay away from doing water activities such as tubing or water skiing, those kind of things where it's very easy to fall into the water and get water up their nose. Staying away from things like diving or jumping into the water, but also learning how to blow air out of your nose or hold your nose when you're jumping in, or even using nose clips can be helpful as well.

Host: And is there any value, Doctor-- like let's say after the fact, let's say we didn't heed your advice and didn't hold our nose or clip our nose or whatever, and we feel like the pressure's gotten in there, can we use like tap water for nasal rinsing? Can we do that? Can we rinse after the fact?

Dr. Anna-Kathryn Burch: No, actually, and that can even be harmful in itself. So, sometimes this particular amoeba can be in our tap water. And some people have gotten infections with this amoeba by using tap water and things like neti pots or other nasal irrigation systems. So, you should always use either distilled water or sterile water or boiled water. You can boil tap water for about a minute, let it cool back down to normal room temperature. And then, you can use that particular water. But you should never use tap water to irrigate your nose.

Host: It's so good that we have experts, right? Because I was thinking, sure, grab some tap water. How hard could it be? But that's why we have you here, of course. So, yes, we can have this conversation, Doctor, and we can tell adults, and adults can probably follow your advice and your expertise and all of that. But what do we do with our kiddos, right? So, parents and kids, how do we keep them safe during these water activities?

Dr. Anna-Kathryn Burch: So, it can be very hard depending upon how old your child is and how well you can have conversations with them. So if they are preteen or teenager, you can sit down and have a conversation with them and explain what are the risks to getting this type of infection. So obviously, you can have preteen or adolescent males that you can't always control, and they're going want jump in and do the things with their friends. But having the conversation with them and trying to educate them prior to, kids save their lives. So, teaching them the proper way to blow out their nose, or holding their nose when they jump in, or again, using the nose clips and actually. The younger the person is, maybe the better it would be to use nose clips because at least you know that they're on the nose. And you're not always having to remind the younger child that they need to be holding their nose. I think that that's typically the age that is harder to explain this to, because obviously they might not be old enough to understand what an amoeba is and those kind of things.

Host: Yeah. I'm not sure all adults are going to be able to follow this conversation, me included. So, my kids are a little bit older, 17, 21, but I never wanted to, you know, parent through fear, but there's a fair amount of fear and rightly so associated with brain-eating amoebas, right? Just saying that out loud. So, give us a sense, like what really happens when folks are infected by this amoeba?

Dr. Anna-Kathryn Burch: So, our nose, obviously, we have nasal passages that we breathe through. But in the back of our nose, we have small, very fragile bones that we call a cribriform plate. And that is kind of the barrier between the back of our nose up through into the brain. And so, what happens is that if you have enough pressure of water where this amoeba lives, that amoeba can make it through the cribriform plate with that pressure and actually follow up into the brain. It follows nerve path to get to the brain. And once it gets there, it starts to make its infection.

Typically, it takes about anywhere between one day and twelve days to start seeing signs and symptoms of this particular infection. But the average is somewhere around five days or so. And then, once that occurs, typically, patients would start feeling headaches. They might have nausea or vomiting, even diarrhea. They can start having fever, stiff necks. They might be very sensitive to light. Those kind of things is what they would first recognize as symptoms.

Host: You know, I'm trying to get a sense of this, like, do I need to be worried about all fresh water? Is it unique to, you know, the area, South Carolina? Like, how common is it, I guess, is what I'm asking?

Dr. Anna-Kathryn Burch: It's in all fresh water. Obviously, it likes hotter temperatures, warmer water up to I think 115 degrees Fahrenheit. So, it's more concentrated obviously in the southeast, because we're much warmer. But that doesn't mean that this can't happen in states where you have cooler temperatures. There's actually been a case in Minnesota as well. So, it does happen in those states that typically don't have as hot a summer as the South does.

Host: Right. So, you gave us a sense earlier, obviously this infection, especially if undiagnosed and untreated, is deadly, right? So, what makes it so difficult to diagnose and treat? Is it the long incubation period, the five days, maybe up to 12 days, and then by the time you see patients it's too late? Like, how does that work?

Dr. Anna-Kathryn Burch: I think that the issue with appropriate diagnosis is that most parents or patients don't think to tell their physician or primary care provider that they have been exposed to fresh water. So, that's what I hope to get across to people in South Carolina and others who might listen to this, that it is important that if you have been in fresh water and then, several days later, you start getting the headaches, the stiff neck. It is so important to tell your primary care physician or your provider that you're seeing in the emergency room or urgent care facility that you have been exposed to fresh water and you got water up your nose, because that clues in the clinician that, "Oh my goodness, this could be Naegleria fowleri." Otherwise, it ends up being so rare that this occurs that a lot of times clinicians think lastly about Naegleria fowleri, and it's been several days before that diagnosis gets made.

Host: Right. It's unlikely that it's a coincidence. It could be, and maybe that's a happy coincidence, but it's unlikely that it is, that you've been in fresh water, you've got water up your nose, and then you're experiencing these symptoms that you're outlining for us today, that's not a coincidence, most likely. So, speak to your providers. Speak, up for sure. Wondering, I'm hoping for some room for optimism here, Doctor. Have there been any recent breakthroughs in terms of treatment and diagnosis, especially cases here in 2025?

Dr. Anna-Kathryn Burch: So, I wish I could say that there was breakthroughs or that we had a miracle drug that's out there. Unfortunately, greater than 97% of people who have this infection die. It has a very high mortality rate. And our current treatment is with up to five different antimicrobials that we put on all at the same time. And there's not one particular drug that is better than the other.

What we do is basically throw the kitchen sink at patients who have this particular infection, because we don't have one particular drug that does the best at killing this organism.

Host: There's not magic pill.

Dr. Anna-Kathryn Burch: Yeah. So, you know, there's so few cases that it makes it difficult to learn what works best, what doesn't work best, just because it's so rare when it happens.

Host: Right. Right. It is rare. But to me, it's what makes it so interesting to talk about, and especially related to the, you know, Prisma Health listening audience, of course. You know, even though it is deadly and it can be difficult to diagnose and treat, like, do we need to be afraid of swimming in lakes and rivers, Doctor?

Dr. Anna-Kathryn Burch: No, I don't think so. I mean, I'm from South Carolina, born and raised here. I grew up in freshwater my entire life. You know, I don't think we need to be afraid of doing the things that we love to do. I think we just need to educate ourselves about what the risks are and how to mitigate those risks. And you do that by making sure that you teach your children how to properly jump into water, blowing out your nose, holding your nose. Being careful about diving into shallow water. Being careful about not disturbing the silt at the bottom of a lake or a river. That's where this amoeba likes to live. And if we are bothering the bottom of the river or lake, all we're doing is taking that amoeba and suspending it into the water above. And that increases the chance, the amount of amoeba that's in the water, so not doing those things. And then, also learning about not using tap water that hasn't been treated appropriately in neti pots and other nasal irrigation systems, which have grown in popularity. A lot of people use those and they're actually really great instruments to use for individuals who get sinusitis yearly. We just need to make sure that we educate ourselves on how to use them properly.

Host: Yeah, it's great advice from an expert today. As you say, like this is pretty rare, but it's an important topic to talk about, especially for the Prisma Health listening audience to the folks in South Carolina, but really anywhere there's fresh water, lakes, rivers, whatever it is. So, thank you so much.

Dr. Anna-Kathryn Burch: You're welcome. I'm so glad that I was able to talk to you today. And thank you so much for getting this out there, all this great information.

Host: And for more information, go to prismahealth.org/news. For more information and other podcasts just like this one, head on over to prismahealth.org/flourish. This has been Flourish, a podcast brought to you by Prisma Health. I'm Scott Webb. Stay well.