Table 2. Nasal rinsing practices, medical histories, and disease presentations of 10 patients with Acanthamoeba infections who performed nasal rinsing, United States1994–2022*.

Year and reference	Age, y/ sex	State	Reason for and type of nasal rinsing	Relevant medical history	Initial symptom(s)	Signs and symptoms	Disease manifestations	Outcome
1994, Murakawa et al. (10)	45/M	CA	Chronic sinusitis; electric nasal irrigator with tap water	HIV/AIDS (CD4: 26 cells/mm3); co-infections: PCP, Candida esophagitis, perianal herpes simplex	Skin lesions	Pruritic, painful, erythematous papulonodular, ulcerative lesions on the extremities, face, and genitalia; seizures; pansinusitis on MRI; osteolytic lesions	Cutaneous, rhinosinusitis, osteomyelitis, suspected GAE	Died
2015, Brondfield et al. (11)	60/F	CA	Chronic sinusitis; nasal irrigation using tap water for several months before symptom onset	Heart transplant (nonischemic cardiomyopathy); chronic kidney disease	Rhinorrhea, sinus pressure, epistaxis	Acute sinusitis and development of septal mass; subcutaneous nodules of left flank and extremities; pathologic fracture of right metatarsal bone underlying a nodule	Cutaneous, rhinosinusitis, osteomyelitis	Survived
2015, Breland et al. (12), Winsett et al. (13)	36/F	TX	Chronic sinusitis; neti pot with tap water for 2 wks before symptom onset	Kidney transplant (ESRD due to diabetes mellitus)	Skin lesions	Painful nodules on bilateral upper extremities, face, and back, spreading to lower extremities and trunk; later, fever, dyspnea, nausea, vomiting, and knee pain with cortical destruction in the proximal fibula; abnormal lung imaging	Cutaneous, osteomyelitis, suspected rhinosinusitis, suspected pulmonary	Survived
2016, CDC, unpub. data†	59/F	MD	Ritual ablution; no further information available	HIV/AIDS (CD4: 97 cells/mm3); co-infections: Salmonella bacteremia	Headache and blurred vision	Headache, blurred vision, multiple brain lesions; later, fever, disorientation/altered mental status, ataxia, weakness, cranial nerve deficits	GAE	Died
2017, Voshtina et al. (14)	73/M	WI	Unknown reason; neti pot using sterile water 1×/wk (submerged filled neti pot in warm tap water to heat)	Cancer: CLL	Focal seizure	Focal seizure and headache; later, fever, lethargy, altered mental status, cranial nerve deficits, cerebral herniation	GAE, suspected rhinosinusitis	Died
2017, CDC, unpub. data†	64/M	OH	Chronic sinusitis; nasal irrigation with undistilled tap water	Cancer: CLL	Sinusitis, skin lesions	Sinusitis and tender, erythematous skin lesions on lower extremities; later, altered mental status, headaches, photophobia, phonophobia, hallucinations, cranial nerve deficits, declining mental status	GAE, cutaneous, suspected rhinosinusitis	Survived
2018, CDC, unpub. data†	32/M	TX	Chronic sinusitis and epistaxis for 2 y; squeeze bottle with saline nasal spray	Microscopic polyangiitis; pauci-immune glomerulonephritis; renal failure	Seizure	Seizure; weakness, paresthesias, fatigue; later, meningismus, altered mental status, fever, aphasia, dysphagia, facial numbness, hemiparesis, cranial nerve deficits, acute respiratory failure	GAE, suspected rhinosinusitis	Survived
2020, CDC, unpub. data†	46/M	TX	Ritual ablution 5×/d	Cancer: AML; stem cell transplant ×2	Neutropenic fever	Fever; later, facial pain, papular and nodular erythematous skin lesions on lower extremities, sinusitis, endophthalmitis, brain lesions on MRI	Cutaneous, suspected GAE, suspected rhinosinusitis, suspected endophthalmitis	Survived
2021, CDC, unpub. data†	66/M	MD	Chronic sinusitis after multiple surgeries for orbital fracture and deviated septum; squeeze bottle 4×/d for years	Cancer: CLL; chronic kidney disease; multiple reconstructive surgeries following orbital fracture	Sinusitis; skin lesion	Sinusitis; progressive, necrotizing facial lesion	Cutaneous, rhinosinusitis	Survived
2022, CDC, unpub. data†	80/M	FL	Chronic sinusitis and nasal surgery; squeeze bottle daily for 3 y (water source unknown)	Cancer: CLL; chronic kidney disease	Headaches related to sinus disease	Chronic headaches; nasal congestion, postnasal drip; occasional nausea and vomiting	Rhinosinusitis	Survived

*AML, acute myeloid leukemia; CDC, Centers for Disease Control and Prevention. CLL, chronic lymphocytic leukemia; ESRD, end-stage renal disease; GAE, granulomatous amebic encephalitis; MRI, magnetic resonance imaging; PCP, Pneumocystis jirovecii pneumonia; †Cases from the CDC free-living amebae database.