Last month, the media reported extensively on a case study involving a Seattle woman who died of a so-called “brain-eating amoeba” she’d contracted from using a neti pot. (A neti pot is a low-tech device that uses gravity and a saline solution to irrigate the sinuses and nose to remove mucus and reduce congestion.)
As reported in the International Journal of Infectious Diseases, the 69-year-old woman had a “distant history of breast cancer,” and a year prior to the diagnosis of the brain infection, had developed a chronic sinus infection. The patient’s primary care physician prescribed sinus irrigation using a neti pot, and it’s believed that the patient used tap water that had been run through a filter, but was not sterilized, to perform regular nasal irrigation.
After using the neti pot for about a month, she developed a rash on her nose that was thought to be rosacea, a common skin condition that causes a red rash on the face. Over the course of the next year, multiple biopsies and prescription ointments could not positively identify or clear up the rash, and she eventually had a seizure that landed her in the hospital. A brain CT scan showed a lesion on the right side of the brain, which was determined not to be evidence of metastatic breast cancer. A biopsy of the lesion was performed and the patient sent home, but her symptoms worsened.
About two weeks later, diagnostic tests returned, pointing to the source of the problem as an amoebic infection from Balamuthia mandrillaris, “a free-living amoeba that is found in the soil and fresh water and is associated with granulomatous amoebic encephalitis,” the case study reports. Despite aggressive treatment, the disease progressed, and about a week later, the woman died. There have only been about 200 cases of human infection worldwide (70 in the U.S.) from this amoeba, which was first discovered during an autopsy of a mandrill monkey at the San Diego Zoo in 1986.
As scary as the situation sounds, the first point to realize is that infection from the B. mandrillaris amoeba is exceedingly rare. “If you dive deep into that article, they couldn’t definitively link the amoeba infection to the neti pot,” says Dr. Eunice Park, a double board-certified ENT and facial plastic surgeon who specializes in nasal and sinus conditions at ProHEALTH Care, a New York-based health care company. “The report shows they didn’t really test the tap water of the patient who suffered from the infection, so it’s sort of speculation. Although there have been other reported cases of amoebic infections, in that particular article it’s hard to make a definitive link,” she says.
Indeed, this isn’t the first time neti pots have made a splash in the health media. Some people have contracted a similar infection linked to incorrect neti pot use caused by Naegleria fowleri, an amoeba that tends to inhabit warm water and is more likely to be found in tropical or semi-tropical climates. People also sometimes contract these amoebas while swimming in lakes and ponds — it’s believed a bit of water that contains the pathogen gets up the nose, opening the door to infection.
Although death by “brain-eating amoeba” makes for a sensational headline, the fact remains that the chances of it happening to you are similar to winning a Mega Millions lottery draw — i.e. slim to none. And while these reports can be scary, they don’t change the fact that neti pots are a centuries-old way of clearing out mucus that can get trapped in the sinuses and nasal passages.
What Is a Neti Pot?
“Neti pots are high-volume irrigation devices,” Park says. While they may call to mind a small teapot with a long neck, that’s not the only shape they come in. “There’s a squeeze-bottle device as well,” she says, which may look like a nasal spray bottle or an old-school sports water bottle.
Whatever shape they take, neti pots can help a range of patients cope with common ailments from allergies to the flu. “People with an acute infection who have a lot of secretion of mucus that collects in the posterior nasal cavity,” may find much relief by a once or twice daily flush of those cavities with a neti pot. “Patients can also use it while they have a cold to temporarily irrigate and wash away the mucus.” This removes the mucus that could give additional pathogens a place to set up shop and cause infection while also reducing post-nasal drip, which causes mucus to drip down the back of the throat leading to sore throats and irritation.
Park says people with chronic sinus problems and allergies can also benefit from using a neti pot regularly to help control post-nasal drip and recurrent infections. And, people who “have an anatomical blockage like a deviated septum or narrow sinuses that prevent the mucus from flowing as easily,” may also derive a big benefit from using a neti pot regularly to clean out those secretions.
Because it’s a versatile, inexpensive and low-tech solution that can help a lot of patients recover from an acute illness like the flu or deal with chronic problems like allergies, Park says she counsels many of her patients to use a neti pot regularly. But — and this is important — the key is to follow “safe-use protocol” in doing so to avoid becoming the subject of a future case study in an infectious diseases journal.
How Can I Use a Neti Pot Safely?
Park counsels her patients to use the squeeze-bottle type device and fill it with filtered, distilled or otherwise purified water. “We also recommend that patients can boil water and then cool it to room temperature.” Don’t use boiling hot water in your neti pot, as this can scald your nose and sinuses leading to even bigger problems. On the flip side, don’t use very cold liquid in your neti pot. Depending on the condition you’re dealing with, you may be prescribed a topical medication to be used in a neti pot that needs to be refrigerated. If you’re using such a medication, make sure you allow it to come up to room temperature before using, as rinsing your sinuses with cold solution can lead to the development of bony growths in your nasal passages.
Neti pots are typically sold with packets of sodium chloride and sodium bicarbonate, a powder that’s added to the water. Labeled as “sinus wash saline packets,” or something similar, one packet should be emptied into the neti pot and stirred or shaken to mix it into the water. The saline solution helps make sinus irrigation, also called lavage, more comfortable, Park says. “When we use regular water, patients will get a burning sensation. The packet adds sodium to the water and makes it more compatible with our mucus secretions and body physiology, so that helps it be more comfortable for the patient. It’s not an antibacterial solution at all,” Park says.
Once you’ve mixed up the solution with warm or room-temperature purified water, lean over the sink and insert the device into a nostril. Squeeze the bottle to force the solution up one nostril, and gravity will pull it out the other nostril, bringing whatever mucus and other detritus may be stuck up there. If you’re using a teapot-shaped neti pot rather than the water bottle device, you’ll need to tilt your head to one side and pour the water out of the spout and into a nostril. It’s a tricky maneuver that takes a few tries to get right, but the principle is the same as with the squeeze bottle — force water up one nostril and let it drain out the other. Be sure to clean both nostrils by running about half the solution one direction and the other half from the other side.
Once you’ve run the batch of saline solution through your nostrils, you’ll probably want to use a tissue to blow your nose and completely clear out any other water and mucus that’s still up there. Then, it’s time to clean the neti pot. Park says it’s important to make sure it’s cleaned properly every time to avoid contracting not just an amoeba but other pathogens that could make you feel less than your best. “It’s recommended that you use dishwasher detergent or baby shampoo and hot water to clean your neti pot.” Park says some people find baby bottle brushes useful in scrubbing out the pot. After each thorough washing, it’s important to “let it completely air dry so there isn’t any mold or mildew in there.” Some neti pot manufacturers provide instructions for how to use your microwave to kill any remaining bacteria.
Park underscores that you shouldn’t use tap water to fill your neti pot. Rather, keep a bottle of distilled or filtered water on hand to make using the neti pot easier, and get a new one regularly, just like you would with a toothbrush. “It’s recommended that you change your neti pot every three months,” she says.
Advances in Detection
The case report noted that “while Balamuthia and Naegleria share some similarities, Balamuthia is more difficult to detect.” This is currently true, and the test that ultimately did make that diagnosis took about two weeks to come back, critical time during which the disease progressed. But new technology could make it easier to detect both infections with a simple blood test in the future.
Dr. Asim Ahmed, medical director for Karius, a life sciences company developing genomic sequencing tests for diagnosis of infectious diseases, says that the technology they’re developing is very similar to liquid biopsy, a technique gaining traction among oncologists as a less-invasive and rapid way of diagnosing cancer.
The company’s founders “realized that when they sequenced human blood to maybe look for cancer causes or even in the noninvasive prenatal diagnosis (of genetic disorders), they noticed they could detect at a very low level pathogens in the bloodstream,” Ahmed says. This led to a lightbulb moment: “If we actually focused on it, we could come up with a novel way to diagnosis infections.”
Dubbed “liquid biopsy for infectious disease,” the technology uses a plasma sample and genomic sequencing tools to separate human DNA from the DNA of foreign agents, such as bacteria, viruses or amoebas. “It’s an open-ended test looking for any pathogen’s DNA in general. So you don’t need to know the specific pathogen you’re looking for,” Ahmed says. “You sequence everything that’s in the plasma, then you subtract out the human DNA, which is the majority of the signals you find. Then you’re left with a bunch of non-human DNA and you compare those against known reference strains of non-human infection strains in a database.” Any hits are ascribed a significance score, and once a certain threshold is surpassed, a positive result is produced. Clinicians can then act on that information and begin a treatment protocol to combat the identified pathogen.
Ahmed, who is also an attending physician in pediatric infectious diseases at Boston Children’s Hospital, says Karius’ technology is a quick-turn around test that costs about $2,000 and can provide results in about a day, eliminating the need for days- or weeks-long laboratory cultures of suspected pathogens. Most conventional infectious disease diagnostics require that the pathologist have an idea what to look for and remove tissue from the site of infection for testing, which can be especially challenging in the context of brain-based infections. “What we measure in the blood is DNA fragments that are released by the pathogen that can be anywhere in the body. Even if (the pathogen) is sequestered in the brain, it can release its DNA contents when it divides, and that DNA can find its way into the plasma such that it can be detected by our technology,” Ahmed explains.
Also, because the test is nonspecific, it can screen many pathogens at once. The company currently curates a database of 1,300 pathogens. This buckshot approach eliminates the need for multiple tests and culturing, which saves time, expense and is far less invasive. Ahmed says the test is anticipated to make a big impact with acute pneumonia and endocarditis, two common and potentially deadly infections that impact the lungs and heart respectively.
The company is in the early days of commercial deployment of this technology, but some medical centers are beginning to use the test to check patient samples. Ahmed believes in the next 5 to 10 years, it will be more widely used. In the meantime, at least one sample of B. mandrillaris has been identified so far, Ahmed says. “We’ve definitely detected it in a patient with a clinically-compatible syndrome and we offered a rapid, noninvasive way of aiding in the diagnosis.”
But he adds that this test won’t replace infectious disease specialists anytime soon. “You still need very experienced and well-trained physicians to interpret the data. Sometimes when you look at findings, there’s still some homework to do” to determine how to combat a specific pathogen and whether the findings match with the patient’s symptoms. “There are some pathogens that we detect that I’ve never heard of before,” which is leading to better understanding of some of these pathogens and how they work.
While there is hope that diagnosing cases of B. mandrillaris and other infectious diseases could be improving in the future, it’s still always better to prevent an illness before it starts. Therefore, you should always follow safe-use protocol when using a neti pot. And as Park notes, neti pots are an “underutilized resource” for helping people cope with a range of upper respiratory issues. When used safely, they can improve your quality of life. “I think it’s a really great recovery tool, especially as we’re in the thick of cold and flu season. Patients should be less worried about the rare amoebic infections and focus on safe-use protocol,” Park says.
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Correction 01/11/19: A previous version of this story misspelled the last name of Dr. Eunice Park.