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case_images: Skin lesion of the left knee 6 months before (A) and on admission (B).
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case_images: Other physical examinations revealed a dark red desquamation infection lesion (about 15 x 10 cm) on the left knee ( Figures 1A, B ).
case_images: Results of next-generation sequencing in cerebrospinal fluid (CSF). (A) mNGS result of nucleotide sequences distributed along the genome of Balamuthia mandrillaris in the case. (B) Read composition of microbes in the CSF sample.
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case_images: B. mandrillaris ( Figures 2A, B ). Based on the available information, including the specific NGS outcome, the history of trauma, and the skin lesion, she was diagnosed with GAE caused by B. mandrillaris.
case_images: The TCR repertoire in blood and cerebrospinal fluid. The donut chart of the blood (A) and cerebrospinal fluid (B) sample from the patient displays the T-cell clonal expansion in the cerebrospinal fluid. The fan-shaped area displays the corresponding clonal frequency. The radian of 1, 2, and 3+ represented the total frequency of TCR sequences having 1, 2, and 3 or more reads in the sample, respectively. The top 5 clones' amino acid sequences of complementary determination region 3 (CDR3) of TCR were shown in the donut chart, and the radian of the region, which was marked with the amino acid sequence, demonstrated the frequency of the corresponding T-cell clones. The larger radian means higher frequency. (C) The frequency of the top T-cell clones in the cerebrospinal fluid and blood samples. (D) The diversity of T-cell repertoire in both peripheral blood and cerebrospinal fluid.
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case_images: T cells to recognize infections, we performed T-cell receptor (TCR) sequencing using peripheral blood and CSF samples. The Top1 TCR in the CSF sample showed high clonal proliferation ( Figures 3A, B ), with a cloning frequency of 15%; the same CDR3 amino acid (AA) sequence CASNRGAENYGYTF was also detected in the peripheral blood, although with a frequency of 3.77E-06 ( Figure 3C ). TCR diversity in the CSF and peripheral blood. The TCR diversity in the CSF was significantly lower than that in peripheral blood ( Figure 3D ), which may be related to the lower number of lymphocytes in the CSF.
case_images: Magnetic resonance imaging (MRI) of the brain performed and spinal cord (T2) on day 15 post-hospitalization. (A-D) The frontal lobes, temporal lobes, ventriculus lateralis, brainstem, cisterna, and cerebellum were displayed as multiple patches, with high signal on T2WI, low signal on T1WI, apparently high signal on T2-Flair, and T1 enhanced. (E) Punctate and patchy lesions were presented as high T2 signals in the cervical and thoracic spinal cord.
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case_images: MRI showed that the multifocal enhanced mass-like lesions were more numerous than before ( Figures 4A-D ). MRI of the cervical thoracic segment revealed that the spinal cord functioned naturally, with punctate and patchy longer T2 signals, which were vaguely enhanced ( Figure 4E ).