Fatal Balamuthia mandrillaris Meningoencephalitis in the Netherlands after Travel to The Gambia

(5). Studies from Japan have also reported an association between travel to India and infection with an S. sonnei clonal group that was multidrug resistant, including resistance to nalidixic acid (6). Furthermore, ciprofloxacin-resistant S. sonnei isolates from foodborne outbreaks in India in 2009 and 2010 (7) had XbaI-PFGE types and resistance profiles visually indistinguishable from those reported in our study. A study of S. sonnei isolates in Bhutan showed that this clonal group was also common there (8). Furthermore , a 2010 outbreak of ciprofloxacin-resistant S. sonnei in Canada associated with men who have sex with men showed XbaI-and BlnI-PFGE patterns that appear similar to the patterns for isolates in this study (9). Antimicrobial drug resistance is a major global problem that is likely to be exacerbated in places with poor sanitation and intensive use of antimicrobial drugs in humans and animals. These factors have contributed to increased ciprofloxacin resistance in Salmonella enterica serovars Typhi and Paratyphi A (10). A review of published literature and informal communication indicates that our observation of ciprofloxacin resistance in S. sonnei infections associated with travel to India is part of a general global trend. This increasing resistance suggests that ciprofloxacin may no longer be suitable for empiric therapy for S. sonnei infection, particularly for patients with a history of travel to the subcontinent of India. Shigella sonnei genome sequencing and phylogenetic analysis indicate recent global dissemination from Europe. Standardization of pulsed-field gel electropho-resis protocols for the subtyping of Escherichia coli O157:H7, Terajima J, et al. Characterization of Shigella sonnei isolates from travel-associated cases in Japan.bial resistance, virulence profiles and molecular subtypes of Salmonella enterica serovars Typhi and Paratyphi A blood isolates from To the Editor: Balamuthia mandrillaris is a free-living ameba that has a worldwide distribution in soil and was first reported in 1990 (1). Approximately 200 B. man-drillaris meningoencephalitis cases have been described, mostly from warm climate areas in South America. Its prevalence in the United States is estimated to be 1 case/ year (2). However, B. mandrillaris meningoencephalitis 896 Emerging BLOCKINInfectious BLOCKINDiseases BLOCKIN • BLOCKIN