AMEBIASIS

Mary Rose A. Cabañero

❖ 10% Symptomatic
I. CASE SCENARIO ♦ Invasive disease
♦ May burrow into colonic epithelium up to the
W.S., A 67 year old malnourished male with mental submucosal level
retardation who was confined to a mental institution was
brought for a consult because of bloody diarrhea C. Life cycle
characterized as watery with particles, occurring about 3 – 5X ❖ Infective stage: Cyst
daily, amounting to approximately 100 – 200cc/episode ❖ Invasive stage: Trophozoite
associated with cramping abdominal pain & anorexia which ❖ Host: Human
was noted 1 week PTC.
Remarkably noted on physical examination was direct
tenderness on the lower abdominal quadrants.

II. INTRODUCTION/EPIDEMIOLOGIC FEATURES

❖ Amebiasis is a disease caused by the protozoan parasite
Entamoeba histolytica.

A. Incidence and Prevalence

❖ Distributed worldwide
♦ Most commonly found in tropical and underdeveloped
regions
❖ Indian Subcontinent, Africa, East Asia (Thailand), Central
and South America (Mexico and Colombia)
❖ 50,000,000 number of people infected per year
❖ 40,000-100,000 deaths per year
♦ Third in causing deaths caused by parasites along with
Schistosomiasis and Malaria, respectively.
❖ 67,900 all age deaths 1. Cysts and trophozoites are passed in feces
❖ 15,500 children below 5 years old. 2. Cysts are typically found in formed stool, whereas
❖ Cases in the Philippines: not well documented. trophozoites are typically found in diarrheal stool.
❖ 7% to over 30% in institutionalized psychiatric and Infection with Entamoeba histolytica (and E.dispar)
mentally retarded patients in the United States, England, occurs via ingestion of mature cysts from fecally
France, Italy, and Japan. contaminated food, water, or hands. Exposure to
❖ Prevalent in countries of low socioeconomic status, poor infectious cysts and trophozoites in fecal matter during
hygiene and sanitation, and crowding. sexual contact may also occur.
❖ Population at Risk: 3. Excystation occurs in the small intestine and
♦ Men having sex with men trophozoites are released, which migrate to the large
♦ Inmates of institutions intestine
♦ Military personnel 4. Trophozoites may remain confined to the intestinal
♦ Travelers and immigrants lumen (A: noninvasive infection) with individuals
continuing to pass cysts in their stool (asymptomatic
B. Agent/ Etiology carriers). Trophozoites can invade the intestinal mucosa
Entamoeba histolytica (B: intestinal disease), or blood vessels, reaching
❖ Pseudopod-forming non-flagellated protozoan parasite extraintestinal sites such as the liver, brain, and lungs
❖ Most invasive among the Entamoeba parasites (C: extraintestinal disease). Trophozoites multiply by
❖ Only member that causes colitis and liver abscess binary fission and produce cysts, and both stages are
❖ Pathogenicity passed in the feces
♦ Contact-dependent cell-killing 5. Cysts can survive days to weeks in the external
♦ Cytotoxic enzymes environment and remain infectious in the environment
♦ Cytophagocytosis due to the protection conferred by their walls.
❖ 90% Asymptomatic Trophozoites passed in the stool are rapidly destroyed
♦ Cyst passer once outside the body, and if ingested would not
♦ Act as reservoir survive exposure to the gastric environment.
 D. Incubation Period: 2 - 4 weeks AMOEBIC LIVER ABSCESS
❖ Most common extra-intestinal form of amebiasis
E. Mode of Transmission ❖ Cardinal manifestations: fever and ruq pain
❖ Pain is either localized in or referred to the right shoulder
❖ Fecal-oral route
❖ Liver is tender, jaundice is rare, hepatomegaly is present (50%)
❖ Eating fecally-contaminated food ❖ Chronic Disease:
❖ Drinking fecally-contaminated water ♦ Older patients from endemic areas
❖ Person-person sexual contact ♦ Wasting with significant weight loss
❖ Complications
♦ If abscess is in left lobe: rupture into the pericardium
III. APPROACH TO DIAGNOSIS ♦ If abscess is in the right lobe:
◦ Rupture into the subphrenic space
◦ Rupture into the pleura (may cause superinfection)
A. Clinical Manifestations ◦ Intraperitoneal rupture (2nd most common complication)

Diseases caused by E. Hystolytica AMEBIC MENINGOENCEPHALITIS

❖ Amoebic colitis ❖ Occurs in 1-2% of patients
❖ Amoebic Liver Abscess ❖ Should be considered in cases of amebiasis with abnormal
❖ Ameboma mental status
❖ Amoebic Meningoencephalitis ❖ Renal involvement is rare
❖ Via hematogenous dissemination, the trophozoites can reach
the brain causing meningoencephalitis.
AMOEBIC COLITIS
❖ Abdominal pain and diarrhea (gradual onset) followed by
malaise and weight loss
❖ There may or may not be presence of blood and mucus on stools
❖ Fever (only in ⅓ of patients) B. Differential Diagnosis
❖ Diarrhea alternating with constipation
❖ 10-12 stools per day
Fulminant Amoebic Colitis Table 2. Differential Diagnosis
❖ Usually occurs in children and in patients taking corticosteroids DISEASE RULE IN RULE OUT
❖ Severe bloody diarrhea, abdominal pain, fever ❖ Headache
❖ Megacolon with huge possibility of rupture ❖ Fever
❖ Predisposing factors: poor nutrition, corticosteroid use, very ❖ Chills
young age (<2 yrs)
❖ Vomiting
❖ Abdominal ❖ Nausea
Table 1. Difference between Bacillary dysentery and Salmonellosis pain ❖ Coated
❖ Diarrhea tongue
Amebic dysentery
❖ Rash “rose
Bacillary dysentery Amebic dysentery
spots”
Acute onset Gradual onset ❖ Epistaxis
Prodromal fever and No prodromal features ❖ Incubation
malaise period of
Vomiting is common No vomiting salmonellosis:
Patient prostrate Patient usually ambulant 12-72 hrs
Watery, bloody diarrhea Bloody diarrhea ❖ Vomiting
Odorless stool Fishy odor stool ❖ Fever
Severe abdominal cramps Mild abdominal ❖ Tenesmus
No Charcot-Layden crystals Charcot Layden-crystals ❖ Endoscopy:
Tenesmus common Tenesmus uncommon ❖ Edematous
Spontaneous recovery Lasts for weeks Shigellosis ❖ Diarrhea and
❖ Bloody Stool hemorrhagic
AMEBOMA mucosa with
❖ Rare disease caused by E. histolytica and occurs in only less than ulcerations
1% of the cases ❖ Rectal
❖ Large local lesion in the bowel usually mistaken as carcinoma prolapse
❖ May be painful or tender or may be asymptomatic ❖ Incubation
❖ Fever, altered bowel movement, dysentery period: 1-2
days
 Table 2. Differential Diagnosis (cont’d)
DISEASE RULE IN RULE OUT PCR AND ELISA
❖ Vomiting
❖ Differentiates E. histolytica and E. dispar
❖ Rice watery
❖ ELISA
stools
♦ 80% sensitivity
❖ Eestlessness
♦ 99% specificity
❖ Irritability
❖ PCR
❖ Fever
♦ Limited by the requirement of sophisticated equipment
❖ Tenesmus
♦ 91% sensitivity
❖ Crampy ❖ Dry mucous
♦ 97% specificity
abdominal membrane
Cholera pain ❖ Rapid heart
SEROLOGICAL TESTS
❖ Diarrhea rate
❖ Indirect Hemagglutination (IHAT)
❖ Dehydration ❖ Low BP
♦ Can detect antibodies of past infection even as long as
❖ Painless
10 years ago
diarrhea
❖ Counter Immunoelectrophoresis (CIE)
❖ Fishy odor in
❖ Agar Gel Diffusion (AGD)
stool
❖ Indirect Fluorescent Antibody Test (IFAT)
❖ Gray
❖ ELISA
appearance
❖ ELISA, AGD, CIE: Antibodies detected are of short duration
of stool
❖ Diarrhea
IMAGING TESTS
❖ Dehydration
❖ Ultrasound
❖ Bloody Stool
❖ Computerized tomography (CT Scan)
Amebic Colitis ❖ Crampy
❖ Magnetic resonance imaging (MRI)
Abdominal
❖ Non invasive
pain
❖ Sensitive
❖ Weight loss
❖ Anorexia
No vomiting
IV. MANAGEMENT
❖ To cure invasive disease at both intestinal and extra-
intestinal sites
D. Diagnostic Tests ❖ To eliminate passage of cysts from the intestinal lumen

MICROSCOPY
❖ Standard method
❖ Detection of cysts and trophozoites
❖ Three stool specimens collected on different days
❖ Dfs with saline: trophozoite motility
❖ Saline with iodine: for differentiation with non-pathogenic
amebae
❖ E. histolytica trophozoites with ingested RBCs: diagnostic
of amebiasis
CONCENTRATIONS METHODS
❖ Formalin Ether/ Ethyl Acetate Concentration Test and
Merthiolate Iodine Formalin Concentration Test
❖ More sensitive than DFS for detection of cysts
❖ Structures noted:
♦ Size, number of nuclei, location and appearance of the
karyosome, appearance of chromatoid bodies,
presence of cytoplasmic structures
NON-PHARMACOLOGIC
❖ Proper hygiene
❖ Oral or intravenous hydration
❖ Healthy and balanced diet to address malnutrition
❖ Boil or filter water before drinking
❖ Wash thoroughly, peel or cook all raw vegetables and
fruits before eating, especially those grown in soil or
when in endemic areas
❖ Avoid using night soil as fertilizer
❖ Avoidance of anal-oral sexual intercourse
PHARMACOLOGIC
❖ Metronidazole: Drug of choice
♦ Drug of choice for invasive amebiasis
♦ Metronidazole 10mg/kg/dose IV/PO 3 times a day (max
dose: 750 mg/dose) for 10-14 days is recommended for
confirmed cases of amoebiasis to avoid relapse.
❖ Tinidazole and Secnidazole
♦ Also effective
❖ Diloxanide furoate
♦ Drug of choice for asymptomatic cyst passers
 ♦ Promote the use of ORS in the management of diarrhea
V. CONTROL AND PREVENTION MEASURES to prevent dehydration, especially among infants and
❖ Community-based efforts children.
♦ Improve environmental sanitation and to provide for ❖ Strategy 5
sanitary disposal of human feces, safe drinking water ♦ Promote breastfeeding and other good feeding
and safe food practices for infants and children
❖ Proper hygiene ❖ Strategy 6
♦ Handwashing should be emphasized ♦ Continue training of health personnel in the early
❖ Food and water consumption diagnosis and treatment of food-borne and waterborne
♦ Drinking water should be boiled or filtered, vegetables diseases
and fruits should be thoroughly washed, use of night ❖ Strategy 7
soil as fertilizer should be avoided ♦ Continue nationwide information campaign for the
❖ Sexual practices prevention and control of food-borne and waterborne
♦ Avoiding sexual practices that involve oral-fecal route diseases.
may reduce the risk of sexual transmission of infective
cysts. VI. CASE RESOLUTION
❖ Household contacts
♦ Household contacts should be traced to prevent spread. ❖ Patient: W.S.
❖ In institutions: patients should be subjected to periodic ❖ Age: 67 yrs old
health checks to detect and prevent potential further ❖ Chief complaint: Bloody diarrhea
spread of the parasite in the institution ❖ History:
❖ Travelers ♦ Watery-based stools 3-5x per day approx. 100-
♦ Patients with history of travel to endemic area should 200cc/episode
be screened for amebiasis prior to corticosteroid use. ♦ Malnourished
♦ Mental retardation
2019-2023 FOOD AND WATER-BORNE DISEASE PREVENTION ♦ Crampy abdominal pain
AND CONTROL PROGRAM (FWBD-PCP) STRATEGIC PLAN ♦ Anorexia
❖ VISION: A food and waterborne disease-free Philippines ❖ Physical examination: Direct tenderness on the lower
❖ MISSION: To reduce the burden of FWBDs and outbreaks abdominal quadrant
❖ GOAL: Reduced morbidity and mortality due to FWBDs ❖ Final Diagnosis : Amebic Colitis
❖ 2012. RA 10611 on Food Safety Act to strengthen the
food safety regulatory system in the country to protect
consumer health and facilitate market access of local Table 3. Pertinent and Negatives
foods and food product PERTINENT(+) PERTINENT(-)
❖ Diarrhea ❖ Fishy-odor stool
❖ 2000 RA Act 9003. 200 providing for an ecological solid
❖ Dehydration ❖ Vomiting
waste management program, creating the necessary
❖ Bloody stool ❖ Fever
institutional mechanisms and incentives declaring certain ❖ Crampy abdominal pain
acts prohibited and providing ❖ Weight loss
❖ 1975 PD No. 856 Code of Sanitation of the Philippines ❖ Anorexia
❖ Strategy 1. ❖ No vomiting
♦ Regulate and monitor food and water sanitation ❖ Gradual onset
practices at the local level through enforcement of ❖ Direct tenderness (Lower
national and local legislations, application of abdominal quadrants)
appropriate technical standards and participation of
non-government agencies
❖ Strategy 2 VII. SUMMARY OF CARE/APPROACHES
♦ Sustain inter-agency collaboration to fast-track
sanitation infrastructure development in poor urban Table 5. Summary of care/approaches
areas and in rural areas with low access to safe water Patient centered Family-focused Community-oriented
and sanitation facilities ❖ Oral ❖ Boil or filter ❖ Improve
❖ Strategy 3 rehydration water before environmental
♦ Promote personal hygiene, food and water sanitation ❖ Proper hand drinking sanitation
practices and the principles of environmental health. hygiene ❖ Proper use of ❖ Provide sanitary
❖ Strategy 4 ❖ Avoid anal-oral latrines ❖ disposal of
sexual ❖ Proper hygiene human feces
intercourse ❖ Screen family ❖ Use of night soil
members for as fertilizer
 ❖ Metronidazole, presence of should be
tinidazole or infection avoided
secnidazole for ❖ Asymptomatic ❖ Provision of safe
symptomatic carriers should drinking water
patient be treated ❖ Health education
❖ Prompt and promotion
diagnosis and ❖ Institutionalized
treatment patients should
❖ Common be subjected to
behaviors of periodic health
the patients checks to detect
such as nail and prevent
biting, potential further
improper food spread of the
handling, and parasite in the
hand-to-mouth institution
or object-to- ❖ Residential
mouth habits cottages of
should be profoundly
prevented retarded
patients and
trainable
patients( px that
could be trained on
proper use of toilet
and personal
hygiene) should
be separated

VIII. REFERENCES
❖ Belizario, V. and De Leon, W., (2004). Philippine textbook
of Medical Parasitology. 2nd edition. Philippines:
University of the Philippines Manila
❖ Harrison’s Principles of Internal Medicine 20th Edition
❖ FWBD Strategic Plan 2019
❖ Philippine Society for Microbiology and Infectious
Diseases. The CPG on the Management of Acute
Infectious Diarrhea in Children and Adults
❖ https://www.cmc.ph/health-conditions/intestinal-
amoebiasis/
❖ https://academic.oup.com/cid/article/29/5/117/337264
❖ https://www.cdc.gov/salmonella/general/salmonellasym
ptoms.html
❖ https://www.cdc.gov/cholera/illness.html
❖ https://link.springer.com/article/10.1007/s00436-005-
0024-