Amebiasis - Morphology

✓ Entamoeba histolytica - Life Cycle

Iran University of
- Epidemiology Medical Sciences

- Clinical manifestations &

pathogenesis
- Diagnosis
- Treatment
- Prevention & control

Pathogenic Free-living Amebae

✓Naegleria
✓Acanthamoeba
✓Balamuthia
Dr Elham Razmjou 1
Amebiasis
Entamoeba histolytica

Dr Elham Razmjou 2
Genus: Entamoeba

Species: E. histolytica Amebiasis (Amebic dysentery)

E. dispar
E. hartmanni
E. polecki
E. coli
E. gingivalis
E. moshkovskii

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 Epidemiology of Entamoeba histolytica
Host: Human

Habitat: caecum & sigmoido-rectal regions

Prevalence
The prevalence of E. histolytica is close to 1% worldwide.
Mortality
Amebiasis is the cause of an estimated 50,000- 100,000 deaths each year.
Entamoeba histolytica is the third leading cause of mortality due to parasitic
disease in humans after malaria and schistosomiasis.
Geographic Distribution
Worldwide, with a higher incidence of amebiasis in developing countries.
The prevalence of amebic infection varies with the level of sanitation
(highest prevalence in areas with poor sanitation).
In industrialized countries, risk groups include male homosexuals,
travelers, recent immigrants, and institutionalized populations.
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 Entamoeba histolytica
Trophozoite
T: 12-15 µ Minuta

Cyst
C: 10-15 µ

Trophozoites Cysts
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Hematophage
Magnata

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Life Cycle
of
Entamoeba
histolytica

Dr Elham Razmjou Galactose & N-acetyl-D-galactosamine specific lectin 7

 Pathogenesis
 Infection with E. histolytica does not necessarily lead to disease.
The outcome depends on :
❑ Parasite factors:
▪Adhesion molecules
(N- acetyl-D-galactosamine inhibitable lectin Gal/Gal Nac)-
adhesion to colonic mucins and host cells to induce contact-dependent cytolysis
e.g., Cysteine proteinase)

▪Strain differences

❑ Host factors’ Contribution:

▪Physicochemical environment of the gut
is influenced by bacterial flora, mucus secretion & gut motility
▪Degree of immunological resistance

▪Nutrition status
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 Mode of Transmission
 The main source of human infection is the ingestion of 4-nucleated
cysts.
➢ Cyst passers to person (fecal-oral route):

▪Food or drink contaminated with feces containing E. histolytica cysts.

▪Use of human feces (night soil) for soil fertilizer.
▪Contamination of food stuff by flies and possibly cockroaches.

➢Fecal-oral self-inoculation

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 Amebiasis Clinical manifestations
vary from no symptoms to severe and fatal symptoms
Clinical signs of the disease include:
I. Intestinal amebiasis
II. Extraintestinal amebiasis
1- Asymptomatic intestinal infection
90% of cases are without clinical symptoms &
the infection is cleared without the disease
(Self-limiting, asymptomatic infection)
Parasites colonize in the lumen, and cysts pass in
the stool. (healthy cyst passer)
2- Symptomatic intestinal infection
9% of cases: Disease occurs when the amoeba
comes into contact with the intestine cells. It then
secretes enzymes, mainly, Cysteine proteinases, that
destroy cell membranes and proteins. This causes
colitis (the pain and inflammation of the colon).
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 Clinical manifestations
I. Intestinal amebiasis
1- Asymptomatic intestinal infection
2- Symptomatic intestinal infection
9% of cases:
After attachment, amoebas produce a cytotoxin that
kills epithelial cells to access deeper tissues.
Amebic Colitis (the pain & inflammation of the colon).

This process can lead to the penetration and digestion of human

tissues, resulting in flask-shaped ulcers in the intestine.

The lesions are limited to the mucosa & submucosa and tend to
spread laterally, creating the flask-shaped amebic ulcer.

This amoebic ulceration initially produces focal and superficial

erosions in the large intestine with unaffected mucosa in
between.

Dr Elham Razmjou Flask-shaped lesion 11

 Flask-shaped lesion
Amoebic ulceration with unaffected
mucosa in between.
Honeycomb-shaped lesion

1-2 mm Dr Elham Razmjou 12

Diffuse ulceration of the mucosa
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 Clinical manifestations
I. Intestinal amebiasis
1- Asymptomatic intestinal infection
2- Symptomatic intestinal infection
❑ Amebic Colitis
❑ Dysentery:
Colitis with diarrhea (sometimes bloody)
accompanied by abdominal pain, cramping,
and numerous bloody stools per day.

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 Clinical manifestations
I. Intestinal amebiasis
1- Asymptomatic intestinal infection
2- Symptomatic intestinal infection
❑ Amebic Colitis
❑ Amebic Dysentery
❑ Amoeboma (Amoebic granuloma)
An inflammatory thickening of the intestinal
wall due to repeated invasion of colon by
E. histolytica.
Localized granulomatous mass
misdiagnosed with carcinoma.
❑ Amoebic Appendicitis
the appendix becomes inflamed and painful.

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 Clinical manifestations
I. Intestinal amebiasis
2- Symptomatic intestinal infection
❑ Amebic Colitis
❑ Amebic Dysentery
❑ Amoeboma (Amoebic granuloma)
❑ Amoebic Appendicitis
Intestinal amebiasis complications
❑ Amoebic peritonitis
Trophozoites penetrate the muscle and serous layers leading to intestinal
perforations -rare but fatal. More than 80% of amebiasis death related to it.
❑ Hemorrhage
Rarely, the involvement of blood vessels at the base of the ulcer may
produce profuse bleeding.

❑ Stricture of colon (narrowness)

secondary to fibrosis and inflammation
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Amoeboma

Stricture of the colon

(narrowness)

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 Clinical manifestations
I. Intestinal amebiasis
II. Extra-intestinal amebiasis
1% of cases:
If the parasites gain access to damaged blood vessels, they could be
carried to various extra-intestinal sites in the body, most frequently, the
liver, where the amoeba causes hepatic amoebiasis.

1- Hepatic amoebiasis (amoebic liver abscesses)

1% of cases:
A high incidence of extra-intestinal infection occurs in the liver (88%),
and of this number, a majority develop in the right lobe of the liver (80%).
Trophozoites are carried to the liver’s right lobe through the
portal venous circulation.
Signs & symptoms:
hepatomegaly, liver tenderness, pain in the upper abdomen, high fever and
anorexia, weight loss, vomiting, fatigue. Dr Elham Razmjou 18
The smallest amoebic liver abscesses may be solid and whitish, only a few
millimeters in diameter. But it soon increases in diameter, with yellowish-
gelatinous content and later a cavity filled with liver-colored fluid and cellular
debris.

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Two abscesses in the right lobe and one abscess in the
left lobe in a patient with the amebic liver abscess
23
Dr Elham Razmjou
 Abdominal computed tomography in a patient
with the amebic liver abscess shows one abscess in
Dr Elham Razmjou the right lobe and one abscess in the left lobe. 24
The most typical presentation of amebic liver abscess is fever, right upper
quadrant pain, and tenderness. Involvement of the diaphragmatic surface of
the liver may lead to right-side pleuritic pain or referred shoulder pain.

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 A posteroanterior (left-hand side) and lateral
(right-hand side) chest radiograph in a patient with
an amebic liver abscess
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 Ultrasound- or CT-guided needle
aspiration of the liver is indicated
only if abscesses are large (> 12 cm),
abscess rupture is imminent, medical
therapy has failed, or abscesses are
present in the left lobe.

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Typical aspirate:
✓ chocolate syrup
✓ Trophozoites are
attached to the margin
of the abscess wall
✓ Trophozoites may be
found in the last
portions of aspirated
material

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Entamoeba histolytica Trophozoite in the liver aspirate,
trichrome stain.
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 Clinical manifestations
II. Extra-intestinal amebiasis
1- Hepatic amebiasis (amoebic liver abscess)
2- Pleuropulmonary amebiasis (amebic lung abscess)

Amebic lung abscess is most commonly

the result of a contiguous spread from a
liver abscess rupturing through the
right hemidiaphragm. However, amebic
lung abscess acquired through
the hematogenous spread has been
reported.

Signs & symptoms:

cough, pleuritic pain, and dyspnea.
The trophozoites of E. histolytica may
be found in the sputum sample of patients.
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 Clinical manifestations
II. Extra-intestinal amebiasis
1- Hepatic amebiasis (amoebic liver abscess)
2- Pleuropulmonary amebiasis (amebic lung abscess)
3- Cerebral amebiasis (amebic brain abscess)
Amebic brain abscesses resulting from
hematogenous spread or amebic liver
abscess.
Signs & symptoms:
abrupt onsets of nausea, vomiting,
headache, and mental status changes.
Progression can be very rapid, sometimes
leading to death within 12-72 hours.
Ameba are shown in a sample
Computed tomography (CT) reveals irregular of brain tissue
lesions without a surrounding capsule or enhancement.
A tissue biopsy sample reveals trophozoites. Dr Elham Razmjou 31
 Clinical manifestations
II. Extra-intestinal amebiasis
1- Hepatic amebiasis (amoebic liver abscess)

2- Pleuropulmonary amebiasis (amebic lung abscess)

3- Cerebral amebiasis (amebic brain abscess)

4- Cutaneous amebiasis

Cutaneous amebiasis can also occur in the skin around sites of

colostomy wound, perianal region, region overlying visceral lesion,
and at the site of drainage of liver abscess.

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Cutaneous amebiasis at the site of drainage of liver abscess.
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A patient with amebiasis liver abscess, with perforation of the
abscess through the abdominal skin. Dr Elham Razmjou 34
 Cutaneous amebiasis occurs in the skin in the sites of the
colectomy wound.
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 Cutaneous amebiasis occurs in the skin around the sites of the
colostomy wound.

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 Cutaneous amebiasis occurs in the perianal region.

perianal ulceration: A 15-month-old boy

three perianal ulcers ranging from 1 to 3 cm with irregular borders and a
necrotic yellowish dirty base with purulent exudates. The ulcer was
surrounded by a reddish, wine-like inflammatory halo and was very
painful. Dr Elham Razmjou 37
Cutaneous amebiasis occurs in the perianal region.

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 Clinical manifestations
II. Extra-intestinal amebiasis
1- Hepatic amebiasis (amoebic liver abscess)

2- Pleuropulmonary amebiasis (amebic lung abscess)

3- Cerebral amebiasis (amebic brain abscess)

4- Cutaneous amebiasis

5- Genitourinary amebiasis
Genitourinary involvement may cause painful genital ulcers or fallopian
tube amebiasis.

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Genitourinary amebiasis: Penis amebiasis

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 Diagnosis
Parasitological diagnosis
Cysts and trophozoites are passed in feces.
Cysts are typically found in the formed stool, whereas trophozoites are
usually found in the diarrheal stool.

E. histolytica is morphologically identical to

Microscopy diagnosis
E. dispar and E. moshkovskii.
Immunodiagnosis
1. Antibody Detection ELISA

2. Antigen Detection ELISA

Molecular diagnosis
PCR
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Treatment
❑ Asymptomatic intestinal infection
✓ Paromomycin
✓ Diloxanide furoate (Furamide)
✓ Metronidazole (Flagyl)

❑ Symptomatic intestinal infection &

Extra-intestinal amebiasis
✓ Metronidazole
✓ Tinidazole
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Prevention of amoebiasis
❑ Cysts of Entamoeba can survive for up to
a month in soil or for up to 45 minutes
under fingernails.
❑ Prevention of amoebiasis is by:
▪ separating food and water from feces
▪ proper sanitation measures

▪ Treatment of patients.
▪ Examination and treatment of food handlers.
▪ Environmental sanitation.
▪ Personal prophylaxis.
▪ Human feces should not be used as fertilizers.

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Pathogenic Free-living Amebae
Naegleria
Acanthamoeba
Balamuthia

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 Naegleria fowleri

Primary Amebic Meningoencephalitis (PAM)

An acute and usually fatal disease of the
central nervous system.

In healthy humans

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Primary amebic meingoencephalitis (PAM)

A brain infection that leads to the

destruction of brain tissue. In its early
stages, symptoms of PAM may be similar
to symptoms of bacterial meningitis.
Initial symptoms of PAM start about five
days (1 to 9 days) after infection.

The initial symptoms may include

headache, fever, nausea, or vomiting.
Later symptoms can include a stiff neck,
confusion, lack of attention to people and surroundings,
loss of balance, seizures, and hallucinations.
After the start of symptoms, the disease progresses rapidly and usually causes
death within about five days (1 to 12 days).

a brain-eating amoeba
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Naegleria fowleri trophozoites are
found in cerebrospinal fluid (CSF)
and tissue.

Cysts are not seen in brain tissue.

Flagellated forms are occasionally

found in CSF.

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Acanthamoeba spp
Acanthamoeba can cause rare but severe infections of the eye, skin, and central
nervous system.
The ameba is found worldwide in the environment in water and soil.
The ameba can be spread to the eyes through contact lens use, cuts, skin wounds, or
inhaled into the lungs.
Most people will be exposed to Acanthamoeba during their lifetime, but very few
will become sick from this exposure.
The three diseases caused by Acanthamoeba are:
Acanthamoeba keratitis:
An infection of the eye that typically occurs in healthy persons and
can result in permanent visual impairment or blindness.
Granulomatous Amebic Encephalitis (GAE):
A severe infection of the brain and spinal cord that typically
occurs in persons with a compromised immune system.
Disseminated infection
A widespread infection can affect the skin, sinuses, lungs, and other organs.
It is also more common in persons with a compromised immune system.
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Acanthamoeba keratitis

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 Acanthamoeba sp. Keratitis

Cyst with a
characteristic shape in
corneal scraping.

Corneal biopsy showing

a trophozoite

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 Balamuthia mandrillaris
Balamuthia mandrillaris, similar to Acanthamoeba, can cause severe
infections of the central nervous system,
granulomatous amebic Encephalitis

Balamuthia amebic encephalitis (BAE)

=granulomatous amebic encephalitis (GAE)

Balamuthia mandrillaris trophozoites in brain tissue

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 Balamuthia mandrillaris
skin lesions
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Balamuthia mandrillaris infection with a significant skin lesion.
Unlike Acanthamoeba, Balamuthia cannot be spread to the eyes, and
Balamuthia infection of the eye is not reported.
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 razmjou.e@iums.ac.ir

Tel: 86703269

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