ENTAMOEBA HISTOLYTICA AND OTHER AMOEBAE

Phylum: Protozoa

Sub-phylum: Sarcodina (Amoeba group)

Infective agent: Entamoeba histolytica

Disease: Amoebiasis
 INTRODUCTION
• Amoebae occur in a number of life supporting natural
habitats eg. water, soil, sewage etc.
• Some free-living amoeba Naegleria and Acanthamoeba spp
in soil and water can invade tissues of man causing fatal
diseases
• Amoebae are essentially scavengers – feed on bacteria
detritus, starch grain etc. however some are parasitic e.g. E.
histolytica
• Few amoebae infect man and most of those are primarily
commensals.
• Of the amoeba that infect man, E. histolytica is the most
pathogenic
 Examples of amoeba which infect man include
1) Iodamoeba bütschilii 7) E. dispar
2) Endolimax nana 8) E. moshkovskii
3) Dientamoeba fragilis 9) E. polecki
4) Achantamoeba sp 10) E. hartmanni
5) E. histolytica 11) E. gingivalis
6) E. coli
MORPHOLOGY

There are two forms:

a) Trophozoite
 The Trophozoic stage
• Irregular shape with pseudopodia

• Are large 20-30µm in diameter

• The nucleus is characterized by a peripheral layer of
chromatin ring in the form of beads and a central karyosome
MORPHOLOGY cont.d
b) The cyst stage
 The Cystic stage

• Oval or spherical in shape

• Presence of 4 nuclei (mature) and , between 1&2 (immature)
• Karysome is compact, usually centrally located but may be eccentric
occasionally.
 EPIDEMIOLOGY 1
• The disease has a worldwide distribution
• It is endemic in most tropical countries with low socio- economic
conditions.
• It is the third leading parasitic cause of death after Malaria and
Schistosomiasis.
• Approximately 480 million (3.55%) of worlds’ population is infected
and annual mortality rate is between 40,000 – 110,000 persons.

• Transmission is feaco-oro through food or water contamination as a

result of exposure to human faeces (poor food handling).
• High risk groups include:

❑ Travelers, immigrants,
❑ Immunocompromised individuals,
❑ Sexually active homosexuals,
❑ Individuals in mental institutions,
❑ Prisoners,
❑ Children in day care centers.
Severe infection can occur in the ff groups of people
❑Children below the age of 5yrs,
❑Pregnant women,
❑Malnourished and individuals taking corticosteroids.
• Prevalence is high in areas where human faeces is used as fertilizers.

• Reservoirs are the asymptomatic cyst carriers (humans).

• Sexual (oro-anal) transmission can also occur.

• Infection among HIV/AIDS patients in Ghana is 14%
• Incubation period ranges from 2-4 weeks
• E. histolytica is usually found in the large intestines in the mucosal
lining.
Life cycle of Entamoeba histolytica
 PATHOGENESIS 1
• E. histolytica can destroy all human tissues however the preferred sites
are the intestinal mucosal, the liver, the brain and skin.

• The trophozoites have the potential to evade cartilage and bones.

• The trophozoites can invade tissues, feed on blood, form abscesses in
mucosa and submucosal layers of the intestines.

• Majority of infected people are asymptomatic (90%) – Luminal

amoebiasis.
• The exact mode of mucosal penetration is not known but it is believed
that amoebae have enzymes which lyse host tissues leading to amoebic
ulcers.
• The ulcers often develop in the caecum, appendix or adjacent portion of
the ascending colon.
• Ulcers are usually raised with a small opening on the mucosal surface
and a larger area of destruction below the surface (flask-shaped)

• These ulcers may be invaded by bacteria leading to secondary

infections
 Pathology of Amoebiasis.

Colonic ulcers from a patient with

amoebiasis; the ulcers measure about
1mm in diameter.
 Pathology of Amoebiasis.

E. histolytica trophozoites in a colonic ulcer

containing ingested red blood cells and
surrounded by eosinophilc debris as a result of
submucosal destruction.
Clinical manifestations of Entamoeba histolytica infection

Infection

Amebic colitis
(intestinal) (90%)

Asymptomatic Symptomatic Strain associated

Colonization (90%) Presentations (10%) Virulence/immunity
?
Genetic differences in
infecting strains/ Host response
multiple -infection ?
Amebic abscesses
(Extra-intestinal) (10%)
 Clinical manifestations 1
1. Intestinal (Luminal) amoebiasis
• Sudden onset with abdominal discomfort
• Diarrhoea with blood or mucus (dysentery), tenesmus
• Abdomen may be tender and liver slightly enlarged
• Colonoscopy or rectosigmoidoscopy may reveal presence of small ulcers
• The ulcers are initially superficial with necrotic base covered with a yellow
exudate
• Ulcers may be perforated on rare occasions and the patient may die of
peritonitis
• As the disease advance, flasks shaped ulcers are formed and the lamina
propia is infiltrated by plasma cells, lymphocytes, neutrophils and
eosinophils.
• There may also be oedema and focal haemorrhage
 Clinical manifestations 3
2. Extraintestinal Amoebiasis
• Amoebic liver abscess
• Is the most common extra-intestinal infection, found in all age
groups but 10x common in adults
• Most of those infected (20%) have histories of amoebic dysentery and
10% of patients have diarrhoea or dysentery at the time of diagnosis of
the abscess.
• The onset is rather abrupt with pain in upper abdomen coupled with
high fever 38-40oC
Symptoms include :–
Fever 38oC – 40oC, profuse sweating, anorexia, weight
loss, nausea, vomiting and fatigue, hepatomegaly, liver
may be hardened.
Mild jaundice is common but not severe obstructive
jaundice
❖In typical abscesses the fluid (aspirate) is odourless
resembling chocolate syrup or anchony paste and
bacteriologically sterile
❖Liver abscesses may heal, rapture or disseminate
2. Other abscesses
Peritonial amoebiasis:
* Is caused by rapture of hepatic liver abscess or by perforation of the
caecum
• It is characterized by sudden increase in abdominal pain, which
resembles septic peritonitis.
Pericardial amoebiasis:
Is the most serious complication of an amoebic liver abscess.
There could also be:
• a) Pleuropulmunary amoebiasis
• b) Cerebral amoebiasis
• c) Genitourinary amoebiasis
• d) Cutaneous amoebiasis
Amoebic balanitis (inflammation of the glans penis)
Amoebiasis of the skin
 Diagnosis
• Microscopy
• Culture methods
• Serological methods
• Sigmoidoscopy
• Polymerase Chain reaction
 TREATMENT
2 classes of drugs are used
a) Luminal amoebicides –
Diloxanide furoate
Iodoquinol
are effective on amoeba in the lumen but not in the tissues
b) Tissue amoebicides –
Metronidazole
Dehydroemetine
Chloroquine
are effective for the elimination of invasive (tissue) forms of E.
histolytica
 Prevention and Control
• Improvement of standard of living
• Good Sanitation practices / water supply / Proper plumbing /
adequate disposal of faeces
• Boiling and filtering of water before use
• Proper food handling / safety – health education
• Avoidance of vegetables grown on soils with human excreta as
fertilizer
• Soaking of salad leaves in vinegar & 50% acetic acid before use. etc
 Other Amoebae

• Entamoeba coli
• Endolimax nana
• Iodamoeba bütschlli
• Naegleria fowleri
• Acanthamoeba spp.
 Entamoeba coli

❑ Non-pathogenic but could be opportunistic

❑ Has a world-wide distribution
❑ Found in the large intestine.
❑ Do not ingest RBCs
❑ Should distinguished from E. histolytica
 Endolimax nana:
• Cosmopolitan, common intestinal amoeba of man, birds & pigs.
• It is non pathogenic
• Has only one nucleus in trophozoite 4 in immature cysts
• It lacks chromatoid bodies and peripheral chromatin.
 Iodamoeba bütschlli
• Common among pigs / monkeys but occasionally occurs in man
Are non-pathogenic
• Cytoplasm contains 1 or more glycogen mass(es), bacteria, yeast
and debris. Red cells are never ingested
 Naegleria fowleri
• Is an amoeboflagellate which has an amoebic phase which
alternates with one possessing 2 flagella.
• Infection occurs through exposure to water in swimming pools,
puddles, moist soil, sewerage etc.
• The amoeba enters the nasal cavity by inhalation (nasal instillation)
or aspiration of water containing the trophozoites.

• This organism invades the neuro-epithelium moving along the

nerves to invade the brain leading to primary amoebic meningo-
encephalitis.
 Acanthamoeba sp
• Are invasive amoeba which cause chronic encephalitis, skin ulcers,
keratitis etc.

• They produce a chronic CNS disease or a serious eye infection, which

is linked to wearing of contact lenses, e.g. soft ones.