Amoebiasi

sPROF. Mrs. VIBHA JACOB

 ENTAMOEBA HISTOLYTICA
 Entamoeba histolytica
was first described by
Lambl in 1859 and Losch
established it
pathogenic nature in
1875 in a dysenteric
patient is St.Petersberg
 Councilman and lafleur in
1981 described amoebic
liver abscess.
 Schauudinn ( 1903 )
differentiated pathogenic
and nonpathogenic
types of Amoebae
Amebiasis
 Amebiasis (am-e-BI-a-sis)
is a disease caused by a
one-celled parasite called
Entamoeba histolytica
(ent-a-ME-ba his-to-LI-ti-
ka).
Although it is more
common in people who
live in tropical areas with
poor sanitary conditions
 Amoebiasis a Major Health
Problem
 Amoebiasis is estimated to cause 70,000
deaths per year world wide Symptoms can
range from mild diarrhea to dysentery
with blood and mucus in the stool. E.
histolytica is usually a commensals
organism. Severe Amoebiasis infections
(known as invasive or fulminant
amoebiasis) occur in two major forms.
Invasion of the intestinal lining causes
amoebic dysentery or amoebic colitis.
AMOEBIASIS Infection occurs when
mature cysts are ingested and pass into
the colon where they divide into
trophozoites; these forms either enter the
tissues or reform cysts. Amoebiasis occurs
in two forms, both of which need
treatment
Bowel lumen amoebiasis is asymptomatic and trophozoites
(noninfective) and cysts (infective) are passed into the
faeces. Treatment is directed at eradicating cysts with
a luminal amoebicide; diloxanide furoate is the drug of
choice; iodoquinol or paromomycin is sometimes used.

4 Tissue invading amoebiasis gives rise to dysentery,

hepatic amoebiasis and liver abscess. A systemically
active drug (tissue amoebicide) effective against
trophozoites must be used, e.g. metronidazole,
tinidazole. Parenteral forms of these are available for
patients too ill to take drugs by mouth. In severe cases
of amoebic dysentery, tetracycline lessens the risk of
opportunistic infection, perforation and peritonitis when
it is given in addition to the systemic amoebicide.
 Transmission of Amebiasis
 Amoebiasis is transmitted
by fecal contamination of
drinking water and
foods, but also by direct
contact with dirty hands
or objects as well as by
sexual contact.
Additionally, geophagy is
a common route of
infection in certain
cultures.


 Nature of the disease

 Symptoms are usually gastrointestinal including

diarrhoea, vomiting, abdominal pain or
discomfort and fever. Symptoms take from a few
days to a few weeks to develop and manifest
themselves, but usually it is about two to four
weeks. Most infected people are asymptomatic
but this disease has the potential to make the
sufferer dangerously ill, especially if there is any
suggestion of immunocompromised.

Events on Amoebiasis
Trophozoites of E.histolytica
Trophozoites and Cystic stages
Cystic stage - E.histolytica
Amoebiasis causes Epithelial
damage
 Numerous Eosinophilic
spherical structure within
necrotic area.
 Tissue showing Amoebic
infection
 The spherical
structure
(Trophozoites) has
one basophilic nuclei
about the size of
RBC’s. Note some
RBC's are
phagocytosed by the
Trophozoites
(erythrophagocytosis)

 Virulence factors
 Trophozoites of E.histolytica interact with host through a
series of steps
1 Adhesion of target cell, phagocytosis and cytopathic
effect
2 E.histolytica induces both Humoral and cell mediated
immune responses.
3 Virulence factors – In many circumstances lumen
dwelling Amoeba may be asymptomatic
4 Causes disease only when invade the Intestine
5 Virulence is associated with secretion of Cysteine
proteniase which assists the organism in digesting the
extracellular matrix and invading tissues
 Cysteine proteinase -
Complement factor
 It C3
is observed
Cysteine proteinase
produced by invasive
strains of E.histolytica
inactivates the
complement factor C3
and are thus resistant
to Complement
mediated lysis.
Cysteine proteinase
virulent facto
r  Cysteine proteinase is an
important virulent
 factor
Its presence makes
E.histolytica is resistant to
complement mediated
 lysis
Can cleave the
extracellular structural
matrix and degrade
fibronectin and laminin,
 as well as type I collagen.
In this process basement
membrane is degraded
and leads to invasion
 Zymodeme
 Lectin binding
Zymodeme analysis,
genome specific DNA
analysis and staining
with Monoclonal
antibodies have been
successfully used as
markers to identify
invasive strains of
E.histolytica
Types of Zymodemes
 Based on
Electrophoretic
mobility E.histolytica
strains are
classified into 22
Zymodemes
 However only 9 are
invasive
 Invasive x Noninvasive strains
 The invasive and non
invasive strains may
appear identical may
represent two distinct
species
 1Invasive strain –
E.histolytica
 2Non invasive strains
reclassified as
E.dispar.


 Host Factor Contributions
 Several factors contribute to influence
infection
1
Stress
2 Malnu
trition
3 Alcoh
olism

4 Cortic
osteri
 Risk Factors

 People in developing countries that have

poor sanitary conditions
 Immigrants from developing countries
 Travellers to developing countries
 People who live in institutions that have
poor sanitary conditions
 HIV-positive patients
 Men who have sex with men

 Dysentery
 No symptoms (in the
majority of cases),
 Vague gastrointestinal
distress,
 Dysentery (with blood
and mucus).


 How the Amebiasis Manifests
 Most cases of amebiasis have very mild
symptoms or none.
 More severe infection may cause fever,
profuse diarrhea, abdominal pain,
jaundice, anorexia, and weight loss.
 In severe cases, it can lead to
development of abscesses (pockets of
amoebae and inflammatory cells) in the
liver or, more rarely, the brain.

 Clinical symptoms are Vague
 Wide spectrum, from asymptomatic
infection ("luminal amebiasis"), to invasive
intestinal amebiasis (dysentery, colitis,
appendicitis, toxic mega colon,
amebomas), to invasive extra intestinal
amebiasis (liver abscess, peritonitis,
pleuropulmonary abscess, cutaneous and
genital amoebic lesions).

Diagnosis of
Amebiasis
 BASICS METHODS IN DIAGNOSIS
 Fresh stool: wet mounts and
permanently stained preparations (e.g.,
trichrome).
 Concentrates from fresh stool: wet
mounts, with or without iodine stain, and
permanently stained preparations (e.g.,
trichrome). Concentration procedures,
however, are not useful for
demonstrating Trophozoites.

 Diagnosis of Amebiasis
 Diagnosis of amebiasis can be very difficult. One
problem is that other parasites and cells can look
very similar to E. histolytica when seen under a
microscope. Therefore, sometimes people are
told that they are infected with E. histolytica
even though they are not. Entamoeba histolytica
and another ameba, Entamoeba dispar, which is
about 10 times more common, look the same
when seen under a microscope

 Microscopy
 This is the traditional
means of diagnosing the
disease—one simply looks
at a sample of stool
under a microscope.
Because E. histolytica is
not always found in every
stool sample, several
samples from different
days may be needed.
Sometimes red blood
cells that have been
ingested by the parasite
are visible.
 Microscopic examination of
Stool
 A sample of freshly
collected fecal
specimen
containing mucous
and blood is
transferred on a
slightly warm slide
and covered with
cover slip and
examined

microscopically
E. histolytica /E. dispar
cyst.
E. histolytica/E. dispar cysts
stained with trichrome
 Specific Diagnosis of active
infection should demonstrate
Trophozoites
 Motile Trophozoites
throwing pseudopodia
and containing red
blood cells found in
large number
 Endoplasm appear
bluish or found glass
in appearance and
nucleus is not visible
but faint outline
may be observed
 Charcot Leyden crystals in stool
examination supports the Diagnosis,
 Cysts have smooth and
thin cell wall and contain
round, retractile
chromotoid bars
 Glycogen mass is not
visible
 RBC’s and pus cells are
found in fair number
 Charcot Leyden crystals,
diamond shaped clear
and retractile structures
are present in faeces
 Doctortvrao’s ‘e’ learning series
IDOINE PREPARATION OF
STOOL
 Routinely not used
 Trophozoites stains
yellow to light brown,
Nucleus is clearly visible
with central
karyosome
Cysts shows a smooth
and hyaline appearance,
Nucleus is clearly seen
and no more than 4
nuclei are present,
Glycogen mass stains
brown, while chromotoid
bars are not stained.
 Mucosal Scrapings
 Mucosal scrapings can be
obtained by
sigmoidoscopy useful in
atypical presentations
and may serve as adjunct
to conventional stool
examination for Ova and
cyst
 Direct wet mount, a
permanently
stained smear and
immuno stained
smears are
 examined.
Doctortvrao’s ‘e’ learning series
Extra intestinal Amoebiasis
 The specimens are
obtained from Liver, lung,
or Brain biopsy samples
and subjected to routine
Histopathology ( H&E)
sections
 Giemsa stained touch
preparations which will
revel Trophozoites in
extra intestinal lesions.
 Amoebic Liver Abscess
 The pus in liver
abscess appear as red
Anchovy sauce like
appearance
 The material
aspirated is likely to
contain Trophozoites
and may be
detected by direct
microscopic
examination
 Serological Diagnosis

 The serological become reactive in invasive

Amoebiasis
 1 Indirect Heamagglutination assay
( IHA )
 2 ELISA
 3 Latex agglutination test
 4 gel diffusion
 5 Counter current Imunoelectrphoresis
 Serological tests remain positive for several years ever after successful
treatment
 Culture
 Cultures are not done routinely
 Boeck and Drbohlav’s medium modified by
Laidlaw extensively used for isolation and
maintenance of E.histolytica.
 Diamonds axenic medium used in studies
on Pathogenicty, antigenic
characterization and drug sensitivity
tests

Do we need culturing for
Diagnosis ?
 Trying to get the
amoeba to grow
outside the body is
very difficult and
unreliable, and is
therefore not
generally done
 Immunity in Amoebiasis
 Infection with invasive
strains of E.histolytica
induce both Humoral
and cellular response.
 Infection offers some
degree of
protection.
 Immunological Tests are not
confirmatory of Acute Infections
 When the body is exposed
to an infection, the
immune system creates
antibodies to fight it off.
These can be detected with
a blood test, and provide
evidence that the person
has been infected with E.
histolytica. Unfortunately,
this test does not
distinguish between past
and present infection

Emerging methods in Diagnosis
 These are considered the
most useful tests for
detecting E. histolytica.
They test directly for the
parasite itself by exposing
some stool to a strip of
paper coated with
antibodies. The parasites
will stick to the antibodies
on the paper. The test
distinguishes E.
histolytica from other
parasites.
 Treating Amebiasis.
 Frequently, either metronidazole (Flagyl) or
tinidazole (Fasigyn) are used to treat
Amebiasis. If this does not work, Chloroquine,
emetine, and dehydroemetine can be used.
Eliminating cysts in carriers who do not have
symptoms is accomplished with diloxanide
furoate (Furamide), iodoquinol (Yodoxin),
and paromomycin. Nitazoxanide is a newer
drug that shows promise against not only E.
histolytica but many other parasites as well.
 Treating extra intestinal
Amoebiasis
 Amoebic abscess is
treated similarly to
dysentery, with
antibiotics. Sometimes
surgical drainage may be
performed, but this is
usually to rule out other
(bacterial) causes of
abscess. It is also
performed if an abscess
is about to, or has
already ruptured.
 Preventing Amoebiasis
 Drink only bottled or boiled (for 1 minute) water, or
carbonated (bubbly) drinks in cans or bottles. Fountain
drinks and any drinks with ice cubes are not safe. Water
can be made safe by filtering it through an "absolute 1
micron or less" filter and dissolving iodine tablets in the
filtered water.
 Avoid fresh fruit or vegetables that were peeled by
someone else.
 Avoid milk, cheese, or dairy products that may not have
been pasteurized.
 Avoid anything sold by street vendors.

 Food safety
 Thoroughly cook all raw foods.
 *Thoroughly wash raw
vegetables and fruits before
eating.
 *Reheat food until the internal
temperature of the food
reaches at least 167º
Fahrenheit.
 Wash your hands before
preparing food, before eating,
after going to the toilet or
changing diapers, after
smoking or after using a tissue
or handkerchief.

Personal Hygiene
 Wash hands thoroughly
with soap and hot
running water for at least
10 seconds after using
the toilet or changing a
baby's diaper.
 Clean bathrooms and
toilets often. Pay
particular attention to
toilet seats and taps.
 Avoid sharing towels or
face washers.
 Vaccines
 Vaccines are being developed and tested
for the treatment of Amebiasis. The
vaccine is a modified version of the
proteins expressed on the surface of E.
histolytica. A study in rodents found that
the vaccine prevented the formation of
liver abscesses, but much more research
is needed to determine if these
vaccines are useful and safe in humans
