Amebiasis

DR. TARIKU
 etiology

E.histolitica
 Epidemiology

 the third most common cause of death from

parasitic disease (after schistosomiasis and malaria)

About 10% of the world's population is infected with

Entamoeba
 the majority with noninvasive Entamoeba dispar
Amebiasis results from infection with E.histolytica
 con

Cysts of E. histolytica and E. dispar are

morphologically identical
 E. histolytica has unique isoenzymes, surface
antigens, DNA markers, and virulence properties
 Transmission

E. histolytica is acquired by ingestion of viable cysts

from fecally contaminated water, food, or hands
Trophozoites are rapidly killed by exposure to air or
stomach acid and therefore cannot transmit
infection.
 Con.

After encystation, infectious cysts are shed in the

stool and can survive for several weeks in a moist
environment
trophozoites invade the bowel mucosa, causing
symptomatic colitis
the bloodstream, causing distant abscesses of the
liver, lungs, or brain.
 Pathogenesis and Pathology

Both trophozoites and cysts are found in the

intestinal lumen
 only trophozoites of E. histolytica invade tissue

Trophozoites attach to colonic mucus and epithelial

cells by Gal/GalNAc.
Trophozoite E.histolitica
Cyst E.histolitica
 Con.

The earliest intestinal lesions are microulcerations of

the mucosa of the cecum, sigmoid colon, or rectum
 con

Submucosal extension of ulcerations under viable-

appearing surface mucosa causes the classic "flask-
shaped" ulcer
 infection is marked by a paucity of inflammatory
cells
 virulence factors

Adhesine lactine-Gal/GalNAc

cysteine proteinases
 Amebas can lyse neutrophils, monocytes,
lymphocytes, and cells of colonic and hepatic lines.
 phospholipase A and pore-forming peptides.
 Con.

E. histolytica is resistant to complement-mediated

lysis—a property critical to survival in the
bloodstream
In contrast, E. dispar is rapidly lysed by complement
and is thus restricted to the bowel lumen
 Con.

intestinal IgA response to Gal/GalNAc reduced the

risk of new E. histolytica infection by 64%.
Serum IgG antibody is not protective
 Clinical manifestations

About 90% of infections are asymptomatic,

10% produce a spectrum of clinical syndromes
ranging from dysentery to abscesses of the liver or
other organs.
 Intestinal amebiasis

Asymptomatic cyst carrage

Amebic colitis
Fulminant amebic colitia
Toxic megacolone
Ameboma
 Intestinal Amebiasis

The most common type of amebic infection is

asymptomatic cyst passage(90%)
 most patients harbor E. dispar.
 Amebic colitis

 develops 2–6 weeks after the ingestion of infectious

cysts.
 A gradual onset of lower abdominal pain and mild
diarrhea is followed by malaise, weight loss, and
diffuse lower abdominal or back pain
 con

 Cecal involvement may mimic acute appendicitis

 Patients with full-blown dysentery may pass 10–12

stools per day. The stools contain little fecal material
and consist mainly of blood and mucus.
In contrast to those with bacterial diarrhea, fewer
than 40% of patients with amebic dysentery are
febrile.
Virtually all patients have heme-positive stools.
 Con.

fulminant amebic colitis: severe abdominal pain,

high fever, and profuse diarrhea
 toxic megacolon: severe bowel dilation with
intramural air and risk for bowel perforation
risks for severe amebic colitis
1. children
2. Use of glucocorticoids
3. Other immunosupresive drugs
 Con.

The association between severe amebiasis

complications and glucocorticoid therapy
emphasizes the importance of excluding amebiasis
when inflammatory bowel disease is suspected.
 ameboma

an asymptomatic or tender mass in bowel lumen

granulation tissue with little fibrous-tissue response.

 confused with cancer on barium studies.

 A positive serologic test or biopsy can prevent
unnecessary surgery in this setting.
 Amebic Liver Abscess

Liver abscesses are always preceded by intestinal

colonization
Trophozoites invade veins to reach the liver through
the portal venous system
the neutrophils are lysed by contact with amebas,
and the release of neutrophil toxins may contribute
to necrosis of hepatocytes.
 con

Young patients with an amebic liver abscess present

in the acute phase with prominent symptoms of <10
days' duration
 Older patients a subacute course lasting 6 months,
with weight loss and hepatomegaly,fever
 con

Most patients are febrile and have right-upper-quadrant

pain, which may be dull or pleuritic in nature and may
radiate to the shoulder.
 Point tenderness over the liver and right-sided pleural
effusion are common
 Jaundice is rare.
one-third of patients with an amebic abscess have active
diarrhea.
About one-third of patients with chronic presentations
are febrile.
 con

10–15% of patients present only with fever

 amebic liver abscess must be considered in the
differential diagnosis of fever of unknown origin
 Con.

 The necrotic contents of a liver abscess are

classically described as "anchovy paste"
bacteriologically sterile granular debris with few or
no cells
 Amebas, if seen, tend to be found near the capsule of
the abscess.
Amebic liver abscess
 Complications of Amebic Liver Abscess

Pleuro pulmonary
Rupture to Pericardial
Rubture to peritonial
Distal abscess
 Pleuropulmonary

 20–30% of patients
is the most frequent complication of amebic liver
abscess.
 Manifestations :sterile effusions, contiguous spread
from the liver, rupture into the pleural space.
Sterile effusions and contiguous spread usually
resolve with medical therapy
 frank rupture into the pleural space requires
drainage
 hepatobronchial fistula

 cough productive of large amounts of necrotic

material that may contain amebas
 carries a good prognosis
 Rupture to pericardium

Rupture into the pericardium, usually from

abscesses of the left lobe of the liver
carries the gravest prognosis
it can occur during medical therapy and requires
surgical drainage
Elective dranage of left lobe amebic liver absess
 Rupture to peritoneum

Abscesses that rupture into the peritoneum may

present as
1. an indolent leak
2. an acute abdomen
require both percutaneous catheter drainage and
medical therapy.
 Other Extraintestinal Sites

The genitourinary tract

1. direct extension of amebiasis from the colon
2. by hematogenous spread of the infection
Painful genital ulcers punched-out appearance and
profuse discharge
Cerebral involvement has been reported in fewer
than 0.1% of patients in large clinical series
respond well to medical therapy
 Diagnostic Tests

Stool examinations
 serologic tests
 noninvasive imaging of the liver
biopsy
 Lab.

Fecal findings suggestive of amebic colitis:-

a positive test for heme
a paucity of neutrophils
 amebic cysts or trophozoites.
The definitive diagnosis of amebic colitis
hematophagous trophozoites of E. histolytica
 con

 trophozoites are killed rapidly by water, drying, or

barium
examine at least three fresh stool specimens
 Examination of a combination of wet mounts,
iodine-stained concentrates
 trichrome-stained preparations of fresh stool
confirms the diagnosis in 75–95% of cases.
 Con.

 sigmoidoscopy with biopsy of the edge of ulcers

Trophozoites in a biopsy specimen from a colonic

mass confirm the diagnosis of ameboma
 trophozoites are rare in liver aspirates because they
are found in the abscess capsule and not in the
readily aspirated necrotic center.
 cysts

the cysts must be differentiated morphologically

Entamoeba hartmanni
Entamoeba coli
Endolimax nana
which do not cause clinical disease and do not
warrant therapy..
 Con.

 the cysts of E. histolytica cannot be distinguished

microscopically from those of E. dispar
 the microscopic diagnosis of E. histolytica can be
made only by the detection of Entamoeba
trophozoites that have ingested erythrocytes
(hematophagous trophozoite)
Positive amebic serology
 Serology

important for parasitologic diagnosis of invasive

amebiasis.
 Enzyme-linked immunosorbent assays (ELISAs)
and agar gel diffusion assays
positive in more than 90% of patients with colitis,
amebomas, or liver abscess.
 serology

Positive results in conjunction with the appropriate

clinical syndrome suggest active disease because
serologic findings usually revert to negative within
6–12 months.
Even in highly endemic areas s fewer than 10% of
asymptomatic individuals have a positive amebic
serology.
The interpretation of the indirect hemagglutination
test is more difficult because titers may remain
positive for as long as 10 years
 con

 10% of patients with acute amebic liver abscess may

have negative serologic findings
 In contrast to carriers of E. dispar, most
asymptomatic carriers of E. histolytica develop
antibodies.
serologic tests are helpful in assessing the risk of
invasive amebiasis in asymptomatic, cyst-passing
individuals in nonendemic areas.

 con

Serologic tests also should be performed in patients

with ulcerative colitis before the institution of
glucocorticoid therapy to prevent the development of
severe colitis or toxic megacolon
 Con.

About three-fourths of patients with an amebic liver

abscess have leukocytosis (>10,000 cells/L)if
symptoms are acute or complications have developed
Invasive amebiasis does not elicit eosinophilia.
 liver enzyme levels are normal or minimally
elevated
 The alkaline phosphatase level is most often
elevated and may remain so for months.
 Radiographic Studies

Radiographic barium studies are potentially

dangerous in acute amebic colitis
Amebomas are usually identified first by a barium
enema, but biopsy is necessary for differentiation
from carcinoma
 con

ultrasonography, CT, and MRI are all useful for

detection of the round or oval hypoechoic cyst
More than 80% of patients who have had symptoms
for >10 days have a single abscess of the right lobe of
the liver
Approximately 50% of patients who have had
symptoms for <10 days have multiple abscesses.
 con

abscesses resolve slowly

 may increase in size in patients who are responding
clinically to therapy
 frequent follow-up ultrasonography may prove
confusing
 Complete resolution of a liver abscess within 6
months can be anticipated in two-thirds of patients
 10% may have persistent abnormalities for a year.
Amebic liver abscess
 Findings associated with complications
include

1. large abscesses (>10 cm)

2. multiple abscesses
3. lesions of the left lobe, which may rupture into
the pericardium
 Differential Diagnosis

intestinal amebiasis
Campylobacter
enteroinvasive Escherichia coli
Shigella
 Salmonella
 Vibrio
IBD
 clue to amebic colitis:

less prominent fever

heme-positive stools
with no or few neutrophils
amebic serologic testing.
 amebic liver abscess
DDx

1. Pulmonary-pneumonia,empyma
2. chycystitis
3. malaria
4. typhoid fever
5. pyogenic liver abscess
 Pyogenic abscess

 typically are older

 have a history of underlying bowel disease
 recent surgery.
 Amebic serology is helpful
 aspiration of the abscess, with Gram's staining and
culture of the material
 Treatment

drugs
 Asymptomatic carriage

luminal agents
1. Iodoquinol 650mg po TID for 20 days
2. Paromomycine 500mg po TID for 10 days
3. Diloxinide furoite 500mg po TID for 10 days
 Indications for the use of luminal agents
eradication of cysts in patients with colitis or a
liver abscess
 treatment of asymptomatic carriers.
The majority of asymptomatic individuals who
pass cysts are colonized with E. dispar, which does
not warrant specific therapy
 acute colitis

metronidazole 750mg PO OR IV tid for 5-7 days

+
luminal agents
or
Tinidazole 2g +luminal agents
 Amebic liver absess

metronidazole 750 mg PO or IV tid for 5-7 days

+
luminal agents
or
tinidazole 2g +luminal agents
or
ornidazole 2g + luminal agents
 Amebic Liver Abscess

Metronidazole is the drug of choice for amebic liver

abscess
tinidazole and ornidazole have been effective as
single-dose
With early diagnosis and therapy, mortality rates
from uncomplicated amebic liver abscess are <1%.
 con

The second-line therapeutic agents

emetine
chloroquine
72% of patients without intestinal symptoms had
bowel infection with E. histolytica
 all treatment regimens should include a luminal
agent to eradicate cysts and prevent further
transmission.
 Amebic liver abscess recurs rarely.
 Aspiration of Liver Abscesses

More than 90% of patients respond dramatically to

metronidazole therapy with decreases in both pain
and fever within 72 h.
 Indications for aspiration of liver abscesses

 to rule out a pyogenic abscess, particularly in

patients with multiple lesions
 the lack of a clinical response in 3–5 days
the threat of imminent rupture
 to prevent rupture of left-lobe abscesses into the
pericardium
 Con.

There is no evidence that aspiration, even of large

abscesses (up to 10 cm), accelerates healing
Percutaneous drainage may be successful even if the
liver abscess has already ruptured.
 Surgery

for bowel perforation

 rupture into the pericardium
 Prevention

 adequate sanitation and eradication of cyst carriage.

avoidance of unpeeled fruits and vegetables and the
use of bottled water.
cysts are resistant to readily attainable levels of
chlorine
disinfection by iodination is recommended
There is no effective prophylaxis.