Medical Protozoology

AMOEBIASIS
3.0 INTRODUCTION
Amoebas primitive unicellular microorganisms with a relatively simple life cycle which
can be divided into two stages:
• Trophozoite – actively motile feeding stage.

• Cyst – quiescent, resistant, infective stage.

Their reproduction is through binary fission, e.g. splitting of the trophozoite or through
the development of numerous trophozoites with in the mature multinucleated cyst.
Motility is accomplished by extension of pseudopodia (“false foot”)

3.1 Entamoeba histolytica

3.1.1 Morphological features

(a) Trophozoites
Viable trophozoites vary in size from about 10-60μm in diameter. Motility is rapid,
progressive, and unidirectional, through pseudopods. The nucleus is characterized by
evenly arranged chromatin on the nuclear membrane and the presence of a small,
compact, centrally located karyosome. The cytoplasm is usually described as finely
granular with few ingested bacteria or debris in vacuoles. In the case of dysentery,
however, RBCs may be visible in the cytoplasm, and this feature is diagnostic for
E.histolytica.

(b) Cyst

Cysts range in size from 10-20μm. The immature cyst has inclusions namely; glycogen
mass and chromatoidal bars. As the cyst matures, the glycogen completely disappears;
the chromotiodials may also be absent in the mature cyst.

3.1.2 Life cycle

Intestinal infections occur through the ingestion of a mature quadrinucleate infective
cyst, contaminated food or drink and also by hand to mouth contact. It is then passed
unaltered through the stomach, as the cyst wall is resistant to gastric juice. In terminal
ileum (with alkaline pH), excystation takes place.

Trophozoites being actively motile invade the tissues and ultimately lodge in the
submucous layer of the large bowel. Here they grow and multiply by binary fission.

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Trophozoites are responsible for producing lesions in amoebiasis. Invasion of blood

vessels leads to secondary extra intestinal lesions.

Gradually the effect of the parasite on the host is toned down together with concomitant
increase in host tolerance, making it difficult for the parasite to continue its life cycle in
the trophozoite phase.

A certain number of trophozoites come from tissues into lumen of bowel and are first
transformed into pre-cyst forms.

Pre-cysts secret a cyst wall and become a uninucleate cyst. Eventually, mature
quadrinucleate cysts form. These are the infective forms.

Both mature and immature cysts may be passed in faeces. Immature cysts can mature
in external environments and become infective.

Figure-1 life cycle of Entamoeba histolytica

3.1.3 Pathogenesis
Trophozoites divide and produce extensive local necrosis in the large intestine. Invasion
into the deeper mucosa with extension into the peritoneal cavity may occur. This can lead
to secondary involvement of other organs, primarily the liver but also the lungs, brain,
and heart. Extraintestinal amebiasis is associated with trophozoites. Amoebas multiply
rapidly in an anaerobic environment, because the trophozites are killed by ambient
oxygen concentration.

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3.1.4 Epidemiology
E.histolytica has a worldwide distribution. Although it is found in cold areas, the incidence
is highest in tropical and subtropical regions that have poor sanitation and contaminated
water. About 90% of infections are asymptomatic, and the remaining produces a
spectrum of clinical syndrome. Patients infected with E.hisolytica pass non-infectious
trophozotes and infectious cysts in their stools. Therefore, the main source of water and
food contamination is the symptomatic carrier who passes cysts. Symptomatic amebiasis
is usually sporadic. The epidemic form is a result of direct person-to-person faecal-oral
spread under conditions of poor personal hygiene.

3.1.5 Clinical features

The outcome of infection may result in a carrier state, intestinal amebiasis, or
exteraintestinal amebiasis. Diarrhoea, flatulence, and cramping are complaints of
symptomatic patients. More severe disease is characterised by the passing of numerous
bloody stools in a day. Systemic signs of infection (fever, leukocytosis, rigors) are present
in patients with extraintestinal amebiasis. The liver is primarily involved, because
trophozoites in the blood are removed from the blood by the portal veins. The right lobe
is most commonly involved, thus pain over the liver with hepatomegaly and elevation of
the diaphragm is observed.

3.1.6 Immunity
E.histolytica elicits both the humeral and cellular immune responses, but it is not yet
clearly defined whether it modulates the initial infection or prevents reinfection.

3.1.7 Laboratory diagnosis

In intestinal amoebiasis:

• Examination of a fresh dysenteric faecal specimen or rectal scraping for trophozoite

stage. (Motile amoebae containing red cells are diagnostic of amoebic dysentery).
• Examination of formed or semiformed faeces for cyst stage. (Cysts indicate infection
with either a pathogenic E.histolytica or non-pathogenic E.dispar.)

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Figure 2-, E.histolytica trophozoite (A) E. histolytica Cyst (B)

3.1.8 Extraintestinal amoebiasis

• Diagnosed by the use of scanning procedures for liver and other organs.

• Specific serologic tests, together with microscopic examination of the abscess

material, can confirm the diagnosis.

3.1.9 Treatment
Acute, fulminating amebiasis is treated with metrondiazole followed by iodoquinol, and
asymptomatic carriage can be eradicated with iodoquinol, diloxanide furoate, or
paromomycin. The cysticidal agents are commonly recommended for asymptomatic
carriers who handle food for public use.
Metronidazole, chloroquine, and diloxanide furoate can be used for the treatment of extra
intestinal amoebiasis.

3.1.10 Prevention
Introduction of adequate sanitation measures and education about the routes of
transmission.
Avoid eating raw vegetables grown by sewerage irrigation and night soil

3.2. OTHER AMEBAE INHABITING THE ALIMENTARY CANAL

Most of these amoebae are commensal organisms that can parasitize the human
gastrointestinal tract.

i) Entamoeba hartmanni in all of its life–cycle stage, E.hartmanni resembles

E.histolytica except in size, yet there is a slight overlap in the size range. The trophozoites
do not ingest red blood cells, and their motility is generally less vigorous than that of
E.histolytica. As in other amebae, infection is acquired by ingestion of food or water
contaminated with cyst-bearing faeces. Identification is based on examination of small
amebae in unstained or iodine-stained preparations. Usually no treatment is indicated,
measures generally effective against faecal-borne infections will control this amoebic
infection.

ii) Entamoeba coli the life cycle stages include; trophozoite, precyst, cyst, metacyst,
and metacystic trophozoite. Typically the movements of trophozoites are sluggish, with
broad short pseudopodia and little locomotion, but at a focus the living specimen cannot
be distinguished from the active trophotozoite of E.histolytica. However, the cysts are
remarkably variable in size. Entamoeba coli is transmitted in its viable cystic stage
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through faecal contamination. Ε.coli as a lumen parasite is non-pathogenic and produces

no symptoms. The mature cyst (with more than four nuclei) is the distinctive stage to
differentiate E.coli from the pathogenic E.histolytica. Specific treatment is not indicated
since this amoeba is non-pathogenic. The presence of E.coli in stool specimen is evidence
for faecal contamination. Prevention depends on better personal hygiene and sanitary
disposal of human excreta.

iii) Entamoeba polecki- arelatively cosmopolitan parasite of hog and monkey. It can
cause human disease but is rarely isolated. The disease is manifested as mild, transient
diarrhoea. The diagnosis of E.polecki infection is confirmed by the microscopic detection
of cysts in stool specimens. Treatment is the same as for E.histolytica infection.
Prevention is achieved by good personal hygiene.

iv) Endolimax nana is a lumen dweller in the large intestine, primarily at the cecal
level, where it feeds on bacteria. The life cycle is similar to E.histolytica. Motility is
typically sluggish (slug-like) with blunt hyaline pseudopodia, Projects shortly. Human
infection results from ingestion of viable cysts in polluted water or contaminated food.
Typical ovoid cysts of E.nana are confirmative. Rounded cysts and living trophozoites are
often confused with E.hartmanni and E.histolytica. No treatment is indicated for this non-
pathogenic infection. Prevention can be achieved through personal cleanliness and
community sanitation.

v) Iodamoeba buetschlii: - the natural habitat is the lumen of the large intestine, the
principal site probably being the caecum. The trophozoite feeds on enteric bacteria; it is a
natural parasite of man and lower primates. It is generally regarded as a non-pathogenic
lumen parasite. No treatment is ordinarily indicated. Prevention is based on good
personal hygiene and sanitation in the community.

vi) Entamoeba gingivalis - only the trophozoite stage presents, and encystation
probably does not occur. E.gingivalis is a commensal, living primarily on exudate from the
margins of the gums, and thrives best on unhealthy gums. No specific treatment is
indicated. However the presence of E.giingivalis suggests a need for better oral hygiene.
The infection can be prevented by proper care of the teeth and gums.

iv) Blastocystis hominis- is an inhabitant of the human intestinal tract previously

regarded as non-pathogenic yeast. Its pathogenecity remains controversial. The organism
is found in stool specimen from asymptomatic people as well as from people with
persistent diarrhoea. B.hominis is capable of pseudopodia extension and retraction, and
reproduces by binary fission or sporulation. The classic form that is usually seen in the
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human stool specimen varies tremendously in size, from 6-40μm. There are thin – walled
cysts involved in autoinfection, and thick–walled cysts responsible for external
transmission via the faecal-oral route. The presence of large numbers of these parasites
(five or more per oil immersion microscopic field) in the absence of other intestinal
pathogens indicates disease. The organism may be detected in wet mounts or trichome –
stained smears of faecal specimens. Treatment with iodoquinol or metronidazole has
been successful in eradicating the organism from intestine and alleviating symptoms.
However, the definitive role of B.hominis in disease remains to be demonstrated. The
incidence and apparent worldwide distribution of the infection indicates preventive
measures to be taken, which involve improving personal hygiene and sanitary conditions.

3.3 PATHOGENIC FREE-LIVING AMOEBAE

Among the numerous free-living amoebae of soil and water habitats, certain species of
Naegleria, Acanthamoeba and Balamuthia are facultative parasites of man. Most human
infections of these amoebae are acquired by exposure to contaminated water while
swimming. Inhalation of cysts from dust may account for some infections.

i) Naegleria fowleri- the trophozoites occur in two forms. Amoeboid forms with single
pseudopodia and flagella forms with two flagella which usually appear a few hours after
flooding water or in CSF.

Figure 3. Naegleria trophozoites in a section of spinal cord from a patient with

amoebic meningoecephalitis

ii) Acanthameba species- the trophozoites have an irregular appearance with spine-
like pseudopodia, and acanthopodia.

iii) Balamuthia species- the trophozoite extends a broad, flat lamellipodia or sub
pseudopodia from it. The trophozoite may be bi-nucleated. Unlike most amoebae the
nuclear envelope breaks down during mitosis.

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Naegleria, Acanthamoeba, Balamuthia organisms are opportunistic pathogens. Naegleria

fowleri causes acute primary amoebic meningoencephalitis. Acantamoeba & Balamuthia
organisms are responsible for granulomatous amoebic encephalitis and single or multiple
brain abscesses, primarily in immunocompromised individuals. Keratitis (eye) and skin
infection by Acanthamoeba may also occur. For the diagnosis of Naegleria, Acanthamoeba,
and Balamuthia infections, specimens of nasal discharge and cerebrospinal fluid; and in
cases of eye infections corneal scraping should be collected. The clinical specimen can be
examined with saline wet-preparation and Iodine stained smear. Treatment of free-living
amoebic infections is largely ineffective.

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