AMOEBIASIS

Amoebiasis

• Amoebiasis is an infection with the intestinal protozoa

Entamoeba histolytica.
• About 90% of infections are asymptomatic
• Remaining 10% produce a spectrum of clinical syndromes
 Amoebias
is
Symptomatic group

Intestinal Extraintestinal

Mild abdominal
discomfort, Liver(liver
Small % - invasive diarrhea to acute abscess), brain,
amoebiasis
fulminating lung, spleen
dysentery
Epidemiology

• Worldwide in distribution

• 3rd most common parasitic death

• India, China, Mexico, Africa, South America

• 2-60 % prevalence (based on ELISA and PCR studies from

stool samples)

• 100,000 deaths/yr.

• 50 million cases/yr.
Epidemiological determinants

• Agent
• Virulence factor
• Host factor
• Environmental factor
• Mode of transmission
• Incubation period
 Agent
s
• Entamoeba histolytica
 Trophozoites
• 18-40 μm in D
• Cytoplasm – # outer clear ectoplasm
# inner granular endoplasm
# food vacuoles with RBCs, leukocytes & tissue
debris
• Motile by pseudopodia extensions
• Nucleus with central karyosome, surrounded by delicate membrane
lined with chromatin granules
• Non infectious
 Agent
• s
Entamoeba histolytica
Precyst
• Intermediate form
• Oval with blunt pseudopodia
• No food vacuoles
Cysts
• Spherical, 10 - 15 μm in D
• Uninucleate, later bi- or quadri- nucleate
• Thick chitinous wall
• Glycogen mass – not in quadrinucleate
• Chromidial or Chromatoid bars
• Infectious
Agent factor

• Source of infection is a case or carrier

• 1∙5 X 107 cysts per day
• Reservoir is only human – several years
• Resistant to chlorine in normal conc.
• Readily killed by freezing or heating(55°C)
• Period of communicability- very long
Host factor

• People in developing countries that have poor sanitary conditions

• Immigrants from developing countries
• Travelers to developing countries
• HIV-positive patients
• All age groups affected
• No gender or racial differences
• Severe if children, old, pregnant,
• Develops anti-amoebic antibodies in tissue invasion
Host factor

• Liver abscesses due to amoebiasis are 10 times more

frequent in adults than in children
• Amoebic liver abscess 7 times more in men than women
• Predominance among men aged 18-50 years
• Increased among postmenopausal women
• Hormonal effect and alcohol can be risk factors
Environment factor

• Low socio-economic status

• Poor sanitation, sewage contamination

• Night soil for agriculture

• Seasonal variation (more in rainy season)

Modes of transmission

• Feco-oral route
• Contaminated water and food
• Direct hand to mouth (cysts under fingernails)
• Vegetables irrigated with sewage polluted water
 Incubation
period
• 2- 4 weeks
Life cycle of E. histolytica
Life Cycle of E.
histolytica
Clinical presentation

• Most common type of amoebic infection is asymptomatic

cyst passage
• Intestinal amoebiasis – abdominal cramps with mild
diarrhea to colitis and dysentery
• Extra-intestinal amoebiasis – Amoebic liver abscess, rarely
lungs, skin, genitalia and CNS are affected
• Ameboma – inflammatory and edematous reaction around
trophozoites
Clinical presentation

• Asymptomatic carriers

• 90% without symptoms

• does not damage lumen

 How the Amoebiasis Manifests
• Most cases of amoebiasis have very mild symptoms or none.

• Wide spectrum, from asymptomatic infection to luminal

amoebiasis and amoebic colitis

• Clinical symptoms are usually vague

• More severe infection may cause fever, profuse diarrhoea,

vomiting, abdominal pain, jaundice, anorexia, and weight
loss.

• Invasive intestinal amoebiasis (dysentery, colitis,

appendicitis, toxic mega colon, amoebomas)
 Clinical presentation
• Amoebic colitis-
• Abdominal cramp to severe pain
• Fever, vomiting, anorexia
• Mucus in stool, dysentery
• Flask shaped ulcer in intestine
 Clinical presentation

• Fulminant colitis-
• <0.5%
• Severely ill with high fever
• Intestinal bleeding, perforation
• Paralytic illus
• CFR-40%
• Uncommonly, a chronic form
of
amoebic colitis can be confused
with inflammatory bowel disease
 Amoebom
a
• Pseudotumoral lesion
• Necrosis, edema and inflammatory thickening of
mucosa and submucosa of intestinal wall
• 1% of cases
• Palpable mass with trophozoites
• Always coexists with ulceration
• Single, rarely multiple in different parts of colon, on skin
at site of amoebic liver aspiration
 Difference between amoebic and
bacillary dysentery
Macroscopy
Character Amoebic dysentery Bacillary dysentery
Number 6-8 motions per day > 10 motions per day

Amount Copious Small

Odour Offensive Odourless

Colour Dark red Bright red

Reaction Acidic Alkaline

Consistency Non-adherent Adherent

 Difference between amoebic and
bacillary dysentery
Microscopy
Character Amoebic dysentry Bacillary dysentry
RBCs In clumps Discrete or in Rouleaux

Pus cells Few Numerous

Macrophages Few Numerous, many have

RBCs and may mimic EH
Eosinophils Present Scarce

Charcot-Leyden crystals Present Absent

Pyknotic bodies Present Absent

Ghost cells Absent Present

Parasites Trophozoites of EH Absent

Bacteria Many motile bacteria Few or Absent

Metastatic lesions in liver

• Amoebic liver abscess- Most common extra-intestinal

presentation
• The parasite reaches liver via portal system
• Occurs within 5 months of dysentery in 95% of cases
• But concomitant active diarrhea is seen in less than a third
of cases
• Pain and point tenderness over right hypochondrium and
fever
• Jaundice rare, pleural effusion is common
Amoebic liver
abscess
 Metastatic lesions in liver
• Older pt. from endemic areas usually have chronic disease

• Right lobe is commonly affected, abscess of left lobe is

more dangerous due to its proximity to heart –> rupture –>
pericardial effusion
• Necrotic cavitary lesion filled with cellular debris and
parasite trophozoites – Anchovy sauce pus
Complications of Amoebic Liver
abscess
• Rupture is the most dreaded complication
• It may spread to pleura, lungs, peritoneum,
pericardium or open outside through the anterior
abdominal wall
 Metastatic lesions in other organs
.
Pulmonary amoebiasis-
.
• Rupture from ALA into pleural space
• Hepato-bronchial fistula with necrotic
material in sputum may mimic blood –
trophozoites can be present
• Serous pleural effusion or contiguous
spread from ALA
Metastatic lesions in other organs

• Cerebral amoebiasis-
• Rare, complication of hepatic /
pulmonary abscess
• Single small lesion in cerebral
hemisphere
• Cutaneous amoebiasis-
• In areas of drainage of liver
abscess/colostomy wound
• Granulomatous ulcerations
Laboratory diagnosis

• Stool (3 consecutive samples)

• Biopsy material from the ulcers (colonoscopy or
sigmoidoscopy)
• Aspirate from liver abscess
• Serum
• Pleural fluid
• Pericardial fluid
• Sputum
Laboratory diagnosis

Microscopy -
• Both saline and iodine wet mounts are prepared
• Any motile trophozoite is better seen in saline mount
• Iodine mount stains the internal structures and is used to identify
cysts
• Charcot-leyden crystals can be seen
• Permanent stains can also be used to stain smears
Laboratory diagnosis

For amoebic liver abscess and other metastatic lesions-

• Radiological examination
• Radio isotope tracing of liver
• Ultrasonography of upper abdomen
• CT and MRI abdomen
 Laboratory diagnosis
Serology-
• Antibody detection
• Antigen detection
• ELISA
• Coagglutination
• IHA
• ELISA
• IFA

Copro-antigen detection by ELISA is another recent and

very useful method
 Treatme
• nt
Symptomatic case:- (amoebic colitis and
amoebic liver abscess)

Drug Dose Frequency Route Duration

Tinidazole 2g/day tid oral 3 days

750mg(adult) 5-10
Metronidazole tid Oral/iv
30mg/kg(children) days
 Treatme
• nt
Luminal infections

Drug Dose Frequency Route Duration

5-10
Parmomycin 30mg/kg qid oral
days

Iodoquinol 650mg tid oral 20 days

 Treatme
nt
• Percutaneous radiography guided aspiration of
abscess:- large left lobe liver abscess, bacterial
superinfection, pyogenic abscess, pleuropulmonary
amoebiasis, empyema, amebic pericrditis

Simple aspiration of amoebic liver abscess

 Treatme
nt
• Asymptomatic cases and cyst passers-

Drug Dose Frequency Route Duration

650mg(adult), 30-
Didohydroxyquin tid oral 20 days
40mg/kg(children)

Diloxanide furoate 500mg tid oral 10 days

Prevention

Primary prevention-
• Sanitation-safe disposal of human excreta, good sanitary
practice like washing hands after defecation and before
eating

• Water supply-water filtration(sand filters), boiling

• Food hygiene- prevent fecal contamination of food and

drink, vegetables washed with aqueous acetic acid(5-
10%)

• Health education- food handlers and public

Prevention

Secondary prevention-

• Early diagnosis

• Treatment
 Summary
• Amoebiasis is an infection with the intestinal protozoa
Entamoeba histolytica.
• About 90% of infections are asymptomatic
• Worldwide in distribution
• Infectious- cyst form
• Poor sanitation, sewage contamination
• Wide spectrum, from asymptomatic infection to luminal
amoebiasis and amoebic colitis
• Invasive intestinal amoebiasis (dysentery, colitis,
appendicitis, toxic mega colon, amoebomas)
• Amoebic liver abscess- Most common extra-
intestinal
presentation
• Diagnosis by stool microscopy and other
investigations
• Treatment tinidazole is prefered