AMOEBA
Amebiasis is an infection caused by the protozoal
organism Entamoeba histolytica and includes amebic
colitis and liver abscess.
Transmission usually occurs by food-borne exposure,
particularly when food handlers are shedding cysts or food
is cultivated in feces-contaminated soil, fertilizer, or water.
Less common means of transmission include contaminated
water, oral and anal sexual practices, and direct rectal
inoculation through colonic irrigation devices.
Pathophysiology:
-E histolytica is a pseudopod-forming, nonflagellated
protozoal parasite that exerts a lytic effect on tissue, a
characteristic for which the organism is named.
-Host cells are killed via the induction of apoptosis;
therefore, the parasite does not kill the host cell but rather
induces its self-destruction.
-Incubation period is 2-26 days with majority 14 days.
Infective dose >103 organisms
- Ingestion of the cyst is followed by excystation in the
small bowel and trophozoite colonization of the colon.
Upon colonization of the colonic mucosa, the trophozoite
may encyst and be excreted in the feces or it may invade
the intestinal mucosal barrier, thereby gaining access to the
circulation, resulting in involvement of the liver, lung, and
other sites.
-Whether infection results in colonization or invasion, the
E histolytica strain and its interaction with bacterial flora;
host genetic susceptibility; and factors such as
malnutrition, sex, age, and immunocompetence may
influence the infection.
Liver involvement occurs following invasion of E
histolytica into mesenteric venules. Amebae then enter the
portal circulation and travel to the liver where they
typically form large abscesses. The abscess contains
acellular proteinaceous debris, which is thought to be a
consequence of induced apoptosis and is surrounded by a
rim of amebic trophozoites invading the tissue.
The right lobe of the liver is more commonly affected than
the left lobe. This has been attributed to the fact that the
right lobe is supplied predominantly by the superior
mesenteric vein, whereas the left lobe is supplied by the
splenic vein.
NB. Patients with amoebic dysentery are not infective-
passing trophozoites.
Morbidity
-E.histolytica probably is second only to malaria as a
protozoal cause of death.
-Asymptomatic intestinal infection occurs in 90-99% of
infected individuals.
- Most infected individuals eliminate the parasite from the
gut within 12 months; however, colonization with E
histolytica carries a low but definite risk of developing
into invasive amebiasis.
-Amebic colitis is complicated by fulminant or necrotizing
colitis with high mortality rate.
-Amebic liver abscess is complicated by intraperitoneal
rupture.
Sex:
-Amebic liver abscess is 7-12 times more common in men
than in women, although the sex distribution is equal in
children.
-.
Physical examination
Amebic colitis
-Fever-some patients
-Weight loss
-Diffuse abdominal tenderness
-Heme-positive stools
-Patients with fulminant colitis are more likely to present
with abdominal pain, distension, and rebound tenderness.
Amebic liver abscess
-Fever
-Right upper quadrant abdominal tenderness
-Durbans sign-intercostal tenderness consistent sign of
amoebic dysentery.
Amebic colitis affects both sexes equally.
Age:
-Young children appear to be at higher risk for fulminant
invasive disease, resulting in a higher mortality rate
Clinical presentation
History:
Amebic colitis
1.Dysentry
Mobile dysentery as patients not usually very sick looking
as in bacillary dysentery where patients are bed ridded.
2.Fulminant colitis
Fulminant or necrotizing colitis is the most serious
manifestation, has high a mortality rate. Predisposing
factors for fulminant colitis include Poor nutrition,
Pregnancy, corticosteroid use, very young age
3.Chronic post amoebic colitis
-Sclerotic changes in the bowel
-Irritable bowel
-No amoeba in the stool
4.Amoeboma of the colon or rectum
-Can be ,mistaken for colorectal cancer but responds well
by medical treatment
5.Perfoaration
Amoebia peritonitis
Pericolic abcess
Internal intestinal fistula.
Amoebic dysentery may present as:
1) Several weeks of abdominal pain, diarrhea, and bloody
stools.
2) Fever is uncommon and occurs in approximately 10-
30% of patients.
3) Weight loss is a common complaint and may be
accompanied by symptoms of volume depletion (eg,
orthostasis).
Amebic liver abscess
1) Fever and right upper quadrant abdominal pain
.Unlike amebic colitis, amebic liver abscess is associated
with fever in 85-90% of patients.
2) Most do not have concomitant colitis, although a history
of dysentery may be obtained.
-History of alcohol abuse is common
Clinically, almost all patients reveal an enlarged liver and
tenderness in the right upper quadrant.
Polymorphonuclear leukocytosis is usually 15,000 to
20,000/mL, and there is moderate anemia
Pleuropulmonary amebiasis
-Rare but serious complication of amebic liver abscess,
-Caused rupture of a superior right upper lobe abscess with
erosion through the diaphragm.
-Patients with this complication present with cough,
pleuritic chest pain, dyspnea, and, occasionally, necrotic
sputum.
Intraperitoneal rupture
From amebic liver abscess occurs. These patients can
present with a rigid abdomen that may be diagnosed
erroneously as a perforated viscus.
Cerebral amebiasis
-Is a rare cause of brain abscess and is characterized by an
abrupt onset of mental status change and/or focal
neurologic deficits.
-Progression to death occurs over 12-72 hours without
adequate therapy.
INVESTIGATIONS
LAB
FHG-Lecocytosis with eosinophilia-Amaeboma
Presence of PMN cells predominant-Liver abscess
Anemia may occur.
ESR-elevated
Microscopy
-Finding quadrinucleated cysts or trophozoites containing
ingested erythrocytes in stool is considered by many to be
diagnostic for amebic colitis.
Antigen detection
-A stool antigen test specific for E histolytica is available
- Monoclonal antibodies specific for the galactose (Gal)/N-
acetyl-D-galactosamine (GalNAc) lectin of E histolytica