AMOEBIASIS

Caused by intestinal protozoan Entamoeba histolytica

Life cycle of amoeba and pathogenesis

The parasite is now known to consist of two separate species: E. dispar (non-
pathogenic) and E. histolytica, which is pathogenic.
Only E. histolytica can give rise to amoebic dysentery or extraintestinal
amoebiasis, e.g. amoebic liver abscess
The infection is transmitted through the faeco-oral route.
Man is the only reservoir of infection and excretes in the faeces the cystic form of
the organism, which can survive in the environment for several weeks
Cysts are ingested by man in infected food or water.
Since they are able to resist the acidic gastric juice, they can pass intact to the
small intestine, where each cyst multiplies into eight amoebules before
excystation
The amoebules develop into mature motile trophozoites, which adhere to the
colonic epithelium.
Colonisation and survival of the organism depend on the presence of coliform
bacteria.
Amoebae lyse colonic epithelium and eventually cause mucosal ulceration, which
may burrow deep into the mucosa taking typically the shape of a flask in cross-
section.
Lesions tare maximal in the caecum
amoeboma, which is a granulomatous mass consisting of amoebae, surrounded
by epitheloid cells, lymphocytes and fibroblasts.
Occasionally amoebae enter the portal circulation and migrate to the liver where
they initiate small inflammatory foci of inflammation and cell lysis, termed as
microabscesses. Several such lesions coalesce to form larger single or multiple
abscesses.
Clinical features

A) Intestinal amebiasis
Intestinal infections may cause asymptomatic cyst passage in stool or non-
dysenteric intestinal amoebiasis,
Patients with acute amoebic dysentery (diarrhea containing mucus and/or blood in
the feces) , lower abdominal colicky pain, abdominal tenderness.
The motions have more stool and less blood, as opposed to those in bacillary
dysentery which are characterised by more blood and pus and little stool
An acute attack usually lasts for a week
Amoeboma presents as a tender palpable lump usually in the right lower quadrant,
with or without diarrhoea and with little or no constitutional symptoms
Acute amoebic appendicitis is also an uncommon mode of presentation of
intestinal Amoebiasis

B) Extraintestinal amebiasis
Extraintestinal amoebic disease chiefly affects the liver
Other sites include the brain, skin, spleen and pelvic organs
Most patients do not give a history of dysentery.
An enlarged, tender liver, cough and pain in the right shoulder are characteristic,
but symptoms may remain vague and signs minimal
Commonly complain of fever and abdominal pain and tender hepatomegaly, and
with intercostal tenderness
The abscess is usually found in the right hepatic lobe.
Liver abscesses may assume large size and may rupture into adjacent structures
such as the pleural cavities, lungs, pericardium and peritoneum

Differential Diagnosis
 Bacterial diarrheal disease- Campylobacter, enteroinvasive Escherichia coli
Inflammatory bowel disease
Extraintestinal amebiasis
Pyogenic liver abscess

Diagnosis

a) Microscopic examination of stool

Microscopy requires demonstration of trophozoites of E. histolytica.
E. histolytica can be microscopically differentiated from the noninvasive
organism E. dispar only by the detection of Entamoeba trophozoites that
have ingested erythrocytes.
Colonoscopy or sigmoidoscopy can be used for diagnose the pathological lesion,
The characteristic findings of amoebic dysentery are of shallow discrete ulcers
with raised margins and normal intervening mucosa.
Routine hematology and chemistry tests are not helpful.

b)Amoebic liver abscesses

Amebic liver abscess can have leukocytosis (>10,000 cells/L).
Amoebic liver abscesses are best identified by ultrasonography;
Ultrasonography gives an assessment of their size and location. It can also be used
for aspiration of abscess( chocolate brown color ). Amoebae can be seen in this
pus.
c) Antigen detection assays
Antibodies are detectable by immunofluorescence in over 95% of patients with
hepatic amoebiasis and intestinal amoeboma but in only about 60% of dysenteric
amoebiasis.

Complications
Intestinal perforation,
Toxic megacolon
Stricture intestine

Treatment
A) Intestinal amebiasis
Metronidazole in a dose of 800 mg thrice a day for 7 days
Newer imidazole derivatives like tinidazole and secnidazole may be equally
effective and may have fewer side effects.
Asymptomatic cyst passers need no treatment.

B)Amoebic liver abscesses

Metronidazole (dose same as above)
The luminal amoebicide diloxanide furoate (500 mg 8-hourly for 10 days) is
added to metronidazole to eliminate the intestinal infection.
 Large abscesses(>5cm) or left lobe of the liver may need therapeutic aspiration or
drainage because of impending rupture
This can be done percutaneously under ultrasound guidance by introducing a pig-
tailed catheter.

Prevention
Amoebiasis at the community level depends on provision of safe water and
adequate sewage disposal.
Individuals should protect themselves by avoiding eating at nonhygienic eating
places.