Entamoeba histolytica: Amebic dysentery; amebic liver abscess

Entamoeba histolytica: Amebic dysentery; amebic liver abscess

Epidemiology: Found worldwide, especially in tropical

areas, Mode of transmission: Ingestion of cysts. Anal-oral transmission due to sexual practice is also a consideration.

Entamoeba histolytica: Amebic dysentery; amebic liver abscess

Pathology: Two-stage life cycle.

The trophozoite (ameba stage) is

motile. The cyst stage is nonmotile. Trophozoites are found in the intestinal and extraintestinal lesions. Cysts predominate in the stools, with somes trophozoites present.
3

Amebic dysentery: Colonization of cecum & colon by Entamoeba histolytica is common. Localized necrosis results in "teardrop" or flask shaped ulcerations. Invasion into the portal submucosa is progressive after penetration of the submucosa. Liver abscess: Penetration of the diaphragm can lead to lung disease. Most liver disease not preceded by dysentery.

flaskbtol
4

Amebiasis
Amebiasis is an infection with the intestinal

protozoan Entamoeba histolytica. About 90% of infections are asymptomatic, and the remaining 10% produce a spectrum of clinical syndromes ranging from dysentery to abscesses of the liver or other organs.

Entamoeba Morphology
Ingested RBC

Nucleus with central karyosome and finely divided peripheral chromatin Pseudopod
E. histolytica trophozoite

Amebiasis Transmission
Humans acquire E. histolytica by:

Ingesting cysts in fecally contaminated food or drink Rarely by directly inoculating trophozoites into colon or other sites (anal sex?)

Fecal-Oral transmission (hand to mouth) Infective cysts and trophozoites pass in feces

10

11

E. histolytica Stages - CYSTS

Usual Infective Stage for humans
Resistant walls maintain viability

If moist can last several weeks Killed by desiccation or boiling Can be concentrated and stained easily Not seen in liquid (diarrheic) stools or tissues

Usual Diagnostic Stage in formed stools

desiccpngrigan

12

Entamoeba Morphology
1-4 ring-like nuclei with finely divided peripheral chromatin

Cyst wall and round shape

Resistant walls maintain viability

Mature E. histolytica Cyst

13

Mature Cysts

14

E. histolytica Stages - TROPHOZOITES

Are the motile, feeding stages that: Cause amebiasis (damage tissue) Spread throughout the body, Labile in liquid stools or tissue, and must be rapidly found or preserved (quick fixation & cold storage) for Dx

preservediawtkn
15

Trophozoite form

16

Pathogenesis of Amebiasis
Trophozoites ... Attach to mucosal epithelial cells (MEC) Lyse MEC Ulcerate and invade mucosa Cause dysentery (diarrhea + blood) Metastasize via blood &/or lymph to Form abscesses in extraintestinal sites ... attchmnmpel
17

Clinical Classification of Amebiasis

(World Health Organization)

Asymptomatic (intestinal) "Cyst Passers Symptomatic Infection: Intestinal Amebiasis: (colon and rectum) Acute Dysenteric (dysentery) Chronic NonDysenteric (self-cured) Extra-Intestinal Amebiasis: Amebic Liver Abscess (ALA) Amebic Pulmonary Abscess Other sites (brain, skin, GU, ?)
18

Asymptomatic Amebiasis
"Cyst Passers
Most common

Infection may continue without clinical

symptoms for weeks to months ...

May spontaneously resolve (self cure)/or Two types of E. histolytica may exist

E. dispar (non-pathogenic) E. histolytica (pathogenic)

19

Intestinal Amebiasis
Two types

Acute Dysenteric (dysentery)

Chronic Non-Dysenteric (self-cured or carrier state)

20

Acute Dysenteric Amebiasis:

Symptoms:

Bloody mucoid diarrhea

RBCs and few WBCs (pus) in stools

Abdominal pain weight loss bloating, tenesmus and cramps

Signs:

Fever (33%) Diffuse abdominal tenderness Tender (enlarged) liver Stools positive for trophozoites +/- WBC

NOT cysts in loose stools

21

Amebic Dysentery
Sigmoidoscopic appearance:
Normal

mucosa... pseudomembrane...

Adherent

Ulcerations Classic

Flask-Shaped ulcer is mythology involvement is rare with early Tx

Sub-mucosal

flaskbtol
22

Chronic Non-Dysenteric Amebiasis:

self-cured carrier state
37% symptomatic >5 years Intermittent diarrhea, mucus, abdominal pain,

flatulence and/or weight loss

E. histolytica trophs (rarely cysts) in stools Positive serology and ulcerations

23

Intestinal Amebiasis Complications

Intestinal perforation and ...

Peritonitis - a surgical emergency

Palpable mass of granulation tissue that may obstruct colon (Differential Dx: CA?) complication of inappropriate steroid therapy

Ameboma

Toxic megacolon

24

Diagnosis of Intestinal Amebiasis

Techniques:

Direct Fecal Smear (trophs and cysts)

Fecal concentration techniques - (cysts)

ZnSO4 or formalin-ether

Permanent Stained Fecal Smear

PVA/Schaudinns fixation + Trichrome stain

Sigmoidoscopy Serologic Tests (for chronic disease)

25

Extra-Intestinal Amebiasis:
Amebic Liver Abscess (ALA) Amebic Pulmonary Abscess Other sites
brain,

skin, GU

26

Amebic Liver Abscess (ALA)

Symptoms Hx of dysentery (1 yr), wt loss, RUQ abdominal pain, chest or shoulder pain Signs fever, hepatomegaly, rales/ronchi base of rt. lung, leukocytosis, Serum Alk Phos elevated in 80% serous pleural effusion & elevation of rt. Hemidiaphragm with atelectasis in 75%

27

Aetiology
Bacterial, parasitic, or fungal in origin.

85% to 90% bacterial or pyogenic.

Bacteria access the liver via the biliary tree or portal vein. Other causes include biliary obstruction, diverticulitis, trauma, inflammatory bowel disease,

28

Amebic Liver Abscess (ALA)

Incidence Liver gets infected by Entamoeba histolytica commonly The most common location of a pyogenic abscess is the right lobe. Chronic alcoholics - prone to get this infection Entamoeba histolytica is endemic in many parts of the world Pathophysiology The amoebic cyst is ingested Cyst develops into the trophozoite form in the colon Reaches the liver through portal circulation Pyogenic abscess may also occur due to the infection by streptococcus milleri and Escherichia coli. Many a time the pyogenic infection follows amoebic infection

29

Amebic Liver Abscess (ALA) Clinical Features

Often the diagnosis of a bacterial abscess is suggested clinically. Fever Pain right hypochondrium Chills Rigors Toxicity Right upper quadrant discomfort Diarrhea weight loss Intercostal tendreness Swelling in the right hypo chondrium or epigastrium tender, enlarged liver.

30

rgorkku

Amebic Liver Abscess (ALA)

31

Amebic Liver Abscess (ALA)

Complications Pulmonary Abscess: by direct extension through the diaphragm into thorax Rupture into the pleural cavity and/or hepatobronchial fistulas => trophozoites in sputum! Extension to other sites, including peritoneum, pericaridum, others

32

Complications:

Pneumonitis Pleural effusion Rupture of the liver abscess into the pleural cavity - causing empyema Rupture into the peritoneal cavity
Treatment percutaneous or surgical drainage (Ultrasound guided repeated aspiration) antibiotics. Metronidazole Antibiotics like cephalosporins, aminoglycosides, tetracyclines In rare cases it may need insertion of a drain. mortality rate is almost 100% if the abscess remains untreated

33

Pleural Effusion secondary to amoebic liver abscess

34

An amoebic liver abscess causing a bulge in the dome of the diaphragm

35

Amoebic liver abscess burst into the right pleural cavity

Burstinto,mskmddk

36

37

38

DX: Laboratory Diagnosis of Hepatic

Amebiasis
Examine stools for trophs/cysts (suggestive)

Blood cell counts - leukocytosis?

Radiologic Studies (flat, CT,) Serologic tests (IHA or ELISA), Liver enzyme profile is usually
normal

Catheterize abscess and aspirate: Examine "anchovy paste"

aspirate for trophozoites and do serologic testing for amebic antigens

Culture

for other pathogens (sterile on first stick)

Chemotherapeutic Trial

anchoiknkcil

39

Treatment of Amebiasis
Location Intestinal
Asymptomatic Mild to moderate intestinal disease Severe intestinal disease Diloxanide furoate or diiodohydroxyquin Metronidazole (Flagyl) Metronidazole plus a lumenal drug lumenal amebicide tissue amebicide both

Clinical Class

Drug Name

Drug Action

Extraintestinal
Hepatic disease Catastrophic disease Metronidazole plus a lumenal drug Emetine HCl both cardiotoxic tissue amebicidal drug
40

Px: Prevention/Control of Amebiasis

Individual measures

Diagnosis and treatment of E. histolytica patients

no animal reservoirs (other than humans) are known

Safe drinking water (boiling or 0.22 m filtration) Cleaning of uncooked fruits and vegetables Prevention of contamination of foods

41

Intestinal amebiasis
Symptomatic amebic colitis develops 2 to 6 weeks

after the ingestion of infectious cysts. Lower abdominal pain and mild diarrhea develop gradually and are followed by malaise, weight loss, and diffuse lower abdominal or back pain. The stools contain little fecal material and consist mainly of blood and mucus < 40% of patients with amebic dysentery are febrile Virtually all patients have heme-positive stools. More fulminant intestinal infection, with severe abdominal pain, high fever, and profuse diarrhea, is rare and occurs predominantly in children.
THE END
42

43