AMOEBIASIS / AMEBIASIS BASICS DESCRIPTION Amebiasis is caused by the intestinal protozoan, Entamoeba histolytica .

Infection results from ingestion of fecally contaminated food, such as garden vegetables or by direct fecal-oral transmission. Most persons are asymptomatic or have minimal diarrheal symptoms. In a few patients, invasive intestinal or extraintestinal (e.g., liver, and less commonly kidney, bladder, male or female genitalia, skin, lung, brain) infection results. Amebic abscess of the liver may develop during the acute attack or 1-3 months later; symptoms may be abrupt or insidious. Entamoeba histolytica has been divided into pathogenic and nonpathogenic strains. The pathogenic strains commonly cause invasive infection while the noninvasive strains cause only asymptomatic intestinal infection. More recently, the non-pathogenic strains have been assigned to a separate species, E. dispar. Unfortunately, the species cannot be distinguished in a routine clinical laboratory. System(s) affected: Gastrointestinal, Renal/Urologic, Reproductive, Exocrine, Nervous Genetics: N/A Incidence/Prevalence in USA: Probably <1% overall, but much higher in some risk groups, such as areas with large immigrant populations Predominant age: All Predominant sex: Male > Female; probably because of greater occupational exposure SIGNS & SYMPTOMS Noninvasive infection (up to 99%) Asymptomatic (90%) Mild diarrhea Abdominal discomfort Invasive intestinal infection Abdominal pain and tenderness Rectal pain Diarrhea Bloody stools Fever (30%) Systemic toxicity Extraintestinal infection Fever Systemic toxicity RUQ abdominal pain and tenderness Nausea and vomiting Diarrhea (50%) Hematuria, dysuria, urinary frequency and urgency CAUSES Infection with Entamoeba histolytica is transmitted through contaminated food or water, or through person-to-person contact RISK FACTORS Low socioeconomic status Institutional living Male homosexuality Invasive disease is more common in certain geographic locations, including some parts of Mexico, South Africa, and India

DIAGNOSIS LABORATORY Stool for ova and parasites (unfortunately, the sensitivity of this exam is poor). Diarrheal stool should be examined immediately for trophozoites in addition to fixed stool specimens (repeated as necessary). In invasive intestinal infection, stools are bloody, but fecal leukocytes are usually absent. Serologic tests (especially indirect hemagglutination [HA]), positive in 85% of colitis patients and most patients with extraintestinal disease. Serologic tests should be done in patients with idiopathic infl amatory bowel disease to rule out amebiasis. In bladder infections - amoebae and/or cysts in urine Liver enzymes and alkaline phosphatase may be elevated in hepatic disease Drugs that may alter lab results: Many drugs interfere with stool exams Disorders that may alter lab results: N/A PATHOLOGICAL FINDINGS Colon biopsy Lysis of mucosal cells (flask ulcers) PAS-stained trophozoites Neutrophils at the periphery Liver biopsy Necrosis surrounded by a rim of trophozoites Liver aspirate - red-brown material (anchovy paste) SPECIAL TESTS N/A IMAGING CT scan or ultrasound for hepatic infection DIAGNOSTIC PROCEDURES Rectosigmoidoscopy with biopsy Needle aspirate of hepatic lesions may be needed to rule out pyogenic infection or superinfection TREATMENT APPROPRIATE HEALTH CARE Outpatient GENERAL MEASURES Fluids and nutrition Electrolyte management SURGICAL MEASURES With severe amebic colitis, surgery may be necessary ACTIVITY In accordance with illness of patient DIET As tolerated PATIENT EDUCATION Avoid conditions of re-exposure MEDICATIONS DRUG(S) OF CHOICE Noninvasive infection Diiodohydroxyquin [also called iodoquinol] 650 mg tid for 20 days Invasive infection Metronidazole (Flagyl) 750 mg tid for 5-10 days, followed by a 20 day course of diiodohydroxyquin to eliminate intestinal carriage Tinidazole (Tindamax) 2 gm daily for 3 days with food for intestinal infection and 2 gm daily for 3-5 days for liver abscess Contraindications: Diiodohydroxyquin - use cautiously in patients with thyroid diseases. Contraindicated in hepatic or renal dysfunction. May cause optic neuritis or peripheral neuropathy. Known allergy to given medication

Precautions: None of the agents are proven safe in pregnancy, but pregnant women with invasive disease should still be treated Significant possible interactions: Metronidazole-ethanol: disulfiram reaction ALTERNATIVE DRUGS Noninvasive infection Diloxanide 500 mg tid for 10 days Paromomycin 500 mg tid for 10 days Invasive infection Dehydroemetine (as effective as metronidazole, but cardiotoxic) 1-1.5 mg/kg/day IM for 5 days Chloroquine (less effective) 600 mg base/day for 2 days, then 200 mg/day for 2-3 weeks. Children 10 mg/kg/day up to maximum of 300 mg/day. FOLLOWUP PATIENT MONITORING Patient signs and symptoms, stool for ova and parasite PREVENTION/AVOIDANCE Avoid risk factors when possible POSSIBLE COMPLICATIONS Toxic megacolon with rupture Rupture of hepatic abscess which may perforate into subphrenic space, right pleural cavity or other nearby organs Bladder perforation, urethral strictures, vesicointestinal fistula EXPECTED COURSE/PROGNOSIS Untreated invasive amebiasis is frequently fatal. With treatment, improvement usually occurs within a few days. Some patients with amebic colitis have irritable bowel symptoms for weeks after successful treatment. Relapses possible. MISCELLANEOUS ASSOCIATED CONDITIONS N/A AGE-RELATED FACTORS Pediatric: More severe in neonates Geriatric: More severe in elderly Others: More severe in patients on corticosteroids and other immunocompromised patients PREGNANCY More severe in pregnancy. Most agents are avoided in pregnancy (especially first trimester) because of concerns of teratogenicity, but invasive disease must still be treated. Paromomycin is sometimes recommended for noninvasive disease because it is not absorbed. Infectious disease consultation should be obtained. REFERENCES Petri WA Jr, Singh U. Diagnosis and management of amebiasis. Clinical Infect Dis 1999;29:1117-25 Bruckner DA. Amebiasis. Clin Microbiol Rev 1992;5:356-369 Ravdin JI. Entamoeba histolytica (amebiasis). In: Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases. 5th Ed. New York, Churchill Livingstone, 2000 Author(s): Rodney D. Adam, MD