Amoebiasis

Prof George Mathew

Definition

Amoebiasis is an infection with intestinal

protozoa Entamoeba Histolytica.
90% of infection asymptomatic.
10% of infection Clinical syndrome.
Ranging from Dysentery to Abscess of the
liver or other organs.
 HISTORY
1875 LOSCH RUSSIAN.
Differentiated the amoebic dysentery from
bacillary dysentery by describing amoeba in the
stool.
1887 KARTULIS EGYPT.
Found amoeba in the pus from a liver abscess.
1881 COUNCILMAN AND COFFLEUR.
Described true bowel lesions and used the term
Amoebic Dysentery.
1903 SCHAUDINN.
Differentiated pathogenic and non pathogenic
types of amoeba.
Amebiasis
Amebiasis (am-e-BI-a-
sis) is a disease
caused by a one-
celled parasite called
Entamoeba histolytica
(ent-a-ME-ba his-to-LI-
ti-ka).
Although it is more
common in people
who live in tropical
areas with poor
sanitary conditions
 ENTAMOEBA
HISTOLYTICA
Entamoeba histolytica
was first described by
Lambl in 1859 and
Losch established it
pathogenic nature in
1875 in a dysenteric
patient is St.Petersberg
Councilman and lafleur
in 1981 described
amoebic liver abscess.
Schauudinn ( 1903 )
differentiated
pathogenic and
nonpathogenic types of
Amoebae
Amoebiasis a Major Health
Problem
Amoebiasis is estimated to cause 70,000
deaths per year world wide Symptoms
can range from mild diarrhea to dysentery
with blood and mucus in the stool. E.
histolytica is usually a commensals
organism. Severe Amoebiasis infections
(known as invasive or fulminant
amoebiasis) occur in two major forms.
Invasion of the intestinal lining causes
amoebic dysentery or amoebic colitis.
 EPIDEMIOLOGY
Third most common cause of death from the
parasitic disease. (after schistosomiasis , Malaria)
480 Million people (world)
12% of worlds population
High risk groups
Travellers, immigrants, immunocompromised
individual, pregnant women, sexually active male.
Mental institutes, prisons, Children in day care
centres.
Cyst carriers
Sexual transmission also occurs.
Trends of Amoebiasis
 Transmission of
Amebiasis
Amoebiasis is
transmitted by fecal
contamination of
drinking water and
foods, but also by direct
contact with dirty hands
or objects as well as
By anal sexual contact.
Additionally,
geophagy(eating mud or
clay) is a common route
of infection in certain
cultures.
 Nature of the disease

Symptoms are usually gastrointestinal

including diarrhoea, vomiting, abdominal
pain or discomfort and fever. Symptoms
take from a few days to a few weeks to
develop and manifest themselves, but
usually it is about two to four weeks. Most
infected people are asymptomatic but this
disease has the potential to make the
sufferer dangerously ill, especially if there
is any suggestion of immunocompromised.
Events on Amoebiasis
Trophozoites of
E.histolytica
Trophozoites and Cystic
stages
Cystic stage -
E.histolytica
Amoebiasis causes Epithelial
damage
 Numerous Eosinophilic
spherical structure within
necrotic area.
 Tissue showing Amoebic
infection
The spherical
structure
(Trophozoites) has
one basophilic nuclei
about the size of
RBCs. Note some
RBC's are
phagocytosed by the
Trophozoites
(erythrophagocytosis
)
 Virulence factors
Trophozoites of E.histolytica interact with host
through a series of steps
1 Adhesion of target cell, phagocytosis and
cytopathic effect
2 E.histolytica induces both Humoral and cell
mediated immune responses.
3 Virulence factors In many circumstances lumen
dwelling Amoeba may be asymptomatic
4 Causes disease only when invade the Intestine
5 Virulence is associated with secretion of Cysteine
proteniase which assists the organism in digesting
the extracellular matrix and invading tissues
 Cysteine proteinase -
Complement factor C3
It is observed
Cysteine proteinase
produced by invasive
strains of
E.histolytica
inactivates the
complement factor
C3 and are thus
resistant to
Complement
mediated lysis.
Cysteine proteinase
virulent factor
Cysteine proteinase is an
important virulent factor
Its presence makes
E.histolytica is resistant
to complement mediated
lysis
Can cleave the
extracellular structural
matrix and degrade
fibronectin and laminin,
as well as type I collagen.
In this process basement
membrane is degraded
and leads to invasion
 Invasive x Noninvasive
strains
The invasive and non
invasive strains may
appear identical may
represent two distinct
species
1 Invasive strain
E.histolytica
2 Non invasive
strains reclassified
as E.dispar.
 Host Factor
Contributions
Severalfactors contribute to
influence infection
1 Stress
2 Malnutrition
3 Alcoholism
4 Corticosteriod therapy
5 Immunodeficiency
6 Alteration of Bacterial flora
 Risk Factors

People in developing countries that

have poor sanitary conditions
Immigrants from developing countries
Travellers to developing countries
People who live in institutions that
have poor sanitary conditions
HIV-positive patients
Men who have sex with men
 Dysentery
No symptoms (in
the majority of
cases),
Vague
gastrointestinal
distress,
Dysentery (with
blood and mucus).
 How Amebiasis Manifests
Most cases of amebiasis have very
mild symptoms or none.
More severe infection may cause fever,
profuse diarrhea, abdominal pain,
jaundice, anorexia, and weight loss.
In severe cases, it can lead to
development of abscesses (pockets of
amoebae and inflammatory cells) in
the liver or, more rarely, the brain.
 Clinical symptoms are
Vague
Wide spectrum, from asymptomatic
infection ("luminal amebiasis"),
to invasive intestinal amebiasis
(dysentery, colitis, appendicitis, toxic
mega colon, amebomas),
as well as invasive extra intestinal
amebiasis (liver abscess, peritonitis,
pleuropulmonary abscess, cutaneous
and genital amoebic lesions).
Diagnosis of
Amebiasis
 BASICS METHODS IN
DIAGNOSIS
Fresh stool: wet mounts and
permanently stained preparations
(e.g., trichrome).
Concentrates from fresh stool: wet
mounts, with or without iodine
stain, and permanently stained
preparations (e.g., trichrome).
Concentration procedures,
however, are not useful for
demonstrating Trophozoites.
 Diagnosis of Amebiasis
Diagnosis of amebiasis can be difficult.
One problem is that other parasites and
cells can look very similar to E. histolytica
when seen under a microscope. Therefore,
sometimes people are told that they are
infected with E. histolytica even though
they are not.
Entamoeba histolytica and another
ameba, Entamoeba dispar, which is about
10 times more common, look the same
when seen under a microscope
 Microscopy
This is the traditional
means of diagnosing
the diseaseone
simply looks at a
sample of stool under
a microscope.
Because E. histolytica
is not always found in
every stool sample,
several samples from
different days may be
needed. Sometimes
red blood cells that
have been ingested by
the parasite are
visible.
Microscopic examination of
Stool
A sample of freshly
collected fecal
specimen
containing mucous
and blood is
transferred on a
slightly warm slide
and covered with
cover slip and
examined
microscopically
E. histolytica /E. dispar
cyst.
E. histolytica/E. dispar cysts
stained with trichrome
 Specific Diagnosis of active
infection should demonstrate
Trophozoites
Motile Trophozoites
throwing
pseudopodia and
containing red blood
cells found in large
number
Endoplasm appear
bluish or found glass
in appearance and
nucleus is not
visible but faint
outline may be
observed
 Charcot Leyden crystals in stool
examination supports the
Diagnosis,
Cysts have smooth and
thin cell wall and
contain round, retractile
chromotoid bars
Glycogen mass is not
visible
RBCs and pus cells are
found in fair number
Charcot Leyden crystals,
diamond shaped clear
and retractile structures
are present in faeces
IDOINE PREPARATION OF
STOOL
Routinely not used

Trophozoites stains
yellow to light brown,

Nucleus is clearly visible

with central karyosome
Cysts shows a smooth
and hyaline appearance,
Nucleus is clearly seen
and no more than 4
nuclei are present,
Glycogen mass stains
brown, while chromotoid
bars are not stained.
 Mucosal Scrapings
Mucosal scrapings can
be obtained by
sigmoidoscopy useful
in atypical
presentations and
may serve as adjunct
to conventional stool
examination for Ova
and cyst

Direct wet mount, a

permanently stained
smear and immuno
stained smears are
examined.
 Serological Diagnosis
The serological tests become reactive in invasive
Amoebiasis
1 Indirect Heamagglutination Assay ( IHA )- Simple-
Highly Specific
2. LATEX AGGLUTINATION TEST- same sensitivity as IHA
3. ELISA-higher sensitivity compared to IHA
4. Gel diffusion
5 Imunoelectrphoresis
4&5Time consuming but has high sensitivity

6.PCR(Polymerase Chain Reaction)needs sophisticated

lab
Nucleic Acid Amplification method(LAMP)-minimal
lab facilities
Serological tests remain positive for several years ever after
successful treatment
 Culture
Cultures are not done routinely
Boeck and Drbohlavs medium
modified by Laidlaw extensively
used for isolation and maintenance
of E.histolytica.
Diamonds axenic medium used in
studies on Pathogenicty, antigenic
characterization and drug sensitivity
tests
Do we need culturing for
Diagnosis ?
Trying to get the
amoeba to grow
outside the body is
very difficult and
unreliable, and is
therefore not
generally done
Emerging methods in
Diagnosis
These are considered
the most useful tests
for detecting E.
histolytica.
They test directly for
the parasite itself by
exposing some stool to
a strip of paper coated
with antibodies.
The parasites will stick
to the antibodies on
the paper.
The test distinguishes
E. histolytica from
other parasites.
 Clinical symptoms
Asymptomatic infection Symptomatic infection

Intestinal Amebiasis Extraintestinal Amebiasis

Dysenteric Non-Dysenteric colitis Hepatic Pulmonary The

extra foci

Liver abscces Acut

nonsupprative

Intestinal Amebiasis symptoms: Diarrhea or dysentery, abdominal pain,

cramping , anorexia, weight loss, chronic fatigue
Pathology of Amebiasis
Flask-like Ulcer
Extra intestinal
Amoebiasis
The specimens are
obtained from Liver,
lung, or Brain biopsy
samples and subjected
to routine
Histopathology ( H&E)
sections
Giemsa stained touch
preparations which will
revel Trophozoites in
extra intestinal lesions.
 Amoebic Liver Abscess
The pus in liver
abscess appear as
red Anchovy sauce
like appearance
The material
aspirated is likely to
contain Trophozoites
and may be detected
by direct microscopic
examination
 Immunological Tests are not
confirmatory of Acute
When the body is
Infections
exposed to an infection,
the immune system
creates antibodies to
fight it off. These can be
detected with a blood
test, and provide
evidence that the person
has been infected with E.
histolytica.
Unfortunately, this test
does not distinguish
between past and
present infection
 Treating extra intestinal
Amoebiasis
Amoebic abscess is
treated similarly to
dysentery, with
antibiotics. Sometimes
surgical drainage may
be performed, but this
is usually to rule out
other (bacterial)
causes of abscess. It is
also performed if an
abscess is about to, or
has already ruptured.
PATHOLOGY
the intestinal lesion
Gut
Minute crypt lesion

Extends through the muscularis mucosa and

submucosa.

Flask shaped ulcer

Thrombosis of blood vessels

Toxic megacolon
Irreversible coagulation necrosis of bowel wall.
 CLINICAL FINDINGS

INTESTINAL AMOEBIASIS

Asymptomatic infection
Mild to moderate colitis (non dysenteric colitis)
Severe colitis (dysenteric colitis)
Localised ulcerative lesions of the colon
Localised granulomatous lesion of the colon
(amoeboma)
Infective colitis
Ulcerative colitis
Colorrectal carcinoma
Intestinal schistosomiasis
Trichuris infection
Balantidiasis
Crohns disease
Diverticulosis
Ileoceacal TB
LABORATORY DIAGNOSIS
Microscopy And Culture
1. Wet Mount Preparation
(i) mounts in saline solution
(ii) mounts in saline + lodine
(iii) mounts in saline + methylene blue
2. Sample Fixative Examination Stain

1. Stool -PVA 10 % formalin Permanently stained Gomori,trichrome,

-sodium acetate acetic slide Iron haematoxylin
acid formalin
2. Sigmoid -PVA, schauddins Permanently Gomori,trichrome
colon fixative Stained slide Iron haematoxylin
3. Aspirate
Direct None Wet mount with
enzyme digest
Fixed PVA, Schauddins Permanently stained
Fixative slide
4. Biopsy Formalin Routine histology PAF Gomori
Haematoxylin and
eosin
Immunological Test
Indirect Haemagglutination

Enzyme Immunoassay
Indirect Immunoflorescence
Latex Agglutination
Gel diffusion
Sensitivity
60 % invasive Bowel disease 100
% with
Amoeboma
 Clinical Drugs of Choice Adult Dosage
presentation
Asymptomahic 1st Choice
Intestinal carrier Diloxanide Furoate 500 mg t.i.d 10 days

2nd Choice
Paramomycin 25 30 mg kg-1 day-1 in 3
(or) doses 7-10 days.
Iodoquinol 650 mg t.i.d 20 days

1st Choice
Intestinal infection
Metronidazole 750 800 mg.t.i.d 10
followed days
by diloxanide furoate 500 mg.t.i.d 10 days
( or )
Tinidazole followed by 2 g/day 2 -3 days
diloxanide furoate 500 mg .t.i.d 10 days
2nd Choice
25 30 mg kg-1 day-1 in 3
Paramomycin
doses 7 10 days
This is the most common extra intestinal
form of invasive amoebiasis.
Adults > children ( 10 : 1 )
Male > female
20 % with past history of dysentery
Clear 'halo' around an amoeba
Destruction of liver tissue
Bulge due to superficial abscess
huge abscess of the inferior
surface of the left lobe.
Intercostal tenderness
 Multiple large amoebic
abscess seen at autopsy.
COMPLICATONS

Right chest
Peritoneum
Pericardium
Amoebic brain abscess - rare
Hemobilia Rupture in to major
bileduct
Portal hypertension
LABORATORY FINDINGS
Normocytic Normochromic anaemia
Leucocytosis -> more than 10 * 10 9 / L
ESR
Stool Cyst or Vegetative form of E . Histolytica
LFT Bilirubin

Transaminases more than 50 %

Alkaline phosphatase more than 75 %

RADIOLOGY
1. CXR Elevated Right Hemi diaphragm
2. Isotope liver scan
3. USG Abdomen B mode , Hypoechoic
4. CTScan

DD
1. Subphrenic Abscess
2. Cholecystitis
3. Liver Hydatid cyst
4. Primary and Secondary carcinoma of
liver
99m Tc sulphur colloid photo liver
scan (anterior view) showing a cold
area in the superior surface of the
left lobe
 X-ray chest showing obliterated
costophrenic angle and an elevated
right dome of the diaphragm
X-ray chest showing an elevated
left dome of the diaphragm
X-ray chest showing a fluid level in a
lung abscess in pulmonary
amoebiasis.
X-ray chest showing left sided
pyopneumothorax
 TREATMENT

1st Choice Metronidazole followed 750-800 mg.t.i.d

by 10 days
diloxanide furoate 500 mg t.i.d. 10
or Days
2g/day 3-5 days
tinidazole followed by
diloxanide furoate 500 mg t.i.d 10
Days

2nd choice dehyderoemetine followed 1-1.5 mg kg-1 day -1

by ( max.90 mg/day ) i.v
5 days

500 mg t.i.d 10
diloxanide furoate days.
 INDICATIONS FOR
ASPIRATION OF AMOEBIC
LIVER ABSCESS
Formal Indications
To rule out a pyogenic abscess (, particularly with
multiple lesions )
As adjunct to medical therapy ( No response after 72
hours )
If rupture is believed to be imminent
Abscess in the left lobe where the risk of rupture is
increased.
Possible Indications
Aspiration of flank abscess.
Chocolate coloured pus.
Brown coloured pus compared to
anchovy sauce.
Ultrasound Guided
Aspiration
SURGERY

1. ALA with Secondary infection

2. Left lobe Abscess
3. Bowel perforation
4. Rupture into pericordium
 PERITONEAL AMOEBIASIS
PERICARDIAL AMOEBIASIS
CEREBRAL AMOEBIASIS
GENITO URINARY AMOEBIASIS
CUTANEOUS AMOEBIASIS
 PRIMARY AMOEBIC MENINGO
ENCEPHALITIS

1. Negleria fowleri
2. Swimming -> 2 14 days
3. Cribriform plate -> olfactory -> sub arachnoid
space
4. Like meningitis picture
5. 200 cases since 1965 , young adults and children
6. Amphotericin B 1 mg / kg per day
AMOEBIC KERATITIS
Acanthamoeba 5 species
MC by A.Castellani, A.Polyphaga
Local propamide and neomycin
Corneal grafting
Contact lense users Avoid raw tap water
Most appropriate Chlorhexidine and hydrogen
peroxide

AMOEBIC MENINGO ENCEPHALITIS

Balamuthia mandriallaris
60 cases since 1990
Albendazole and itraconazole
 Treating Amebiasis.
Frequently, either metronidazole (Flagyl)
or tinidazole (Fasigyn) are used to treat
Amebiasis.
If this does not work, Chloroquine,
emetine, and dehydroemetine can also
be used especially for ALA.
Eliminating cysts in carriers who do not
have symptoms is accomplished with
diloxanide furoate (Furamide),
iodoquinol (Yodoxin), and paromomycin.
Nitazoxanide is a newer drug that shows
promise against not only E. histolytica but
many other parasites as well.
 Preventing Amoebiasis
Drink only bottled or boiled (for 1 minute) water,
or carbonated (bubbly) drinks in cans or bottles.
Fountain drinks and any drinks with ice cubes are
not safe. Water can be made safe by filtering it
through an "absolute 1 micron or less" filter and
dissolving iodine tablets in the filtered water.
Avoid fresh fruit or vegetables that were peeled
by someone else.
Avoid milk, cheese, or dairy products that may
not have been pasteurized.
Avoid anything sold by street vendors.
 Immunity in Amoebiasis
Infection with
invasive strains of
E.histolytica induce
both Humoral and
cellular response.
Infection offers
some degree of
protection.
 Vaccines
Vaccines are being developed and
tested for the treatment of Amebiasis.
The vaccine is a modified version of
the proteins expressed on the surface
of E. histolytica. A study in rodents
found that the vaccine prevented the
formation of liver abscesses, but much
more research is needed to determine
if these vaccines are useful and safe
in humans
 Food safety
Thoroughly cook all raw
foods.
* Thoroughly wash raw
vegetables and fruits before
eating.
* Reheat food until the
internal temperature of the
food reaches at least 167
Fahrenheit.
Wash your hands before
preparing food, before
eating, after going to the
toilet or changing diapers,
after smoking or after using
a tissue or handkerchief.
Personal Hygiene
Wash hands
thoroughly with soap
and hot running water
for at least 10 seconds
after using the toilet
or changing a baby's
diaper.
Clean bathrooms and
toilets often. Pay
particular attention to
toilet seats and taps.
Avoid sharing towels
or face washers.