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Amebiasis Jason Kim Theoklis Zaoutis 3rd edition Database DEFINITION Clinical syndromes associated with Entamoeba histolytica

a infection. Most common clinical manifestation is intestinal amebiasis.

Intestinal disease may be asymptomatic or have mild symptoms such as abdominal discomfort, flatulence, constipation, and occasionally diarrhea. Nondysenteric colitis is characterized by intermittent diarrhea and abdominal pain. Acute amebic colitis (dysenteric) is associated with grossly bloody stools with mucus, abdominal pain, and tenesmus.

CAUSES Entamoeba histolytica is nonflagellated protozoan parasite. Other species of the Entamoeba family are nonpathogenic including the morphologically identical E. dispar. PATHOPHYSIOLOGY Fecal-oral transmission E. histolytica is excreted as cysts or trophozoites in the stool of infected patients.

Ingested cysts are unaffected by gastric acid and produce trophozoites that colonize and invade the colon. The parasite has the ability to lyse human cells including colonic epithelium and immune effector cells such as neutrophils, macrophages, and lymphocytes. The host immune response contributes significantly to the destruction of host tissues. Amebas disseminate directly from the intestine to the liver in up to 10% of patients. Dissemination from the liver to the lung, heart, brain, and spleen has been described. The incubation period is typically 13 weeks but can range from a few days to months or years.

EPIDEMIOLOGY Spreads person to person via fecal-oral transmission. Less common modes of transmission include food and water. Sexual transmission can occur among homosexual males.

Worldwide distribution involving an estimated to 10% or more of the world's population. Most common in tropical areas with infection rates as high as 20%50%. The highest morbidity and mortality is seen in developing countries in Central America, South America, Africa, and Asia. Amebiasis accounts for 4050 million cases of colitis worldwide and leads to 40,000110,000 deaths annually.

The estimated prevalence in the United States is 4%. The very young, the elderly, and patients with underlying immunosuppression or malnutrition are at highest risk for severe disease.

COMPLICATIONS Amebic liver abscesssecond most common presentation of amebiasis, often not associated with amebic dysentery Amebomaabdominal mass representing granulation tissue in the colon

Extraintestinal manifestations of amebiasis are presumed to be a result of direct extension from liver abscesses. These include: Pericarditis Pleuropulmonary abscess or empyema Bronchohepatic fistula Genitourinary tract abscess Cerebral abscess Cutaneous amebiasis

Differential Diagnosis INFECTION Salmonella Shigella

Campylobacter Yersinia Clostridium difficile Escherichia coli (enteroinvasive and enterohemorrhagic) Pyogenic abscess Echinococcal cyst

INFLAMMATORY BOWEL DISEASE Crohn disease Ulcerative colitis MISCELLANEOUS Ischemic colitis Diverticulitis

Arteriovenous malformations Hepatoma Data Gathering

The diagnosis is often missed in children because the disease is not included in the differential. Patients in whom the diagnosis should be considered include: Immigrants from or travelers to endemic areas Children with bloody stools or mucus in stools

Children with hepatic abscess The febrile child with right upper quadrant pain and tenderness, abdominal pain, or discomfort The child with hepatomegaly, typically without jaundice.

P.117 Laboratory Aids The diagnosis of amebiasis depends on the recognition of typical symptoms and: ROUTINE LABORATORY TESTS Complete blood count typically reveals a leukocytosis. Transaminases are often not elevated.

Occult blood is detected in stool.

MICROSCOPIC DIAGNOSIS Identification of trophozoites or cysts in the stool. Serial stool samples, usually three, are recommended. Samples obtained within 12 hours of passage should be examined by wet mount and fixed in formalin and polyvinyl alcohol.

Serial stool samples are necessary since cysts may be shed intermittently. Three serial stool samples will detect up to 70% of patients with amebic colitis and 50% of patients with hepatic abscess. Stool samples should not be contaminated by urine, water, barium, enema substances, laxatives, or antibiotics since these substances may destroy or interfere with identification of the trophozoites.

SEROLOGY Serum antiamebic antibodies are considered an adjunct to diagnosis. Approximately 85% of patients with amebic dysentery and 99% of patients with liver amebiasis will have positive serology. RADIOGRAPHIC STUDIES Ultrasound, CT, or MRI of the liver. Chest radiographs in patients with hepatic amebiasis may reveal elevation of the right hemidiaphragm. BIOPSY STUDIES Amebae are difficult to visualize in abscess aspirates and substantial risk is associated with CT or ultrasound-guided procedures including bleeding, peritonitis secondary to spillage of amebae or rupture of echinococcal cysts.

Colonic or rectal mucosa visualized by colonoscopy reveals ulcerations and amebae can often be found around these lesions.

Therapy SPECIFIC The goal of treatment is the elimination of tissue-invading trophozoites and intestinal cysts. The choice of treatment regimens depends on the clinical presentation. Agents that are active against E. histolytica are divided into two categories: drugs with activity against intraluminal amebae and drugs with activity against extraintestinal and invasive amebiasis.
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Asymptomatic intestinal amebiasisintraluminal agents Iodoquinol is the drug of choice. The recommended dosage is 3040 mg/kg per day (max. 1,950 mg) given orally in three divided doses for 20 days. Alternative agents include diloxanide furoate (Furamide) at doses of 20 mg/kg per day (max. 1,500 mg/day) given orally in three divided doses OR paromomycin, 2535 mg/kg per day given orally in three divided doses for 7 days. Acute amebic colitis or extraintestinal amebiasis Metronidazole (a tissue active agent) 3550 mg/kg per day given orally in three divided doses for 10 days (max. 2,250 mg/day) PLUS a course of treatment with an intraluminal active agent (as above). Approximately one third of patients treated with metronidazole alone will relapse.

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Patients with large liver abscesses or who have failed medical therapy should be considered candidates for surgical or percutaneous drainage.

PREVENTION Treatment of drinking water Hand washing

Appropriate disposal of human fecal waste Use of condoms

INFECTION CONTROL MEASURES Standard precautions are recommended for the hospitalized patient. Follow-Up Clinical improvement is expected within 72 hours of initiation of therapy Follow-up stool examination is always necessary to insure eradication of intestinal amebae

For amebic abscesses, drainage should be considered if response to medical therapy has not occurred in 4 to 5 days

PITFALLS Misdiagnosis is a common problem with amebiasis. Since it is not common in the United States, amebiasis may initially be misdiagnosed as bacterial dysentery.