Brazilian Journal of Infectious Diseases

Print ISSN 1413-8670

Braz J Infect Dis vol.7 no.2 Salvador Apr. 2003
doi: 101!"0#S1413-8670$003000$0000$
Hepatic amebiasis


Jos Maria Salles; Luis Alberto Moraes; Mauro Costa Salles
%ederal &ni'ersit( of Par)* Bel+,#P-. /edical Science Sc0ool
Santa 1asa* S2o Paulo#SP* Brazil
1orres3ondence


ABSTRACT
-,e4iasis can 4e considered t0e ,ost a55ressi'e disease of t0e
0u,an intestine* res3onsi4le in its in'asi'e for, for clinical
s(ndro,es* ran5in5 fro, t0e classic d(senter( of acute colitis to
e6tra-intestinal disease* 7it0 e,30asis on 0e3atic a,e4iasis*
unsuita4l( na,ed a,e4ic li'er a4scess %ound 7orld7ide* 7it0 a
0i50 incidence in India* tro3ical re5ions of -frica* /e6ico and
ot0er areas of 1entral -,erica* it 0as 4een fre8uentl( re3orted in
-,azonia 90e tro30ozoite reac0es t0e li'er t0rou50 t0e 3ortal
s(ste,* 3ro'o:in5 enz(,atic focal necrosis of 0e3atoc(tes and
,ulti3le ,icro-a4scesses t0at coalesce to de'elo3 a sin5le lesion
70ose central ca'it( contains a 0o,o5eneous t0ic: li8uid* 7it0
t(3icall( reddis0 4ro7n and (ello7 color si,ilar to ;anc0o'(
3aste; <i50t u33er 8uadrant 3ain* fe'er and 0e3ato,e5al( are
t0e 3redo,inant s(,3to,s of 0e3atic a,e4iasis Jaundice is
re3orted in cases 7it0 ,ulti3le lesions or a 'er( lar5e a4scess*
and it affects t0e 3ro5nosis ad'ersel( Besides c0est radio5ra30(*
ultrasono5ra30( and co,3uterized to,o5ra30( 0a'e 4rou50t
re,ar:a4le contri4utions to t0e dia5nosis of 0e3atic a4scesses
90e conclusi'e dia5nosis is ,ade 0o7e'er 4( t0e findin5 of
Entamoeba histolytica tro30ozoites in t0e 3us and 4( t0e
detection of seru, anti4odies to t0e a,oe4a Durin5 t0e
e'olution of 0e3atic a,e4iasis* in s3ite of t0e a'aila4ilit( of 0i50l(
effecti'e dru5s* so,e i,3ortant co,3lications ,a( occur 7it0
re5ularit( and are a result of local 3erforation 7it0 e6tension into
t0e 3leural and 3ericardiu, ca'ities* causin5 3ul,onar(
a4scesses and 3urulent 3ericarditis* res3ecti'el( 90e ru3tures
into t0e a4do,inal ca'it( ,a( lead to su430renic a4scesses and
3eritonitis 90e treat,ent of 0e3atic a,e4iasis is ,ade 4(
,edical t0era3(* 7it0 ,etronidazole as t0e initial dru5* follo7ed
4( a lu,inal a,e4icide In 3atients 7it0 lar5e a4scesses* s0o7in5
si5ns of i,,inent ru3ture* and es3eciall( t0ose 70o do not
res3ond to ,edical treat,ent* a 3ercutaneous draina5e ,ust 4e
3erfor,ed 7it0 eit0er ultrasound or co,3uterized to,o5ra30(
5uidance Sur5ical draina5e 4( la3aroto,( is reser'ed to 3atients
7it0 secondar( infections
Key Words: Entamoeba histolytica* 0e3atic a,ea4iasis


-,e4iasis is t0e ,ost a55ressi'e 3rotozoal disease t0at affects
t0e 0u,an 4o7el* considered t0e second or t0ird leadin5 cause of
deat0 a,on5st t0e 3arasitic diseases* sur3assed onl( 4( ,alaria
and sc0istoso,iasis
In s3ite of t0e 5reat nu,4er of as(,3to,atic 3atients infected 4(
Entamoeba dispar or e'en 4( so,e strains of Entamoeba
histolytica t0at re,ain in t0e lu,inal surface of t0e 4o7el*
a,e4iasis in its in'asi'e for,* is res3onsi4le for enteric
s(ndro,es* ran5in5 fro, fran: d(senter( to ful,inant colitis*
70ic0 is 0i50l( let0al =nce t0rou50 t0e 4o7el 7all* tro30ozoites
in'ade t0e 3ortal circulation and disse,inate s(ste,icall(*
reac0in5 t0e li'er to cause 0e3atic a,e4iasis
<e3orted in t0e ,etro3olitan re5ions of de'elo3in5 countries*
0e3atic a,e4iasis is ende,ic in 90ailand* India* >5(3t and Sout0
-frica* 7it0 0i50 ,ortalit( rates ?1@ In /e6ico* a national
serosur'e( de,onstrated t0at 84A of t0e 3o3ulation 7as
e63osed to in'asi'e a,e4iasis* re3resentin5 1 ,illion cases of t0e
disease ?$@ In Brazil* t0ou50 t0ere is lac: of national re3orts* t0e
incidence of 0e3atic a,e4iasis differs fro, one re5ion to anot0er*
4ein5 unco,,on in t0e sout0 and 3re'alent in t0e nort0 ?3*4@ In
t0is re5ion 0e3atic a,e4iasis is 'er( i,3ortant and its 0i50
fre8uenc( 0as 4een re3orted 4( different in'esti5ators ?!-8@
B9a4le 1C


&ntil no7* it re,ains unclear 70( 0e3atic a,e4iasis is ,ore
co,,on in ,en t0an in 7o,en Indi'iduals in t0e fourt0 and fift0
decades of life are ,ost co,,onl( afflicted

at!o"e#esis
Des3ite t0e ne7 conce3ts re5ardin5 a,e4iasis* 7it0 s3ecial
e,30asis on t0e 4iolo5ical differences 4et7een Entamoeba dispar
Bnonin'asi'e* non3at0o5enic* nonanti5enicC* res3onsi4le for ,ore
t0an "0A of a,e4ic infections and Entamoeba histolytica
Bin'asi'e and 3at0o5enicC* so,e as3ects of t0e 3at0o5enesis of
a,e4iasis are still unclear ?"@
90e tro30ozoite ,a( re,ain confined to t0e intestinal lu,en as a
si,3le 4oarder* feedin5 on 4acteria and cellular de4ris
So,eti,es* 0o7e'er* de3endin5 on t0e 5enetic and
i,,unoenz(,atic 3rofile* and t0e 3arasiteDs a4ilit( to 3roduce
3roteol(tic enz(,es and to resist to co,3le,ent-,ediated l(sis*
t0e tro30ozoite 4eco,es 'irulent* and starts its in'asion of t0e
intestinal ,ucosa It can t0en esta4lis0 3ersistent e6tra-intestinal
infection t0rou50out t0e 3ortal 'eins radicles* ,ost co,,onl( in
t0e li'er ?10@ In re5ions 70ere a,e4iasis is ende,ic* a 'ariet( of
conditions* includin5 cli,ate conditions* o'ercro7din5* i5norance*
3o'ert(* ,alnutrition* su4o3ti,al sanitation* i,3aired cellular and
0u,oral i,,unit(* 3la( an i,3ortant role in t0is e6acer4ation
?11@
%ollo7in5 de3ression of t0e 3rotecti'e ,ucus 4lan:et*
tro30ozoites attac0 to t0e cells of inter5landular e3it0eliu, and*
7it0 t0e aid of 3roteol(tic enz(,es t0at de5rade elastin* colla5en
and fi4ronectin* es3eciall( c(steine 3roteinase* 30os30oli3ase and
0e,ol(sin ?1$@* t0e( in'ade t0e colonic e3it0eliu, 4( disru3tion
of t0e e6tra cellular ,atri6 90e first si5nal of colonic a55ression
,a( 4e ,anifested as a non-s3ecific t0ic:enin5 of t0e ,ucosa or
4( 3in0ead-size ,icronodules* 'isi4le 4( si5,oidosco3( Pe3tide-
,ediated l(soso,e enz(,es released 4( t0e l(sed
3ol(,or30onuclear leucoc(tes and ,onoc(tes* contri4ute to t0e
destruction of 0ost tissue and e6tend t0e lesion 90e tro30ozoites
in'ade t0e su4,ucosa and s3read out laterall(* creatin5 t0e
classic flas:-s0a3ed a,e4ic ulcer ?13@ B%i5ure 1C


Eisto3at0olo5( s0o7s necrotic areas and 'ascular con5estion
90ere is little infla,,ation in contrast 7it0 t0e e6tension of t0e
lesion 90e a,oe4as ,a( 4e found in t0e surface la(er of t0e
ulcers or in adFacent sites ?14@ In'adin5 t0e s,all 'essels of
su4,ucosa* t0e tro30ozoites 5ain access to t0e su3erior
,esenter(* and disse,inatin5 t0rou50out t0e 4lood strea,* t0e(
reac0 t0e 3ortal s(ste, to cause ,icroe,4olus and infarction of
s,all 'ascular 4ranc0es <esistin5 co,3le,ent-,ediated l(sis*
t0e tro30ozoites 3ass to t0e li'er* causin5 areas of focal necrosis
-,e4ic l(sis of neutro30ils at t0e ed5e of t0e lesion* releases
,ediators* and t0is leads to 0e3atoc(te deat0* e6tendin5 t0e
da,a5e to distant 0e3atic cells and increasin5 t0e nu,4er of
s,all lesions t0at coalesce to de'elo3 a lar5er 0e3atic lesion*
70ic0 is unsuita4l( na,ed t0e a,e4ic a4scess 90e content of its
central ca'it( is a t0ic:* clott( e6udate 90is is 5enerall(
0o,o5eneous* and 'aries in color* ran5in5 fro, crea,(-70ite to
dirt( 4ro7n and 3in:* si,ilar to ;anc0o'( sauce; ?1!@ B%i5ure $C
90is ,aterial is al,ost al7a(s sterile* e6ce3t 70en a secondar(
infection 0as occurred* allo7in5 differential dia5nosis fro, a
3(o5enic a4scess 90e a,e4ae can 4e found at t0e ed5e of t0e
lesion* 4ut are rarel( detected in t0e 3us or 7it0in t0e a4scess
ca'it( itself ?16@


90e 0e3atic lesion is usuall( solitar(* and ,ost fre8uentl( is
located in t0e ri50t lo4e* situated conti5uousl( 7it0 t0e li'er
ca3sule Garia4le in size* in so,e cases it ,a( occu3( ,ore t0an
80A of t0e 70ole li'er surface B%i5ure 3C 90is ,a( 4e e63lained
4( t0e lar5er 'olu,e of t0e ri50t lo4e* 70ic0 recei'es ,ost of t0e
'enous draina5e fro, t0e ri50t colon* a se5,ent of t0e 4o7el
fre8uentl( affected 4( intestinal a,e4iasis ?17@ 90e a,e4ic
lesions of t0e left lo4e are less co,,on* and ,ulti3le a4scesses
,a( occur in ad'anced cases of a,e4iasis 9a4le $ s0o7s t0e
to3o5ra30( of 0e3atic lesions re3orted in Par) state




Cli#ical Ma#i$estatio#s
90e clinical ,anifestations of 0e3atic a,e4iasis are so t(3ical t0at
t0e( ,i50t su55est t0e dia5nosis in t0e areas 70ere it is
3re'alent* suc0 as in -,azonia Some days or mo#t!s a$ter
t!e o#set o$ classic dyse#tery% or as usually !appe#s%
&it!out a#y symptoms or a !istory o$ i#testi#al amebiasis%
t0e clinical features 4e5in to a33ear Des3ite t0e size and t0e site
of t0e 0e3atic lesion* t!e most commo# symptoms are $e'er%
pai# a#d !epatome"aly(
In 3atients 7it0 acute o#set% t!e $e'er is "e#erally prese#t
i# more t!a# )*+ o$ t!e cases( It is o$te# 'ery !i"!%
co#ti#uous or i#termitte#t a#d accompa#ied by c!ills%
&ea:ness and 3rofuse 3ers3iration In c!ro#ic $orms t!e $e'er
is lo& a#d de'elops more "radually% &it!out c!ills or
s&eati#"
Abdomi#al pai# is t!e earliest a#d most $re,ue#t
complai#t% prese#t i# almost -**+ o$ t!e patie#ts It starts
as a feelin5 of 0ea'iness* and t0en 4eco,es a s!arp pai# t!at
i#creases accordi#" to t!e positio# o$ t!e body* co,3ellin5
t0e 3atient to $i#d relie$ i# bed by tur#i#" to t!e opposite
side o$ t!e lesio#( In a4scesses of t!e ri"!t lobe t!e pai# is
$elt i# t!e ri"!t !ypoc!o#dria% i# t!e ri"!t subcostal area
or i# t!e cystic poi#t% a#d may radiate to t!e s!oulder%
ri"!t side o$ t!e #ec. or t!e bac.( In a4scesses o$ t!e le$t
lobe% t!e pai# is located i# t!e epi"astria a#d le$t
!ypoc!o#dria a#d radiates to t!e le$t bac. a#d le$t
scapular re"io#s(
Besides t0ese 3re'ailin5 s(,3to,s* 3atients ,a( also co,3lain
of malaise% #ausea% 'omiti#"% a#ore/ia a#d &ei"!t loss(
0iarr!ea may be prese#t i# about 1+ o$ t!e cases% &it! 2
to 3 episodes per day o$ a &atery stool% &it! mucus a#d
blood% te#esmus% abdomi#al crampi#" a#d diste#sio# due
to potassium loss In so,e 3atients* 70en diarr0ea is a4sent
si5,oidosco3( ,a( s0o7 t0e a,e4ic ulcers ?1"@
Jau#dice is an unusual feature* re3orted in o#ly 3+ o$ t!e
cases Its a33earance su55ests t0e e6istence o$ lar"e or
multiple abscesses% bacterial i#$ectio# a#d dera#"eme#t o$
!epatic $u#ctio# 410@ T!e prese#ce o$ 5au#dice may
&orse# co#siderably t!e pro"#osis( Dr( cou50* c0est 3ain
and decreased 4reat0 ,a( 4e due to 3leuro3ul,onar( e6tension
of t0e infla,,ator( 3rocess in t0e lesions of t0e su3erior surface
Hepatome"aly is t!e most importa#t p!ysical si"# in
0e3atic a,e4iasis 90e enlar5e,ent of t0e li'er 'aries 7it0 t0e
size and t0e site of t0e lesion 90ere ,a( 4e a 5eneralized
enlar5e,ent* do7n7ard enlar5e,ent or u37ard enlar5e,ent of
t0e ri50t or left lo4e* co,3ressin5 t0e dia30ra5, In t0is
situation t0ere is a decrease in t0e a4ilit( to 4reat0e* and t0e
3atient co,3lains of d(s3nea In t0e lar5er a4scesses* a ,ass or
a lu,3 ,a( so,eti,es 4e seen in t0e ri50t 0(3oc0ondria or
e3i5astria ?1!@ B%i5ure 4C In t0e a4scesses of t0e left lo4e* t0e
,ass is 3al3a4le at t0e left 0(3oc0ondria 90e tenderness ,a( 4e
diffuse or localized In cases 7it0 se'ere tenderness* t0e 3atient
a'oids t0e 3al3ation* e'en 4efore t0e e6a,iner reac0es t0e
affected area


90e s(,3to,s of 104 cases of 0e3atic a,e4iasis ad,itted at
Eos3ital Jo2o de Barros Barreto fro, 1""0 to $000 are 5i'en in
9a4le 3


0ia"#osis
-fter t0e old da(s of s3leno3orto5ra30( and less sensiti'e tests*
t0e #o#6i#'asi'e ima"i#" procedures% i#cludi#"
ultraso#o"rap!y% computeri7ed tomo"rap!y* ,a5netic
resonance i,a5in5 and* 3rinci3all( serolo"y% !a'e dramatically
impro'ed t!e cli#icia#8s a4ilit( to 3ro,3tl( dia5nosis 0e3atic
a,e4iasis and 8uic:l( start treat,ent
-,on5 t0e la4orator( findin5s* t0e 4lood count re'eals a mild
de"ree o$ a#emia t!at may be eit!er #ormoc!romic or
!ypoc!romic( In t0e ,aForit( of cases* a mild to moderate
leu.ocytosis is 3resent* 7it0 an a'era5e 70ite 4lood cell count
of 16*000 In 3atients 7it0 ,ulti3le a4scesses* or 4acterial
infection* t0e leu:oc(tosis ,a( 4e se'ere* acco,3anied 4(
#eutrop!ilia% 7it0 an increased 3ercenta5e of i,,ature for,s
si,ilar to a leu:e,oid reaction ?$1@
90e reco'eri#" o$ trop!o7oites a#d cysts of Entamoeba
histolytica i# $eces o$ patie#ts &it! !epatic amebiasis
stre#"t!e#s t!e !ypot!esis o$ amebic etiolo"y Hi'er
function tests are not 'er( 0el3ful* 3resu,a4l( 4ecause too little
li'er tissue is affected - moderate ele'atio# o$ al.ali#e
p!osp!atase% as &ell as !ypoalbumi#emia a#d
tra#sami#ases% &ould su""est t!e possibility o$ a lar"e
abscess ?$$@
In i,a5in5 studies* an ele'atio# o$ t!e ri"!t !emidiap!ra"m
i# c!est radio"rap!y is a commo# $i#d &!e# t!ere are
lesio#s o$ t!e ri"!t lobe 9%i5ure !C In lesions of t0e left lo4e*
t0e ele'ation is seen on t0e o33osite side ?$3@
:ltraso#o"rap!y is t!e most &idely used i#itial ima"i#"
procedure i#dicated $or patie#ts &it! a !istory a#d
symptoms o$ !epatic amebiasis In addition to its lo7 cost and
accessi4ilit(* it 0as t0e a4ilit( to ra3idl( detect 0e3atic lesions at
t0e different sta5es of t0e disease* deter,inin5 t0eir nu,4er* size
and e6act 3osition B%i5ure 6C It ,a( e'en differentiate a solid
tu,or fro, an a4scess and a 4iliar( tract disease fro, a lesion It
is also 'er( 0el3ful in 5uidin5 3ercutaneous cat0eter li'er
draina5e and in follo7in5 t0e course of infection and its clinical
resolution ?$4*$!@ -t ultrasono5ra30( t0e a,e4ic 0e3atic lesion
tends to 4e round or o'al* 0(3oec0oid* 7it0 7ell-defined ,ar5ins
B%i5ure 6C




90e a4do,inal 19 scan is anot0er 'alua4le i,a5in5 3rocedure*
7it0 5reater resolution and sensiti'it( in detectin5 0e3atic
lesions* es3eciall( t0e s,aller ones* 70ic0 is useful for earl(
dia5nosis ?$7@ In t0e 19 scan* an a,e4ic a4scess usuall(
a33ears as a rounded* 7ell-defined* lo7-densit( lesion* 7it0 an
0o,o5eneous se3tated ca'it(* and 7it0 considera4le fluid B%i5ure
7C


In s3ite of t0e i,3ortant su33ort 3ro'ided 4( i,a5in5 studies*
t0e definiti'e confir,ation of 0e3atic a,e4iasis is 4ased on a
de,onstration of Entamoeba histolytica tro30ozoites in t0e
as3irated 3us* or ,ore fre8uentl( fro, t0e necrotic ,aterial
o4tained 4( needle 4io3s( of t0e ed5e or t0e 4otto, of t0e
lesion Ne'ert0eless* t0e a,e4a 7ill 4e found in onl( a s,all
3ercenta5e of cases
1onsiderin5 t0e 0u,oral i,,une res3onse to Entamoeba
histolytica* serolo5( 0as 4eco,e a 'alua4le tool for dia5nosis*
detectin5 s3ecific circulatin5 anti4odies a5ainst t0e in'asi'e
for,s* and indicatin5 t0e etiolo5( 7it0 a reasona4le ,ar5in of
safet(* and t0erefore differentiatin5 0e3atic a,e4iasis fro, a
3(o5enic a4scess ?$7@ -,on5 t0e 'ariet( of serolo5ical tests
a'aila4le no7ada(s* indirect 0e,a55lutination BIE-C* e'en 70en
used in serolo5ical studies* is a 'er( sensiti'e assa(* 4ein5
3ositi'e in "0 to 100A of 3atients 7it0 li'er a,e4iasis Indirect
i,,unofluorescence is also 'er( 0el3ful* 5i'in5 'alues 0i50er
t0an 1:800 in a4out 70A of t0e sus3ects >nz(,e-i,,unoassa(
B>HIS-C* eit0er I5I class or total i,,uno5lo4ulin* is t0e ,ost
sensiti'e assa( and no7 re3laces IE- It 0as a sensiti'it( of "8A*
and it is e6traordinaril( useful in t0e earl( sta5es of 0e3atic
a,e4iasis ?$8@
Because of t0e lo7 3ositi'it( of ,icrosco3ic dia5nosis* anti5en
detection can 4e an essential adFunct ,et0od <ecent studies
indicate i,3ro'ed sensiti'it( and s3ecificit( of fecal anti5en
assa(s for in'asi'e strains* 7it0 t0e use of ,onoclonal anti4odies
t0at can distin5uis0 4et7een Entamoeba histolytica and
Entamoeba dispar ?$"@ &nfortunatel( t0is test is not (et
a'aila4le co,,erciall(

0i$$ere#tial 0ia"#osis
Des3ite a si,ilarit( 7it0 se'eral diseases suc0 as 0e3ato,a*
acute c0olec(stitis* 3arasitic c(sts* su430renic and 3ul,onar(
a4scesses 3ro'o:ed 4( 4acteria* t0e differential dia5nosis of
0e3atic a,e4iasis ,ust 4e esta4lis0ed 3rinci3all( a5ainst
3(o5enic a4scess ?30*31@
-lt0ou50 e3ide,iolo5ical infor,ation ,a( s0o7 t0e 3atient to 4e
fro, an area ende,ic for a,e4iasis* acute onset of fe'er*
a4do,inal 3ain and 0e3ato,e5al( are co,,on to 4ot0 a,e4ic
and 3(o5enic a4scesses* and la4orator( findin5s and t0e i,a5es
o4tained fro, radio5ra30(* ultrasono5ra30( and 19 scan studies*
are not decisi'e for deter,inin5 an a4solute difference 4et7een
a,e4ic and 3(o5enic a4scesses
90e real difference is 4ased on t0e follo7in5:
-4scesses
-,e4ic P(o5enic
Serolo5( BIE-#>HIS-C 3ositi'e ne5ati'e
Bacteriolo5( of t0e 3us ne5ati'e 3ositi'e BJC
De,onstration of E. histolytica 3ositi'e ne5ati'e
90era3eutic efficac( ,etronidazole anti4ioticsBJJC
BJC Ira,-ne5ati'es BE. coli, Klebsiella, Proteus, B. flagilis);
BJJC -,ino5l(cosides* ce30alos3orins* 8uinolones* clinda,(cin

Complicatio#s
In s3ite of t0e a'aila4ilit( of effecti'e dru5s* co,3lications ,a(
4e found 7it0 re5ularit( durin5 t0e course of 0e3atic a,e4iasis
Its a33earance de3ends on t0e size* nu,4er and localization of
t0e lesions* and t0e( ,a( interfere unfa'ora4l( 7it0 t0e
3ro5nosis of t0e disease
%irstl(* t0e li'er is 3rone to 4acterial in'asion due to its
anato,ical location and function Since ,ost of t0e 4lood su33l(
fro, t0e lar5e 5ut drains into t0e ri50t lo4e of t0e li'er t0rou50
t0e 3ortal s(ste,* translocated or5anis,s* suc0 aero4ic and
anaero4ic >ntero4acteriaceae* ,a( reac0 t0e 0e3atic sinusoids*
4ein5 30a5oc(tized ,ost of t0e ti,e K0en t0e ,ononuclear-
,acro30a5e s(ste, is una4le to destro( t0e in'aders* t0e(
su4se8uentl( inflict cellular inFur( and secondar( 4acterial
infection* 3roducin5 clinical s(,3to,s of se'ere illness t0at are
distinct fro, t0ose of a,e4ic a4scess ?1!@ 90ere is t0e ris: of
se3sis* needin5 3ro,3t dia5nosis and t0era3( 7it0 anti4iotics
<e3eated li'er as3irations 7it0out a33ro3riate tec0ni8ue and
ase3sis ,a( also 4e res3onsi4le &nder t0ese circu,stances
Staphylococcus aureus is t0e 3rinci3al in'ader ?$0@ Secondar(
infection is not a fre8uent co,3lication* 4ein5 re3orted onl( in
10A to $0A of t0e 3atients 7it0 lar5e and ,ulti3le lesions
90e s3readin5 of t0e a,e4ic lesion to adFoinin5 structures*
in'ol'in5 a conti5uous ,ec0anis,* is a fre8uentl( re3orted
co,3lication 90e close 'icinit( of t0e dia30ra5, to t0e su3erior
surface of t0e 0e3atic lesion ,a( lead to infla,,ator( reactions
of t0e dia30ra5, itself* su430renic s3ace* 3leura* lun5s and
3ericardiu, ?3$@ 1linicall( t0is can result in atelectasis* 3leuritis*
e,3(e,a and 3ul,onar( condensation 90ese are fre8uentl(
detected at t0e ri50t 0e,it0ora6* corres3ondin5 to lesions of t0e
ri50t lo4e of t0e li'er* re3orted in ,ost cases B%i5ure 8C -n
intensi'e 3ain localized o'er t0e lo7er ri4 ca5e on t0e ri50t side*
a dr( cou50* s0ortness of 4reat0* and se'ere d(s3nea in a 3atient
7it0 0e3atic a,e4iasis* are su55esti'e s(,3to,s of an initial
3ul,onar( co,3lication* t0at de,ands ur5ent c0est radio5ra30ic
or 19 scan studies ?33@


Due to t0e e6tre,e fra5ilit( of t0e lesion 7all and 4ecause of
inner 3ressure* a ru3ture ,a( occur at so,e 3oint of t0e li'er
ca3sule* 7it0 e6tension into t0e 3ericardiu,* 3leural and
3eritoneal ca'ities ?34@ 90is is* in fact* one of t0e co,,onest
co,3lications of 0e3atic a,e4iasis* 7it0 an incidence 'ar(in5
fro, !A to $0A of t0e cases It often in'ol'es t0e ri50t c0est*
alt0ou50 t0e left side can also 4e affected
=n t0e su3erior surface* 70en t0e a4scess e6tends u37ard* t0e
3rocess reac0es t0e dia30ra5, and t0e o'erl(in5 3leura* causin5
e,3(e,a t0at can e,3t( into a 4ronc0us and for, a 4ronc0o-
3leuro-0e3atic fistula 90e in'asion of t0e lun5 3arenc0(,a 4(
Entamoeba histolytica* leads to de'elo3,ent of interstitial
3neu,onitis* follo7ed 4( li8uefaction and for,ation of a lun5
a4scess 90is a4scess ,a( ru3ture into a 4ronc0us and 3ro'o:e
'o,ica* a sudden and 3rofuse e63ectoration of 3utrid 3urulent
,atter ?3!*36@ -,e4ic 3ul,onar( a4scesses are 3rone to result
fro, lesions of t0e ri50t lo4e* and t0eir incidence 'aries fro, $A
to 4A B%i5ure "C -,on5 104 cases of 0e3atic a,e4iasis studied
in E&JBB* it 7as found in less t0an $A In lesions of t0e left lo4e*
t0e sa,e clinical s(ndro,es can 4e seen at t0e left 0e,it0ora6
?37@


90e e6tension of t0e 0e3atic a,e4iasis to t0e 3ericardiu,* also
t0rou50 a ,ec0anis, of conti5uit(* is res3onsi4le for serious
s(ndro,es t0at ran5e fro, ,ild 3ericarditis to catastro30ic
3urulent 3ericarditis ?38*3"*40@ -lt0ou50 e6tre,el( unco,,on
in t0e cases of acute onset* t0is co,3lication leads to a life
t0reatenin5 e,er5enc(* causin5 cardiac ta,3on,ent* and it is
in'aria4l( let0al ?41@ B%i5ure 10C <arel(* a c0ronic 3erforation is
descri4ed* 5i'in5 rise to constricti'e 3ericarditis - s0ar3 3ain in
t0e left 0e,it0ora6 and clinical si5ns of 3ericarditis de,and an
i,,ediate co,3le,entar( in'esti5ation


So,eti,es* as a conse8uence of a do7n7ard e6tension* t0e
0e3atic lesion ,a( lea: into t0e 3eritoneal ca'it( as a localized
a4scess of t0e left anterior or 3osterior su430renic s3aces* or in
t0e for, of a free 3erforation* causin5 5eneralized 3eritonitis 7it0
conse8uent 3ol(,icro4ial infection* and a s(ndro,e of acute
a4do,inal 3ain B%i5ure 11C 90is is t0e second ,ost co,,on
co,3lication of 0e3atic a,e4iasis after 3leuro3ul,onar(
in'ol'e,ent* 7it0 an incidence 'ar(in5 fro, !A to 10A* and
0i50 ,ortalit( ?4$*43*44@ &ltrasono5ra30( and 19 scan studies
can identif( t0e lar5e 0e3atic a4scesses read( to ru3ture*
re8uirin5 i,,ediate draina5e


- retros3ecti'e anal(sis of 104 cases 7it0 0e3atic a,e4iasis
studied at t0e E&JBB is 5i'en in 9a4le 4


Treatme#t
90e disco'er( of s(ste,ic a,e4icides* ,ainl( in t0e
nitroi,idazole 5rou3* 7it0 0i50 tissular diffusion* and en0anced
ca3a4ilit( to cross t0e 7all and reac0 t0e interior of t0e a4scess
at a 'er( 0i50 concentration Bfour ti,es t0e /I1 for Entamoeba
histolyticaC* 0as 4een res3onsi4le for a dra,atic c0an5e in t0e
treat,ent of in'asi'e a,e4iasis* reducin5 co,3lications and
t0erefore ,ortalit(
In contrast 7it0 t0e last four decades* 70en 3atients 7it0 0e3atic
a,e4iasis 7ere s(ste,aticall( su4,itted to sur5ical draina5e 4(
la3aroto,(* ,edical t0era3( no7ada(s is t0e treat,ent of c0oice*
indicatin5 sur5ical draina5e onl( for e6tre,el( lar5e lesions in
70ic0 ru3tures are 4elie'ed to 4e i,,inent ?4!*46@
Because of its 0i50l( let0al action a5ainst t0e tro30ozoite of
Entamoeba histolytica and fa'ora4le 30ar,aco:inetics* 7it0 fast
intestinal a4sor3tion* e6cellent 4ioa'aila4ilit(* 7ides3read
distri4ution in ,ost 4od( tissues and a 0alf-life of 14 0ours*
,etronidazole is t0e indicated dru5 for t0e treat,ent of 0e3atic
a,e4iasis ?47@
In criticall( ill 3atients* 7it0 lar5e and ,ulti3le a4scesses*
,etronidazole is used at !00 ,5 4( IG infusion e'er( 8 0ours* for
fi'e or ten da(s B( oral route t0e ,etronidazole dose ,ust 4e
7!0 to 800 ,5* t0ree ti,es dail( for 10 da(s for adults and !0
,5#:5#da( for c0ildren /ost 3atients treated 7it0 ,etronidazole
i,3ro'e after 3 or 4 da(s and cure 0as 4een re3orted in ,ore
t0an "0A of t0e cases 90is dru5 is a'aila4le in ca3sules of $!0
and !00 ,5* and !00 ,5 for IG infusions
1o,,on side effects of ,etronidazole include nausea* 'o,itin5*
0eadac0e* a4do,inal disco,fort and a ,etallic taste ,entioned
4( al,ost all 3atients /ore serious ad'erse reactions* suc0 as
ata6ia* confusion* inso,nia* 3arent0esis or e'en seizures are
rarel( seen Since t0is dru5 crosses t0e 3lacenta and enters t0e
4reast ,il:* its indication ,ust 4e considered carefull( for
3re5nant cases 90ou50 t0ere is insufficient data on 0u,an
4ein5s* t0e ,uta5enic and carcino5enic 3otential of
,etronidazole 0as 4een 7idel( studied in ani,als ?48@
Durin5 t0e last fe7 (ears t7o i,idazole deri'ates 0a'e 4een
introduced in Brazil* 4ot0 7it0 0i50 a,e4icide action and an
e6tended 0alf-life* es3eciall( secnidazole ?4"@ 9inidazole is
indicated as a ,etronidazole su4stitute for non-co,3licated cases
of in'asi'e a,e4iasis* and is used orall(* at $5 dail(* for ! da(s
?!0@ Secnidazole 0as t0e sa,e 30ar,acod(na,ics as
,etronidazole* 4ut it 0as different 30ar,aco:inetics* 7it0 a
,uc0-e6tended 0alf-life* ,aintainin5 0i50 concentrations in
tissues for ,ore t0an $4 0ours So,e studies 7it0 secnidazole
0a'e s0o7n t0at a sin5le dail( dose of $ 5 for fi'e da(s is
effecti'e for unco,3licated a,e4ic a4scesses Ne'ert0eless*
treat,ent of 0e3atic a,e4iasis 7it0 lar5e and ,ulti3le lesions
,ust 4e ,ade 7it0 ,etronidazole ?!1@
Nitazo6anide* a ne7* recentl( introduced* dru5* 7it0 efficac(
a5ainst c(sts and tro30ozoites of Entamoeba histolytica 0as
s0o7n 5ood results in t0e treat,ent of intestinal a,e4iasis ?!$@
10loro8uine* an anti,alarial dru5 is also effecti'e a5ainst t0e
tro30ozoite of Entamoeba histolytica. Kit0 an e6cellent tissue
distri4ution* it ,aintains 0i50 concentrations in 0e3atic
3arenc0(,a and t0erefore 7it0in t0e a,e4ic lesion Its use is
restricted. it is reco,,ended e6clusi'el( as an adFunct of
,etronidazole* for 3atients 7it0 lar5e and ,ulti3le a,e4ic
a4scesses 90e indicated 3osolo5( is 300 ,5 e'er( 1$ 0ours*
follo7ed 4( 300 ,5 dail( for $1 da(s
9o 3re'ent rela3ses after t0e treat,ent 7it0 ,etronidazole* e'en
in t0e a4sence of d(senter( and ot0er s(,3to,s of enteric
a,e4iasis* a lu,inal a,e4icide ,ust 4e ad,inistered to eradicate
c(sts and tro30ozoites fro, t0e intestine It is i,3ortant to
re,e,4er t0at in accordance 7it0 t0e 30ar,aco:inetics of
i,idazoles* t0ese dru5s 0a'e a s0ort sta( in t0e 4o7el lu,en*
70ic0 is not sufficient for an effecti'e action a5ainst t0e a,oe4as
?!3@
In Brazil t7o lu,inal a,e4icides* teclosan and et0o30a,ide* are
a'aila4le for use 9eclosan is an acetoa,id deri'ati'e* 7it0out
intestinal a4sor3tion* re,ainin5 in t0e 4o7el and e6creted 7it0
t0e feces Is a'aila4le in ca3sules 7it0 100 and !00 ,5 and s(ru3
7it0 !0 ,5#!,l 90e reco,,ended 3osolo5( is !00 ,5 orall(
e'er( 1$ 0ours for t0ree da(s or 1*!00 ,5 ta:en as a sin5le dose
?!4@ >t0o30a,ide is a cle30a,ide deri'ati'e* 7it0out intestinal
a4sor3tion and is e6creted onl( 4( t0e di5esti'e route Kit0 5ood
acti'it( a5ainst c(sts and tro30ozoites in t0e 4o7el lu,en it is
used !00 ,5 t7ice a da( for t0ree da(s ?!!@
/an( in'esti5ators 0a'e reco,,ended t0e treat,ent of 3atients
7it0 EIG infection follo7in5 t0e e'idence t0at Entamoeba
histolytica is a4le to 3roduce a lecit0in ,ito5en for l(,30oc(tes
t0at could tri55er EIG-1 re3lication ?!6@ 90e findin5 of 3atients
7it0 0e3atic a,e4ic lesions 70o are EIG sero3ositi'e* so,e of
t0e, 7it0 an infection de'elo3ed after t0e onset of a,e4ic li'er
a4scess* see,s to 4e 3roof of t0is relations0i3 ?!7@ Ne'ert0eless
in'asi'e a,e4iasis is unco,,on in a considera4le nu,4er of EIG
3ositi'e 3atients* and t0e 3arasite t0at is so,eti,es identified is
Entamoeba dispar ?!8*!"@
Durin5 t0e treat,ent of 0e3atic a,e4iasis* in addition to
c0e,ot0era3(* a 3ercutaneous li'er as3iration ,a( 4e re8uired*
5uided 4( ultrasono5ra30( and 3erfor,ed 7it0 care and ase3sis
to a'oid conta,ination ?60*61@ -s3iration 5enerall( en0ances
clinical reco'er(* accelerates resolution and 3re'ents
co,3lications 90is 3rocedure is 3erfectl( indicated in t0e
follo7in5 circu,stances ?6$@:
Persistence of clinical s(,3to,s* es3eciall( a4do,inal 3ain and
fe'er
Har5e li'er a4scesses of t0e ri50t lo4e in i,,inence of ru3ture
-4scesses of t0e left lo4e
Pre5nant 3atients 7it0 a,e4ic lesion for 70o, ,etronidazole is
contraindicated
-,e4ic li'er a4scesses 7it0 3leuro3ul,onar( co,3lications
Hac: of clinical i,3ro'e,ent
90e earl( dia5nosis of 0e3atic a,e4iasis 4( serolo5( and i,a5in5
studies* t0e a'aila4ilit( of effecti'e dru5s and 3ercutaneous
draina5e 0as ,ade sur5ical treat,ent 'er( rare ?63@
Ne'ert0eless* considerin5 t0e 'er( 0i50 ,ortalit( of t0e
s(ndro,es of ru3ture* 7it0 serious 3ul,onar( i,3lications*
3ericarditis* or ,ore fre8uentl(* su430renic a4scess or e'en
3eritonitis 7it0 se3sis* sur5ical treat,ent can 4e a4solutel(
necessar(* and s0ould 4e su33le,ented 4( anti4iotics and ot0er
t0era3( ?64*6!@
In t0e a4sence of co,3lications* ra3id clinical i,3ro'e,ent is
seen Patients 5raduall( res3ond to ,etronidazole t0era3( alone
7it0in a fe7 da(s to a 7ee:* 7it0 disa33earance of fe'er* ri50t
u33er-8uadrant 3ain* anore6ia and ot0er usual co,3laints
Ee3atic ca'it( 0ealin5 ,a( occur 7it0in fro, 3 to 1$ ,ont0s and
,ust 4e ,onitored 4( ultrasono5ra30(
No7ada(s* t0e 3ro5nosis of 0e3atic a,e4iasis* dia5nosed earl(
and 3ro3erl( treated* is 8uite fa'ora4le and ,ortalit( s0ould 4e
a33ro6i,atel( zero Ei50er rates of ,ortalit( are directl( lin:ed
to serious co,3lications* ,ainl( 3ericarditis and 3eritonitis
90e treat,ent of 104 cases of 0e3atic a,e4iasis in E&JBB is
su,,arized in ta4le !


re'e#tio#
-,e4iasis* 4ein5 a social 3ro4le,* its definiti'e eradication*
de3ends on t0e i,3ro'e,ent of 3u4lic 0ealt0 ,easures*
ade,uate sa#itatio#% clea# &ater supplies a#d abo'e all%
better !ealt! educatio#( 90is 0as not 4een an eas( tas: in
areas in 70ic0 resources for 0ealt0 care 3ro5ra,s are scarce
&ndou4tedl( t!e de'elopme#t o$ a 'acci#e &ould be t!e
most eco#omical strate"y $or t!e pre'e#tio# o$ amebic
i#$ectio# a#d co#se,ue#tly i#'asi'e amebiasis -lt0ou50 not
(et co,,erciall( a'aila4le* t0ere 0as 4een continuous 3ro5ress in
t0is field

Re$ere#ces
1 Kals0 J- Pre'alence of Entamoeba histolytica infection In:
<a'din JI* ed -,e4iasis: 0u,an infection 4( Entamoeba
histolytica Ne7 Lor:: Hi'in5stone* -);;:"3-10! ? Hin:s @
$ 1a4alero J* Gi'eros /* Sal'atierra B* et al Seroe3ide,iolo5(
of a,e4iasis in /+6ico -, J 9ro3 /ed E(5 -));.!0:41$-
" ? Hin:s @
3 <e( H >nta,oe4a 0istol(tica e -,e4Mase II: - doenNa In:
Parasitolo5ia /+dic $ ed <io de Janeiro. Iuana4ara Ooo5an*
-))- ? Hin:s @
4 /anesc0( H-P -4scesso -,e4iano na -,azPnia 90esis
BHi're DocQnciaC 1entro Bio,+dico da &ni'ersidade %ederal do
Par) Bel+,* -)<2 ? Hin:s @
! <i4eiro Neto EJ* Bec:,an 1< -4scesso -,e4iano do
%M5ado In: Ee3atolo5ia 1linica e 1irRr5ica S2o Paulo. Ser'ier*
-);=:!41-8 ? Hin:s @
6 10a'es H1 -4scesso -,e4iano do %M5ado* DissertaN2o
B/estrado e, 1irur5ia IastrenterolS5icaC* &ni'ersidade %ederal
do <io de Janeiro <io de Janeiro* -);< ? Hin:s @
7 Pardal PP=* et al >studo e3ide,iolS5ico* clMnico e la4oratorial
do a4scesso 0e3)tico a,e4iano no Par) Ger Soc Br)s /+d 9ro3
-))-.$4:138-43 ? Hin:s @
8 /oraes H- >studo clMnico de 104 casos de a4scesso 0e3)tico
a,e4iano do fM5ado no EJBB In: <e' Br)s 1ir -))).$$7:!4-60
? Hin:s @
" <eed SH Ne7 conce3ts re5ardin5 t0e 3at0o5enesis of
a,e4iasis 1lin Infect Dis -))3.$1Bsu33lC:S18$-! ? Hin:s @
10 <a'din J I -,e4iasis 1lin Infect Dis -))3.$0: 14!3-8
? Hin:s @
11 1un0a -S* et al -,e4Mase In: 1astroH* <oc0a =* 1un0a -
9S3icos e, Iastrenterolo5ia 1ed* <io de Janeiro. /edisi
-))-.!4: $87-316 ? Hin:s @
1$ 1astellano->s3inosa /* /arinez-Palo,a - Pat0o5enesis of
intestinal a,oe4iasis: fro, ,olecules to disease 1lin /icro4iol
<e' 1***.13: 318-30 ? Hin:s @
13 <a'din JI* 1roft B9* Iuerrant < 1(to3at0o5enic
,ec0anis,s of Entamoeba histolytica J 1lin In'est -);-.68:
130!-13 ? Hin:s @
14 Brandt E* Perez-9a,o(o < Pat0olo5( of 0u,an a,e4iasis J
Pat0ol -)<<.1:3!1-68 ? Hin:s @
1! -da,s >B* /acHeod = In: In'asi'e -,e4iasis: -,e4ic li'er
a4scess and its co,3lications /edicine -)<<.!6:3$!-34
? Hin:s @
16 <odri5ues %il0o -* /anesc0( H-* Gianna 1/* et al
-4scesso a,e4iano do fM5ado <e'ista de 1iQncias BiolS5icas
-)=>.1:163-76 ? Hin:s @
17 Oa3oor =P -,e4ic li'er a4scess Bo,4a( Eos3ital Journal
-))*. 33$: !-8 ? Hin:s @
18 S0ar,a /P* -c0ar(a SO* Gerna NB* et al 1linical 3rofile of
,ulti3le a,oe4ic a4scesses* J -ssoc P0(sicians India
-))*.38:837-" ? Hin:s @
1" Dono'an J-* Lellin ->* <als PK Ee3atic a4scess Korld J
Sur5 -))-. 1!: 16$-" ? Hin:s @
$0 -0,ed -* /ac-da,s PKJ* Stur, -K S(ste,ic
,anifestations of in'asi'e a,e4iasis 1lin Infect Dis -))1.1!:74-
8$ ? Hin:s @
$1 Petri K-* Petri Jr* &3inder S Dia5nosis and ,ana5e,ent of
a,e4iasis 1lin Infect Dis -))).$":117-$! ? Hin:s @
$$ Sala:o I- Hi'er function tests in t0e dia5nosis of 0e3atic
a,e4iasis J 9ro3 /ed E(5 -)=<.70:1"-$$ ? Hin:s @
$3 Oi,ura O* Stoo3en /* <eeder //* et al -,e4iasis:
,odern dia5nostic i,a5in5 7it0 3at0olo5ical and clinical
correlations Se,in <oent5enol -))<.3$:$!0-7! ? Hin:s @
$4 Oartzeinstein D* <ic:erson G* Braude - Ne7 conce3ts of
a,e4ic li'er a4scess deri'ed fro, 0e3atic i,a5in5* serodia5nosis
and 0e3atic enz(,es in 67 consecuti'e cases in San Die5o
/edicine -);1.61:$37-41 ? Hin:s @
$! Stoo3en / Ha ultrasono5rafia ( la to,o5rafia
co,3utadorizada e, el dia5nSstico Del a4scesso 0e3)tico
a,i4iano -rc0 In'est /+d B/+6icoC -);*.11:317-$4
? Hin:s @
$6 S0irini' B* Oa:es0 J -,oe4ic li'er a4scess 19 and /<I
Bo,4a( E J -))<.3":!4-6$ ? Hin:s @
$7 -ssore( -* -5uac(l /-* Iuerra J/* et al -,e4iasis
in'asi'a %or,as e6traintestinales ( co,3licaciones Dia5nSstico
3arasitolS5ico e serolS5ico <e' 1lin >s3 -);3.76:$71-8
? Hin:s @
$8 9ri4oule( D< &tilisation du test >HIS- 3our le dia5nosti8ue
serolo5i8ue de lDa,e4iase 0+3ati8ue Ttude co,3ar+e a'ec 4
autres ,+t0odes i,,unoflorescence* 0+,a5lutination 3assi'e et
fi6ation du co,3le,ent Bull Soc Pat0 >6ot -);1.7!:1$-!
? Hin:s @
$" Ea8ue <* -li IO/* Petri K- Jr 1o,3arison of P1<*
isoenz(,e anal(sis and anti5en detection of Entamoeba
histolytica infection J 1lin /icro4iol -));.36:444"-!$
? Hin:s @
30 1onter <H* Pitt E-* 9o,3:ins <O* et al Differentiation of
3(o5enic fro, a,e4ic 0e3atic a4scess Sur5 I(necol =4stet
-);=.16$.114-7 ? Hin:s @
31 Barnes P%* De 1oc: O/* <e(nolds 9N* et al - co,3arison
of a,e4ic and 3(o5enic a4scesses of t0e li'er /edicine
-);<.66:47$-8 ? Hin:s @
3$ Su4ra,anian < -,e4iasis e6traintestinal ,anifestations J
-ssoc P0(sician Undia -)=;.16:$"1-4 ? Hin:s @
33 >lic0i >N* >ta7o &S 0est co,3lications of a,e4ic li'er
a4scess: a re3ort of si6 cases fro, Ni5eria >ast -fr /ed J
-))2.71:18"-"$ ? Hin:s @
34 Ireane( I1* <e(nolds 9B* Dona'an -*J <u3tured a,e4ic
li'er a4scess -rc0 Sur5 -);3.1$0:!!!-" ? Hin:s @
3! I4arra-Perez 1 90oracic co,3lications of a,e4ic li'er
a4scess: re3ort of !01 cases 10est -);-.7": 87$-7
? Hin:s @
36 Hand( /J* Setia7an E* Eersc0 I* et al Ee3atic and
t0oracic a,e4iasis -J< -);*.13!:44"-!4 ? Hin:s @
37 Oa3ur = P 1linical s(ndro,es 3roduced 4( left lo4e a4scess
Bo,4a( Eos3 J -))*.3$: 70-8 ? Hin:s @
38 /andra5o,-Sanc0ez <* 1ortez->s3inoza 9 Sanc0ez <* et al
<u3ture of an a,e4ic li'er a4scess into t0e 3ericardiu,:
3resentation of a case and re'ie7 of t0e current ,ana5e,ent
Ee3ato5astrenterolo5( -))2. 41: !8!-7 ? Hin:s @
3" %ree,an -H* B0oola OD Pneu,o3ericardiu, co,3licatin5
a,oe4ic li'er a4scess S -fri /ed J -)<=.4$6:!0-$ ? Hin:s @
40 -da,s >B -,oe4ic 3ericarditis /edicine -)<2.17:1013-6
? Hin:s @
41 Io,ersall IN* 1urrie J* Jeffre( < -,oe4iasis: a rare cause
of cardiac ta,3onade Brit Eeart J -))2.71 336-" ? Hin:s @
4$ Kallace J< -,e4ic 3eritonitis follo7in5 ru3tures of an
a,e4ic li'er a4scess -rc0 Sur5 -)<;.113:33$-! ? Hin:s @
43 >55leston %* Eanda EO* Ger50ese / -,e4ic 3eritonitis
secondar( to a,e4ic li'er a4scess Sur5er( -);1. "1:46-!1
? Hin:s @
44 =0ana J- -4do,e a5udo e a,e4Mase 1ol Br)s 1ir
-);<.1:7-14 ? Hin:s @
4! 90o,3son J>* %orlenza S* Ger,a < -,e4ic li'er a4scess: a
t0era3eutic a33roac0 <e' Infect Dis -);3.7:171-"
? Hin:s @
46 -rauFo <* Bic0ara 1N* 10a'es H1 et al -,e4Mase In:
DoenNas Infecciosas e Parasit)rias: >nfo8ue -,azPnico Par):
1eFu3 -))<:!81-"6 ? Hin:s @
47 Po7ell SJ* >lsdon < /etronidazole in a,oe4ic d(senter( and
a,oe4ic li'er a4scess Hancet -)==.$:13$"-31 ? Hin:s @
48 <ol %J1 /etronidazole: re'ie7 of its use and to6icit( J
-nti,ic 10e,ot0 -)<<.3:$0!-" ? Hin:s @
4" Eu55ins D Dro5as antia,e4ianas <e' Br)s 1lin 9era3
-);1.11:683-700 ? Hin:s @
!0 /a5allan -< -4scesso a,i4iano del 0i5ado 9rata,iento
,+dico co, defirentes es8ue,as <e' Eos3 Ju) /+6ico
1***.67:!1-4 ? Hin:s @
!1 Salles J/1 -'aliaN2o da efic)cia do secnidazol na a,e4Mase
a5uda <e' Br)s /+d 9ro3 -);).$$:33-! ? Hin:s @
!$ 1a4ello <<* et al Nitazo6anida for t0e treat,ent of
intestinal 3rotozoan and 0el,int0ic infections 9rans <o(al Soc
9ro3 /ed E(5 -))<."1:701-3 ? Hin:s @
!3 -nderson /D* =ldfield >1 Hu,inal a5ents for in'asi'e
a,e4iasis: nice or necessar(V -, J Iastrenterolo5(
-))>.88:"64-! ? Hin:s @
!4 %ernandes P >,3re5o do teclosan na a,e4Mase intestinal e,
dose Rnica %ol0a /+dica -)<;.77:141-! ? Hin:s @
!! Salles J/* Gieira /9 -'aliaN2o da ati'idade da etofa,ida na
a,e4Mase intestinal = Eos3ital -)<*.7!:331-6 ? Hin:s @
!6 <eed SH* <a'din JI -,e4iasis In: Blaser /J* S,it0 PD*
<a'din JI Infections of t0e 5astrointestinal tract $ ed* Ne7
Lor:. <a'en Press -))3.133-6 ? Hin:s @
!7 -llan-Jones >* /indel -* Sar5eaunt PI =utco,e on
untreated infection 7it0 Entamoeba histolytica in 0o,ose6ual
,en 7it0 and 7it0out EIG anti4od( B/J -);;.$"7:6!4-7
? Hin:s @
!8 <eed SH* Kessel DK* Da'is 1% Entamoeba histolytica and
-IDS -, J /ed -))*."0:$6"-71 ? Hin:s @
!" 1i,,er,an S Pre'alencia de 3arasitoses intestinais e,
3acientes 3ortadores da SMndro,e da I,unodeficiQncia -d8uirida
B-IDSC 9ese B/estradoC >scola Paulista de /edicina-&ni'ersidade
%ederal de S2o Paulo S2o Paulo* -)); ? Hin:s @
60 Saras7at G-* -5ar7al DO* BaiFal SS* et al Percutaneous
cat0eter-draina5e of a,e4ic li'er a4scess 1lin <adiol
-))1.4!:187-" ? Hin:s @
61 <a,ani -* <a,ani <* Ore,an /S &ltrasound-5uided needle
as3irate of a,e4ic li'er a4scess Post5rad /ed J -))>.60:381-3
? Hin:s @
6$ De Ha <e( NJ Indications for as3iration of a,e4ic li'er
a4scess Sout0 -fr /ed J -);).7!:376 ? Hin:s @
63 <als PK* Barnes P%* et al /edical treat,ent of 0e3atic
a,e4ic a4scess: rare need for 3ercutaneous draina5e <adiolo5(
-);<.16!:80!-7 ? Hin:s @
64 Ja'ed I* S(ed -L Ha3arosco3ic draina5e of li'er a4scess Br
J Sur5 -));.86:330-$ ? Hin:s @
6! -ndre -< Sur5ical considerations in t0e ,ana5e,ent of
a,oe4ic li'er a4scess Bo,4a( Eos3 E -))<.3":110-4
? Hin:s @


Correspo#de#ce to
Dr Jos+ /aria Salles
-' Gisconde de Souza %ranco* 1348
Wi3 code: 660!3-000* Bele,-Par)* Brazil
P0one B!! "1C $$3-76!" %a6 B!! "1C $$3-!487
>-,ail: sallesXnautilusco,4r
<ecei'ed on 03 -3ril $00$
re'ised 08 -u5ust $00$