Spp Entamoeba histolytica

At least 4 species of amoebae live in the human intestinal tract :

o Entamoeba histolytica,
o E. dispar
o Entamoeba coli
o Endolimax nana
o Iodamoeba butschlii.
The intestinal amoebae have 2 stages in their life cycles, a motile trophozoite and
a cyst.
E. histolytica is the only proven pathogen among the amoebae producing both
intestinal and extraintestinal lesions.
Naegleria fowleri
This is a freeliving amoebae found in soil and
!ater.
"uman infections have been reported from many
parts of the !orld and result from s!imming in
contaminated !ater.
#nfection by $aegleria appears to be more
common than by Acanthamoeba.
Acanthamoeba castellani
%bi&uitous, free living amoebae found in soil
and !ater.
"uman infections have been reported from
many parts of the !orld
'esult from s!imming in contaminated !ater.
(an also result from infected contact lens
solutions
#nfection by $aegleria appears to be more
common than by Acanthamoeba.
)isease Amoebiasis
#nfection by E. histolytica is found !orld!ide, but occurs most fre&uently in tropical
countries
*S+ areas !ith poor sanitation
About ,2- of pple in %S are affected. The disease is !idely prevalent among
male homosexuals
Primary amoebic meningoencephalitis (PAM)
This is a purulent meningitis and a rapidly fatal
encephalitis
(linically the condition is described as /primary
amoebic meningitis0 1+A23 as the central
nervous system is primarily involved, unli4e
infections !ith *ntamoeba histolytica in !hich
brain involvement is usually secondary.
5ranulomatous amoebic encephalitis15A*3
This can cause a brain infection too, but
progresses more slo!ly. (an become
chronic.
Amoebic 4eratitis
S4in or lung lesions
6ife cycle (ysts are passed in feces .
#nfection by Entamoeba histolytica occurs by ingestion of mature cysts in fecally
contaminated food, !ater, or hands.
*xcystation occurs in the small intestine and trophozoites are released,
!hich migrate to the large intestine.
The ingested cysts differentiate into trophozoites in the ileum 7%T tend to colonize
the rectum and colon
The trophozoites multiply by binary fission and produce cysts , !hich are
passed in the feces .
7ecause of the protection conferred by their !alls, the cysts can survive days to
!ee4s in the external environment and are responsible for transmission.
1Trophozoites can also be passed in diarrheal stools, but are rapidly destroyed
once outside the body, and if ingested !ould not survive exposure to the gastric
environment.3
%bi&uitous in nature, found in fresh !ater la4es
and ponds
Three life cycle stages
8 amoeba !ith pseudopodia
8 motile biflagellate form
8 resistant cyst stage
Amoebae
#n many cases, the trophozoites remain confined to the intestinal lumen 1 :
noninvasive infection3 of individuals !ho are asymptomatic carriers, passing cysts
in their stool.
#n some patients the trophozoites invade the intestinal mucosa 1 : intestinal
disease3, or, through the bloodstream, extraintestinal sites such as the liver, brain,
and lungs 1 : extraintestinal disease3, !ith resultant pathologic manifestations.
Trophozoites invade the colonic epithelium and secrete enzymes that cause
localized necrosis
6ittle inflammation occurs at the site
As the lesions reaches the muscularis layer, a typical flas4 shaped ulcer forms that
can undermine and destroy large areas of the intestinal epithelium
+rogression into the submucosa leads to invasion of portal circulation by the
trophozoites
7y far the most fre&uent site of systemic disease is the liver !here abscesses
containing trophozoites form
#t has been established that the invasive and noninvasive forms represent t!o
separate species, respectively E. histolytica and E. dispar, ho!ever not all persons
infected !ith E. histolytica !ill have invasive disease. These t!o species are
morphologically indistinguishable.
Stages Trophozoites 2otile 9eeding Stage
(yst form is infective
Amoebae stage 1trophozoite stage3 infective Stages in life cycle
Trophozoite
(yst
'oute of
Transmission
:rganism is ac&uired by ingestion of cysts that are tm primarily by the fecal oral
route in contaminated food and !ater
Anal oral transmission among the male homosexuals, also occurs
9ecal exposure during sexual contact 1in !hich case not only cysts, but also
trophozoites could prove infective3.
There is $: animal reservoir
+ossible entry through respiratory tract, eyes,
s4in
$:T* nasal route of infection is not as
common as in $aegleria
2ay aspirate !ater into the lungs and get
infection in lung
8 (an infect the eye or s4in by direct trauma
8 +resumed hematogenous dissemination to the
($S
8 #nfection associated !ith debilitation or
immunosuppression
16evinson says that the infection occurs
primarily in immunocompromised pple for
Acanthamoeba, !hile $aegleria infections occur
in other!ise healthy pple usually children3
(arriage Asymptomatic cyst passers may transmit disease
Since cysts are the transmissible stage, and cysts are not passed in diarrhea
$o carriers
Amoeba is free living in environment
$o carriers
Amoeba is free living in environment
hence !ill not get amoebiasis from the diarrhea stools 1(;STS only found in
$:'2A6 ST::6S3
+athogenesis Non- Invasive: Amoebae on mucosa surface
(an either be an Asymptomatic cyst passer carriers
:' $ondysenteric diarrhea1T"#S #S $:T 76::); "*$(* $:T );S*$T*';3,
cramps, abdominal discomfort
Invasive: $ecrosis of mucosa < ulcer due to destruction of mucosa
)ysentery
)iarrhea !ith mucus and blood in stools
$ote that dysentery can be either amoebic or bacterial. "ence should loo4 for
"ematophagous trophozoites present in stools characteristic of amoebic dysentery
Metastases- Extraintestinal Amoebiasis: )issemination primarily via blood
stream
*.g. portal vein !hich !ill affect liver 1+'*):2#$A$T S#T* A99*(T*)3
'esults in amoebic abscess
:ther sites infre&uent
7rain, cutaneous, pulmonary
$:T* that cutaneous amoebiasis is 'A'*
#n cases of *=T'A#$T*ST#$A6 A2:*7#AS#S
Amoebafree stools common should not be surprised $:T to find amoeba in
stools because the amoeba move out of the gut.
(linical
+resentation
#ntestinal Amoebiasis:
Asymptomatic cyst passer
1. Symptomatic $ondysenteric infection 1colitis3
2. Amoebic dysentery 1acute3
3. Amoeboma 1amoebic granuloma3
4. Amoebic appendicitis
(omplications and se&uelae of intestinal amoebiasis
,. 9ulminant colitis
2. +ost dysenteric colitis
>. Stricture
4. #ntussusception
?. +erforation and peritonitis
@. +erianal ulceration
"epatic Amoebiasis:
This is a big problem !ith amoebiasis
1acute nonsuppurative and liver abscess3
o 9ever
o 6iver enlargement
o 6iver tenderness
+rimary Amoebic 2eningoencephalitis 1+A23
The infection occurs for Acanthamoeba occurs
primarily in immunocompromised pple
7%T $aegleria infections occur in other!ise
healthy pple usually children
#nfection !ith these organisms should be
suspected in individuals !ith
meningoencephalitis !ho have been s!imming
in fresh !ater pools, ponds or hot springs > to A
days previously.
8 ,,4 days incubation period
8 #nfection introduced through nasal cavity and
olfactory bulbs
8 Symptoms usually !ithin a fe! days after
s!imming in !arm still !aters
8 Symptoms include headache, lethargy,
disorientation, coma 1fairly non specific3
8 'apid clinical course, death in 4? days after
onset of symptoms
8 24 survivors B:'6)B#)*
Chronic granulomatous amoebic
encephalitis (GAE)
8 A type of meningoencephalitis, Cgranulomatous
amoebic encephalitis0 15A*3 is caused by
Acanthamoeba spp.
8 (an be subacute or chronic disease !ith focal
granulomatous lesions in the brain.
:n postmortem examination,
8 2icroscopic examination of the infected brain
sho!s nests of amoebae !ith extensive
haemorrhagic reaction mostly involving the
basilar portion of the cerebrum and cerebellum.
8 #n Acanthamoeba infections cysts and
trophozoites may also be found. amoebae not
detected in spinal fluid.
8 The route of ($S invasion is thought to be
hematogenous, !ith the primary site being s4in,
respiratory tract or eyes
8 :nset insidious !ith headache, personality
changes, slight fever
8 +rogresses to coma and death in !ee4s to
months
Inections o the s!in
o 6iver abscess
o +us is bro!nish yello! !ith consistency of anchovy paste
Complications o liver abscess"
o 'upture or extension
o 7acterial infection
o "aematogenous spread to other organs.
#nvolvement of other organs 1lung, brain, spleen, etc3 may occur !ithout manifest
liver involvement.
8 S4in lesions have also been associated !ith
Acanthamoeba infections.
Amoebic inection o the eye
Pre#isposing actors
8 :cular trauma
8 (ontact lens 1contaminated cleaning solutions3
this has become the most common disease
associated !ith acanthamoeba infection
$ymptoms
8 :cular pain
8 (orneal lesions 1refractory to usual
treatments3
8 Amoebic 4eratitis can also occur
8 Together !ith %veitis and corneal ulceration
8 #nfections have been seen in both hard and
soft lens !earers.
(omplications o %lcer enlargement
o (olitis
o +eritonitis
o 2etastasis 1see extraintestinal amoebiasis3
o :ccasional amoeboma 1can form a tumor li4e mass. 5ranulomatous
type mass that can obstruct the intestine and loo4 li4e a tumor3
)iagnosis Intestinal Amoebiasis"
,. Stool examination for trophozoitesDcysts
#t ta4es a trained microbiologist to differentiate E. histolytica for the other protozoa
in intestine particularly *.dispar
2. Sigmoidoscopy
6oo4 for ulcers in the large intestine lining. At most can inspect li4e less than a
meter of intestine
%eaptic Amoebiasis"
,. Stool examination
Stool sample may be ta4en 7%T because this is extraintestinal, hence stool
samples may be negative
2. Serology
>. #maging
This is the preferred method. %se (T scan or ultrasound
)iagnosis is usually at autopsy
Microscopy o C$&
)iagnosis can be made by microscopic
examination of the (S9 !hich may reveal the
presence of the trophozoites.
(S9 may sho! red cells and is bacteriologically
sterile.
Culture o organism
The amoebae can also be cultured by
inoculating (S9 on to nonnutrient agar plates
previously seeded !ith *schericia coli.
'n post mortem
2icroscopic examination of the infected brain
sho!s nests of amoebae !ith extensive
haemorrhagic reaction mostly involving the
basilar portion of the cerebrum and cerebellum.
Amoebic Eeratitis: )emonstration of amoebae
in corneal scrapings
Microscopic examination o the C$&
)iagnosis can be made by microscopic
examination of the (S9
8 Bhich 2A; reveal the presence of the
trophozoites.
8 The (S9 may sho! red cells and is
bacteriologically sterile.
8 Amoebae not detected in spinal fluid
8 (ysts and trophozoites detectable in
histological specimens
Culture
The amoebae can also be cultured by
inoculating (S9 on to nonnutrient agar plates
previously seeded !ith *schericia coli.
4. Abscess aspiration
1seldom need to do this to diagnose no!, only aspirate !hen the lesion is about to
rupture and spread it to other organs
o 'eddish bro!n li&uid
Trophozoites at abscess !all 1not in the li&uid. Bhen aspirating fluid, !ill locate the
parasites at the tail end of the drainage of the abscess !hen they drop off the !all3
Fecal Examination
Techniques that can be used to identify E.histolytica
)irect Bet Smear
Saline
#odine
(oncentration 1sedimentation and flotation3
9ormalinethyl acetate sedimentation
Finc sulphate flotation
Treatment The treatment of choice for symptomatic intestinal amoebiasis or hepatic
abscesses is 2*T':$#)AF:6* 196A5;63 or tinidazole
"epatic abscesses need not be drained
Asymptomatic cyst carriers should be treated !ith ido&uinol or paromomycin
Amphotericin 7
&rom (evinson
+rognosis ho!ever is poor even in treated cases
)ifficult, limited success
8 (orneal grafts often re&uired
These may be effective in acanthamoeba
infections
+entamidine
Eetoconazole
9lucytosine
+revention +revention involves avoiding fecal contamination of food and !ater and observing
good personal hygiene such as hand !ashing
+urification of municipal !ater supplies is usually effective, but outbrea4s of
amebiasis in city d!ellers still occurs !hen contamination is heavy
+rohibit use of night soil 1human feces3 for fertilization of crops
#n areas of endemic infection, vegetables should be coo4ed