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1. E. histolytica trophozoites colonize the mucosal surface of the large

intestine. The trophozoites adhere to the mucus layer and ingest
bacteria and cellular debris from the lumen. Adherence is mediated
by a protein called the eh-lectin which is expressed on the surface
of trophozoites. This non-invasive infection is usually asymptomatic,
or exhibits symptoms ranging from mild abdominal discomfort to
diarrhea and cramps. [Top][Bottom]

2. A breakdown in the mucous barrier can lead to a contact-dependent

killing of the epithelial cells. Proteases secreted by the trophozoites
may weaken the mucus. Necrotic and apoptotic mechanisms are
probably involved in the killing of the host cells. This necrosis of the
mucosa will lead to an invasive disease characterized by dysentery
(ie, blood and mucus in the feces). In addition, the breakdown of
the tissue and extracellular matrix (ECM) implies that proteases are
also involved in the pathogenesis. [Top][Bottom]

3. The trophozoites will continue to advance laterally and downward

into the submucosa producing a 'flask-shaped' ulcer. Necrotic
material is found in the center of the ulcer and most of the ameba
are at the border between the healthy and damaged tissue.
Neutrophils and other immune effector cells are also killed. The
ameba are now ingesting host cells instead of bacteria and
hematophagous trophozoties can be observed. Ulcers can coalesce
and lead to the shedding of patches of mucosa. The severity of the
dysentery increases in terms of the number of stools and the
amount of mucus and blood. [Top][Bottom]

4. The trophozoites can also penetrate the muscle and serous layers
leading to intestinal perforations. Perforation of the intestinal wall is
a dramatic event that can lead to peritonitis or leakage into the
abdominal cavity. Erosion of blood vessels can lead to massive
hemorrhage. An inflammatory thickening of the intestinal wall,
called an ameboma, or amebic granuloma, can also be formed in
response to the ameba. The ameboma presents as a painful
palpable mass that can be mistaken for a tumor. [Top][Bottom]

5. Trophozoites can also gain access to the circulatory system and be

disseminated. The liver is the primary site of extraintestinal
amebiasis and hematogenous spread to other organs is rare.
Metastasis to the liver involves the portal vein which carries blood
from the colon directly to the liver. Dissemination to other tissues
most often entails the direct extension of hepatic or colonic lesions.
Extraintestinal amebiasis is often characterized by ameba free
stools. [Top][Bottom]

These pages are developed and maintained by Mark F. Wiser, Tulane University (2000). Last update on June 30,

As discussed above, E. histolytica is pathogen that exhibits a wide spectrum of

virulence, ranging from an avirulent commensal to a highly invasive and
destructive organism (see discussion of pathogenicity vs. virulence). Some of
this difference in virulence is explained by the existence of the morphologically
identical, but avirulent, E. dispar. E. dispar has never been associated with a
symptomatic invasive disease and infection does not elicit serum antibodies. In
contrast, anti-ameba humoral responses are observed in both asymptomatic and
symptomatic E. histolytica infections. This suggests that even in asymptomatic
cases there is a limited amount of invasion. However, infection with E.
histolytica does not always lead to invasive disease, though, in that only about
10% of the infected individuals will develop symptomatic invasive amebiasis.
The factors responsible for the pathogenesis of E. histolytica are not well
understood. One approach to understanding the pathogenesis is to compare
possible virulence factors between these two closely related species.

Pathology results from host-parasite interactions, and therefore, host

factors, parasite factors or a combination of both may contribute to the
disease state. For example, the development of invasive disease could be
due to quantitative or qualitative aspects of the host immune response.
Recruitment of neutrophils and intense inflammation are noted in the
early phases of amebic invasion. However, inflammation surrounding
established ulcers and abscesses if often minimal given the degree of
tissue damage.

The nature of protective immune responses is not clear. Innate or

nonspecific immunity, as well as acquired immunity, are probably both
important for the prevention of invasive disease. The mucous layer
covering the epitheilial cells can prevent contact between trophozoite and
host cells. In addition, mucosal IgA responses do occur as a result of
infection and fecal IgA against a trophozoite surface lectin (see Eh-lectin)
are associated with a lower incidence of new E. histolytica infections. High
titers of serum antibodies also develop in patients with liver abscesses.
However, since the invasive disease is often progressive and unremitting,
the role of these anti-ameba antibodies is in question. Cell-mediated
responses appear to play a role in limiting the extent of invasive
amebiasis and protecting the host from recurrence following successful

Resistance to the host immune response is another possible virulence

factor which could contribute to the development and exacerbation of
invasive disease. For example, one phenotypic difference between E.
dispar and E. histolytica is the resistance of the latter to complement
mediated lysis (see E. dispar). In addition, E. histolytica rapidly degrades
secretory IgA and possibly suppresses T-cell responses to E. histolytica
antigens. E. histolytica is also able to kill cells, including neutrophils and
other immune effector cells, in a contact dependent manner. Lysis of
neutrophils could also release toxic products which contribute to the
destruction of host tissue. However, the role of these various phenomena
in pathogenesis is not known.

Invasion of intestinal mucosa by E. histolytica is an active process

mediated by the parasite and distinct steps can be recognized (Figure,
click here for larger image and detailed legend). Trophozoites adhere to
the mucus layer (step 1). This adherence per se probably does not
contribute to pathogenesis and is simply a mechanism for the ameba to
crawl along the substratum. Depletion of the mucus barrier allows for the
trophozoite to come in contact with epithelial cells. Epithelial cells are
killed in a contact dependent manner leading to a disruption of the
intestinal mucosa (step 2). The trophozoites will continue to kill host cells
in the submucosa and further disrupt the tissue as they advance (step 3).
Disruption of the intestinal wall (step 4) or metastasis via the circulatory
system (step 5) is also possible. Adherence, cytotoxicity, and disruption of
the tissues are important factors in the pathogenesis of E. histolytica.
Parasite proteins which could play a role in these processes include: the
Eh-lectin, amebapore, and proteases.
Eh-lectin. E. histolytica can kill cells within minutes of adhering to them
in the presence of extracellular calcium. Adherence of E. histolytica
trophozoites to host cells and colonic mucins is mediated by a lectin-
activity expressed on the ameba's surface. This lectin binds galactose or
N-acetyl-D-galactosamine (GalNAc) with a high affinity and is also called
the galactose-inhibitable adherence protein (GIAP) or the Gal/GalNAc
lectin. The contact-dependent killing of target cells is almost completely
inhibited by galactose or GalNAc and target cells lacking terminal
galactose residues on their surface glycoproteins are resistant to
trophozoite adherence and cytotoxicity. This suggests that the Gal/GalNAc
lectin is an important virulence factor. In addition, the Eh-lectin is
involved in resistance to complement mediated lysis. Because of its
potential role in adherence and virulence and since fecal IgA against it
protect against amebic colitis, the Gal/GalNAc is a vaccine candidate
(Petri et al, 2006, Arch. Med. Res. 37:288).

The Eh-lectin is a heterodimer consisting of a 170 kDa heavy chain and a

31-35 kDa light chain joined by disulfide bonds. An intermediate subunit
of 150 kDa is noncovalently associated with the heterodimer. The heavy
chain has a transmembrane domain and a carbohydrate binding domain.
All of subunits are encoded by multigene families. There are five members
of the heavy chain family, 6-7 members of the light chain family and 30
members of the intermediate chain family. The members of the heavy
chain gene family exhibit 89-95% sequence identity at the amino acid
level whereas the light chain family members are less conserved sharing
only 79-85% sequence identity.

E. dispar also expresses Gal/GalNAc lectin on its surface. Both E. dispar

and E. histolytica need to adhere to the mucous layer which is medicated
by the Gal/GalNAc lectin. Mucus is composed of glycoproteins called
mucins. The predominant mucin found on the intestinal mucosa is Muc2
which is extensively glycosylated with O-linked GalNAc residues. The
sequence of the light and heavy chain genes from E. dispar are
homologous, but not identical, to those of E. histolytica. Antigenic
differences between the GIAP of E. dispar and E. histolytica have also
been described in that only two epitopes out of six are shared between
the two species (see E. dispar). It is not known whether these sequence
differences can account for the differences in virulence between E. dispar
and E. histolytica. Adherence is obviously important for both species, but
it is possible that the adherence is qualitatively or quantitatively different
between the two species.

[Review on the Eh-lectin: Petri et al (2002) Annu. Rev. Microbiol. 56:39.]

Amebapore. A family of pore-forming polypeptides has been identified in

E. histolytica and E. dispar. The three family members are designated as
amebapore A, B and C with amebapore A being predominant expressed.
The mature polypeptide is 77 amino acids long and forms dimers at low
pH (4-6). Three of these dimers then assemble into a hollow ring-shaped
structure. This hexamer then can intercalate into membranes and
introduce 2 nm pores (i.e., holes) which results in cell death. The pore-
forming activity is dependent on this assembly process beginning with the
dimerization. Amebabpore A is 95% identical (i.e., four residues are
different) between E. histolytica and E. dispar. In addition, the E. dispar
amebapore has approximately half of the pore-forming activity as the E.
histolytica amebapore. This difference in pore-forming activity has been
attributed to a glutamate residue at position 2 in the E. histolytica
amebapore, as compared to a proline residue in the E. dispar amebapore.
This particular amino acid residue is important for the formation of the
dimers and it is believed that the dimers of E. dispar amebapore are less

Amebapore is localized to vacuolar compartments (eg, food vacuoles)

within the trophozoite and is most active at acidic pH suggesting that the
major function of amebapore is to lyse ingested bacteria. Nonetheless,
amebapore is implicated as a virulence factor in that genetic manipulation
of E. histolytica resulting in decreased expression of amebapore leads to a
reduction in pathogenicity (ability to form liver abscesses) as well as a
reduction in bacteriocidal activity (Bracha et al Mol. Microbiol. 34:363,
1999). Similarly, modified E. histolytica completely devoid of amebapore
production are unable to form liver abscesses in model systems (Zhang et
al, Inf. Imm. 72:678, 2004). However, these amebas are able to cause
inflammation and tissue damage in models for amebic colitis.

[Review on amebapore: Leippe et al, Tr. Parasitol. 21:5, 2005.]

Proteases. Proteases are enzymes that degrade other proteins and could
contribute to the pathogenesis cause by E. histolytica. In this regard, E.
histolytica expresses and secretes higher levels of cysteine proteases, a
particular class of protease, than E. dispar. Cysteine proteases have been
shown to disrupt the polymerization of MUC2, the major component of
colonic mucus. This degraded mucus is less efficient at blocking
adherence of trophozoites to epithelial cells. Destruction of the
extracellular matrix (ECM) by proteases may also facilitate trophozoite
invasion. Inhibitors of cysteine proteases can decrease liver abscess size
in experimental models.

Twenty different cysteine protease genes have been identified in E.

histolytica. Orthologs of two of the E. histolytica cysteine protease genes
are not found in E. dispar. One of these, designated CP5, is expressed at
high levels on the trophozoite surface. Mutants expressing lower levels of
CP5 had a reduced ability to generate liver abscesses in a hamster
amebiasis model. However, these mutants also had a reduced growth rate
and lower erythrophagocytic activity, thus it is not clear whether CP5
directly participates in the invasiveness of E. histolytica. Furthermore
inhibition of 90% of CP5 activity did not affect the ability of E. histolytica
trophozoites to destroy cell monolayers in vitro. CP1, CP2, and CP5 are
the most abundantly expressed cysteine proteases in E. histolytica,
whereas CP3 is the most abundant in E. dispar. Interestingly, over
expression of CP2 in E. dispar increased the ability of trophozoites to
destroy cell monolayers in vitro. However, the over expression of CP2 did
not lead to the ability of E. dispar to form liver abscesses in gerbils.
Therefore, it is not clear the precise roles proteases may play in

In summary, the pathogenesis associated with E. histolytica infection is

primarily due to its ability to invade tissues and kill host cells. Several
potential virulence factors have been identified (see Table). However, it is
not clear the exact role these various virulence factors play in the
development of invasive disease. One approach to understanding the
pathogenesis is to compare these factors from E. histolytica and E. dispar.
These two species are closely related and the potential virulence factors
are found in both species. Adherence, cytolytic activity and proteolytic
activity are inherent biological features of both species and these
activities do not necessarily lead to pathology. However, there are
qualitative and quantitative differences between E. histolytica and E.
dispar which may account for the differences in virulence. These genetic
differences between E. histolytica and E. dispar indicate that pathogenesis
is in part an inherent feature of the parasite. However, pathogenesis is
probably due to the combined effects of several host and parasite factors,
and the virulence may represent the degree to which the host can control
trophozoite invasion and replication.

[See Huston, 2004, Tr. Parasitol. 20:23 or Ralston and Petri, 2011, Tr.
Parasitol. 27:253 for reviews on pathogenesis.]
These pages are developed and maintained by Mark F. Wiser, Tulane University (2000). Last update on June 3, 2015