AMEBIASIS Epidemiology and Etiology Because of its worldwide distribution and serious

gastrointestinal manifestations, amebiasis is one of the most important parasitic diseases of

humans. 9 , 18 – 21 The major causative organism in amebiasis is E histolytica , which inhabits the
colon and must be differentiated from the Entamoeba dispar and a recently identified species,

E moshkovskii which are associated with an asymptomatic carrier state. E dispar is considered
nonpathogenic, while the status of E moshkovskii remains to be defined. 19 Although E
histolytica and E dispar are indistinguishable morphologically, monoclonal antibodies have been
used to separate the two. 20 , 21 The Entamoeba histolytica II kit (TechLab, Blacksburg, VA)
remains the most specific test for E histolytica . 19 Invasive amebiasis is almost exclusively the
result of E histolytica infection. Approximately 50 million cases of invasive disease result each year
worldwide, leading to an excess of 100,000 deaths. 19 , 21 The incidence of amebiasis is estimated
at approximately 4% in the general U.S. population. 21 The highest incidence is found in
institutionalized mentally retarded patients, sexually active homosexuals, patients with AIDS, and
new immigrants from endemic areas (e.g., Mexico, India, West and South Africa, and portions of
Central and South America). 19 , 21

Pathology E histolytica invades mucosal cells of colonic epithelium, producing the classic flask-
shaped ulcer in the submucosa. 19 – 23 The trophozoite has a cytolethal effect on cells through a
toxin. If the trophozoite gets into the portal circulation, it will be carried to the liver, where it
produces abscess and periportal fibrosis. 19 – 24 Amebic ulcerations can affect the colon,
perineum, and genitalia, and abscesses may occur in the lung and brain. 20 – 24

Clinical Presentation The most frequent clinical manifestations of the disease are gastrointestinal (
Table 124–2 ). Amebic liver abscesses can spread to the lungs and
pleura. 20 , 21 Pericardial infections, although rare, may be associated with extension of the
amebic abscess from the left lobe of the liver. Erosion of liver abscesses also present as peritonitis.
19 – 22

Review of the patient’s history and recent travel should be strongly emphasized. Intestinal
amebiasis is diagnosed by demonstrating E histolytica cysts or trophozoites (may contain ingested
erythrocytes) in fresh stool or from a specimen obtained by sigmoidoscopy. Three stool samples
obtained 24 to 36 hours apart will produce a 60% to 90% yield for E histolytica. Microscopy may not
differentiate between the pathogenic E histolytica and the nonpathogenic E dispar in stools.
Sensitive techniques are available to detect E histolytica in stool, including ELISA and antigen
detection. 19 – 21 , 23 Endoscopy with scraping or biopsy may provide more definitive diagnosis
where stool examinations do not provide adequate evidence. 19 , 21 When amebic liver abscess is
suspected from initial physical examination and history, confirmatory diagnostic procedures will
include serology and liver scans (using isotopes by ultrasound or computed tomography) or
magnetic resonance imaging. 20 , 21 Leukocytosis (>10,000/mm 3 ) and an elevated alkaline
phosphatase concentration (>75%) are common findings. In rare instances, needle aspiration of the
hepatic abscess may be attempted using ultrasound guidance. 20 – 22 , 24

TREATMENT Amebiasis DESIRED OUTCOME In amebiasis, the goals of therapy are initially to
eradicate the parasite by use of specific amebicides and then to render supportive therapy.

TREATMENT REGIMENS A number of different regimens have been suggested depending on the
category of amebiasis: asymptomatic cyst passers, intestinal amebiasis, and amebic liver abscess. 13
, 19 – 22 Electrolyte replacement, antibiotic therapy, and nutritional support are essential
adjunctive treatment modalities. Large hepatic abscess or amebic pericarditis may require needle
aspiration, percutaneous catheter drainage, or, rarely, surgery before drug therapy. 20 – 22 Most
regimens require a combination of drugs administered concurrently or sequentially. 19 , 21 , 24 A
careful history should be taken when one of the differential diagnoses is ulcerative colitis because
corticosteroid administration has the potential to unmask amebiasis and produce toxic megacolon.
22

PHARMACOLOGIC THERAPY M etronidazole (Flagyl), dehydroemetine, and chloroquine (Aralen) are

tissue-acting agents, whereas iodoquinol (Yodoxin), diloxanide furoate (Furamide), and
paromomycin (Humatin

amebicides. A systemic agent may be so well absorbed that only small amounts of the drug stay in
the bowel, which might prove ineffective as a luminal agent. 20 – 23 A luminal-acting agent, on the
other hand, may be too poorly absorbed to be effective in the tissue. In the asymptomatic cyst
passer, it is necessary to eradicate the causative agent from the lumen to prevent intestinal
amebiasis or the development of amebic liver abscess. Drug effectiveness must be monitored by
stool examination, that is, from one to three negative specimens from 1 to 3 months after
treatment.

Asymptomatic cyst passers and patients with mild intestinal amebiasis should receive one of the
following luminal agents: paromomycin 25 to 35 mg/kg/day 3 times daily for 7 days, iodoquinol 650
mg 3 times daily for 20 days, or diloxanide furoate 500 mg 3 times daily for 10 days. 1 6 These
regimens have cure rates of between 84% and 96%. 2 1 Diloxanide furoate is available only from
Ponorama Compounding Pharmacy (6744 Balboa Blvd., Van Nuys, CA 91406, (800) 247–9767; or
Medical Center Pharmacy, New Haven, CT, (203) 688–6816]. 1 6 The pediatric dose for
paromomycin is the same as in adults, whereas the dose of iodoquinol is 30 to 40 mg/kg/day
(maximum:2 g) in three doses for 20 days, and the dose of diloxanide furoate is 20 mg/kg/day in
three doses for 10 days. 1 6 Paromomycin is the preferred luminal agent in pregnant patients. 1 3, 2
1 P atients with severe intestinal disease or liver abscess should receive metronidazole 750 mg 3
times daily for 10 days, followed by a course of one of the luminal agents indicated earlier. 13 , 20 –
21 Tinidazole 2 g mg once daily for 5 days has been suggested for amebic liver abscess. 16 , 22 In
the pediatric patient, the dose of oral metronidazole is 50 mg/kg/day in divided doses to be followed
by a luminal agent. 16 Patients who are too ill to take oral metronidazole should receive the drug
in equivalent doses by the intravenous route. 2 1

Evaluation of Therapeutic Outcomes F ollowup in patients with amebiasis should include repeat
stool examination, serology, colonoscopy (for colitis), or computed tomography (CT) (for liver
abscess) between days 5 and 7, at the end of the course of therapy, and a month after the end of
therapy. Most patients with either intestinal amebiasis or colitis will respond in 3 to 5 days with
amelioration of symptoms. Patients with liver abscesses may take from 7 to 10 days to respond;
patients not responding during this period may require aspiration of abscesses or exploratory
laparotomy. Serial liver scans have demonstrated healing of liver abscesses over 4 to 8 months after
adequate therapy. 22

Sanitation and Preventive Measures Travelers and tourists visiting an epidemic area should avoid
local tap water, ice, salads, and unpeeled fruits. Water can be disinfected by the use of iodine
(tincture of iodine or commercial sources: Potable Aqua tablet (Wisconsin Pharmacal) or 5% to 10%
acetic acid, but boiled water is probably the safest. An alternative or additional measure may be to
carry a portable water purifier (such as Safewater, Durango, CO, www.outgear.com ). Because food
handlers in Asia and Latin America may be a source of amebiasis, travelers should avoid eating at
food stalls and open markets.

HELMINTHIC DISEASES M ost intestinal helminthic infections may not be associated with clearly
defined manifestation of disease, but they can cause significant pathology. 9 , 25 – 33 One factor
that determines the pathogenicity of helminths is their population density. Light infections may be
fairly well tolerated, whereas high populations of intestinal helminths can result in predictable
disease presentations. In the United States,

these infections are seen most frequently in recent immigrants from Southeast Asia, the Caribbean,
Mexico, and Central America. 1 , 8 , 26 , 27 Other populations that have a high risk of infestation
include institutionalized patients (both young and elderly), preschool children in daycare centers,
residents of Indian reservations, and homosexual individuals. Certain conditions and drugs (fever,
corticosteroids, and anesthesia) can cause atypical localization of worms. 34 – 38
Immunocompromised hosts can be overwhelmed by some helminthic infections, such as
strongyloidiasis. 34 NEMATODES