Amoebiasis

ENTAMOEBA HISTOLYTICA
 Entamoeba histolytica was
first described by Lambl in
1859 and Losch established it
pathogenic nature in 1875 in
a dysenteric patient is
St.Petersberg
 Councilman and Lafleur in
1981 described amoebic liver
abscess.
 Schaudinn ( 1903 )
differentiated pathogenic and
nonpathogenic types of
Amoebae
Amebiasis
 Amebiasis is a disease caused
by a one-celled parasite called
Entamoeba histolytica

Although it is more common in

people who live in tropical
areas with poor sanitary
conditions
 Amoebiasis a Major Health Problem
 Amoebiasis is estimated to cause 70,000 deaths
per year world wide Symptoms can range from
mild diarrhea to dysentery with blood and
mucus in the stool. E. histolytica is usually a
commensals organism. Severe Amoebiasis
infections (known as invasive or fulminant
amoebiasis) occur in two major forms. Invasion
of the intestinal lining causes amoebic dysentery
or amoebic colitis.
Trends of Amoebiasis
MORPHOLOGY
Trophozoites and Cystic stages
Trophozoites of E.histolytica
Cystic stage - E.histolytica
Life Cycle
 Transmission of Amebiasis
 Amoebiasis is transmitted by
fecal contamination of
drinking water and foods,
but also by direct contact
with dirty hands or objects
as well as by sexual
contact.
 Additionally, geophagy is a
common route of infection
in certain cultures.
Pathology
 Nature of the disease

 Symptoms are usually gastrointestinal including

diarrhoea, vomiting, abdominal pain or discomfort and
fever. Symptoms take from a few days to a few weeks
to develop and manifest themselves, but usually it is
about two to four weeks. Most infected people are
asymptomatic but this disease has the potential to make
the sufferer dangerously ill, especially if there is any
suggestion of immunocompromised.
Amoebiasis causes Epithelial damage
 Tissue showing Amoebic infection
 The spherical structure
(Trophozoites) has one
basophilic nuclei about
the size of RBC’s. Note
some RBC's are
phagocytosed by the
Trophozoites
(erythrophagocytosis)
 Virulence factors
 Trophozoites of E.histolytica interact with host through a series
of steps
1 Adhesion of target cell, phagocytosis and cytopathic effect
2 E.histolytica induces both Humoral and cell mediated immune
responses.
3 Virulence factors – In many circumstances lumen dwelling
Amoeba may be asymptomatic
4 Causes disease only when invade the Intestine
5 Virulence is associated with secretion of Cysteine
proteniase which assists the organism in digesting the
extracellular matrix and invading tissues
 Cysteine proteinase - Complement
factor C3
 It is observed Cysteine
proteinase produced by
invasive strains of
E.histolytica inactivates
the complement factor
C3 and are thus resistant
to Complement
mediated lysis.
Cysteine proteinase virulent factor
 Cysteine proteinase is an
important virulent factor
 Its presence makes
E.histolytica is resistant to
complement mediated lysis
 Can cleave the extracellular
structural matrix and degrade
fibronectin and laminin, as
well as type I collagen.
 In this process basement
membrane is degraded and
leads to invasion
 Invasive x Noninvasive strains
 The invasive and non
invasive strains may appear
identical may represent two
distinct species
 1 Invasive strain –
E.histolytica
 2 Non invasive strains
reclassified as E.dispar.

 Doctortvrao’s ‘e’ learning series

 Host Factor Contributions
 Several factors contribute to influence infection
1 Stress
2 Malnutrition
3 Alcoholism
4 Corticosteriod therapy
5 Immunodeficiency
6 Alternation of Bacterial flora
 Doctortvrao’s ‘e’ learning series
 Risk Factors

 People in developing countries that have poor

sanitary conditions
 Immigrants from developing countries
 Travellers to developing countries
 People who live in institutions that have poor
sanitary conditions
 HIV-positive patients
 Men who have sex with men
 Doctortvrao’s ‘e’ learning series
 Dysentery
 No symptoms (in the
majority of cases),
 Vague gastrointestinal
distress,
 Dysentery (with blood
and mucus).

 Doctortvrao’s ‘e’ learning series

 How the Amebiasis Manifests
 Most cases of amebiasis have very mild
symptoms or none.
 More severe infection may cause fever, profuse
diarrhea, abdominal pain, jaundice, anorexia, and
weight loss.
 In severe cases, it can lead to development of
abscesses (pockets of amoebae and
inflammatory cells) in the liver or, more rarely,
the brain.
 Doctortvrao’s ‘e’ learning series
 Clinical symptoms
 Wide spectrum, from asymptomatic infection
("luminal amebiasis"), to invasive intestinal
amebiasis (dysentery, colitis, appendicitis, toxic
mega colon, amebomas), to invasive extra
intestinal amebiasis (liver abscess, peritonitis,
pleuropulmonary abscess, cutaneous and genital
amoebic lesions).
 Doctortvrao’s ‘e’ learning series
Diagnosis of Amebiasis
 BASICS METHODS IN
DIAGNOSIS
 Fresh stool: wet mounts and permanently
stained preparations (e.g., trichrome).
 Concentrates from fresh stool: wet mounts,
with or without iodine stain, and permanently
stained preparations (e.g.,
trichrome). Concentration procedures,
however, are not useful for demonstrating
Trophozoites.
 Doctortvrao’s ‘e’ learning series
 Diagnosis of Amebiasis
 Diagnosis of amebiasis can be very difficult. One
problem is that other parasites and cells can look very
similar to E. histolytica when seen under a microscope.
Therefore, sometimes people are told that they are
infected with E. histolytica even though they are not.
Entamoeba histolytica and another ameba, Entamoeba
dispar, which is about 10 times more common, look the
same when seen under a microscope
 Doctortvrao’s ‘e’ learning series
 Microscopy
 This is the traditional means
of diagnosing the disease—
one simply looks at a sample
of stool under a microscope.
Because E. histolytica is not
always found in every stool
sample, several samples from
different days may be
needed. Sometimes red blood
cells that have been ingested
by the parasite are visible.
 Microscopic examination of Stool
 A sample of freshly
collected fecal specimen
containing mucous and
blood is transferred on a
slightly warm slide and
covered with cover slip
and examined
microscopically
 Doctortvrao’s ‘e’ learning series
E. histolytica /E. dispar cyst.
E. histolytica/E. dispar cysts stained
with trichrome
E. hartmanni
Specific Diagnosis of active infection
should demonstrate Trophozoites
 Motile Trophozoites
throwing pseudopodia
and containing red blood
cells found in large
number
 Endoplasm appear bluish
or found glass in
appearance and nucleus
is not visible but faint
outline may be observed
IDOINE PREPARATION OF
STOOL
 Routinely not used
 Trophozoites stains yellow to
light brown,
Nucleus is clearly visible with
central karyosome
Cysts shows a smooth and
hyaline appearance, Nucleus
is clearly seen and no more
than 4 nuclei are present,
Glycogen mass stains brown,
while chromotoid bars are
not stained.
 Mucosal Scrapings
 Mucosal scrapings can be
obtained by sigmoidoscopy
useful in atypical
presentations and may serve
as adjunct to conventional
stool examination for Ova
and cyst
 Direct wet mount, a
permanently stained smear
and immuno stained smears
are examined.
 Doctortvrao’s ‘e’ learning series
Extra intestinal Amoebiasis
 The specimens are obtained
from Liver, lung, or Brain
biopsy samples and subjected
to routine Histopathology (
H&E) sections
 Giemsa stained touch
preparations which will revel
Trophozoites in extra
intestinal lesions.
 Amoebic Liver Abscess

 The material aspirated is

likely to contain
Trophozoites and may
be detected by direct
microscopic examination
 Serological Diagnosis
 The serological become reactive in invasive
Amoebiasis
 1 Indirect Heamagglutination assay ( IHA )
 2 ELISA
 3 Latex agglutination test
 4 gel diffusion
 5 Counter current Imunoelectrphoresis
 Serological tests remain positive for several
years ever after successful treatment
 Culture
 Cultures are not done routinely
 Boeck and Drbohlav’s medium modified by
Laidlaw extensively used for isolation and
maintenance of E.histolytica.
 Diamonds axenic medium used in studies on
Pathogenicty, antigenic characterization and
drug sensitivity tests

 Doctortvrao’s ‘e’ learning series

Do we need culturing for Diagnosis ?
 Trying to get the amoeba
to grow outside the body
is very difficult and
unreliable, and is
therefore not generally
done
 Immunity in Amoebiasis
 Infection with invasive
strains of E.histolytica
induce both Humoral
and cellular response.
 Infection offers some
degree of protection.
 Immunological Tests are not
confirmatory of Acute Infections
 When the body is exposed to an
infection, the immune system
creates antibodies to fight it off.
These can be detected with a
blood test, and provide evidence
that the person has been
infected with E. histolytica.
Unfortunately, this test does not
distinguish between past and
present infection
 Doctortvrao’s ‘e’ learning series
Emerging methods in Diagnosis
 These are considered the
most useful tests for
detecting E. histolytica. They
test directly for the parasite
itself by exposing some stool
to a strip of paper coated
with antibodies. The parasites
will stick to the antibodies on
the paper. The test
distinguishes E. histolytica
from other parasites.
 Treating Amebiasis.
 Frequently, either metronidazole (Flagyl) or
tinidazole (Fasigyn) are used to treat Amebiasis. If this
does not work, Chloroquine, emetine, and
dehydroemetine can be used.
 Eliminating cysts in carriers who do not have
symptoms is accomplished with diloxanide furoate
(Furamide), iodoquinol (Yodoxin), and
paromomycin. Nitazoxanide is a newer drug that
shows promise against not only E. histolytica but many
other parasites as well.
 Treating extra intestinal Amoebiasis
 Amoebic abscess is treated
similarly to dysentery, with
antibiotics. Sometimes
surgical drainage may be
performed, but this is usually
to rule out other (bacterial)
causes of abscess. It is also
performed if an abscess is
about to, or has already
ruptured.
 Preventing Amoebiasis
 Drink only bottled or boiled (for 1 minute) water, or carbonated
(bubbly) drinks in cans or bottles. Fountain drinks and any
drinks with ice cubes are not safe. Water can be made safe by
filtering it through an "absolute 1 micron or less" filter and
dissolving iodine tablets in the filtered water.
 Avoid fresh fruit or vegetables that were peeled by someone else.
 Avoid milk, cheese, or dairy products that may not have been
pasteurized.
 Avoid anything sold by street vendors.
 Doctortvrao’s ‘e’ learning series
 Food safety
 Thoroughly cook all raw foods.
 * Thoroughly wash raw vegetables
and fruits before eating.
 * Reheat food until the internal
temperature of the food reaches at
least 167º Fahrenheit.
 Wash your hands before preparing
food, before eating, after going to
the toilet or changing diapers, after
smoking or after using a tissue or
handkerchief.
 Doctortvrao’s ‘e’ learning series
Personal Hygiene
 Wash hands thoroughly with
soap and hot running water
for at least 10 seconds after
using the toilet or changing a
baby's diaper.
 Clean bathrooms and toilets
often. Pay particular attention
to toilet seats and taps.
 Avoid sharing towels or face
washers.
 Vaccines
 Vaccines are being developed and tested for the
treatment of Amebiasis. The vaccine is a
modified version of the proteins expressed on
the surface of E. histolytica. A study in rodents
found that the vaccine prevented the formation
of liver abscesses, but much more research is
needed to determine if these vaccines are useful
and safe in humans
 Doctortvrao’s ‘e’ learning series
 Created for Awareness to
Medical and Paramedical
workers in Developing World
 Zymodeme
 Lectin binding
Zymodeme analysis,
genome specific DNA
analysis and staining with
Monoclonal antibodies
have been successfully
used as markers to
identify invasive strains
of E.histolytica
Types of Zymodemes
 Based on
Electrophoretic mobility
E.histolytica strains are
classified into 22
Zymodemes
 However only 9 are
invasive
Numerous Eosinophilic spherical
structure within necrotic area.
 Charcot Leyden crystals in stool
examination supports the Diagnosis,
 Cysts have smooth and thin
cell wall and contain round,
retractile chromotoid bars
 Glycogen mass is not visible
 RBC’s and pus cells are
found in fair number
 Charcot Leyden crystals,
diamond shaped clear and
retractile structures are
present in faeces
 Doctortvrao’s ‘e’ learning series
Events on Amoebiasis