Entaboeba Histolytica and Non-pathogenic Amoebae History Amebic infection first described by Fedor Losch in 1875 in St.

Petersburg, Russia In 1890, Sir William Osler reported the first North American case of amebiasis , when he observed amoebae in stool and abscess fluid from a physician who previously resided in Panama. E. histolytica was first coined by Fritz Schaudin in 1903 In 1913, in Phil., Walker and Sellards documented the cyst as the infective stage of E. histolytica. Life cycle was then established by Dobell in 1925. Introduction Entamoeba histolytica protozoan causing amebiasis Humans and primates are the only natural hosts Highest prevalence at developing countries where barriers feces food water supplies are inadequate Most cases are asymptomatic however, dysentery and invasive extraintestinal disease can occur Amebic liver abscess most common manifestation of invasive amebiasis Other organs may be involved including pleuropulmonary, cardiac, cerebral, renal, genitourinary, and cutaneous sites. Primary affects migrants from and travelers to endemic regions, men who have sex with men, and immunosupressed or institutionalized individuals

Cysts and trophozoites are passed in feces . Cysts are typically found in formed stool, whereas trophozoites are typically found in diarrheal stool. Infection by Entamoeba histolytica occurs by ingestion of mature cysts contaminated food, water, or hands. Excystation in fecally occurs

in the small intestine and trophozoites are released, which migrate to the large intestine. The trophozoites multiply by binary fission and produce cysts , and both stages are passed in the feces . Because of the protection conferred by their walls, the cysts can survive days to weeks in the external environment and are responsible for transmission. Trophozoites passed in the stool are rapidly destroyed once outside the body, and if ingested would not survive exposure to the gastric environment. In many cases, the trophozoites remain confined to the intestinal lumen ( : noninvasive infection) of individuals who are asymptomatic carriers, passing cysts in their stool. In some patients the trophozoites invade the intestinal mucosa ( : intestinal disease), or, through the bloodstream, extraintestinal sites such as the liver, brain, and lungs ( : extraintestinal disease), with resultant pathologic manifestations. It has been established that the invasive and noninvasive forms represent two separate species, respectively E. histolyticaand E. dispar. These two

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species are morphologically indistinguishable unless E. histolytica is observed with ingested red blood cells (erythrophagocystosis). Transmission can also occur through exposure to fecal matter during sexual contact (in which case not only cysts, but also trophozoites could prove infective).

Life cycle E histolytica transmitted via ingestion of the cystic form (infective stage) Cysts viable in the environment for weeks to months can be found in fecally contaminated soil, fertilizer, or water on the contaminated hands of food handlers. Fecal oral transmission can also be transmitted through anal sexual practices or direct rectal inoculation through colonic irrigation devices. Excystation also occurs in the terminal ileum or colon, resulting to thropozoites (invasive form) Thropozoites can penetrate and invade the colonic mucosal barrier, leading to tissue destruction, bloody diarrhea and colitis resembling inflammatory bowel disease Trophozoites can spread hematogenously via the portal circulation to the liver or even to more distant organs Pathophysiology Ingestion of E histolytical from the environment followed by excystations in the terminal ileum or the colon to form highly motile trophozoites Upon colonization in the colonic mucosa, the trophozoite may: Encyst and is then excreted in the feces or May invade the intestinal mucosal barrier and gain access to the blood stream and disseminate to the liver, lungs and other sites Excreted cysts reach the environment completing the cycle Disease may be caused by small number of cysts Encystations and excystation are poorly understood Adherence of the trophozoites to the colonic epithelial cells seems to be mediated by galactose/ N acetylgalactosamine (GAL/ GalNAc)- specific lectin

Mucosal immunoglobulin A (IgA) response against this lectin can result to fewer recurrent infections Both lytic and apoptotic pathways have been described. Cytolysis can be undertaken by amoebapores, a family of peptides capable of forming pores in the lipid bilayers Furthermore, in the animal models of liver abcess, trophozoites induced apoptosis via a non-Fas and non-tumor necrosis factor1receptor pathway Amoebapores, a sublytic concentrations, can also induce apoptosis Pathophysiology CYSTEINE PROTEASES Cysteine proteinases have been directly implicated in invasion and inflammation of the gut and may amplify interleukin 1 (IL1)mediated inflammation by mimicking the action of human IL1 converting enzyme, cleaving IL1 precursor to its active form Cysteine proteinases can also cleave and activate anaphylatoxins C3a and C5a, as well as IgA and IgG Epithelial cells also produce various inflammatory mediators, including IL1, IL2, and cyclooxygenase-2, leading to the attractions of neutrophils and macrophages Corticosteroid therapy it is known to worsen the clinical outcome, possibly because of its blunting effect in this innate immune response Additional host defenses, including the compliment system, to be inhibited directly by the trophozoites, suggested by the findings that a region of the GAL/ GalNAcspecific lectin showed antigenic cross reactivity with CD59, a membrane inhibitor of the C5b-9 attack complex in human RBC Trophozoites that reach the liver create unique abscesses with well-circumscribed region of dead hepatocytes surrounded by few inflammatory cells and trophozoites and unaffected hepatocytes, suggesting that E histolytica are able to kill hepatocytes without direct contact

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Sites of Predilection The most common site for localization of e histolytica in the intestine are cecum and descending colon Secondary sites included are liver lung and skin Amebic liver abscess Most common metastatic complication of amebiasis the greatet pitfall in clinical tropical medicine (Walters 1970) Other complications: Amebiasis of the lung Amebic pericarditis by direct extension Amebic abscess of the brain and other organs, spleen, psoas muscle, buttocks and thigh by systemic spread Geographical distribution Most intense at India and Mexico Rarely found in persons who have never been to tropics Many abscess in children found before and after death in Nigeria and Durban Common in some ship stewards and kitchen staff who are well nourished Pathology Trophozoites reach portal system via portal veins A number of small necrotic foci form, which is not treated, tends to enlarge and coalesce into one or more big abscess Amebic hepatitis is a very early stage of liver abscess Single abscess: 65-75% Multiple abscess: 25-35% Right lobe affected 4x as often as the left Necrotic patches liquefy and coalesce, forming characteristic ragged abscess cavities full of viscid chocolate-brown (anchovy sauce) thick pus which contains disorganized liver tissues and clots or streaks of blood Trophozoites of E histolytica found in pus after drainage of abscess for few days and present in large numbers in the walls of the abscess cavity With secondary infection with pyogenic organisms, trophozoites tend to disappear

Features found in 764 cases of amebic liver abscess in Thailand (Harinasuta et al 1968) Presenting symptoms: o Fever and pain at RCM most common o Referred pain at right shoulder o Abdominal mass o Jaundice, dysentery, abdominal pain rarely Presenting signs: o Fever o Tenderness of the liver o Hepatomegaly o Leukocytosis o CXR shows raised right diaphragm

Complications: Spread to the lung: pleural effusion o May develop in the right pleural cavity in association with liver abscess in the upper R lobe of the liver o Liver abscess may rupture in the R pleural cavity causing pleurisy, effusion or empyema o R side is invariably involved , and signs are those pleural effusion but enlargement of liver may suggest diagnosis o Pleural cavity may contain pus and anchovy sauce kind and trophozoites may be found in it Direct spread o R basal pneumonia that does not respond to antibiotics o Sputum suggest amebiasis with small hemoptysis or quantities of reddish brown material sometimes containing trophozoites o R diaphragm is raised and lung is consolidated or contains abscess

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Hepatobronchial fistula may develop which drains abscess successfully Hematogenous spread o Rare o Single or multiple abscess or areas of consolidation o Sputum may contain trophozoites but these are probably E gingivalis if they do not contain red cells.

Other complications o Amebic peritonitis o Amebic pericarditis o Amebic abscess of the brain o Amebic balanitis

with asymptomatic amebiasis who are monitored for one year eventually develop colitis and or extraintestinal disease Case fatality rates associated with amebic colitis range from 1.9-9.1%. Amebic colitis evolves to fulminant necrotizing colitis or rupture approximately 0.5% of cases; in such cases, mortality rates jumps to greater than 40% Mortality rate due to amebic liver abscess has fallen top 1-3% in the last century following the introduction of effective medical treatment Amebic liver abscess is complicated by sudden intraperitoneal rupture in 2-7% of patients, leading to a higher mortality rate. Diagnosis of Amebiasis 1. Stool examination Look for trophozoites Direct fecal smear Concentration of formalinfixed stools Polyvinyl alcohol (PVA) fixed stools, trichromestained smears Trophozoites in diarrheic stools; cysts in formed stools Multiple stools (5-6 over 10days) as necessary Challenges in diagnosis of Amebiasis Problem of over diagnosis E. histolytica vs E. coli or Edomilax nana E. histolytica vs E. hartmanni or E. dispar Use of laboratory techniques that lack sensitivity Lack of training of laboratory staff Problems with diagnosis E. histolytica and E. dispar o Morphologically identical o Same size range o Can be differentiated by: Isoenzyme analysis Restriction fragment polymorphism Typing with monoclonal antibodies

Amebic balinitis
E. histolytica VS. E. dispar E. histolytica E. dispar Commensal (including in patients with HIV infection) pathogenic Entamoeba

In western countires, 2030% of men having sex with men are colonized with E. dispar Cannot be differentiated by direct examination In Brazil and Egypt, E histolytica and E dispar infections are equally prevalent Mortality and morbidity Amebiasis is second only to malaria in terms of protozoa- associated mortality Combined prevalence of amebic colitis and amebic lever abscess estimated 40-50M cases annually worldwide, resulting to 40,000- 100,000 deaths. Asymptomatic intestinal amebiasis occurs in 90% of individuals; only 4-10% of individuals

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E hartmanni o small race of E histoplytica o Separated from the other two primarily based on size Pathogenic Amebae: Presence of ingested RBC

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Serologic examination For extraintestinal amebiasis Positivity indicates active tissue invasion Gel diffusion technique Takes 3 days; reliable indication For present disease ELISA Indicates present/ past infection IFA if high titer positive, recommend treatment Proctoscopic examination Locates ulcer, aspirate mucus Examine directly for hematophagous trophozoites

For extraintestinal amebiasis: X-ray CT scan Sonography

Entamoeba histolytica Epidemiology High risk populations: tourists, institutionalized people, immigrants, homosexuals Man to man transmission by cysts Cysts can withstand weak chlorination and cold Flies and cockroaches with cysts Cross-connections of water pipes lead to epidemics Part of gay bowel syndrome Sexual transmission rare Parasitologic studies on food handlers using DFS and FECT Cumulative Investigators Study site prevalence School canteens in Avila et al 61.8 intramuros and U-belt Esparar and Tertiary hospital 42.4 Belizario in Manila

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We are supposed to be protected Sec 15 and 19 no person shall be emplouyed to any food establishment without a health certificate issued by the local health authority which shall be issued only after the required physical examinations are performed at prescribed intervals. We are not adequately protected from infected food handlers!!! There is no mention of a stool examination as a requirement. o Food handlers may carry pathogens without exhibiting symptoms In cases where stool examination is prerequisite, the usual practice is the examination of only one sample using DFS. There is hope that we will adequately protect from infected food handlers!!! Guidelines for parasitologic screening for food handlerscurrently being developed by a multi-agency technical working group We are pushing for: o The use of stool concentration technique as a requirement o Accreditation of laboratories o Certification of proficiency of laboratory staff GOOD NEWS: BETTER LATE THAN NEVER!

Treatment Asymptomatic amebiasis o Treated with luminant agent (iodoquinol, paromomycin, diloxanide, furoate) to eradicate infection o Recommendation is based on two arguments: Invasive disease may develop Shedding of E histolytica cysts in the environment is a public concern Asymptomatic E disparinfections should not be treated, but education should be pursued since it is a marker of a fecal-oral transmission Amebic colitis is first treated with nitroimidazole derivative (metronidazole being the only one available in US) followed by a luminal agent to eradicate colonization. Amebic liver abscess can be cured without drainage and even by one dose of metronidazole. Clinical divergence should occur during the first 3-4 days of treatment. Metronidazole failure may be an indication of surgical intervention. Treatment with luminal agent should also follow Disseminated amebiasis should be treated with metronidazole, which can cross the blood brain barrier Empirical antibacterial agents should be used concomitantly if perforated viscus is a concern Control and prevention Control of mechanical vectors Food handlers education and screening Food safety initiatives o Inspection and grading of food establishments

Ui In Omnibus Glorificetur Deus

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