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AMOEBIASIS Amoebiasis, or Amebiasis, refers to infection caused by the amoeba Entamoeba histolytica.

[1][2] The term Entamoebiasis is occasiona y seen but is no on!er in use"[citation needed] it refers to the same infection. #i$e%ise amoebiasis is sometimes incorrect y used to refer to infection %ith other amoebae, but strict y s&ea$in! it shou d be reser'ed for Entamoeba histolytica infection. Other amoebae infectin! humans inc ude([)]

*arasites o Dientamoeba fragilis, %hich causes +ientamoebiasis o Entamoeba dispar o Entamoeba hartmanni o Entamoeba coli o Entamoeba moshkovskii o Endolimax nana and o Iodamoeba butschlii.

E,ce&t for Dientamoeba, the &arasites abo'e are not thou!ht to cause disease.

-ree i'in! amoebas.[.][/] These s&ecies are often described as 0o&&ortunistic free1 i'in! amoebas0 as human infection is not an ob i!ate &art of their ife cyc e. o Naegleria fowleri, %hich causes *rimary amoebic menin!oence&ha itis o Acanthamoeba, %hich causes 2utaneous amoebiasis[3] and Acanthamoeba $eratitis o Balamuthia mandrillaris,[4] %hich causes 5ranu omatous amoebic ence&ha itis and *rimary amoebic menin!oence&ha itis o Sappinia diploidea

A !astrointestina infection that may or may not be sym&tomatic and can remain atent in an infected &erson for se'era years, amoebiasis is estimated to cause 46,666 deaths &er year %or d %ide.[7] Sym&toms can ran!e from mi d diarrhea to dysentery %ith b ood and mucus in the stoo . E histolytica is usua y a commensa or!anism.[8] Se'ere amoebiasis infections 9$no%n as in'asi'e or fulminant amoebiasis: occur in t%o ma;or forms. In'asion of the intestina inin! causes amoebic dysentery or amoebic co itis. If the &arasite reaches the b oodstream it can s&read throu!h the body, most fre<uent y endin! u& in the i'er %here it causes amoebic i'er abscesses. #i'er abscesses can occur %ithout &re'ious de'e o&ment of amoebic dysentery. =hen no sym&toms are &resent, the infected indi'idua is sti a carrier, ab e to s&read the &arasite to others throu!h &oor hy!ienic &ractices. =hi e sym&toms at onset can be simi ar to baci ary dysentery, amoebiasis is not bacterio o!ica in ori!in and treatments differ, a thou!h both infections can be &re'ented by !ood sanitary &ractices.

Transmission

Amoebiasis is usua y transmitted by the feca 1ora route, but it can a so be transmitted indirect y throu!h contact %ith dirty hands or ob;ects as %e as by ana 1ora contact. Infection is s&read throu!h in!estion of the cyst form of the &arasite, a semi1dormant and hardy structure found in feces. Any non1encysted amoebae, or tropho!oites, die <uic$ y after ea'in! the body but may a so be &resent in stoo ( these are rare y the source of ne% infections. Since amoebiasis is transmitted throu!h contaminated food and %ater, it is often endemic in re!ions of the %or d %ith imited modern sanitation systems, inc udin! M>,ico, 2entra America, %estern South America, South Asia, and %estern and southern Africa.[16] Amoebic dysentery is often confused %ith 0tra'e er?s diarrhea0 because of its &re'a ence in de'e o&in! nations. In fact, most tra'e er?s diarrhea is bacteria or 'ira in ori!in.

Prevention
To he & &re'ent the s&read of amoebiasis around the home (

=ash hands thorou!h y %ith soa& and hot runnin! %ater for at east 16 seconds after usin! the toi et or chan!in! a baby?s dia&er, and before hand in! food. 2 ean bathrooms and toi ets often" &ay &articu ar attention to toi et seats and ta&s. A'oid sharin! to%e s or face %ashers.

To he & &re'ent infection(


A'oid ra% 'e!etab es %hen in endemic areas, as they may ha'e been ferti i@ed usin! human feces. Boi %ater or treat %ith iodine tab ets. A'oid eatin! Street -oods es&ecia y in &ub ic & aces %here others are sharin! sauces in one container

5ood sanitary &ractice, as %e as res&onsib e se%a!e dis&osa or treatment, are necessary for the &re'ention of E histolytica infection on an endemic e'e . E histolytica cysts are usua y resistant to ch orination, therefore sedimentation and fi tration of %ater su&& ies are necessary to reduce the incidence of infection.[11]

Nature of the disease


Most infected &eo& e, &erha&s 86A[citation needed], are asym&tomatic, but this disease has the &otentia to ma$e the sufferer dan!erous y i . It is estimated by the =or d Bea th Or!ani@ation that about 46,666 &eo& e die due to amoebiasis annua y %or d%ide[citation needed] . Infections can sometimes ast for years. Sym&toms ta$e from a fe% days to a fe% %ee$s to de'e o& and manifest themse 'es, but usua y it is about t%o to four %ee$s. Sym&toms can ran!e from mi d diarrhoea to dysentery %ith b ood and mucus. The b ood comes

from amoebae in'adin! the inin! of the intestine. In about 16A of in'asi'e cases the amoebae enter the b oodstream and may tra'e to other or!ans in the body. Most common y this means the i'er, as this is %here b ood from the intestine reaches first, but they can end u& a most any%here. Onset time is hi!h y 'ariab e and the a'era!e asym&tomatic infection &ersists for o'er a year. It is theorised that the absence of sym&toms or their intensity may 'ary %ith such factors as strain of amoeba, immune res&onse of the host, and &erha&s associated bacteria and 'iruses. In asym&tomatic infections the amoeba i'es by eatin! and di!estin! bacteria and food &artic es in the !ut, a &art of the !astrointestina tract.[citation needed] It does not usua y come in contact %ith the intestine itse f due to the &rotecti'e ayer of mucus that ines the !ut. +isease occurs %hen amoeba comes in contact %ith the ce s inin! the intestine. It then secretes the same substances it uses to di!est bacteria, %hich inc ude en@ymes that destroy ce membranes and &roteins. This &rocess can ead to &enetration and di!estion of human tissues, resu tin! first in f as$1sha&ed u cers in the intestine. Entamoeba histolytica in!ests the destroyed ce s by &ha!ocytosis and is often seen %ith red b ood ce s inside %hen 'ie%ed in stoo sam& es. Es&ecia y in #atin America,[citation needed] a !ranu omatous mass 9$no%n as an amoeboma: may form in the %a of the ascendin! co on or rectum due to on!1 astin! immuno o!ica ce u ar res&onse, and is sometimes confused %ith cancer.[12] 0Theoretica y, the in!estion of one 'iab e cyst can cause an infection.0[1)]

Diagnosis of human illness

Immature E histolytica"E dispar cyst in a concentrated %et mount stained %ith iodine. This ear y cyst has on y one nuc eus and a ! yco!en mass is 'isib e 9bro%n stain:. -rom 2+2Cs +i'ision of *arasitic +iseases

Asym&tomatic human infections are usua y dia!nosed by findin! cysts shed in the stoo . Darious f otation or sedimentation &rocedures ha'e been de'e o&ed to reco'er the cysts from feca matter and stains he & to 'isua i@e the iso ated cysts for microsco&ic e,amination. Since cysts are not shed constant y, a minimum of three stoo s shou d be e,amined. In sym&tomatic infections, the moti e form 9the tro&ho@oite: can often be seen in fresh feces. Sero o!ica tests e,ist and most indi'idua s 9%hether %ith sym&toms or not: %i test &ositi'e for the &resence of antibodies. The e'e s of antibody are much hi!her in indi'idua s %ith i'er abscesses. Sero o!y on y becomes &ositi'e about t%o %ee$s after infection. More recent de'e o&ments inc ude a $it that detects the &resence of amoeba &roteins in the feces and another that detects ameba +EA in feces. These tests are not in %ides&read use due to their e,&ense.

Amoebae in a co on bio&sy from a case of amoebic dysentery. Microsco&y is sti by far the most %ides&read method of dia!nosis around the %or d. Bo%e'er it is not as sensiti'e or accurate in dia!nosis as the other tests a'ai ab e. It is im&ortant to distin!uish the E histolytica cyst from the cysts of non&atho!enic intestina &roto@oa such as Entamoeba coli by its a&&earance. E histolytica cysts ha'e a ma,imum of four nuc ei, %hi e the commensa Entamoeba coli cyst has u& to 7 nuc ei. Additiona y, in E histolytica# the endosome is centra y ocated in the nuc eus, %hi e it is usua y off1 center in Entamoeba coli -ina y, chromatoida bodies in E histolytica cysts are rounded, %hi e they are ;a!!ed in Entamoeba coli. Bo%e'er, other s&ecies, Entamoeba dispar and E moshkovskii, are a so commensa s and cannot be distin!uished from E histolytica under the microsco&e. As E dispar is much more common than E histolytica in most &arts of the %or d this means that there is a ot of incorrect dia!nosis of E histolytica infection ta$in! & ace. The =BO recommends that infections dia!nosed by microsco&y a one shou d not be treated if they are asym&tomatic and there is no other reason to sus&ect that the infection is actua y E histolytica. Ty&ica y, the or!anism can no on!er be found in the feces once the disease !oes e,tra1 intestina .[citation needed] Sero o!ica tests are usefu in detectin! infection by E histolytica if the or!anism !oes e,tra1intestina and in e,c udin! the or!anism from the dia!nosis of other disorders. An O'a F *arasite 9OF*: test or an E histolytica feca anti!en assay is the &ro&er assay for intestina infections. Since antibodies may &ersist for years after c inica cure, a &ositi'e sero o!ica resu t may not necessari y indicate an acti'e infection. A ne!ati'e sero o!ica resu t ho%e'er can be e<ua y im&ortant in e,c udin! sus&ected tissue in'asion by E histolytica.[citation needed]

Relative frequency of the disease


In o der te,tboo$s it is often stated that 16A of the %or d?s &o&u ation is infected %ith Entamoeba histolytica.[citation needed] It is no% $no%n that at east 86A of these infections are due to E dispar. Ee'erthe ess, this means that there are u& to /6 mi ion true E histolytica infections and a&&ro,imate y se'enty thousand die each year, most y from i'er abscesses or other com& ications. A thou!h usua y considered a tro&ica &arasite, the first case re&orted 9in 174/: %as actua y in St *etersbur! in Gussia, near the Arctic 2irc e.[1.] Infection is more common in %armer areas, but this is both because of &oorer hy!iene and the &arasitic cysts sur'i'in! on!er in %arm moist conditions.[16]

Treatment
Main artic e( Amoebicide E histolytica infections occur in both the intestine and 9in &eo& e %ith sym&toms: in tissue of the intestine andHor i'er.[16] As a resu t, t%o different c asses of dru!s are needed to treat the infection, one for each ocation. Such anti1amoebic dru!s are $no%n as amoebicides or amebicides.

Complications
In the ma;ority of cases, amoebas remain in the !astrointestina tract of the hosts. Se'ere u ceration of the !astrointestina mucosa surfaces occurs in ess than 13A of cases. In fe%er cases, the &arasite in'ades the soft tissues, most common y the i'er. On y rare y are masses formed 9amoebomas: that ead to intestina obstruction.9Mista$en for 2a caecum and a&&endicu ar mass: Other oca com& ications inc ude b oody diarrhea, &erico ic and &ericaeca abscess. 2om& ications of he&atic amoebiasis inc udes subdia&hra!matic abscess, &erforation of dia&h!ram to &ericardium and & eura ca'ity, &erforation to abdomina ca'ita $amoebic peritonitis% and &erforation of s$in $amoebic cutis%. *u monary amoebiasis can occur from he&atic esion by haemota!enous s&read and a so by &erforation of & eura ca'ity and un!. It can cause un! abscess, &u mono & eura fistu a, em&yema un! and broncho & eura fistu a. It can a so reach brain throu!h b ood 'esse and cause amoebic brain abscess and amoebic menin!oence&ha itis. 2utaneous amoebiasis can a so occur s$in around site of co ostomy %ound, &eriana re!ion, re!ion o'er yin! 'iscera esion and at the site of draina!e of i'er abscess. Iro!enita tract amoebiasis deri'ed from intestina esion can cause amoebic 'u 'o'a!initis $&ay's disease%, recto'esic e fistu a and recto'a!ina fistu a. Entamoeba histolytica infection is associated %ith ma nutrition and stuntin! of !ro%th.[1/]

Food analysis
E histolytica cysts may be reco'ered from contaminated food by methods simi ar to those used for reco'erin! (iardia lamblia cysts from feces. -i tration is &robab y the most &ractica method for reco'ery from drin$in! %ater and i<uid foods. E histolytica cysts must be distin!uished from cysts of other &arasitic 9but non&atho!enic: &roto@oa and from cysts of free1 i'in! &roto@oa as discussed abo'e. Geco'ery &rocedures are not 'ery accurate" cysts are easi y ost or dama!ed beyond reco!nition, %hich eads to many fa se y ne!ati'e resu ts in reco'ery tests.[

Outbrea s
The most dramatic incident in the ISA %as the 2hica!o =or d?s -air outbrea$ in 18)) caused by contaminated drin$in! %ater" defecti'e & umbin! &ermitted se%a!e to contaminate %ater.[14] There %ere 1,666 cases 9%ith /7 deaths:. In 1887 there %as an outbrea$ of amoebiasis in the Ge&ub ic of 5eor!ia.[17] Bet%een 23 May and ) Se&tember 1887, 144 cases %ere re&orted, inc udin! 41 cases of intestina amoebiasis and 163 &robab e cases of i'er abscess.
!ntroduction

About 16 &ercent of the %or d?s &o&u ation is infected %ith E.Bisto ytica. It is the third most common cause of death 9after Schistosomiasis and Ma aria: from &arasitic infections. It has a 'ery hi!h incidence in tro&ica countries i$e India, Me,ico, 2entra and South America. About 86 &ercent of infections are asym&tomatic 9do not &roduce any sym&toms: and the remainin! 1O &ercent &roduces a s&ectrum 'aryin! from dysentery to amoebic i'er abscess.
Cause and Pathogenesis

It is caused by a &roto@oa, Entamoeba Bisto ytica. It is common y s&read by %ater contaminated by faeces or from food ser'ed by contaminated hands. E'en 'e!etab es !ro%n in soi contaminated by faeces can transmit the disease. =hen the cyst of Entamoeba Bisto ytica enters the sma intestine, acti'e amoebic &arasites 9tro&ho@oites: are re eased, %hich can in'ade the e&ithe ia ce s of the ar!e intestines, causin! f as$1 sha&ed u cers. It can a so s&read to other or!ans i$e the i'er, un!s, and brain by in'adin! the 'enous system of the intestines. If it in'ades the i'er, it causes formation of the ty&ica ancho'y &aste i$e &us. Asym&tomatic carriers &ass cysts in the faeces.
"ymptoms and "igns

It can either occur as intestina or e,tra1intestina amoebiasis. !ntestinal amoebiasis

The most common ty&e of amoebic infection is asym&tomatic cyst &assa!e. Sym&tomatic &atients initia y ha'e o%er abdomina &ain and diarrhoea and ater de'e o& dysentery 9%ith b ood and mucus in stoo :. -u minant infection %ith hi!h !rade fe'er, se'ere abdomina &ain and &rofuse diarrhoea occurs in chi dren and in &atients recei'in! steroids. Se'ere !astric distention of the bo%e can occur. 2#$tra%intestinal amoebiasis *atients sho% sym&toms of fe'er and ri!ht u&&er abdomina &ain. Jaundice is rare. Amoebic i'er abscesses can a so &resent as &yre,ia of un$no%n ori!in. The abscess can sometimes ru&ture into the & eura , &eritonea or &ericardia ca'ities.
!nvestigations and Diagnosis

Stoo e,amination is the commonest e,amination done for dia!nosis. Thou!h neutro&hi s and 2harcot1#eyden crysta s can be found, haemato&ha!ous tro&ho@oites are dia!nostic. Since tro&ho@oites are $i ed ra&id y by %ater or dryin!, at east three fresh stoo s&ecimens ha'e to be e,amined for a &ositi'e dia!nosis. -resh stoo or concentrated stoo e,amination is &ositi'e in 4/ to 8/ &ercent of &atients. Sero o!y is &ositi'e in more than 86 &ercent &atients %ith in'asi'e amoebiasis. Barium studies are contraindicated in acute amoebic co itis for fear of &erforation. I trasound, 2T and MGI scans of the abdomen can be usefu in dia!nosin! he&atic amoebiasis. Since abscesses reso 'e s o% y or may e'en increase in si@e durin! treatment, c inica res&onse is more im&ortant in the fo o%1u& rather than re&eated scans. Acute intestina amoebiasis shou d be differentiated from or!anisms causin! tra'e er?s diarrhoea 9%hich is due to a bacteria ca ed Escherischia 2o i: and a so inf ammatory bo%e disease. Amoebic i'er abscess has to be differentiated from &yo!enic abscess %hich are seen in o der &atients %ith under yin! bo%e disease or after sur!ery.
Treatment and Prognosis

Asym&tomatic &atients can be treated %ith umina a!ents i$e #iodo<uino or +i o,anide -uroate. *atients %ith acute co itis re<uire su&&orti'e thera&y 9rehydration: and Metronida@o e, fo o%ed by umina a!ents. Metronida@o e is a so the dru! of choice for amoebic i'er abscess. Second ine a!ents i$e 2h oro<uine and Emetine are no on!er used. *ro!nosis is !enera y !ood %ith treatment un ess com& ications of abscess ru&ture occurs %hen sur!ica inter'ention may be re<uired.
Prevention

Treatment of asym&tomatic cyst carriers and !ood sanitation and %ater faci ities are fundamenta in the &re'ention of amoebiasis. Daccines are not a'ai ab e. "ource +r. D.Gamasubramaniam MBBS, M+, MG2*.

+r.D.Gamasubramaniam is an Assistant *rofessor of Medicine and heads the +i'ision of Infectious +iseases at the Sri Gamachandra Medica 2o e!e and Gesearch Institute Bome( Amoebiasis

Amoebiasis / Amoebic Dysentery : Definition, Types, Causes, Symptoms, Diagnosis and general treatment of Amoebiasis/ Amoebic Dysentery
Amoebiasis is a common infection of the human !astrointestina tract. It has a %or d %ide distribution. It is.a ma;or hea th &rob em in the %ho e of 2hi,na, South East and =est Asia and #atin America, es&ecia y Me,ico. 5 oba y it %as estimated that, in 1871, .76 mi ion &eo& e carried E histolytica in their intestina tract and a&&ro,imate y one1tenth of infected &eo& e, i.e., .7 mi ion suffered from in'asi'e amoebiasis. It is &robab e that in'asi'e amoebiasis, accounts annua y for .6,666 to 116,666 deaths in the %or d 9):. *re'a ence rates 'ary from as o% as 2 &er cent to 36 &er cent or more in areas de'oid of sanitation 9.:. In areas of hi!h &re'a ance. Amoebiasis occurs in endemic forms as a resu t of hi!h e'e s of transmission and constant reinfection. E&idemic %ater1born infections can occur if there is hea'y contamination of drin$in! %ater su&& y. Amoebiasis, a ty&e of !astro, is a cause of diarrhoea amon! tra'e ers to de'e o&in! countries. It is caused by a &arasite $no%n as Entamoeba histolytica that infects the bo%e . Amoebiasis is a &arasitic infection of the ar!e intestine. Amoebiasis can affect anyone, most common y affects youn! to midd e1a!ed adu ts. The term 0amoebiasis0 has been defined as the condition of harbourin! the &roto@oan &arasite Entamoeba histolytica %ith or %ithout c inica manifestations. The sym&tomatic disease occurs in ess than 16 &er cent of infected indi'idua s. The sym&tomatic !rou& has been further subdi'ided into intestina and e,traintestina amoebiasis. On y a sma &ercenta!e of those ha'in! intestina infection %i de'e o& in'asi'e amoebiasis. The intestina disease 'aries from mi d abdomina discomfort and diarrhoea to acute fu minatin! dysentery. E,traintestina amoebiasis inc udes in'o 'ement of i'er 9 i'er abscess:, Iun!s, brain, s& een, s$in, etc. Amoebiasis is a &otentia y etha disease. It carries substantia morbidity and morta ity. It is the sim& est or!anism of the anima $in!dom %hich be on!s to the c ass of Ghi@o&oda, order of Amoebida, !enus of Entamoeba and s&ecies of E.Bisto ytica.

Causes of Amoebiasis
Amoebiasis is causes by a &arasite that can i'e in humans %ithout ma$in! them i , or it can ma$e a &erson 'ery sic$ by !oin! into or!ans i$e the i'er or heart. The &arasite on y i'es in humans, and can be s&read from &erson to &erson. *eo& e can !et the disease by eatin! food, or drin$in! %ater that contain the &arasite. A &erson may

a so s&read the disease by not %ashin! their hands after !oin! to the toi et or chan!in! a na&&y, and then hand in! food for other &eo& e. Amoebiasis is caused by &otentia y &atho!enic strains of E histolytica Gecent studies ha'e sho%n that E histolytica can be differentiated into at east 17 @ymodemes 9a @ymodeme is a &o&u ation of or!anisms differin! from simi ar &o&u ations in the e ectro&horetic mobi ities of one or more en@ymes:. It has furthermore been sho%n that &atho!enic strains are a from &articu ar @ymodemes" that non, in'asi'e strains are from <uite distinct @ymodemes" that in'asi'e strains can !i'e rise to faeca cysts, and the or!anisms breed true . The iso1en@yme characteristics do not, ho%e'er, determine %hy a &articu ar @ymodeme is ab e to in'ade. Isoen@yme e ectro&horetic mobi ity ana ysis ha'e so far identified 4 &otentia y &atho!enic and 11 non1&atho!enic @ymodems.

Forms of Amoebasis & Amoebic Dysentery


E histolytica e,ists in t%o forms 1 'e!etati'e 9tro&ho@oite: and cystic forms. Tro&ho@oites d%e in the co on %here they mu ti& y and encyst. The cysts are e,creted in stoo . In!ested cysts re ease tro&ho@oites %hich co oni@e the ar!e intestine. Some tro&ho@oites in'ade the bo%e and cause u ceration, main y in the caecum and ascendin! co on" than in the rectum and si!moid. Some may enter a 'ein and reach the i'er and other or!ans. The tro&ho@oites are short1 i'ed outside the human body" they are not im&ortant in the transmission of the disease. In contrast the cysts are infecti'e to man and remain 'iab e and infecti'e for se'era days in faeces, %ater, se%a!e and soi in the &resence of moisture and o% tem&erature. The cysts are not affected by ch orine in the amounts norma y used in %ater &urification, but they are readi y $i ed if dried, heated 9to about? // de! 2: or fro@en.

'o( its spread


Amoebiasis may occur at any a!e. There is no se, or racia difference in the occurrence of the disease. Amoebiasis is fre<uent y a househo d infection. =hen an indi'idua in a fami y is infected, others in the fami y may a Iso be affected. S&ecific a ntiamoebic antibodies are &roduced %hen tissue in'asion ta$es & ace. There is stron! e'idence that ce 1mediated immunity & ays an im&ortant &art in contro in! the recurrence of in'asi'e amoebiasis . Amoebiasis occurs %hen the &arasites are ta$en in by mouth. *eo& e %ith amoebiasis ha'e Entamoeba hisolytica &arasites in their faeces. The infection can s&read %hen infected &eo& e do not dis&ose of their faeces in a sanitary manner or do not %ash their hands &ro&er y after !oin! to the toi et. 2ontaminated hands can then s&read the &arasites to food that may be eaten by other &eo& e and surfaces that may be touched by other &eo& e. Bands can a so become contaminated %hen chan!in! the na&&ies of an infected infant. Amoebiasis can a so be s&read by(

-aeca 1ora route. This may readi y ta$e & ace throu!h inta$e of contaminated %ater or food. E&idemic %ater1borne infections can occur if there is hea'y contamination of drin$in! %ater su&& y. De!etab es, es&ecia y those eaten ra%, from fie ds irri!ated %ith se%a!e &o uted %ater can readi y con'ey infection. Diab e cysts ha'e been found on the hands.and under fin!er nai s. This may ead to direct hand to mouth transmission. Se,ua transmission by ora 1recta contact is a so reco!ni@ed, es&ecia y amon! ma e homose,ua s. 9Bi: Dectors such as f ies, coc$roaches and rodents are ca&ab e of carryin! cysts and contaminatin! food and drin$.

"ymptoms of Amoebiasis & Amoebic Dysentery


Most of the cases may not ha'e any sym&toms at a and function on y as carriers and a so function as s&readers, &o utin! the areas %here'er they !o. The disease sym&toms usua y start after a &eriod of 411/ days of infection %hich is ca ed the incubation &eriod. The sym&toms are in t%o forms( 1. By burro%in! the intestines and ma$in! u cers, %hich b eed and cause anaemia or other diseases due to added infection 2. Absorbin! the food from the host or ettin! out to,ic substances in the intestines Isua y sym&toms start %ith diarrhoea 9%atery stoo s: and abdomina &ain 9most y in ri!ht hy&ochondrium: *oor a&&etite or fear of food due to abdomina &ain and oose stoo s #ater, %ith increased intensity of the infection, fe'er, nausea and b oody stoo s i.e. characteristic amoebic dysentery %ith s imy mucous occurs and com& icate the condition In due course, the &atient oses %ei!ht and stamina Sometimes a er!ic reactions can occur throu!hout the body, due to re ease of to,ic substances or dead &arasites inside the intestines.

Diagnosis of Amoebiasis & Amoebic Dysentery


"tool e$amination 1 Microsco&ic e,amination for identifyin! demonstrab e E.B cysts or tro&ho@oites in stoo sam& es is the most confirmati'e method for dia!nosis. Tro&ho@oites sur'i'e on y for a fe% hours, so the dia!nosis most y !oes %ith the &resence of cysts. But fresh %arm faeces a %ays sho% tro&ho@oites. The cysts are identified by their s&herica nature %ith chromatin bars and nuc eus. They are noticed as bro%nish e!!s %hen stained %ith iodine. )iopsy a so can &oint out E.B cysts or tro&ho@oites. Culture of the stoo a so can !uide us for dia!nosis. )lood tests may su!!est infection %hich may be indicated as eucocytosis 9increased

e'e of %hite b ood ce s:, a so it can indicate %hether any dama!e to the i'er has occurred or not. *ltrasound scan 1 it shou d be &erformed %hen a i'er abscess is sus&ected.

Treatment of Amoebiasis & Amoebic Dysentery


Sym&tomatic cases( At the hea th centre e'e , sym&tomatic cases can be treated effecti'e y %ith metronida@o e ora y and the c inica res&onse in .7 hours may confirm the sus&ected dia!nosis. The dose is )6m!H$!Hday, di'ided into ) doses after mea s, for 71 16 days. Tinida@o e can be used instead of metronida@o e. Sus&ected cases of i'er abscess shou d be referred to the nearest hos&ita . 9ii: Asymptomatic infections) In an endemic area, the concensus is not to treat such &ersons because the &robabi ity of reinfection is 'ery hi!h 9):. They may ho%e'er be treated, if the carrie is a food hand er. In non1endemic areas they are a %ays i$e y to h treated. They shou d be treated %ith ora diiodohyro,y<uin, 3/6 m t.d.s. 9adu ts: or )61.6 m!H$!Hday 9chi dren: for 26 days, or ore di o,anide furoate, /66 m! t.d.s. for 16 days 9adu ts:. At &resent there is no acce&tab e chemo&ro&hy a,is for amoebiasis. Mass e,amination and treatment cannot be considered so ution for the contro of amoebiasis.

Amoebiasis
Amoebiasis is caused by the &roto@oan Entamoeba histolytica.1 Amoebiasis is often asym&tomatic but may cause dysentery and in'asi'e e,traintestina disease.2

Bumans are the on y reser'oir, and infection occurs by in!estion of mature cysts in food or %ater, or on hands contaminated by faeces.) The cysts of E histolytica enter the sma intestine and re ease acti'e amoebic &arasites 9tro&ho@oites:, %hich in'ade the e&ithe ia ce s of the ar!e intestines, causin! f as$1sha&ed u cers. Infection can then s&read from the intestines to other or!ans, e.!. i'er, un!s and brain, 'ia the 'enous system. Asym&tomatic carriers &ass cysts in the faeces and the asym&tomatic carria!e state can &ersist indefinite y. 2ysts remain 'iab e for u& to 2 months. In'asi'e amoebiasis most often causes an amoebic i'er abscess but may affect the un!, heart, brain, urinary tract and s$in.2

E histolytica 9the cause of in'asi'e amoebiasis: must be differentiated from Entamoeba dispar, %hich is a norma commensa of the !astrointestina tract.. #pidemiology About 16 &ercent of the %or d?s &o&u ation is infected %ith E histolytica.2 It is the third most common cause of death 9after schistosomiasis and ma aria: from &arasitic infections. Dery common in South and 2entra America, =est Africa and South1East Asia. Gare in tem&erate c imates.

About 86A of infections are asym&tomatic and the remainin! 16A &roduce a s&ectrum of disease 'aryin! from dysentery to amoebic i'er abscess.2

Presentation Incubation &eriod may be as short as 4 days and tissue in'asion most y occurs durin! first . months of infection.

Intestinal amoebiasis

The most common ty&e of amoebic infection is the asym&tomatic &assa!e of cysts. Sym&tomatic &atients initia y ha'e o%er abdomina &ain and diarrhoea and ater de'e o& dysentery 9%ith b ood and mucus in stoo :. Amoebic co itis %ith dysentery( oose stoo s %ith fresh b ood. *atient is usua y !enera y %e %ith mi d or moderate abdomina &ain. Sym&toms often f uctuate o'er %ee$s or e'en months %ith &atient becomin! debi itated. Abdomina tenderness in one or both i iac fossae but may be !enera ised. *a &ab y thic$ened !ut. #o% fe'er. Abdomina distension in more se'ere y i &atients &assin! re ati'e y sma amounts of stoo sometimes. Amoebic co itis %ithout dysentery( chan!e in bo%e habit, b ood stained stoo s, f atu ence and co ic$y &ain, tenderness in ri!ht i iac fossa or other & aces o'er co on. May disa&&ear or &ro!ress to dysentery. Gecta b eedin!( may occasiona y be on y si!n, %ith or %ithout tenesmus 9common in chi dren:. Amoeboma( o Abdomina mass, %hich is usua y in ri!ht i iac fossa. o May be &ainfu and tender. o -e'er, a tered bo%e habit and there may be intermittent dysentery. o May be sym&toms of &artia or intermittent bo%e obstruction. -u minant co itis( more i$e y in chi dren and &atients ta$in! steroids" hi!h !rade fe'er, se'ere abdomina &ain, increasin! distension of abdomen %ith 'omitin! & us %atery diarrhoea. Absent bo%e sounds. K1ray may sho% free &eritonea !as %ith acute !aseous di atation of the co on. #oca ised &erforation and a&&endicitis( dee& u cer may cause sudden &erforation %ith &eritonitis or may ea$ causin! &erico ic abscess or retro&eritonea infection. May a so resemb e sim& e a&&endicitis, often %ith si!ns of dysentery.

Hepatic amoebiasis

Isua y no current and often no history of dysentery. Isua y occurs %ithin 7 %ee$s to 1 year of infection. *resents %ith s%eatin! and &yre,ia, &ainfu i'er or dia&hra!m to!ether %ith %ei!ht oss often a&&earin! insidious y, but &ain may a&&ear abru&t y. -e'er is ty&ica y remittin! %ith &rominent e'enin! rise %ith brief ri!ors and &rofuse s%eatin! Often anaemia and dry &ainfu cou!h.

#i'er en ar!ement %ith oca ised tenderness in ri!ht hy&ochondrium, e&i!astrium and intercosta s&aces o'er yin! i'er. May find e&i!astric mass from eft1 obe esion. I&%ard en ar!ement may cause bu !in! of ri!ht chest %a %ith raised u&&er e'e of i'er du ness on &ercussion. May hear reduced breath sounds or cre&itations at ri!ht un! base. Abscess may e,tend into ad;acent structures, usua y the ri!ht chest, &eritoneum and &ericardium. If e,tends into un! &roduces he&atobronchia fistu a %ith e,&ectoration of bro%nish, necrotic i'er tissue. May a so cause &eritonitis, &ericarditis, brain abscess or !enitourinary disease.

Differential diagnosis Other causes of infecti'e co itis, u cerati'e co itis, co orecta carcinoma. In chronic infection, other &ossib e dia!noses inc ude 2rohn?s disease, i eocaeca tubercu osis, di'erticu itis, anorecta ym&ho!ranu oma 'enereum. Amoebic i'er abscess has to be differentiated from &yo!enic abscess %hich may occur &articu ar y in o der &atients %ith under yin! bo%e disease or after sur!ery. !nvestigations -u b ood count 9 eucocytosis:, raised ESG, abnorma i'er function tests 9raised a $a ine &hos&hatase and transaminases: Stoo e,amination(2 o Microsco&ic stoo e,amination for tro&ho@oites from a sin! e stoo sam& e in amoebic co itis is on y u& to /6A sensiti'e but e,amination of ) stoo sam& es 9ta$en o'er a &eriod of u& to 16 days: im&ro'es the sensiti'ity to 7/18/A. o E histolytica shou d be differentiated from other Entamoeba spp.) The =or d Bea th Or!anisation no% recommends that intestina amoebiasis shou d be dia!nosed %ith s&ecific stoo E histolytica testin! 9e.!. cu tures, anti!en testin! or &o ymerase chain reaction: rather than e,aminin! stoo for o'a and &arasites. .

Sero o!y( antibody testin! is &ositi'e in 8/A of cases of i'er abscess, 36A of in'asi'e bo%e disease and near y 166A of &atients %ith amoeboma./ *o ymerase chain reaction 9*2G: tests 9faeces, abscess as&irate or other tissues:. Barium studies are contraindicated in acute amoebic co itis because of the ris$ of &erforation. I trasound, 2T and MGI scans of the abdomen can be usefu in dia!nosin! he&atic amoebiasis. I trasound or 2T1!uided i'er abscess as&iration. *roctosco&y, si!moidosco&y or co onosco&y( mucosa scra&in!s for bio&sy and E histolytica testin!.

Abscesses reso 'e s o% y and may increase in si@e durin! treatment and so c inica res&onse is more im&ortant in monitorin! &ro!ress rather than re&eated scans.

+anagement - uid and e ectro yte re& acement, !astric suction and b ood transfusion may be re<uired. +i o,anide furoate is the dru! of choice for asym&tomatic &atients %ith E histolytica cysts in the faeces 9metronida@o e and tinida@o e are re ati'e y ineffecti'e:. Metronida@o e is the first choice for treatment of acute in'asi'e amoebic dysentery. Tinida@o e is a so effecti'e.3 Treatment %ith metronida@o e or tinida@o e is fo o%ed by a 161day course of di o,anide furoate to destroy any amoebae in the !ut.3 +i o,anide furoate is a so !i'en as a 161day course for chronic infections.3 Amoebic abscesses of the i'er( o Metronida@o e and tinida@o e are effecti'e for amoebic abscesses of the i'er.3 o +i o,anide furoate is ineffecti'e a!ainst he&atic amoebiasis but a 161day course shou d be !i'en at the com& etion of metronida@o e or tinida@o e treatment to destroy any amoebae in the !ut. o Sur!ica draina!e of an uncom& icated amoebic i'er abscess is unnecessary and shou d be a'oided. o Bo%e'er the abscess shou d be as&irated if there is a ris$ that it may ru&ture or if metronida@o e eads to no im&ro'ement after 42 hours of treatment. As&iration may need to be re&eated. o *ercutaneous catheter draina!e im&ro'es the outcome for &atients %ith amoebic em&yema or amoebic &ericarditis. o #a&arotomy is re<uired for ru&ture of a i'er abscess. Complications, Amoebic co itis may ead to fu minant or necrotisin! co itis, to,ic me!aco on, amoeboma or a recto'a!ina fistu a. Amoebic i'er abscess( may e,tend andHor ru&ture into the abdomen or chest, or disseminate and cause a brain abscess. Prognosis In uncom& icated disease, morta ity rate is ess than 1A but is much hi!her in com& icated se'ere disease, e.!. fu minant amoebic co itis, chest in'o 'ement or cerebra amoebiasis. More se'ere i ness occurs in chi dren 9es&ecia y neonates:, the immunosu&&ressed, ma nourished, &re!nancy and &ost1&artum. Gecurrence is common if amoebae are not com& ete y eradicated. The bo%e hea s ra&id y and com& ete y" he&atic abscesses usua y disa&&ear %ithin 7 months to 2 years.

Prevention Successfu contro of amoebiasis de&ends on &re'ention of infection throu!h ade<uate sanitation, safe food and %ater and !ood &ersona hy!iene of the &o&u ation. Eo 'accine is yet a'ai ab e.

!ntroductionAmoebiasis &roto@oa infection of human bein!s initia y in'o 'es the co on, but may s&read to soft tissues, most common y to the i'er or un!s, by conti!uity or hemato!enous or ym&hatic dissemination. Amoebiasis is the third eadin! &arasitic cause of death %or d%ide, sur&assed on y by ma aria and schistosomiasis. On a ! oba basis, amoebiasis affects a&&ro,imate y /6 mi ion &ersons each year, resu tin! in near y 166,666 deaths. #tiologic AgentEnatamoeba Bisto ytica

*re'a ent in unsanitary areas 2ommon in %arm c imate Ac<uired by s%a o%in! 2ysts sur'i'es a fe% days outside of the body 2yst &asses to the ar!e intestine and hatch into tro&ho@oites. It &asses into the mesenteric 'eins, to the &orta 'ein, to the i'er, thereby formin! amoebic i'er abscess.

Entamoeba Bisto ytica has t%o de'e o&menta sta!es(

1. Tro&ho@oitesH'e!etati'e form o Tro&ho@oites are facu tati'e &arasites that may in'ade the tissues or may be found in the &arasiti@ed tissues and i<uid co onic contents. 2. 2yst o 2yst is &assed out %ith formed or semi1formed stoo s and are resistant to en'ironmenta conditions. o This is considered as the infecti'e sta!e in the cyc e of E. histo ytica "ource- Buman E,creta !ncubation Period- The incubation &eriod in se'ere infection is three days. In subacute and chronic form it asts for se'era months. In a'era!e cases the incubation &eriod 'aries from three to four %ee$s Period of Communicability- The microor!anism is communicab e for the entire duration of the i ness. +odes of Transmission1. The disease can be &assed from one &erson to another throu!h feca 1ora transmission. 2. The disease can be transmitted throu!h direct contact, throu!h se,ua contact by oro!enita , oroana , and &rocto!enita se,ua acti'ity. ). Throu!h indirect contact, the disease can infect humans by in!estion of food es&ecia y uncoo$ed eafy 'e!etab es or foods contaminated %ith feca materia s containin! E. histo ytica cysts. -ood or drin$s maybe contaminated by cyst throu!h &o ution of %ater su&& ies, e,&osure to f ies, use of ni!ht soi for ferti i@in! 'e!etab es, and throu!h unhy!ienic &ractices of food hand ers. Clinical +anifestations1. Acute amoebic dysentery o S i!ht attac$ of diarrhea, a tered %ith &eriods of consti&ation and often accom&anied by tenesmus. o +iarrhea, %atery and fou sme in! stoo often containin! b ood1strea$ed mucus o 2o ic and !aseous distension of the o%er abdomen o Eausea, f atu ence, abdomna distension and tenderness in the ri!ht i iac re!ion o'er the co on 2. 2hronic amoebic dysentery o Attac$ dysentery that asts for se'era days, usua y succeeded by consti&ation o Tenesmus accom&anied by the desire to defacate o Anore,ia, %ei!ht oss, and %ea$ness

#i'er may be en ar!ed The stoo at first is semif uid but soon becomes %atery, b oody, and mucoid o Da!ue abdomina distress, f atu ence, consti&ation or irre!u arity of bo%e o Mi d to,emia, constant fati!ue and assitude o Abdomen oses its e asticity %hen &ic$ed u& bet%een fin!ers o On si!moidosco&y, scattered u ceration %ith ye o%ish and erythematous border o The !an!renous ty&e 9fata cases: is characteri@ed by the a&&earance of ar!e s ou!hs of intestina tissues in the stoo accom&anied by hemorrha!e. ). E,traintestina forms
o o 1. o o o o o

Be&atic *ain at the u&&er ri!ht <uadrant %ith tenderness of the i'er Abscess may brea$ throu!h the un!s, &atient cou!hs ancho'y1sauce s&utum Jaundice Intermittent fe'er #oss of %ei!ht or anore,ia

Clinical Features1. Onset is !radua 2. +iarrhea increases and stoo becomes b oody and mucoid ). In untreated cases(

Anatomy and PhysiologyAmebiasis is an intestina i ness thatCs ty&ica y transmitted %hen someone eats or drin$s somethin! thatCs contaminated %ith a microsco&ic &arasite ca ed Entamoeba histolytica 9E histolytica:. The &arasite is an amoeba, a sin! e1ce ed or!anism. ThatCs ho% the i ness !ot its name L amebiasis. In many cases, the &arasite i'es in a &ersonCs ar!e intestine %ithout causin! any sym&toms. But sometimes, it in'ades the inin! of the ar!e intestine, causin! b oody diarrhea, stomach &ains, cram&in!, nausea, oss of a&&etite, or fe'er. In rare cases, it can

s&read into other or!ans such as the i'er, un!s, and brain. I. "tructure. The /! "ystem consists of the ora structures, eso&ha!us, stomach, sma intestine, ar!e intestine and associated structures. A. Oral "tructures inc ude the i&s, teeth, !in!i'ae and ora mucosa, ton!ue, hard &a ate, soft &a ate, &haryn, and sa i'ary ! ands. B. The esophagus is a muscu ar tube e,tendin! from the &haryn, to the stomach. 1. Eso&ha!ea o&enin!s inc ude( a. The u&&er eso&ha!ea s&hincter at the crico&haryn!ea musc e. b. The o%er eso&ha!ea s&hincter 9#ES:, or cardiac sphincter# %hich norma y remains c osed and o&ens on y to &ass food into the stomach. 2. The "tomach is a muscu ar &ouch situated in the u&&er abdomen under the i'er and dia&hra!m. Te stomach consists of three anatomic areas( the fundus, body 9i.e., cor&us:, and antrum 9i.e., &y orus: +. "phincters. The #ES a o%s food to enter the stomach and &re'ents ref u, into the eso&ha!us. The &y oric s&hincter re!u ates f o% of stomach contents 9chyme: into the duodenum. E. The small intestine, a coi ed tube, e,tends from the &y oric s&hincter to the i eoceca 'a 'e at the ar!e intestine. Sections of the sma intestine inc ude the duodenum, ;e;unum and i eum -. The large intestine is a shorter, %ider tube be!innin! at the i eoceca 'a 'e and endin! at the anus. The ar!e intestine consists of three sections( 1. The cecum is a b ind &ouch that e,tends from the i eoceca 'a 'e to the 'ermiform a&&endi,. 2. The co on, %hich is the main &ortion of the ar!e intestine, is di'ided into four anatomic sections( ascendin!, trans'erse, descendin! and si!moid. ). The rectum e,tends from the si!moid co on to the anus.

5. The ileocecal valve &re'ents the return of feces from the cecum into the sma intestine and ies at the u&&er border of the cecum. B. The appendi$, %hich co ects ym&hoid tissues, arises from the cecum. I. The 5I tract is com&osed of fi'e ayers. 1. An inner mucosa ayer ubricates and &rotects the inner surface of the a imentary cana . 2. A submucosa ayer is res&onsib e for secretin! di!esti'e en@ymes. ). A ayer of circu ar smooth musc e fibers is res&onsib e for mo'ement of the 5I tract. .. A ayer of on!itudina smooth musc e fibers a so faci itates mo'ement of the 5I tract. /. The &eritoneum, an outer serosa ayer, co'ers the entire abdomen and is com&osed of the &arieta and 'iscera ayers. II. Function. The 5I system &erforms t%o ma;or body functions( di!estion and e imination. A. Digestion of food and f uid, %ith absor&tion of nutrients into the b oodstream, occurs in the u&&er 5I tract, stomach and sma intestines. 1. +i!estion be!ins in the mouth %ith che%in! and the action of &tya in, an en@yme contained in sa i'a that brea$s do%n starch. 2. S%a o%ed food &asses throu!h the eso&ha!us to the stomach, %here di!estion continues by se'era &rocesses. a. Secretion of !astric ;uice, containin! hydroch oric acid and the en@ymes &e&sin and i&ase 9 and renin in infants: b. Mi,in! and churnin! throu!h &erista tic action ). -rom the &y orus, the mi,ed stomach contents 9i.e. chyme: &ass into the duodenum throu!h the &y oric 'a 'e. .. In the sma intestine, food di!estion is com& eted, and most nutrient absor&tion occurs. +i!estion resu ts from the action of numerous &ancreatic and intestina en@ymes 9e.!., try&sin, i&ase, amy ase, actase, ma tase, sucrase9 and bi e.

B. #limination of %aste &roducts throu!h defacation occurs in the ar!e intestines and rectum. In the ar!e intestine, the cecum and ascendin! co on absorb %ater and e ectro ytes from the no% com& ete y di!ested materia . The rectum stores feces for e imination. Pathophysiology 0aboratory Diagnosis1. Stoo e,am 9cyst, %hite and ye o% &us %ith & enty of amoeba: 2. B ood e,am 9#eu$ocytosis: ). *roctosco&yHSi!moidosco&&y +ia!nosis of amoebiasis can be 'ery difficu t. One &rob em is that other &arasites and ce s can oo$ 'ery simi ar to E histolytica %hen seen under a microsco&e. Therefore, sometimes &eo& e are to d that they are infected %ith E histolytica e'en thou!h they are not. Entamoeba histolytica and another ameba, Entamoeba dispar, %hich is about 16 times more common, oo$ the same %hen seen under a microsco&e. In i$e infection %ith E histolytica, %hich sometimes ma$es &eo& e sic$, infection %ith E dispar does not ma$e &eo& e sic$ and therefore does not need to be treated. If you ha'e been to d that you are infected %ith E histolytica but you are fee in! fine, you mi!ht be infected %ith E dispar instead. Infortunate y, most aboratories do not yet ha'e the tests that can te %hether a &erson is infected %ith E histolytica or %ith E dispar. Inti these tests become more %ide y a'ai ab e, it usua y is best to assume that the &arasite is E histolytica. A b ood test is a so a'ai ab e but is on y recommended %hen your hea th care &ro'ider thin$s that your infection may ha'e s&read beyond the intestine 9!ut: to some other or!an of your body, such as the i'er. Bo%e'er, this b ood test may not be he &fu in dia!nosin! your current i ness because the test may sti be &ositi'e if you had amoebiasis in the &ast, e'en if you are no on!er infected no%. Complications1. Amebic co itis o -u minant or necroti@in! co itis o To,ic me!aco on o Ameboma o Gecto'a!ina fistu as 2. Amebic i'er abscess o Intrathoracic or intra&eritonea ru&ture %ith or %ithout secondary bacteria infection o +irect e,tension to & eura or &ericardium ). Brain abscess

Treatment1. 2. ). .. /. Metronida@o e 9- a!y : 766m! TI+ K / days Tetracy ine 2/6 m! e'ery 3 hours Am&ici in, <uino ones su fadia@ine Stre&tomycin SO., 2h oram&henico #ost f uid and e ectro ytes shou d be re& aced

Se'era antibiotics are a'ai ab e to treat amoebiasis. Treatment must be prescribed by a physician. Mou %i be treated %ith on y one antibiotic if your E histolytica infection has not made you sic$. Mou &robab y %i be treated %ith t%o antibiotics 9first one and then the other: if your infection has made you sic$. Nursing +anagement1. Obser'e iso ation and enteric &recaution 2. *ro'ide hea th education and instruct &atient to o Boi %ater for drin$in! or use &urified %ater o A'oid %ashin! food from o&en drum or &ai o 2o'er efto'er food o =ash hands after defacation and before eatin! o A'oid !round 'e!etab es 9 ettuce, carrots, and the i$e: +ethods of Prevention1. 2. ). .. /. 3. Bea th education Sanitary dis&osa of feces *rotect, ch orinate, and &urify drin$in! %ater Obser'e scru&u ous c ean iness in food &re&aration and food hand in! +etection and treatment of carriers - y contro 9they can ser'e as 'ector:

=hat is amoebiasisN Amoebias is an inf ammation of the intestines caused by a &arasite, Entamoeba histolytica. This microsco&ic &arasite enters the body throu!h contaminated food or %ater. The infection is common in areas %ith &oor sanitation or i'in! conditions. This &arasite can i'e in the intestine %ithout causin! sym&toms, or it can &roduce se'ere sym&toms. It is a 'ery common &rob em in India. Bo% does it occurN
Infection occurs by eating food or drinking water contaminated with faeces, containing the parasite, Entamoeba histolytica. Another source of the infection is food (usually raw vegetables and fruit) that has been handled by an infected person. People with amoebiasis pass Entamoeba histolytica parasites in their faeces. he infection spreads when infected people do not dispose of their faeces in a sanitary manner or do not wash their hands properly after going to the toilet. !ontaminated hands can then spread the

parasites to food that may be eaten by other people and surfaces that may be touched by other people. "ands can also become contaminated when changing the nappies of an infected infant.

=hat are the sym&tomsN The sym&toms of intestina amoebiasis inc ude diarrhoea, abdomina cram&s, bo%e mo'ements strea$ed %ith b ood or mucus, nausea or 'omitin! and occasiona y fe'er. The time inter'a bet%een the &arasite?s entry into the body and the a&&earance of the first sym&toms ran!es from a fe% days to a fe% %ee$s, usua y 'aries from t%o to four %ee$s. Bo% is it dia!nosedN
he doctor will review the symptoms, and order a stool test after e#amining the patient. he parasite can be detected by a microscopic e#amination of freshly passed stool. $ccasionally, making the diagnosis is difficult in cases with symptoms for a long time. %ometimes sigmoidoscopy is done, which is a procedure in which the doctor uses a lighted, fle#ible tube to look inside the lower part of the colon (large intestine).

Bo% is it treatedN
he doctor will prescribe medication such as metronidazole, diloxanide furoate, dehydroemetine, emetine, or paromomycin. he doctor may prescribe more than one drug. If medication is stopped when the symptoms are gone but before the parasite is eliminated from the body, the infection may return. An anti&diarrhoeal medication may also be prescribed. Metronidazole can produce a metallic taste in the mouth and may give rise to nausea. Alcoholic drinks must be avoided while taking metronidazole. he symptoms of diarrhoea usually last from ' to () days but can last up to ) weeks. *ecurrences are possible.

Bo% can care be ta$en at homeN


+et the bowel rest by drinking only clear li,uids such as water, -uice, tea and oral rehydrating or electrolyte solutions. It is important to drink fre,uently so that dehydration is avoided. .rinking small amounts at fre,uent intervals is better accepted in cases of nausea. Avoid solids because they can cause cramps. +ight soups, toast, rice and eggs are good foods to eat during recovery. Is hospitalisation necessary for amoebiasis/ 0sually amoebiasis can be managed on an out&patient basis. "owever, in severe cases, involving the liver or other organs, re,uire hospitalisation. $ther indications for hospitalisation include1

Treatment fai ure 2ases of chronic dysentery

If i'er abscess or any other e,traintestina infection is sus&ected Bo% can amoebiasis be &re'entedN O Ensurin! a safe drin$in! %ater su&& y by boi in! or fi terin! %ater is usua y effecti'e for &re'ention. 2h orine is not effecti'e in $i in! the &arasite. A'oid unsanitary %ater su&& ies. O =ash hands %ith soa& and %arm %ater after !oin! to the toi et and before eatin! or &re&arin! food. O *ro&er food stora!e and &re'entin! its contamination %ith faeces, f ies, and contaminated %ater is a so im&ortant. Gead more at( htt&(HHdoctor.ndt'.comHto&icdetai sHndt'HtidH122HAmoebiasis.htm Nc& Amebiasis is caused by Entamoeba histolytica# a &roto@oan found %or d%ide. The hi!hest &re'a ence of amebiasis is in de'e o&in! countries %here barriers bet%een human feces and food and %ater su&& ies are inade<uate. A thou!h most cases of amebiasis are asym&tomatic, dysentery and in'asi'e e,traintestina disease can occur. Amebic i'er abscess is the most common manifestation of in'asi'e amebiasis, but other or!ans can a so be in'o 'ed, inc udin! & euro&u monary, cardiac, cerebra , rena , !enitourinary, and cutaneous sites. In de'e o&ed countries, amebiasis &rimari y affects mi!rants from and tra'e ers to endemic re!ions, men %ho ha'e se, %ith men, and immunosu&&ressed or institutiona i@ed indi'idua s. E histolytica is transmitted 'ia in!estion of the cystic form 9infecti'e sta!e: of the &roto@oa. Diab e in the en'ironment for %ee$s to months, cysts can be found in feca y contaminated soi , ferti i@er, or %ater or on the contaminated hands of food hand ers. -eca 1ora transmission can a so occur in the settin! of ana se,ua &ractices or direct recta inocu ation throu!h co onic irri!ation de'ices. E,cystation then occurs in the termina i eum or co on, resu tin! in tro&ho@oites 9in'asi'e form:. The tro&ho@oites can &enetrate and in'ade the co onic mucosa barrier, eadin! to tissue destruction, secretory b oody diarrhea, and co itis resemb in! inf ammatory bo%e disease. In addition, the tro&ho@oites can s&read hemato!enous y 'ia the &orta circu ation to the i'er or e'en to more distant or!ans. Amebic infection %as first described by -edor #osch in 174/ in St. *etersbur!, Gussia. In 1786, Sir =i iam Os er re&orted the first Eorth American case of amebiasis, %hen he obser'ed amebae in stoo and abscess f uid from a &hysician %ho &re'ious y resided in *anama. The s&ecies name E histolytica %as first coined by -rit@ Schaudin in 186). In 181), in the *hi i&&ines, =a $er and Se ards documented the cyst as the infecti'e form of E histolytica. The ife cyc e %as then estab ished by +obe in 182/.

Pathophysiology

E histolytica is a &seudo&od1formin!, nonf a!e ated &roto@oa &arasite that causes &roteo ysis and tissue ysis 9hence its name: and can induce host1ce a&o&tosis. Bumans and &erha&s nonhuman &rimates are the on y natura hosts. In!estion of E histolytica cysts from the en'ironment is fo o%ed by e,cystation in the termina i eum or co on to form hi!h y moti e tro&ho@oites. I&on co oni@ation of the co onic mucosa, the tro&ho@oite may encyst and is then e,creted in the feces or may in'ade the intestina mucosa barrier and !ain access to the b ood stream and disseminate to the i'er, un!, and other sites. E,creted cysts reach the en'ironment to com& ete the cyc e. +isease may be caused by on y a sma number of cysts, but the &rocesses of encystation and e,cystation are &oor y understood. The adherence of tro&ho@oites to co onic e&ithe ia ce s seems to be mediated by a !a actoseHN 1acety !a actosamine 95A#H5a EAc:Ps&ecific ectin.[1, 2] A mucosa immuno! obu in A 9I!A: res&onse a!ainst this ectin can resu t in fe%er recurrent infections.[)] Both ytic and a&o&totic &ath%ays ha'e been described. 2yto ysis can be underta$en by amoeba&ores, a fami y of &e&tides ca&ab e of formin! &ores in i&id bi ayers.[1] -urthermore, in anima mode s of i'er abscess, tro&ho@oites induced a&o&tosis 'ia a non1-as and nonPtumor necrosis factor1Q1 rece&tor &ath%ay.[.] The amoeba&ores, at sub ytic concentrations, can a so induce a&o&tosis. 2ysteine &roteinases ha'e been direct y im& icated in in'asion and inf ammation of the !ut and may am& ify inter eu$in 9I#:P1Pmediated inf ammation by mimic$in! the action of human I#11Pcon'ertin! en@yme, c ea'in! I#11 &recursor to its acti'e form.[1, /] The cysteine &roteinases can a so c ea'e and inacti'ate the ana&hy ato,ins 2)a and 2/a, as %e as I!A and immuno! obu in 5 9I!5:.[3, 4] E&ithe ia ce s a so &roduce 'arious inf ammatory mediators, inc udin! I#11B, I#17, and cyc oo,y!enase12, eadin! to the attraction of neutro&hi s and macro&ha!es.[7, 8] 2orticosteroid thera&y is $no%n to %orsen the c inica outcome, &ossib y because of its b untin! effect on this innate immune res&onse. Additiona host defenses, inc udin! the com& ement system, cou d be inhibited direct y by the tro&ho@oites, su!!ested by the findin! that a re!ion of the 5A#H5a EAcPs&ecific ectin sho%ed anti!enic crossreacti'ity %ith 2+/8, a membrane inhibitor of the 2/b18 attac$ com& e, in human red b ood ce s. [16] Tro&ho@oites that reach the i'er create uni<ue abscesses %ith %e 1circumscribed re!ions of dead he&atocytes surrounded by fe% inf ammatory ce s and tro&ho@oites and unaffected he&atocytes, su!!estin! that E histolytica are ab e to $i he&atocytes %ithout direct contact.[1] The !enus Entamoeba contains many s&ecies, some of %hich 9ie, E histolytica# Entamoeba dispar# Entamoeba moshkovskii# Entamoeba polecki# Entamoeba coli# Entamoeba hartmanni: can reside in the human interstitia umen. E histolytica is, thus far, the on y Entamoeba s&ecies definite y associated %ith disease" the others are considered non&atho!enic.[11] More recent studies ha'e reco'ered E dispar and E moshkovskii from &atients %ith !astrointestina sym&toms, but a causa re ationshi& is undetermined.[11]

E dispar and E histolytica cannot be differentiated by direct e,amination, but recent mo ecu ar techni<ues estab ished them as t%o different s&ecies, %ith E dispar bein! commensa 9inc udin! in &atients %ith BID infection: and E histolytica &atho!enic.[11] In fact, it is no% estimated that many indi'idua s %ith Entamoeba infections are co oni@ed %ith E dispar, %hich a&&ears to be 16 times more common than E histolytica.[11] Bo%e'er, in certain re!ions 9e!, Bra@i , E!y&t:, asym&tomatic E dispar and E histolytica infections are e<ua y &re'a ent.[1] In =estern countries, a&&ro,imate y 26A1)6A of men %ho ha'e se, %ith men are co oni@ed %ith E dispar.[11]

Frequency

*nited "tates
The o'era &re'a ence of amebiasis is a&&ro,imate y .A. Bo%e'er, certain !rou&s are &redis&osed to amebic co itis, inc udin! 'ery youn! &atients, &re!nant %omen, reci&ients of corticosteroids, and ma nourished indi'idua s.[1] In 188), a tota of 2846 cases of amebiasis %ere re&orted to the 2enters for +isease 2ontro and *re'ention 92+2:" ))A of cases %ere re&orted in Bis&anic immi!rants and 14A in immi!rants from Asia or the *acific Is ands. Tra'e ers to endemic areas are at ris$ for infection" 16A of indi'idua s returnin! %ith diarrhea %ere found to ha'e amebiasis.[1] Amebic i'er abscess has been re&orted in tra'e e,&osures as short as . days 9median, ) mo:, %hereas amebic co itis is uncommon in short1term tra'e ers.

!nternational
Entamoeba s&ecies infect a&&ro,imate y 16A of the %or d?s &o&u ation. The &re'a ence of Entamoeba infection is as hi!h as /6A in areas of 2entra and South America, Africa, and Asia. In E!y&t, )7A of indi'idua s &resentin! %ith acute diarrhea to an out&atient c inic %ere found to ha'e amebic co itis.[1]E histolytica sero&re'a ence studies in Me,ico re'ea ed that more than 7A of the &o&u ation %ere &ositi'e.[12] Asym&tomatic E histolytica infections seem to be re!ion1de&endent, as hi!h as 11A in Bra@i . Since the introduction of mo ecu ar techni<ues, it is estimated that /66 mi ion indi'idua s %ith Entamoeba infection are co oni@ed by E dispar.[11]

ortality/ orbidity

Amebiasis is second on y to ma aria in terms of &roto@oa1associated morta ity. The combined &re'a ence of amebic co itis and amebic i'er abscess is estimated at .61/6 mi ion cases annua y %or d%ide, resu tin! in .6,6661166,666 deaths.[11,
1, 1)]

Asym&tomatic intestina amebiasis occurs in 86A of infected indi'idua s. Bo%e'er, on y .A116A of indi'idua s %ith asym&tomatic amebiasis %ho %ere monitored for one year e'entua y de'e o&ed co itis or e,traintestina disease.[11] 2ase fata ity rates associated %ith amebic co itis ran!e from 1.8A18.1A. Amebic co itis e'o 'es to fu minant necroti@in! co itis or ru&ture in a&&ro,imate y 6./A of cases" in such cases, the morta ity rate ;um&s to !reater than .6A.[1.]

The morta ity rate due to amebic i'er abscess has fa en to 11)A in the ast century fo o%in! the introduction of effecti'e medica treatment. Ee'erthe ess, amebic i'er abscess is com& icated by sudden intra&eritonea ru&ture in 214A of &atients, eadin! to a hi!her morta ity rate.[1]

!ace

In Ja&an and Tai%an, BID sero&ositi'ity is a ris$ factor for in'asi'e e,traintestina amebiasis.[1/] This has not been obser'ed e se%here.

Se"

Amebic co itis affects both se,es e<ua y.[1] Amebic i'er abscess is 4112 times more common in men than in %omen, %ith a &redominance amon! men a!ed 171/6 years. The reason for this se,ua dis&arity is un$no%n, a thou!h hormona effects may be im& icated, as the &re'a ence of amebic i'er abscess is a so increased amon! &ostmeno&ausa %omen. A coho may a so been an im&ortant ris$ factor. The se,ua distribution is e<ua in chi dren.[1]

Age
Dery youn! chi dren seem to be &redis&osed to fu minant co itis.

'istory

Amebic co itis o The most common &resentation of amebic co itis is !radua onset of b oody diarrhea, abdomina &ain, and tenderness s&annin! se'era %ee$sC duration. o Gecta b eedin! %ithout diarrhea can occur, es&ecia y in chi dren. o On y a&&ro,imate y 161)6A of &atients %ith amebic co itis de'e o& fe'er. o =ei!ht oss and anore,ia may occur. o -u minant or necroti@in! co itis usua y manifests as se'ere b oody diarrhea and %ides&read abdomina &ain %ith e'idence of &eritonitis and fe'er. o *redis&osin! factors for fu minant co itis inc ude &oor nutrition, &re!nancy, corticosteroid use, and 'ery youn! a!e. Amebic i'er abscess o The most ty&ica &resentation of amebic i'er abscess is fe'er, ri!ht u&&er <uadrant &ain, and tenderness of ess than 16 daysC duration. o In i$e amebic co itis, amebic i'er abscess is associated %ith fe'er in 7/1 86A of cases. o A more subacute &resentation can be seen, %ith concomitant %ei!ht oss and anore,ia. o 2ou!h can occur. Jaundice is unusua .

Acute abdomina sym&toms and si!ns shou d &rom&t ra&id in'esti!ation for intra&eritonea ru&ture. o Si,ty to 46A of &atients %ith amebic i'er abscess do not ha'e concomitant co itis, a thou!h a history of dysentery %ithin the &re'ious year may be obtained. o Amebic i'er abscess may manifest years after tra'e to or residency in an endemic area. o A history of a coho abuse is common, but a c ear causa re ationshi& is unc ear. * euro&u monary amebiasis( 2ou!h, & euritic chest &ain, and res&iratory distress may be c ues to ru&ture throu!h the dia&hra!m, a rare but serious com& ication of amebic i'er abscess. 2erebra amebiasis o Occurrin! in 6.3A of amebic i'er abscess cases, abru&t onset of nausea, 'omitin!, headache, and menta status chan!e shou d &rom&t ra&id in'esti!ation for 2ES in'o 'ement. o *ro!ression can be 'ery ra&id.
o

Physical

Amebic co itis o -e'er 9161)6A: o =ei!ht oss 9.6A: o +iffuse abdomina tenderness 91217/A: o Beme1&ositi'e stoo s 9461166A: o Abdomina &ain, distension, and rebound tenderness i$e y in fu minant co itis Amebic i'er abscess o -e'er 97/186A: o Gi!ht u&&er <uadrant abdomina tenderness 97.186A: o =ei!ht oss 9))1/6A: o Be&atome!a y 9)61/6A: o Jaundice 93116A:

Causes

Amebiasis is an infection caused by the &roto@oa or!anism E histolytica# %hich can cause co itis and other e,traintestina manifestations, inc udin! i'er abscess 9most common: and & euro&u monary, cardiac, and cerebra dissemination. E histolytica is transmitted &rimari y throu!h the feca 1ora route. Infecti'e cysts can be found in feca y contaminated food and %ater su&& ies and contaminated hands of food hand ers. Se,ua transmission is &ossib e, es&ecia y in the settin! of ora 1ana &ractices.

Amebiasis Differential Diagnoses

Differentials

Abdomina Abscess Arterio'enous Ma formations 2am&y obacter Infections 2ho ecystitis 2o itis, Ischemic +i'erticu itis Echinococcosis Escherichia 2o i Infections Be&atitis A Be&atitis, Dira Be&atoce u ar Adenoma Inf ammatory Bo%e +isease *erforated abdomina 'iscus *ericarditis *eritonitis *yo!enic Be&atic Abscesses Gi!ht o%er obe &neumonia Sa mone osis Shi!e osis

0aboratory "tudies

Microsco&y[11] o Microsco&ic stoo e,amination for tro&ho@oites from a sin! e stoo sam& e in amebic co itis is on y ))1/6A sensiti'e. E,amination of ) stoo sam& es o'er no more than 16 days can im&ro'e the detection rate to 7/18/A.

o o

Trichrome stain of Entamoeba histo ytica tro&ho@oites in amebiasis. T%o dia!nostic characteristics are obser'ed. T%o tro&ho@oites ha'e in!ested erythrocytes, and a ) ha'e nuc ei %ith sma , centra y ocated $aryosomes. Stoo eu$ocytes may be found, but in fe%er numbers than in shi!e osis. Stoo e,amination findin!s in &atients %ith amebic i'er abscess are usua y ne!ati'e. Ge&eated stoo sam& in! in &atients %ith &ro'en amebic

i'er abscess is &ositi'e in 71.6A of cases. Identification of the &arasite in a i'er abscess as&irate is on y 26A sensiti'e. The &resence of intracyto& asmic red b ood ce s in tro&ho@oites is dia!nostic of E histolytica infection, a thou!h recent studies demonstrated the same &henomenon %ith E dispar. The =or d Bea th Or!ani@ation 9=BO: recommends that intestina amebiasis be dia!nosed %ith an E histolytica 1s&ecific test, thus renderin! the c assic stoo o'a and &arasite e,amination obso ete.

2u ture[11] o Kenic cu ti'ation, first introduced in 182/, is defined as the !ro%th of the &arasite in the &resence of an undefined f ora. This techni<ue is sti in use today usin! modified #oc$e1e!! media. o A,enic cu ti'ation, first achie'ed in 1831, in'o 'es !ro%th of the &arasite in the absence of any other metabo i@in! ce s. On y a fe% strains of E dispar ha'e been re&orted to be 'iab e in a,enic cu tures. o 2u tures can be &erformed usin! feca or recta bio&sy s&ecimens and i'er abscess as&irates. The success rate is bet%een /6A and 46A, but the techni<ue is technica y difficu t. O'era , it is ess sensiti'e than microsco&y. Anti!en detection[11] o En@yme1 in$ed immunosorbent assay 9E#ISA: is used to detect anti!ens from E histolytica in stoo sam& es. Se'era $its are commercia y a'ai ab e. o Anti!en1based E#ISA $its usin! monoc ona antibodies a!ainst the 5A#H5a EAcPs&ecific ectin of E histolytica 9E histolytica II, Tech#ab, B ac$sbur!, DA: yie d an o'era sensiti'ity of 41A1166A and s&ecificity of 8)A1166A. One study sho%ed a much o%er sensiti'ity 91..2A:. o In &atients %ith amebic i'er abscess, serum and i'er as&irate anti!en detection usin! the same $it %as sho%n to yie d a sensiti'ity of 83A and 166A, res&ecti'e y. o Other stoo detection $its use monoc ona antibodies a!ainst the serine1 rich anti!en of E histolytica 9O&timum S $it, Mer in +ia!niosti$a, Bornheim1Berse , 5ermany: or a!ainst other s&ecific anti!ens 9Entamoeba 2E#ISA1*ATB, 2e abs, Broo$'a e, Austra ia" *roS&ecT EIA, Gem e Inc, #ene,a, RM:. o Eo s&ecific anti!en tests are a'ai ab e for the detection of E dispar and E moshkovskii from c inica sam& es. Sero o!y[11] o Mu ti& e sero o!ic assays are a'ai ab e for the dia!nosis of amebiasis. o E#ISA is the most used assay throu!hout the %or d and is used to measure the &resence of serum anti ectin antibodies 9I!5:. The sensiti'ity for detection of antibodies to E histolytica in &atients %ith amebic i'er abscess is 84.8A, %hereas the s&ecificity is 8..7A. -a se1ne!ati'e resu ts can occur %ithin the first 4116 days fo o%in! infection.

Immunof uorescent assay 9I-A: is a so ra&id, re iab e, and re&roducib e. In the settin! of amebic i'er abscess, the sensiti'ity and s&ecificity of I-A %as sho%n to be 8).3A and 83.4A, res&ecti'e y. o Indirect hema!! utination 9IBA: is 'ery s&ecific 988.1A: but is ess sensiti'e than E#ISA. o Immunoe ectro&horesis, counter1immunoe ectro&horesis 92IE:, and immunodiffusion tests use the &reci&itation &ro&erty of anti!en1antibody com& e,es in a!ar. 2IE is time1consumin! but has sho%n a sensiti'ity of 166A in in'asi'e amebiasis. o 2om& ement fi,ation 92-: is ess sensiti'e than other techni<ues. o The sero&ositi'ity &re'a ence is 'ery hi!h in endemic areas, imitin! antibody1based testin! for dia!nosin! current y acti'e disease, since antibodies can &ersist for years after infection. *o ymerase chain reaction[11] o E histolytica can be identified in 'arious ty&es of c inica s&ecimens, inc udin! feces, tissues, and i'er abscess as&irates. o A %ide 'ariety of &o ymerase chain reaction 9*2G: methods tar!etin! different !enes, inc udin! a sma 1subunit rGEA !ene 917S r+EA:, )61 $+a anti!en !ene, serine1rich &rotein !ene, chitinase !ene, hemo ysin !ene, and e,trachromosoma circu ar +EA, ha'e been described for the detection and differentiation of E histolytica# E dispar# and E moshkovskii. o Sensiti'ities can 'ary accordin! to sam& in! and the s&ecific tar!et !ene used. *erformed on feces, *2G yie ds a sensiti'ity that is simi ar to that of stoo anti!en1based assay. o *2G1based tests ha'e been stron! y endorsed by the =BO. o A&& ication of *2G1based methods in routine dia!nosis is sti 'ery imited, as the !eneration of nons&ecific +EA fra!ments from en'ironmenta and c inica sam& es often eads to fa se1&ositi'e resu ts Eons&ecific aboratory tests o Amebic i'er abscess #eu$ocytosis %ithout eosino&hi ia 976A: E e'ated a $a ine &hos&hatase 976A: Mi d y e e'ated transaminases Mi d anemia E e'ated erythrocyte sedimentation rate
o

!maging "tudies

Both u trasono!ra&hy and 2T scannin! are sensiti'e but nons&ecific for amebic i'er abscess. #esions are usua y so itary and ocated in the ri!ht he&atic obe 946176A:, a thou!h mu ti& e abscesses are &ossib e. On sono!rams, amebic i'er abscesses usua y a&&ear as a homo!enous hy&oechoic round esion.

On 2T scans %ith intra'enous contrast, amebic i'er abscess can a&&ear as a rounded, o%1attenuation esion %ith an enhancin! rim. -urthermore, the abscess may be homo!enous or se&tated, %ith or %ithout obser'ab e f uid e'e s.

Procedures

#i'er as&iration o I trasound1 or 2T1!uided need e as&iration shou d be &erformed %hen a dia!nosis must be estab ished 'ery ra&id y, since &yo!enic i'er abscess can &resent and a&&ear in a simi ar fashion. o #i'er abscess as&irate is usua y an odor ess thic$ ye o%1bro%n i<uid c assica y referred to as 0ancho'y &aste.0 o As&irate can be sent for microsco&y, cu ture, anti!en detection, and *2G, %here a'ai ab e. A 5ram stain shou d a so be &erformed if a &yo!enic etio o!y is sus&ected c inica y. 2o onosco&y o 2o onosco&y can be &erformed for bio&sy in the settin! of ne!ati'e findin!s on stoo s studies, inc udin! anti!en testin!. Tissue can be sent for microsco&ic e'a uation, cu ture, and *2G, %here a'ai ab e. o -u minant co itis is a re ati'e contraindication to co onosco&y since the ris$ of intestina &erforation is increased. o A friab e and diffuse y u cerated mucosa resemb in! inf ammatory bo%e disease can be obser'ed. o A carcinoma i$e annu ar esion ca ed ameboma can a so be seen, usua y in the cecum and ascendin! co on.[1, 13]

'istological Findings

The intestina bio&sy s&ecimen shou d be ta$en from the ed!e of u cers and e'a uated for moti e tro&ho@oites. Bisto&atho o!ica findin!s can com&rise of mucosa thic$enin!, mu ti& e discrete u cers se&arated by re!ions of norma 1a&&earin! co onic mucosa, diffuse y inf amed and edematous mucosa, necrosis, or %a &erforation. Amebic in'asion throu!h the mucosa and into submucosa tissues is the ha mar$ of amebic co itis. #atera e,tension throu!h the submucosa tissues !i'es rise to the c assic f as$1 sha&ed u cer of amebic co itis. +ifferent chemica stains can be used, inc udin! &eriodic acid1Schiff stain, %hich ma$es E histolytica a&&ear ma!enta in co or.

Trichrome stain of Entamoeba histo ytica tro&ho@oites in amebiasis. T%o dia!nostic characteristics are obser'ed. T%o tro&ho@oites ha'e in!ested erythrocytes, and a ) ha'e nuc ei %ith sma ,

centra y ocated $aryosomes. Trichrome stain of an Entamoeba histo ytica cyst in amebiasis. Each cyst has . nuc ei %ith characteristica y centra y ocated $aryosomes. 2ysts measure 1211/ mm.

+edical Care
Most indi'idua s %ith amebiasis may be treated on an out&atient basis. Se'era c inica scenarios may fa'or in&atient care, as fo o%s(

Se'ere co itis and hy&o'o emia re<uirin! intra'enous 'o ume re& acement #i'er abscess of uncertain etio o!y or not res&ondin! to em&irica thera&y -u minant co itis re<uirin! sur!ica e'a uation *eritonitis and sus&ected amebic i'er abscess ru&ture

"urgical Care

*rom&t sur!ica e'a uation is needed in sus&ected cases of fu minant co itis, &eritonitis, or &erforated 'iscus. Sur!ica inter'ention is usua y indicated in different c inica scenarios( uncertain dia!nosis 9&ossibi ity of &yo!enic i'er abscess:" concern of bacteria su&rainfection in amebic i'er abscess" fai ure to res&ond to metronida@o e after .1 day treatment duration" em&yema after amebic i'er abscess ru&ture" ar!e eft1

sided amebic i'er abscess re&resentin! ris$ of ru&ture in the &ericardium" and se'ere y i &atient %ith imminent amebic i'er abscess ru&ture.[1] Sur!ica draina!e of uncom& icated amebic i'er abscess is !enera y unnecessary and shou d be a'oided. *ercutaneous catheter draina!e im&ro'es the outcome in the treatment of amebic em&yema and is ife1sa'in! in amebic &ericarditis. *ercutaneous catheter draina!e shou d be used ;udicious y in the settin! of oca i@ed intraabdomina f uid co ections. A thou!h contro'ersia , it mi!ht be used to as&irate ar!e amebic i'er abscesses 9S)66 cm):.[1]

Consultations

Infectious disease s&ecia ist 5enera sur!eon 5astrointestina s&ecia ist

+edication "ummary

Asym&tomatic amebiasis shou d be treated %ith a umina a!ent 9iodo<uino , &aromomycin, di o,anide furoate: to eradicate infection. This recommendation is based on t%o ar!uments( -irst, in'asi'e disease may de'e o&" second, sheddin! of E histolytica cysts in the en'ironment is a &ub ic hea th concern.[1] Asym&tomatic E dispar infections shou d not be treated, but education shou d be &ursued since it is a mar$er of feca 1ora contamination.[1] Amebic co itis is first treated %ith a nitroimida@o e deri'ati'e 9metronida@o e bein! the on y one a'ai ab e in the Inited States:, fo o%ed by a umina a!ent to eradicate co oni@ation.[1] Amebic i'er abscess can be cured %ithout draina!e and e'en by one dose of metronida@o e. 2 inica defer'escence shou d occur durin! the first )1. days of treatment. Metronida@o e fai ure may be an indication for sur!ica inter'ention. Treatment %ith a umina a!ent shou d a so fo o%.[1] +isseminated amebiasis shou d be treated %ith metronida@o e, %hich can cross the brain1b ood barrier. Em&irica antibacteria a!ents shou d be used concomitant y if &erforated 'iscus is a concern.

Amebicides
Class Summary
*arasite biochemica &ath%ays are sufficient y different from the human host to a o% se ecti'e interference by chemothera&eutic a!ents in re ati'e y sma doses.

Iodoquinol #$odo"in%
Amebicida a!ainst E histolytica. 2onsidered effecti'e a!ainst tro&ho@oite and cyst forms.

&aromomycin #Humatin%
Amebicida and antibacteria amino! ycoside obtained from a strain of Streptomyces rimosus, acti'e in intestina amebiasis a!ainst tro&ho@oite and cyst forms of E histolytica. Gecommended for the treatment of Diphyllobothrium latum, *aenia saginata, *aenia solium, Dipylidium caninum, and +ymenolepis nana.

Dilo"anide #'ntamide, Furamide%


+ich oroacetamide deri'ati'e. Amebicida a!ainst tro&ho@oite and cyst forms of E histolytica. Eot a'ai ab e in Inited States.

etronida(ole #Flagyl%
Acti'e a!ainst 'arious anaerobic bacteria and &roto@oa. A&&ears to be absorbed into ce s. Intermediate metabo i@ed com&ounds are formed and bind +EA and inhibit &rotein synthesis, causin! ce death. Antimicrobia effect may be due to &roduction of free radica s. Indicated for in'asi'e amebiasis.

Tinida(ole #Fasigyn%
/1Eitroimida@o e deri'ati'e used for susce&tib e &roto@oa infections. Indicated to treat intestina amebiasis and amebic i'er abscess caused by E histolytica in adu ts and chi dren a!ed ) y and o der.

iodoquinol #!"% ) $odo"in

2 ass( Anti&arasitic A!ents

Adult Dosing 1 *ses


Dosing Forms * Strengt+s
tab ets

216m! 3/6m!

Intestinal Amebiasis
3/6 m! *O *2 TI+ for 26 days

,t+er Indications * -ses


Entamoeba histo ytica Off1 abe ( ba antidiasis, B astocystis hominis, +ientamoeba fra!i is

Pediatric Dosing 1 *ses


Dosing Forms * Strengt+s
tab ets

216m! 3/6m!

Intestinal Amebiasis
)61.6 m!H$!Hday di'ided *O *2 TI+ *O for 26 days" not to e,ceed 1.8/ !Hday htt&(HHreference.medsca&e.comHdru!Hyodo,in1iodo<uino 1).23/3T16

Pathophysiology of Amoebiasis
2hen cyst is swallowed, it passes through the stomach unharmed and shows no activity while in an acidic environment. 2hen it reaches the alkaline medium of the intestine, the metacyst begins to move within the cyst wall, which rapidly weakens and tears. he ,uadrinucleate amoeba emerges and divides into amebulas that are swept down into the cecum. his is the first opportunity of the organism to coloni3e, and its success depends on one or more metacystic tropho3oites making contact with the mucosa. 4ature cyst in the large intestines leaves the host in great numbers (the host remains asymptomatic). he cyst can remain viable and infective in moist and cool environment for at least (5 days, and in water for '6 days. he cysts are resistant to levels of chlorine normally used for water purification. hey are rapidly killed by purification, desiccation and temperatures below 7 and above )6 degrees.

he metacystic tropho3oites of their progenies reach the cecum and those that come in contact with the oral mucosa penetrate or invade the epithelium by lytic digestion. he tropho3oites burrow deeper with tendency to spread laterally or continue the lysis of cells until they reach the sub&mucosa forming flash&shape ulcers. here may be several points of penetration. 8rom the primary site of invasion, secondary lesions maybe produced at the lower level of the large intestine. Progenies of the initial colonies are s,uee3ed out to the lower portion of the bowel and thus, have the opportunity to invade and produce additional ulcers. Eventually, the whole colon may be involved. E. histolytica has been demonstrated in practically every soft organ of the body. ropho3oites which reach the muscularis mucosa fre,uently erode the lymphatics or walls of the mesenteric venules in the floor of the ulcers, and are carried to the intrahepatic portal vein. If thrombi occur in the small branches of the portal veins, the tropho3oites in thrombi cause lytic necrosis on the wall of the vessels and digest a pathway into the lobules. he colonies increase in si3e and develop into abscess. A typical liver abscess develops and consists of1 !entral 3one necrosis 4edian 3one of stoma only An outer 3one of normal tissue newly invaded by amoeba. 4ost amoebic abscess of the liver are in the right lobe. 9e#t to the liver, the organ which is the fre,uent site of e#tra&intestinal amoebiasis is the lungs. his commonly develops as an e#tension of the hepatic abscess.