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CASE R E P O R T

ELSEVIER

AMEBIASIS OF THE PENIS


MOHAMED J. HEJASE, RICHARD BIHRLE, GILBERTO CASTILLO, AND CHRISTOPHER L. COOGAN

ABSTRACT
Penile amebiasis is rarely a recognized entity because the penis is not the usual site of presentation for
amebiasis. Homosexual men have a higher risk of acquiring the lesion. Amebic ulcers resemble cutaneous
lesions arising from squamous cell carcinoma, chancroid, primary syphilis, granuloma inguinale, and many
other causes. An amebic ulcer should be suspected in a patient with balanoposthitis that resists antibiotic
therapy. Biopsy is fundamental to isolate the trophozoites to confirm the diagnosis. Metronidazole and hy-
drochloric emetine are still the treatment of choice. This diagnosis should especially be considered in cases
of lesions detected in patients who practice anogenital sex or who are immunocompromised. UROLOGY 48:
151-154, 1996.

mebiasis of the penis is a rare disease. About ulceration on the ventral surface of his foreskin
A 20 cases have been reported in the world lit-
erature to date. 1-11 However, many cases are still
(Fig. 1 ). On physical examination, a 2-cm irreg-
ular ulcer with a nonraised border covered by a
unpublished. Entamoeba histolytica is the etiologic serous exudate was evident. The patient also dem-
agent of h u m a n amebiasis. 8'12'13 Enteric infections, onstrated bilateral inguinal adenopathy. Serologic
which have traditionally been associated with con- testing for syphilis, h u m a n immunodeficiency vi-
taminated food or water, are now being found in rus (HIV), and hepatitis B surface antigen was
patients without such exposure. Transmission negative. Microscopic evaluation of the exudate
might be achieved by direct inoculation or revealed numerous E. histolytica trophozoites. Se-
through anal intercourse with a person suffering rologic titers were elevated, and examination of
from amebic dysentery. 8'9 It has been reported as stool samples revealed the presence of trophozo-
the result of coitus with a woman who had vul- ites. The treatment of the ulcer included local ap-
vovaginal amebiasis. 2'8 plication of nitrofurazone for 10 days with each
We present four cases of amebiasis, emphasizing dressing change. In addition to local care, a 10-day
the importance of a high index of suspicion for ac- course of oral metronidazole (800 mg three times
curate clinical diagnosis. The epidemiology, evalua- daily) was administered. Two-week follow-up ex-
tion, and treatment are all discussed. Urologists amination of the penis demonstrated complete
should consider amebiasis in the differential diagnosis healing of the ulcer.
of patients with penile lesions, especially those pa-
tients who are at high risk of acquiring such lesions. CASE 2
A 15-year-old uncircumcised man with a history
CASE REPORTS of active homosexuality presented with a 0.5-cm
necrotic ulceration on his distal foreskin. A mal-
CASE 1 odorous serous exudate was noted. Edema of the
A 39-year-old uncircumcised man presented foreskin prevented adequate retraction. Painless
with a history of foul-smelling exudate and tender bilateral inguinal adenopathy was found. Light mi-
croscopy in dark field for Treponema was negative,
From the Department of Urology, Hospital General de Zona as were serologic syphilis and gonorrhea tests. No
IMSS No. 33, Monterrey, Nuevo Leon, Mexico, and the Indiana HIV studies were performed at that time (1983).
University Medical Center, Indianapolis, Indiana Microscopic examination of the exudate showed
Reprint requests: Richard Bihrle, M.D., Department of Urol- abundant E. histolytica trophozoites. Biopsy of the
ogy, Indiana University Medical Center, University Hospital, lesion demonstrated a chronic inflammatory pro-
Suite 1725, 550 North University Blvd., Indianapolis, IN 46202-
5250 cess with infiltration of polymorphonucleated cells
Submitted: October 26, 1995, accepted (with revisions): Jan- and abundant eosinophils. Hydrochloric emetine
uary 4, 1996 (1 m g / k g / d a y intramuscularly) and ampicillin

COPYRIGHT 1996 BY ELSEVIER SCIENCE INC. 0090-4295/96/$15.00


ALL RIGHTS RESERVED PII S 0 0 9 0 - 4 2 9 5 ( 9 6 ) 0 0 1 0 8 - 2 1 S1
FIGURE 1. Penile amebiasis lesion shown on admis- FIGURE 2. Photomicrograph shows granular tissue,
sion. light epithelial hyperplasia, cytolysis, and the tropho-
zoites. Arrow marks trophozoite (hematoxglin and eosin
100).
(500 mg orally four times daily) for a total of 10
days were initiated. Because of incomplete reso-
lution of the lesion, the patient then received 10
days of oral metronidazole ( 1000 mg three times
a day). Two weeks following commencement of
therapy, the ulceration was completely healed. The
final scarring resulted in phimosis, which was later
treated by circumcision.

CASE 3
A 26-year-old man presented with a 15-day his-
tory of painful swelling of the penile foreskin and
a foul-smelling and blood-stained preputial dis-
charge. The foreskin could not be retracted. A bi-
opsy was obtained because a neoplasm was sus- FIGURE 3. Lesion detected upon admission prior to
pected. Within a week, the entire foreskin had treatment.
been destroyed by an ulcer. The entire penis was
edematous with no significant regional lymphad-
enopathy. Syphilis, gonorrhea, Chlamydia, and tered for 10 days. The patient was discharged
HIV tests were negative. Histologically, biopsy when he was asymptomatic. One month later, no
demonstrated a granuloma rich in trophozoites ulcers were detected on his penis.
(Fig. 2). Treatment consisted of hydrochloric em-
etine ( 1 m g / k g / d a y intramuscularly) and metron- COMMENT
idazole (1000 mg orally three times a day) for 2 Within the last two decades, the sexual trans-
weeks. He was examined 30 days later and found mission of protozoal pathogens generally acquired
to be completely asymptomatic with a normal by the fecal-oral route, such as Giardia lamblia
phallus.
and E. histolytica, has become apparent in the ur-
ban homosexual community. 14-16 E. histolytica is
CASE 4 endemic in Africa, South America, Mexico, and In-
A 52-year-old man was admitted with a 3-week dia. In the United States, the prevalence is lower,
history of a painful, exudative, and foul-smelling but several groups are at high risk of acquiring
ulceration on the ventral aspect of his foreskin that amebiasis. 8'17-19 Humans are the only known res-
grew rapidly, destroying his glans (Fig. 3 ). He had ervoir for E. histolytica.
already failed a 2-week course of oral tetracycline E. histolytica is a parasite that exists in two
(500 mg four times daily). Test results for syph- forms, cyst and trophozoite. The cyst is the infec-
ilis, gonorrhea, and HIV were negative. Biopsy of tious form and may yield up to eight trophozo-
the ulcer revealed the presence of trophozoites and ites. 2 It is estimated that as many as 10% of the
an inflammatory process. Oral metronidazole ( 750 world's population is infected with E. histolytica,
mg three times per day) and hydrochloric emetine and this organism is responsible for as many as
(1 m g / k g / d a y intramuscularly) were adminis- 100,000 deaths per year worldwide. 2 The incu-

1 52 UROLOGY 48 (1), 1996


bation period for amebiasis varies from a few days TABLE I. Classical presentation of
to several months, but it is usually 2 to 4 weeks, t6 genital ulcer
Penile amebiasis starts as pruriginous hyperemic
Classical Presentation Disease
zone on the foreskin that evolves into a vesicle.
Several days later, this vesicle will evolve into a Painless superficial round Squamous cell carcinoma
painful, irregular ulcer with a viscous exudate that ulcer with elevated
is often foul smelling. The ulcer spreads rapidly base and mildly rolled
and may surround the entire penile shaft. If mis- edges
Grouped vesicles* Genital herpes
diagnosed and mistreated, this ulcerative process Traumatic ulcer
Onset during sexual
may cause significant penile deformity or even activity*
penile loss. 8-1 Previous studies in the United Recurrences associated Fixed drug reaction
States and elsewhere have demonstrated that a his- with the same systemic
tory of syphilis a n d / o r gonorrhea is highly corre- medicine*
lated with sexually transmitted amebiasis. 13'17-19 Painful deep ulcer with Chancroid
Genital primary l e s i o n s - - w h e t h e r papular, ve- undermined border
sicular; or p u s t u l a r - - q u i c k l y erode to an ulcera- Painless, firm, rolled, and Granuloma inguinale
tive phase. Ulcer characteristics can be valuable in elevated ulcer border
formulating a differential diagnosis (Table I).21 A Painless, firm, indurated Primary syphilis
deep genital ulcer suggests chancroid, whereas the ulcer
ulcers of syphilis, herpes, and lymphogranuloma * Pathognomonic.
venereum are more superficial. Primary penile
squamous cell carcinoma may occur at any ana-
tomic location of the penis. The fiat variety typi-
cally appears as a superficial round ulcer on a idly die after passage; therefore, stool samples
slightly elevated base, and it grows laterally and must be examined within 20 minutes of collection.
infiltrates deeply. A high index of suspicion for Serologic studies are also used in the diagnosis of
penile cancer and a low threshold for biopsy of all invasive amebiasis. Asymptomatic cyst passers will
penile lesions--including balanoposthitis--that usually have serologically low titers, but patients
do not respond to a short trial of conservative an- with invasive disease will have elevated titers. 2
timicrobial therapy are the primary requirements The necessity of treating asymptomatic cyst pass-
for early diagnosis and treatment of patients with ers is controversial. In a controlled study in To-
penile cancer. 22 The histologic picture confirms ronto, Canada, E. histolytica was isolated in stool
the acute and chronic inflammatory processes. It samples from 27% of the homosexual and 1% of
shows abundant granular tissue, light epithelial the heterosexual men, and G. lamblia was isolated
hyperplasia, and a superficial band of necrosis in from 13% of the homosexual and 3% of the het-
which trophozoites are encountered. These organ- erosexual men. 24 Most E. histolytica infections in
isms are n u m e r o u s and easy to identify by routine homosexual men are believed to be asympto-
staining procedures, s-n matic. 24
The clinical presentation of a penile ulcer shows Genital ulcer disease is a risk factor for the
great variability; a study by Chapel et al. 23 has transmission of h u m a n retroviral infection. An
demonstrated that even an experienced clinician u n d e r s t a n d i n g of this interaction is emerging
can misdiagnose 40% of genital ulcers. The differ- and will have an impact on the treatment and
ential diagnosis of an acute genital ulcer can be a control programs for the agents causing genital
difficult problem for physicians working in the ulcer disease. 25 The increased risk of contracting
sexually transmitted disease field. Although each acquired i m m u n o d e f i c i e n c y s y n d r o m e (AIDS)
etiology has its typical symptoms and signs, there with increasing age appears to be greater than
is tremendous overlap in clinical presentation. that associated with acquiring syphilis or ame-
What appears to be a classic picture may actually biasis, a finding that suggests a true increase in
be another infectious process. 22 As a result of the susceptibility. However, it is also possible that
nonspecificity of the clinical findings, the etiologic the apparent difference between the age distri-
diagnosis of genital ulcer disease requires labora- bution of reported cases of AIDS and reported
tory confirmation. cases of syphilis and amebiasis is the result of
The diagnosis of intestinal amebiasis is made by the long latency believed to be associated with
identifying E. histolytica cysts or trophozoites in AIDS. 26 Moreover, because the risk factors for
stool. A single stool specimen will usually detect a m e b i a s i s - - i n c l u d i n g multiple sexual partners,
one third of infected patients, and it is usually rec- poor hygiene, and anogenital s e x - - i s similar to
o m m e n d e d that three separate stool specimens be those for AIDS, declining sexual transmission of
examined to rule out amebiasis. Trophozoites rap- amebiasis might be used to predict decreasing

UROLOGY 48 (1), 1996 1 53


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cline in i n c i d e n c e s h o u l d follow the initial de- clining rates of amebiasis in Los Angeles County: a sentinel
crease in amebiasis rates b y several years.12 This for decreasing acquired immunodeficiency syndrome (AIDS)
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1 54 UROLOGY 48 (1), 1996