Amoebiasis

Dr.T.V.Rao MD
 ENTAMOEBA
HISTOLYTICA
Entamoeba histolytica
was first described by
Lambl in 1859 and
Losch established it
pathogenic nature in
1875 in a dysenteric
patient is St.Petersberg
Councilman and lafleur
in 1981 described
amoebic liver abscess.
Schauudinn ( 1903 )
differentiated
pathogenic and
nonpathogenic types of
Amoebae
Amebiasis
Amebiasis (am-e-BI-a-
sis) is a disease
caused by a one-
celled parasite called
Entamoeba histolytica
(ent-a-ME-ba his-to-LI-
ti-ka).
Although it is more
common in people
who live in tropical
areas with poor
sanitary conditions
Amoebiasis a Major Health
Problem
Amoebiasis is estimated to cause 70,000
deaths per year world wide Symptoms
can range from mild diarrhea to dysentery
with blood and mucus in the stool. E.
histolytica is usually a commensals
organism. Severe Amoebiasis infections
(known as invasive or fulminant
amoebiasis) occur in two major forms.
Invasion of the intestinal lining causes
amoebic dysentery or amoebic colitis.
Trends of Amoebiasis
 Transmission of
Amebiasis
Amoebiasis is
transmitted by fecal
contamination of
drinking water and
foods, but also by direct
contact with dirty hands
or objects as well as by
sexual contact.
Additionally, geophagy
is a common route of
infection in certain
cultures.

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 Nature of the disease

Symptoms are usually gastrointestinal

including diarrhoea, vomiting, abdominal
pain or discomfort and fever. Symptoms
take from a few days to a few weeks to
develop and manifest themselves, but
usually it is about two to four weeks. Most
infected people are asymptomatic but this
disease has the potential to make the
sufferer dangerously ill, especially if there is
any suggestion of immunocompromised.
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Events on Amoebiasis
Trophozoites of
E.histolytica
Trophozoites and Cystic
stages
Cystic stage -
E.histolytica
Amoebiasis causes Epithelial
damage
 Numerous Eosinophilic
spherical structure within
necrotic area.
 Tissue showing Amoebic
infection
The spherical
structure
(Trophozoites) has
one basophilic nuclei
about the size of
RBCs. Note some
RBC's are
phagocytosed by the
Trophozoites
(erythrophagocytosis)
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 Virulence factors
Trophozoites of E.histolytica interact with host
through a series of steps
1 Adhesion of target cell, phagocytosis and
cytopathic effect
2 E.histolytica induces both Humoral and cell
mediated immune responses.
3 Virulence factors In many circumstances lumen
dwelling Amoeba may be asymptomatic
4 Causes disease only when invade the Intestine
5 Virulence is associated with secretion of Cysteine
proteniase which assists the organism in digesting
the extracellular matrix and invading tissues
 Cysteine proteinase -
Complement factor C3
It is observed
Cysteine proteinase
produced by invasive
strains of
E.histolytica
inactivates the
complement factor
C3 and are thus
resistant to
Complement
mediated lysis.
Cysteine proteinase
virulent factor
Cysteine proteinase is an
important virulent factor
Its presence makes
E.histolytica is resistant
to complement mediated
lysis
Can cleave the
extracellular structural
matrix and degrade
fibronectin and laminin,
as well as type I collagen.
In this process basement
membrane is degraded
and leads to invasion
 Zymodeme
Lectin binding
Zymodeme analysis,
genome specific DNA
analysis and staining
with Monoclonal
antibodies have been
successfully used as
markers to identify
invasive strains of
E.histolytica
Types of Zymodemes
Based on
Electrophoretic
mobility
E.histolytica strains
are classified into
22 Zymodemes
However only 9 are
invasive
 Invasive x Noninvasive
strains
The invasive and non
invasive strains may
appear identical may
represent two distinct
species
1 Invasive strain
E.histolytica
2 Non invasive
strains reclassified
as E.dispar.

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 Host Factor
Contributions
Several factors contribute to
influence infection
1 Stress
2 Malnutrition
3 Alcoholism
4 Corticosteriod therapy
5 Immunodeficiency
6 Alternation of Bacterial flora
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 Risk Factors

People in developing countries that

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

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

The serological become reactive in invasive

Amoebiasis
1 Indirect Heamagglutination assay ( IHA
2 ELISA
3 Latex agglutination test
4 gel diffusion
5 Counter current Imunoelectrphoresis
Serological tests remain positive for several years ever after
successful treatment
 Culture
Cultures are not done routinely
Boeck and Drbohlavs medium modified
by Laidlaw extensively used for isolation
and maintenance of E.histolytica.
Diamonds axenic medium used in studies
on Pathogenicty, antigenic
characterization and drug sensitivity
tests

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