Amoebiasis

Author: Marie Hartley, Staff Writer, 2009.


Amoebiasis - codes and concepts
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What is amoebiasis?

Amoebiasis is a disease caused by Entamoeba histolytica, a protozoa which is found worldwide. Humans are the natural reservoir of E. histolytica, and infection occurs via faecal-oral transmission (e.g. contaminated hands, water, or food, and oral-anal sex). The main symptom of infection is diarrhoea.

There is a higher incidence of amoebiasis in developing countries where barriers between human faeces and food and water supplies are inadequate. Risk factors for amoebiasis in developed countries include travellers to endemic regions, men who have sex with men, and immunosuppressed or institutionalised people.

The life cycle of E. histolytica includes the formation of cysts and trophozoites, both of which are passed in faeces. Cysts can survive days to weeks in the external environment and are mainly responsible for transmission of disease.

Annually an estimated 50 million people are infected by invasive E. histolytica, leading to 100,000 deaths.

What are the symptoms of amoebiasis?

Many cases of amoebiasis are asymptomatic with the cysts and trophozoites remaining confined to the intestinal lumen (inside the tube of the intestine). However in some patients the trophozoites invade the intestinal mucosal wall leading to bloody diarrhoea and colitis. The trophozoites can also invade the bloodstream and spread the infection to other organs including the liver (most common), lung, heart, brain, and skin.

Cutaneous amoebiasis is very rare, but is easily diagnosed and treated. E. histolytica can spread to the skin and mucous membranes either by:

  • contiguous spread of internal disease to neighbouring regions — for example, rectal amoebiasis may spread to the perianal skin, vulva, or the penis of sexual contacts during anal intercourse; liver abscesses may extend to the skin of the abdominal wall
  • external inoculation with contaminated hands — for example, to the face
Amoebiasis
Clinical formClinical features
Amoebic colitis
  • Most commonly presents as gradual onset of bloody diarrhoea, abdominal pain, and tenderness over several weeks
  • Some patients develop fever, weight loss, and loss of appetite
  • Fulminant or necrotising colitis can develop
Amoebic liver abscess
  • Most commonly presents as fever, pain in the right upper quadrant of the abdomen, and tenderness
  • Jaundice can occur
  • 60-70% of patients with amoebic liver abscess do not have concomitant colitis
  • Intraperitoneal rupture is a complication (rupture into the cavity that contains the abdominal organs)
  • Rarely, the abscess may rupture through the diaphragm, causing cough, pleuritic chest pain (pain due to inflammation of the lining of the lung), and respiratory distress
  • In around 0.6% of cases of liver abscess, dissemination and formation of brain abscess can occur causing nausea, vomiting, headache and change in mental status
Cutaneous amoebiasis
  • Begins as a deep-seated swelling that ruptures and ulcerates with subsequent necrosis (tissue death) of the skin and underlying tissue.
  • Results in a painful ulcer with indurated (hardened) and undermined (tissue destruction underlying intact skin) margins, surrounding redness, and a necrotic base that discharges blood and pus
  • The ulcer can enlarge rapidly with interposing normal areas

How is amoebiasis diagnosed?

The most common method of diagnosis of amoebiasis is microscopic identification of E. histolytica cysts and trophozoites in faeces, liver abscess aspirates, or biopsy samples. Note: E. histolytica cannot be distinguished microscopically from E. dispar, which is harmless. Confirmation of E. histolytica infection requires serology, antigen detection, or identification of E. histolytica genetic material:

  • Serology assays (blood tests) can detect E. histolytica immunoglobulins (antibodies) that are produced in response to the infection. Detectable E. histolytica-specific antibodies may persist for years after successful treatment, so the presence of antibodies does not necessarily indicate current infection
  • E. histolytica antigens can be detected from stool samples
  • Polymerase chain reaction can also confirm the diagnosis by identifying E. histolytica genetic material from faeces, biopsy specimens, and liver abscess aspirates

What is the treatment for amoebiasis?

Intestinal amoebiasis is treated with a luminal agent, such as iodoquinol, paromomycin, or diloxanide furoate. These agents are not approved by Medsafe for use in New Zealand but may be obtained by medical practitioners through their manufacturers under Section 29.

  • Asymptomatic E. histolytica infection should be treated to eradicate infection and prevent further shedding of cysts into the environment.
  • Treatment of invasive disease usually consists of oral or intravenous metronidazole as well as a luminal agent to eradicate colonisation of the intestine.
  • Alternative treatments include tinidazole, emetine hydrochloride, and pentamidine

Following treatment, invasive amoebiasis carries a good prognosis. Fulminant colitis and liver abscess rupture are associated with higher mortality rates.

Prevention of amoebiasis.

  • Prevent faecal contamination of food and water through improved sanitation, hygiene, and water treatment.
  • In endemic areas, water should be boiled for more than one minute, and uncooked vegetables should be washed with a detergent soap and soaked in acetic acid or vinegar for 10-15 minutes before consumption.
  • Avoid sexual practices that involve faecal-oral contact.
  • Screen family members or close contacts of an index case of amoebiasis.

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References

  • Lupi O, Bartlett BL, Haugen RN, Dy LC, Sethi A, Klaus SN, Machado Pinto J, Bravo F, Tyring SK. Tropical dermatology: Tropical diseases caused by protozoa. J Am Acad Dermatol. 2009 Jun;60:897-925

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