Dr.S.Palanivelrajan,M.D (Final Year P.

G)
Stanley Medical College
Chennai

Definition

Amoebiasis is an infection with intestinal
protozoa Entamoeba Histolytica.
90% of infection asymptomatic.
10% of infection Clinical syndrome.
Ranging from Dysentery to Abscess of the
liver or other organs.

PHYLUM SARCOMASTIGOPHORA
SUBPHYLUM SARCODINA
SUPER CLASS RHIZOPODA
CLASS LOBOSEA
SUB CLASS GYMNAMOEBIA
ORDER AMOEBIDA
SUBORDER TUBULINA

ENTAMOEBA HISTOLYTICA

HISTORY
1875 LOSCH RUSSIAN.
Differentiated the amoebic dysentery from bacillary
dysentery by describing amoeba in the stool.
1887 KARTULIS EGYPT.
Found amoeba in the pus from a liver abscess.
1881 COUNCILMAN AND COFFLEUR.
Described true bowel lesions and used the term
Amoebic Dysentery.
1903 SCHAUDINN.
Differentiated pathogenic and non pathogenic types
of amoeba.

Third most common cause of death from the
parasitic disease. (after schistosomiasis , Malaria)
480 Million people (world)
12% of worlds population
High risk groups
Travellers, immigrants, immunocompromised
individual, pregnant women, sexually active male.
Mental institutes, prisons, Children in day care
centres.
Cyst carriers
Sexual transmission also occurs.
EPIDEMIOLOGY
the intestinal lesion
Gut
Minute crypt lesion

Extends through the muscularis mucosa and submucosa.

Flask shaped ulcer

Thrombosis of blood vessels

Toxic megacolon

Irreversible coagulation necrosis of bowel wall.
PATHOLOGY
Tumor like lesion

Several cms in length

M C in caecum

Multiple

Histologically tissue edema
patchy round cell infiltration

Types intussusceptions
stricture like
AMOEBOMAS
Asymptomatic infection
Mild to moderate colitis (non dysenteric colitis)
Severe colitis (dysenteric colitis)
Localised ulcerative lesions of the colon
Localised granulomatous lesion of the colon
(amoeboma)
CLINICAL FINDINGS

INTESTINAL AMOEBIASIS
Infective colitis
Ulcerative colitis
Colorrectal carcinoma
Intestinal schistosomiasis
Trichuris infection
Balantidiasis
Crohns disease
Diverticulosis
Ileoceacal TB
LABORATORY DIAGNOSIS
Microscopy And Culture
1. Wet Mount Preparation
(i) mounts in saline solution
(ii) mounts in saline + lodine
(iii) mounts in saline + methylene blue
2. Sample Fixative Examination Stain
1. Stool


2. Sigmoid
colon
3. Aspirate
Direct

Fixed

4. Biopsy

-PVA 10 % formalin
-sodium acetate acetic
acid formalin
-PVA, schauddins
fixative

None

PVA, Schauddins
Fixative
Formalin

Permanently stained
slide

Permanently
Stained slide

Wet mount with
enzyme digest
Permanently stained
slide
Routine histology


Gomori,trichrome,
Iron haematoxylin

Gomori,trichrome
Iron haematoxylin





PAF Gomori
Haematoxylin and
eosin
Enzyme Immunoassay
Indirect Immunoflorescence
Latex Agglutination
Gel diffusion
Sensitivity
60 % invasive Bowel disease 100 % with
Amoeboma

Immunological Test
Indirect Haemagglutination
Clinical
presentation
Drugs of Choice Adult Dosage
Asymptomahic
Intestinal carrier






Intestinal infection


1
st
Choice
Diloxanide Furoate

2
nd
Choice
Paramomycin
(or)
Iodoquinol

1
st
Choice
Metronidazole
followed
by diloxanide furoate
( or )
Tinidazole followed by
diloxanide furoate

2
nd
Choice
Paramomycin

500 mg t.i.d 10 days


25 30 mg kg
-1
day
-1
in 3
doses 7-10 days.
650 mg t.i.d 20 days


750 800 mg.t.i.d 10
days
500 mg.t.i.d 10 days

2 g/day 2 -3 days
500 mg .t.i.d 10 days

25 30 mg kg
-1
day
-1
in 3
doses 7 10 days
PREVENTION
Health Education
Improved water supply
Chlorination not effective
Amoebic cysts
Destroyed by
200 parts / 10
6
of Iodine 5 10 acetic acid.
Heating > 68
0
C
Removed by
sand filtration
Boling for 10 minutes kill the cysts
This is the most common extra intestinal
form of invasive amoebiasis.
Adults > children ( 10 : 1 )
Male > female
20 % with past history of dysentery

PATHOGENESIS
Journey of E. Histolytica to the Liver
1. Direct Extension from the Gut to the Liver
2. Via the Lymphatics
3. Along the portal stream
Infarction Enzymatic Dissolution

Clear 'halo' around an amoeba
Destruction of liver tissue
Congestion of the sinusoids
Bulge due to superficial abscess
Shaggy appearance of the walls of
the abscesses
Abscess surrounded by a distinct
area of severe congestion
Abscess showing a thick fibrous
wall
CLINICAL FEATURES
Symptoms
Pain
Diarrhoea and / or Dysentery
Weight Loss
Cough
Dyspnoea
Physical findings
Localized tenderness
Enlarged Liver
Fever
Rales,rhonchi
Localized intercostal tenderness
Epigatric Tenderness
Jaundice

huge abscess of the inferior
surface of the left lobe.
Clinical enlargement of the
left lobe of the liver.
Compression Sign
Point tenderness
Intercostal tenderness
Multiple large amoebic
abscess seen at autopsy.
COMPLICATONS
Right chest
Peritoneum
Pericardium
Amoebic brain abscess - rare
Hemobilia Rupture in to major bileduct
Portal hypertension
LABORATORY FINDINGS
Normocytic Normochromic anaemia
Leucocytosis -> more than 10 * 10
9
/ L
ESR
Stool Cyst or Vegetative form of E . Histolytica
LFT Bilirubin

Transaminases more than 50 %

Alkaline phosphatase more than 75 %

RADIOLOGY
1. CXR Elevated Right Hemi diaphragm
2. Isotope liver scan
3. USG Abdomen B mode , Hypoechoic
4. CTScan
DD
1. Subphrenic Abscess
2. Cholecystitis
3. Liver Hydatid cyst
4. Primary and Secondary carcinoma of liver
5. Lesions of the right lung and right pleura
Anterior view of 133/Rose Bengal
dot liver scan showing a small cold
area on the inferior surface of the
left lobe.
99m Tc sulphur colloid photo liver
scan (anterior view) showing a cold
area in the superior surface of the
left lobe
X-ray chest showing obliterated
costophrenic angle and an elevated
right dome of the diaphragm
X-ray chest showing an elevated
left dome of the diaphragm
X-ray chest showing a fluid level in a
lung abscess in pulmonary
amoebiasis.
X-ray chest showing left sided
pyopneumothorax
X-ray chest demonstrating the more
lateral and vertical spread of an
empyema following a liver abscess
CAT SCAN
Peritoneoscopic view of amoebic
liver abscess.
1st Choice







2nd choice
Metronidazole followed
by
diloxanide furoate
or
tinidazole followed by
diloxanide furoate


dehyderoemetine followed
by


diloxanide furoate
750-800 mg.t.i.d
10 days
500 mg t.i.d. 10
Days
2g/day 3-5 days
500 mg t.i.d 10
Days

1-1.5 mg kg-1 day -1
( max.90 mg/day ) i.v
5 days

500 mg t.i.d 10
days.

TREATMENT
Formal Indications
To rule out a pyogenic abscess (, particularly with
multiple lesions )
As adjunct to medical therapy ( No response after 72 hours )
If rupture is believed to be imminent
Abscess in the left lobe where the risk of rupture is increased.
Possible Indications
To reduce the period of disability
INDICATIONS FOR
ASPIRATION OF AMOEBIC
LIVER ABSCESS
Aspiration of flank abscess.
Color Anchovy sauce, Chocolate color or pinkish
brown, varying colors
Odour Odourless
Consistency thick , Viscosity thick lubricating Oil ,
Quantity Accroding to the size of the abscess
Microscopy Dead and deformed Hepatocytes
RBCS Few Polymorphs
Trphozoites of E.Histolytica present in 10
to 25 % cases
Microbiology Sterile
PUS IN AMOEBIC LIVER ABSCESS
Hepatoma, livercyst, Hemangimoa
DD
A bottle of anchovy sauce and
amoebic pus.
Bile aspirated from liver
abscess
Different coloured pus obtained
during a single session by changing
the direction of the needle.
Chocolate coloured pus.
Dirty yellowish pus
Ivory or creamy white pus.
Brown coloured pus compared to
anchovy sauce.
Pus resembling color of tea. Tea and
anchovy sauce placed on either side
for comparision.
Specks of necrotic tissue floating in
the pus
Thin yellow pus from a 'chronic'
abscess
1. ALA with Secondary infection
2. Left lobe Abscess
3. Bowel perforation
4. Rupture into pericordium

SURGERY
1. Haematogenous pulmonary amoebiasis without liver
involvement.
2. Haematogenous pulmonary amoebiasis with
independent liver abscess.
3. Pulmonary amoebiasis extending from a liver
abscess.
4. Broncho hepatie fistula with pulmonary
involvement.
5. Empyema entering from a liver abscess
PULMONARY AMOEBIASIS

PERITONEAL AMOEBIASIS
PERICARDIAL AMOEBIASIS
CEREBRAL AMOEBIASIS
GENITO URINARY AMOEBIASIS
CUTANEOUS AMOEBIASIS

PRIMARY AMOEBIC MENINGO
ENCEPHALITIS
1. Negleria fowleri
2. Swimming -> 2 14 days
3. Cribriform plate -> olfactory -> sub arachnoid space
4. Like meningitis picture
5. 200 cases since 1965 , young adults and children
6. Amphotericin B 1 mg / kg per day


Acanthamoeba 5 species
MC by A.Castellani, A.Polyphaga
Local propamide and neomycin
Corneal grafting
Contact lense users Avoid raw tap water
Most appropriate Chlorhexidine and hydrogen
peroxide

AMOEBIC KERATITIS
Balamuthia mandriallaris
60 cases since 1990
Albendazole and itraconazole
AMOEBIC MENINGO ENCEPHALITIS