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Case No. 26 LIM, YOONTAEK Clark Case EF, a fresh college graduate, is applying for a job at a pharmaceutical company. Routine laboratory examinations were requested. Fecalysis revealed: (+) E. histolitica Asymptomatic Entamoeba histolytica Protozoan parasite, cause of diarrhea, dysentery, liver abscess and other syndromes Occurs primarily in developing countries, but immigrants, travelers, diagnosed with infection in U.S. Must be distinguished clinically from Entamoeba dispar, a morphologically identical parasite that is non-invasive and does not cause disease Onset of colitis usually gradual with symptoms > 1 wk, distinguishing it from bacterial dysentery Infective stage : mature tetranucleated cyst Transmission Polluted water supply Unclean handling by injected individuals Droppings of flies and other insects Use of human excrement an vegetable gardens Gross carelessness in personal hygiene In homosexual acquired through sexual, anal intercourse SITES OF INFECTION Colon: dysentery, ameboma (tumor-like lesion of colonic lumen; can be confused radiographically with cecal cancer), toxic megacolon Liver: abscess, can rupture causing peritonitis Lung: empyema (right sided- direct extension from liver) Heart: pericarditis (direct extension from liver) Brain: abscess (hematogenous spread, rare) Skin: usually perineal, genital GU: recto-vaginal fistula Diagnosis of amebic colitis 1. 2. 3. 4. 5. 6. Observation of red cell-containing motile trophozoites on fresh stool smear (insensitive); always heme + stool Colonoscopy: biopsy or scraping at margin of colonic mucosal ulcer: parasite may be seen; H&E shows necrosis, classic flaskshaped ulcer Stool antigen test that distinguishes Eh from E. dispar is available, more sensitive than microscopy of stool Serology 99% sens. for amebic liver abscess; 88% sens. for colitis, but Abs may be present yrs. later so that serology may not be useful in immigrants from Eh-endemic regions Ultrasound of liver: cannot distinguish amebic from pyogenic abscess, but can guide aspiration if necessary Liver abscess aspiration--yields anchovy paste-like material, lack of WBCs (due to lysis by parasite) clue to diagnosis, parasites usually not seen Laboratory Diagnosis Microscopy Microscopic identification of cysts and trophozoites in the stool is the common method 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). E. histolytica trophozoites can also be identified in aspirates or biopsy samples obtained during colonoscopy or surgery Trophozoites of Entamoeba histolytica Line drawing Trichrome stain Trophozoites of Entamoeba histolytica with ingested erythrocytes (trichrome stain) Invasive form Active, progressive, indirectional Found in liquid stool Eccenteric karyosome, “bulls eyes” 1 nucleus Presence of ingested RBC Killed by exposure to air or stomack acid -> cannot cause infection Cysts of Entamoeba histolytica Line drawing Stained with trichrome Wet mounts stained with iodine Infective stage Found in formed stool 4 nuclei Cigar-shape chromatoidal body With glycogen mass Diagnosis Immunodiagnosis Antibody Detection; Enzyme immunoassay (EIA) kits for Entomoeba histolytica 95% of patients with extraintestinal amebiasis 70% of patients with active intestinal infection 10% of asymptomatic persons who are passing cysts Detectable E. histolytica-specific antibodies may persist for years after successful treatment, so the presence of antibodies does not necessarily indicate acute or current infection Antigen Detection Useful as an adjunct to microscopic diagnosis in detecting parasites and to distinguish between pathogenic and nonpathogenic infections Diagnosis Molecular methods PCR is the method of choice for discriminating between the pathogenic species (E. histolytica) from the nonpathogenic species (E. dispar) Treatment of amoebiasis by Rang Acute invasive intestinal amoebiasis resulting in acute severe amoebic dysentery : metronidazole (or tindazole) followed by diloxanide Chronic intestinal amoebiasis : diloxanide Hepatic amoebiasis : metronidazole followed by diloxanide Carrier state : diloxanide Treatment of amoebiasis by katzung Clinical setting DOC (adult dosage) Alternative drugs (adult) Asymptomatic intestinal infection Luminal agent : Mild to moderate intestinal infection Metronidazole, 750mg tid or 500mg IV every 6hours 10days + Luminal agent Luminal agent + Tetracyclin, 250mg tid 10days or Erythromycin, 500mg qid 10days Severe intestinal infection Same as mild to moderate infection Luminal agent + Tetracyclin, 250mg tid 10days or Dehydroemetine or emetine, 1mg/kg SC or IM 3~5days Hepatic abscess, ameboma and other detraintestinal disease Same as mild to moderate infection Dehydroemetine or emetine, 1mg/kg SC or IM 8~10days followed by (in abscess only) chloroquine, 500mg bid 2days then 500mg qd 21days + Luminal agent *Diloxanide furoate : not available in U.S. Diloxanide furoate, 500mg tid 10days Iodoquinol, 650mg tid for 21days Paromomycin, 10mg/kg tid for 7days Treatment for asymptomatic patient Luminal agents alone should be used (not absorbed) Iodoquinol: 650 mg tid x 20 days Paromomycin: 25-35 mg/kg/d in 3 divided doses x 7 days Metronidazole (nitroimidazole) DOC for treatment of extraluminal amoebiasis Kills trophozoites but has no effect on the cysts Most effective drug available for invasive amoebiasis involving the intestine or the liver, but less against in the lumen of the gut MOA : damage to the DNA of the trophozoite by toxic oxygen products generated from the drug Pharmacokinetics Given orally Rapidly and completely absorbed. Peak conc : 1~3 hours T1/2 : 7 hours Excreted in urine Also used in Giardiasis (DOC), Trichomoniasis (DOC) Metronidazole (nitroimidazole) S/E Frequent: GI intolerance, metallic taste, headache, dark urine (harmless) Occasional: peripheral neuropathy (with prolonged use, usually reversible), phlebitis at injection sites, disulfiram-like reaction with alcohol, insomnia, stomatitis. Drug interaction Disulfiram and ethanol : avoid co-administration Barbiturates may decrease metronidazole levels Iodoquinol Lumninal agent 90% not absorbed Unknown mechanism Effective for trophozoite in lumen but not in bowel wall or tissue S/E GIT Increase protein bound iodine Dermatitis, urticaria Neurotoxin Nephrotoxin Diloxanide furoate Luminal agent Inactive against tissue trophozoite Unknown mechanism Direct amoebicidal action, affecting the amoebae before encystment DOC for asymptomatic infection No serious side effects Contraindicated in pregnancy S/E Itchy rash (urticaria) Itching (pruritus) Excess gas in the stomach and intestines (flatulence) Vomiting Paromomycin sulfate An aminoglycoside Luminal only S/E GIT Renal toxicity Caution with GIT ulceration since drug can be absorbed with more toxicity Emetine & Dehydroemetine For tissue trophozoite Oral unreliable IM or SC is preferred; never IV – toxic Only for 3~5 days not more than 10days Dehydroemetine is preferred (less tosic) For severe amoebiasis where metronidazole cannot be used Combine with luminal agent S/E Pain at injection site : sterile abscess Arrythmia, CHF, hypotension Contraindication Cardiac disease Renal disease ( cannot be excreted & may accumulated ) Young children & pregnancy Thank you!