Postgrad Med J: first published as 10.1136/pgmj.55.646.548 on 1 September 1979. Downloaded from Postgraduate MUedical Journal (August 1979) 55, 548-552 Fatal intestinal amoebiasis M. G. THUSE F.R.C.S. Gravesend and North Kent Hospital, Bath Street, Gravesend, Kent Summary perforation of the gut. This invasion of tissues de- The clinical presentations of amoebic colitis are di- pends on the virulence of the amoeba and the host- verse. Amoebiasis is comparatively rare in the U.K. resistance. Various precipitating causes for per- and, unless the clinician is aware of the condition, foration have been mentioned, e.g. parturition, wrong diagnosis often leads to delay in appropriate external trauma, surgery, etc. (DeSa, 1974). treatment resulting in high mortality. Diagnosis rests on clinical suspicion, stool examination, sigmoido- Material scopy with rectal biopsy and serological tests. Amoe- This article presents 3 cases of fulminating biasis is readily treatable and death from it should be amoebic colitis which were treated in the Dartford very rare. group of hospitals. Patient no. 1 was treated in 1977 and patients nos 2 and 3, which were treated in Introduction 1970, were collected from the medical records. Although amoebiasis is more common in tropical Protected by copyright. and subtropical climates, it is a universal disease Case histories and has been reported from places as remote as Alaska. About 3 deaths from amoebiasis and prob- Patient no. 1 ably about 200 new cases of clinical amoebiasis A 50-year-old white male patient, who had occur annually in England and Wales (Stamm, 1975), recently returned from Nigeria after a business trip Amoebiasis is an infestation of human tissues by of 2-3 months, was admitted with abdominal pain the pathogenic unicellular Entamoeba histolytica of 2 weeks' duration. He had had pyrexia for the which exists in 2 forms-the cystic (sporozoite) past 10 days, which he had attributed to influenza. and vegetative (trophozoite). Man is the main The pain had become severe over the past 2 days reservoir of infection. Infection is acquired by and was mainly located in the right hypochondrium. swallowing the cysts (passed in the stools of patients During those 2 weeks he had developed anorexia and or of asymptomatic carriers) in food, contaminated had lost 9 5 kg in weight. He also gave a history of by faecally soiled fingers or by the use of human constipation followed by watery diarrhoea with a faeces as fertilizer on soil. large amount of slime, but no blood, for 3 days The amoebae, in vegetative forms, normally (10-12 bowel actions/day). He did not suffer from http://pmj.bmj.com/ thrive only in the large bowel. They may be harmless indigestion or fat intolerance and he consumed 2-3 and ingest bacteria and other particles of faecal pints of beer every day. matter. As they travel along the colon, and as the Examination revealed: a heavily built, slightly faeces become more and more solid, the amoebae obese man in severe pain. He was hot and flushed encyst and are excreted as the mature infective cyst. and toxic; temperature 38 5°C; pulse 120/min, Although often amoebae in the colonic lumen are regular; BP 100/50 mmHg; abdomen distended with harmless, owing to some ill-understood factors they tenderness and rigidity in the right upper quadrant may invade the gut wall. Immune-suppression due to of the abdomen; bowel sounds present; per on September 26, 2021 by guest. any cause, and other bowel infections favour this rectal-tenderness present. invasion. Amoebae invade the tissues by secreting A provisional diagnosis of acute cholecystitis was lytic enzymes. This' Iytic activity of the amoeba is made. Investigations revealed: Hb 13 g/dl, WBC the casue of its penetration and necrotizing activity 17 x 109/l, serum electrolytes-sodium 124 mmol/l, in the tissues. From the colonic wall, it sometimes chlorides 88 mmol/l, potassium 4-5 mmol/l, bicar- invades other tissues, such as the liver, by the flow bonate 23 mmol/l, urea 10 mmol/l, amylase 60 of blood. Somogyi units. When amoebae invade mucosal and submicosal Chest X-ray-consolidation of right lower lobe, tissues of the colon, they form typical flask-shaped raised right dome of diaphragm. X-ray of abdomen ulcers. In rare instances, they invade muscle layers -no gas under diaphragm, fluid levels present. and further outward invasion of tissues results in He was kept under observation with nil by mouth; 0032-5473/79/0800--0548 $02.00 C 1979 The Fellowship of Postgraduate Medicinc Postgrad Med J: first published as 10.1136/pgmj.55.646.548 on 1 September 1979. Downloaded from Fatal intestinal amoebiasis 549 nasogastric aspirations; intravenous fluids; anal- The post-mortem examination revealed a huge gesics (60 mg/4-6 hr i.m. pentazocine) and anti- amoebic abscess in the right lobe of the liver which biotics (i.m. ampicillin with cloxacillin 500 mg/6 hr). had perforated posteriorly under the diaphragm. On day 2, his condition remained the same, but The fluorescent amoebic antibody test was positive he was sweating profusely and was cold and clammy. (titre 1: 256). Immunofluorescent staining of Temperature 37°C; pulse 100/min; BP 140/99mmHg; smears from the colonic ulcer revealed trophozoites abdomen was slightly distended; blood film for of E. histolytica. malarial parasites was negative; a blood sample was sent for amoebic CFT. As he still had offensive Patient no. 2 diarrhoea, stools were sent for examination. They A 63-year-old white male patient, had been were reported later as negative for pathogens. diagnosed as a case of ulcerative colitis for the past On day 3, he still had profuse intermittent sweating, 9 years and had been treated at various times with although he was apyrexial. Of interest was an area prednisolone enemas, prednisolone and salazo- of skin over the right upper quadrant of the abdo- pyrine tablets with resulting remissions. He was ad- men, which was cold compared to the rest of the mitted with swelling of the ankles of 2 weeks' duration abdomen; the cold area disappeared in 2 hr. He and diarrhoea, occasionally blood-stained but with- continued to have offensive diarrhoea. Repeat blood out mucus, of 4 days' duration. He gave a history of examination gave similar findings as on the 1st day, dysentery while in Ceylon in 1944. His general con- indicating leucocytosis. In the night his condition dition was good. Abdominal examination showed deteriorated and he became delirious. He had hic- slight generalized discomfort, no tenderness. coughs, tachycardia (pulse 120/min) and was sweat- Investigations revealed: Hb 10-4 g/dl; WBC ing profusely. The abdomen was distended, but bowel 90 x 101/l; ESR 34 mm/hr; serum electrolytes- sounds were present. A large paracolic abscess was sodium 135 mmol/l; chlorides 106 mmol/l; potassium suspected and gentamicin 80 mg thrice/day was 3.7 mmol/l; urea 5 mmol/l. Liver function tests- Protected by copyright. added to the ampicillin and cloxacillin injection. normal. Faeces-no pathogens. Sigmoidoscopy- On day 4, he continued to have offensive diarrhoea, ulcerations in rectum and lower sigmoid colon. was apyrexial, and the tongue was clean; pulse Barium enema-extensive involvement of the colon 90/min regular; there was good urinary output in with obliteration of the normal mucosal pattern. the previous 24 hr. He still complained of pain and A procto-colectomy was carried out after a few tenderness in the right side of the abdomen, and days, as his symptoms were not improving. His there was some guarding in the right iliac fossa condition deteriorated and he died 2 days after (RIF). Repeat X-ray of the abdomen showed a few surgery. distended loops of the small gut with a few fluid levels. The histopathology of the colon showed chronic At 8.00 p.m. about 100 ml of 'coffee-ground' fluid active ulcerating colitis with a few burrowing ulcers was aspirated via the nasogastric tube; this was under the submucosa. In some ulcers amoebae were positive for blood. seen. Sections stained by the fluorescent antibody A laparatomy in the night revealed fulminating technique were positive for amoebae. colitis, with abscesses along the right paracolic http://pmj.bmj.com/ gutter and near the splenic flexure and on both sides Patient no. 3 under the diaphragm. The colon from the caecum A 44-year-old white female with rheumatoid to the pelvic colon appeared oedematous, pale, arthritis was admitted with diarrhoea of 5 days' dura- white and friable. A sub-total colectomy with tion, haematemesis for one day, and abdominal pain terminal ileostomy was carried out. The colon from for 2-3 days. the caecum to the upper part of the rectum was re- She had had 'influenza' 4 months before and had moved and the upper end of the rectum was brought subsequently developed nausea, anorexia, and indi- out through the lower part of the incision as proc- gestion. Abdominal pain was mainly on the right on September 26, 2021 by guest. tostomy (mucous fistula). The patient had a cardiac side; and more severe after food. She had lost arrest and died 45 min after completion of the 12-7 kg in weight during the past 3 months. Her operation. bowels were basically regular, though loose. Men- The histopathology of the excised colon showed struation was regular. She had been taking indo- extensive necrosis and perforation of the caecum, methacin for the past 2 weeks for her arthritic pain. most of the caecal wall being converted into a grey She suffered from fat intolerance. No jaundice in slough.