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Amoebic Liver Abscess in Natal African Children

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Amoebic Liver Abscess in Natal African Children J AMOEBIC LIVER AmCliSS IN NATAL AFRICAN CHILDREN Town Being a thesis submittedCape for the Degree ofof Doctor of Medicine in the University of Cape Town By JO.ANN. SCRAGG University July, 1961 The copyright of this thesis vests in the author. No quotation from it or information derived from it is to be published without full acknowledgementTown of the source. The thesis is to be used for private study or non- commercial research purposes only. Cape Published by the University ofof Cape Town (UCT) in terms of the non-exclusive license granted to UCT by the author. University CONTENTS page Introduction l Historical Rev-lew 3 Intestinal Amoebiasis in childhood 5 Incidence of Entamoeba histol.ytica infection 5 Amoebic dysentery 7 Conclusions 10 Amoebic liver abscess in children 11 Conclusions 19 Amoebiasis in children in Natal 21 Incidence of Entamoeba histolytica infection 21 Amoebic dysentery 21 Amoebic liver abscess 2.4 Conclusions 26 Clinical material 27 Unproved cases 28 Proved cases 31 Age distribution 32 Sex distribution 32 Clinical features 34 Pain 34 Fever 3i .. Tender hepatomegaly 35 CONTENTS ( contd.) page Abdominal distension 38 Palpable mass in the liver 41 Location and number of abscesses 41 Haematological findings 44 Leucocytosis 44 Anaemia 45 Liver function tests 46 Radiological investigation 47 History of dysentery 48 Concomitant unproved amoebic dysentery 48 Concomitant proved amoebic dysentery 49 Nature of pus 51 Appearance 51 Parasitological findings 52 Bacteriological findings 54 Complications 55 Rupture of abscess 55 Brain abscess 58 Jaundice 59 Mortality 6o Treatment 64 Specific anti-amoebic therapy 64 CONTENTS (contd.) page Emetine Chloroquine Diiodohydroxyquinoline 61 .. Antibiotics 64 Aspiration of the abscess 65 Surgical drainage 65 Supportive measures 66 Discussion 66 Conclusions 73 Su1nma.ry 80 Appendix 1 - Reported cases of amoebic liver abscess 82 in children Appendix 2 - Summary of findings in 100 cases amoebic 92 liver abscess Ackn011ledgments 110 References 111 Plate l. Reproduction from Virchows Archives showing the title of a paper published by L6sch from Russia. in 1875. Also shown are Losch' s drawings of the amoebae described i n this paper X\"11. 11asse1ufte r..twidlelung von Amoben im Dickdarm. A¥1 Uf lli•ik ,on Prof. E. E ic.hwald. Von F. Lil sch , •r......_ .&_....11tk• ue• Priutdoc.tnttft deor inn•,~" Jlht41c1n in S1 Pc1e,,bu,.i: . ( Hitt1u Toi. X. Fig. 1- J l Im Dickdarru dH Menscben sind Am i! ben bisher so selten beobadltet worden. dus selbst R. Leuck a rt '), dieser grilndliche u d rielerfahrene forscher auf dem Gebiete der menschlic hen 3. 6 Parasiten, an ihrem Vorkommen daelbst zweitelt un d de11 einz,gen 1 bilher wo n Lamb I ) verilfentlichlen fall als Ver we chsel11n @ patho­ lOlildler u lliger Gebilde mil Am!lben ansieht. Der vorloegende fall, den ich im Verlaufe mehrerer Monate in der Kli nik vo n 2. Prof. Ei eb wald zu beobachlen Gelegenheit hatle, b oe lel daher C ,roues lnteraae dar. a J. lu*o• • ...., •• ... ArcH01elulln Gou,rroP8ltD1 , 24 Jahre alt, "' urdt 4H 3. "-btr ta7S uo ... lliai• Hl.. oommen . s.;..,. AIIM&fl udl •• er u• ft'IIH Ihle im Sommer I &7 1 n1eh ~ ' , llallplltl«, - ArNit ta ,...._ ... tnn.. to bltnolkt 1n 1in11u borl uld icen• .....,_ "-"ii, .., _..._ ._. Nkioll ... Illa ock liftolich dorm1111on ~. .... • ai..1 le s, .... wor old, 111'ot I• B,uo 1ul,anr~t••· la • ') Dit -iollclln ,.,..,._,_II. Ludart. IMS. S. 140 . .I) A• .. Fr,1& .,_.,...,..,. .... la ....... I. 1\cll. S. SH. INTRODUCTION A great difference of' opinion still exists with regard to the incidence of amoebic dysentery in infants and young children. While many authors have stated that amoebic dysentery does not occur, or is a medical curiosity in childhood, others have stressed that this is not so and that it should be kept in mind in investigating diarrhoea in infants and children even in temperate zones. By the term amoebiasis one assumes that infection with Entamoeba histolytica has occurred. This infection may not have given rise to symptoms or signs. Hoare (19.50 and 1952) stated that "Although !• histolytica is a pathogenic para.site, capable of invading the tissues of the host with the production of lesions and clinical symptoms of disease, in most cases it does not manifest any evidence of virulence, for in up to 90'fa of persons harbouring this pa.rasite the infection is symptomless and the host is a carrier. In most carriers the amoebae live in the lumen of the gut as harmless oolllllensals •••" From maey of the reports of amoebiasis it is impossible to determine whether an author is discussing asymptomatic amoebiasis or &llOebic dy'sentery. This failure to correlate the finding of'!• histo­ ].ytica in the stools of children with the actual number with dysenteric signs has led to much contusion. -2- MalliY authors still believe tha.t the complications of amoebic dysentery are much less frequent in children than in adults. Faced with the problem of a high incidence of amoebic infection and its complications in the .Af'rican child in Durban, I was prompted to search the literature on this subject in order to compare the incidence, complications and mortality as found in Natal African children, with the disease in childhood. elsewhere and to compare and contrast the findings in children with those in adults. -3- HISTORICAL REVIEW It was L6sch in Russia who in 1875 identified amoebae in the stools of a young peasant from Archangel. He was able to infeet a dog with these amoebae (which he named "Amoeba .£:21:!") and at post­ mortem examination of the dog there was ulceration of the large intestine with amoebae in the ulcers. The patient when he died showed a similar condition of ulceration with amoebae present in the large intestine. Some modern workers still cite Lambl as the discoverer of the intestinal 8.IDOeba of man in 1859. According to Dobell (1919) the paper published by Lambl in 1859 made no mention of amoebae. Dobell stated that the work in which amoebae were mentioned appeared in 1860 and probably few people have really seen this work, which is very difficult to obtain. Dobell believed that the small "amoebae" described by La.abl in the intestine of a child who died of enteritis were in fact small degenerating individuals of the flagellate TrichollOllU hominis. Do bell ( 1919) quoted Koch as furnishing the next discovery of importance which was published in 1887. Koch had occasion in 1883 to carry out autopsy examinations on 5 cases of ccy-sentery in Egypt, 2 of them complicated by liver abscess. Sections of the intestinal ulcers of 4 and of the liver abscess in 1 revealed the presence of amoebae. In the same year of 1887 Pfeiffer saw amoebae similar to those /described •• ' ' -4- described by Lasch in the stools of children suffering from dysenter,y and Kartulis also found amoebae in liver pus. This latter author had earlier (1886) reported. on the finding of amoebae in 1,50 patients with dysentery in Egypt. Osler in .America, in 1890, discovered amoebae in liver abscesses and this led Councilman and Lafleur in 1891 to publish a master'.cy' study on "amoebic dysenter.r" and "uoebic abscess of the liver" which terms they introduced. They gave the organism the name of "Alloeba dysenteriae" and it was not until 1903 that it received. the name "histolYtica" from Schaudinn. According to Councilman and Laf'leur (1891), Leukart (1880) reported that Sonsino in Cairo had found large numbers of amoebae in the intestinal mucus of a child who died of dysentery. It is interesting to note that in some of the earlier refer­ ences to the disease in children, the diagnosis was made because of the presence of the complication of liver abscess. Thus probably the earliest reference in the literature is that of Brown who in 1824, '' reported "a case of great enlargement, suppuration and u1ceration of ' the liver in a child aged 12 months". This occurred in a little Negress in Cuba, following dysenter,y. Revim.ng the literature makes it obvious that amoebiasis is a highly controversial subject. The disease in childhood. appears to be the subject of even greater controversy. ·•· -5- INTESTINAL AMOEBIASIS IN CHILIEOOD Incidence of Entamoeba histolytica int'ection Many surveys among children in ditterent parts of the world had revealed that in:f"ection with!• histolytioa {not necessarily producing dysentery) was common in certain areas. Willets (1914) bad reported an incidence of 29}& positive stools in Philippine children. Debell (1921) in a study on the incidence of intestinal protozoa in the inhabitants of Britain, found that there was an appreciable incidence of!• histolytioa in the children examined, with for example the following variations: 1.6)& in Leeds, 3.)% in Bristol and 5.~ in Shettield. In 1930 Meleney, and later in 1931 Milam and Meleney, con­ ducted an epidemiological study of amoebie.sis in Tennessee showing the incidence of infection to be very high { 38)0 , appearing first in the 2 year old group. However, no correlation could be found between the occurrence of dysentery and the harbouring of!• histolytica. In southwestern Virginia., Faust (19.30) found that 16 • .5% of the age group up to 5 years harboured!• histolytica. Later in 1931 he pointed out the value of diagnosis of cases in which only cysts are passed as contrasted with those in which active trophozoites are seen. His study suggested a racial tolerance to the parasite, as in the most heavily infected communities cysts were more common than trophozoites /and •• -6- and vice versa. Examination of' stools :from children in orphanages in New Orleans showed that 55.5% were infected, but cysts only were recovered :from these stools.
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