An Underestimated Sexually Transmitted Infection: Amoebiasis Anne Claire Billet, Arnaud Salmon Rousseau, Lionel Piroth, Capucine Martins
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Reminder of important clinical lesson BMJ Case Rep: first published as 10.1136/bcr-2018-228942 on 10 May 2019. Downloaded from CASE REPORT An underestimated sexually transmitted infection: amoebiasis Anne Claire Billet, Arnaud Salmon Rousseau, Lionel Piroth, Capucine Martins Infectious diseases, Centre SUMMARY 120/60 mm Hg and his pulse was 110 bpm and Hospitalier Universitaire Dijon- Entamoeba histolytica is a cosmopolitan pathogenic regular. He reported losing 5 kg over the past 6 Bourgogne, Dijon, France parasite. It is spread via the feco-oral route and, to a months. His right upper abdominal quadrant was lesser extent, via sexual intercourse. We report a case of hypersensitive, but there was no clinical hepato- Correspondence to hepatic and intestinal amoebiasis in a 67-year-old man megaly or jaundice. No other abnormality was Dr Capucine Martins, capucine3martins@ gmail. com who had never travelled to an endemic area. Abdominal detected. His blood results were as follows: haemo- CT investigations detected two liver abscesses and globin 117 g/L, white blood cells 20×109/L (mainly Accepted 1 May 2019 chronic colitis. Positive amoebic serology and a positive neutrophils), C reactive protein 298 mg/L, total PCR test for E. histolytica in the hepatic liquid and faeces bilirubin 10 µmol/L, serum creatinine 90 mmol/L, confirmed the diagnosis. Curative metronidazole and alanine transaminase (ALT) 38 IU/L, aspartate tiliquinol-tilbroquinol were administered successfully. The transaminase (AST) 23 IU/L and serum albumin patient had been contaminated through heterosexual 19 g/L. He tested negative for HIV, and there was no intercourse with his healthy French female partner who hypogammaglobulinaemia. Abdominal and pelvic was a carrier of the parasite. Though unusual, amoebiasis CT showed two hepatic abscesses in the VI and VII as a result of sexual transmission should be considered segments (58 and 67 mm in diameter, respectively) in non-endemic areas in people who have never travelled (figure 1) and signs of chronic colitis and proctitis abroad, particularly in the presence of clinical symptoms (figures 2 and 3). such as liver abscesses or chronic diarrhoea. INVESTIGATIONS A reddish fluid was aspirated from the hepatic abscesses with the use of ultrasonography (US) BACKGROUND guidance. Blood cultures were sterile. The bacterial Entamoeba histolytica is a protozoan that causes stool culture was negative. The faeces were nega- non-febrile intestinal infection or febrile hepatic tive for Clostridium difficile and Cryptosporidium. http://casereports.bmj.com/ infection, and it is the third most deadly parasitic In the fluid taken from the liver abscess, bacterial infection. Amoebiasis is highly prevalent in low-in- and mycobacterial cultures were negative, but come and middle-income countries and is mainly 1 PCR for E. histolytica was positive. E. histolytica transmitted via the feco-oral route. In high-income was also positive in the faeces. Amoebic serology countries, amoebiasis usually occurs in migrants and was positive with a titre superior to 1/2560 (cut- travellers returning from endemic areas. To a lesser off >1/320), confirming a diagnosis of autochtho- extent, it can be also transmitted sexually, in partic- nous intestinal and hepatic amoebiasis. ular with men who have sex with men.2 Genuine European autochthonous cases are scarce.3–6 We DIFFERENTIAL DIAGNOSIS present here a rare case of a French heterosexually In the case of our patient, three diagnoses were contracted autochthonous amoebiasis. possible (in order of probability): on October 1, 2021 by guest. Protected copyright. 1. A bacterial abscess from a digestive tract infection. CASE PRESENTATION 2. A bacterial abscess secondary to infectious In July 2018, a 67-year-old French man was endocarditis. admitted to hospital for liver pain associated with 3. A parasitic abscess. fever. He was on irbesartan 300 mg per day for chronic hypertension. He was retired from the TREATMENT public service and had a female partner. He had After percutaneous drainage, the patient started © BMJ Publishing Group never travelled outside Europe. on intravenous ceftriaxone 2 g per day and metro- Limited 2019. Re-use Six months previously, he had developed non-fe- nidazole 500 mg three times per day. Ceftriaxone permitted under CC BY-NC. No brile bloody diarrhoea (5–15 stools per day). He commercial re-use. See rights was stopped after 3 days once the amoebic serology and permissions. Published consulted his general practitioner only 3 months was known to be positive. Overall, the patient was by BMJ. after the start of symptoms. The bacterial stool treated with metronidazole for 10 days followed by culture was negative at this time. Ciprofloxacin tiliquinol-tilbroquinol two tablets two times per day To cite: Billet AC, 500 mg two times per day for 7 days was not Salmon Rousseau A, for 10 days. Piroth L, et al. BMJ Case effective. Three months later, he presented to the Rep 2019;12:e228942. emergency room for right upper quadrant pain, OUTCOME AND FOLLOW-UP doi:10.1136/bcr-2018- associated with fever for the past 48 hours. He had Within 48 hours, fever, bloody diarrhoea and 228942 a low-grade fever (38.5°C), blood pressure was hepatic pain disappeared, and most of his laboratory Billet AC, et al. BMJ Case Rep 2019;12:e228942. doi:10.1136/bcr-2018-228942 1 Reminder of important clinical lesson BMJ Case Rep: first published as 10.1136/bcr-2018-228942 on 10 May 2019. Downloaded from Figure 1 Abdominal CT showing the two cystic abscess cavities. parameters normalised. At follow-up 2 months later, no recur- rence was observed and the stool sample was negative. W AY OF TRANSMISSION The patient had never travelled outside of Europe, but his French Figure 3 Abdominal CT showing simultaneous intestinal and hepatic female partner had travelled in endemic areas including South amoebiasis. America, India, Burma, Vietnam and Laos. She had also had a prior heterosexual relationship with a man who was diagnosed with intestinal amoebiasis. She had never presented symptoms. transmitted cases have been reported, but three cases of hepatic abscesses were reported in a group of Canadian tourists who had Her serology was positive with a titre superior to 1/2560, but 8 abdominal US did not show liver abscess. She was started on intergroup sexual relationships. More recently in France, a case of amoebiasis was reported in a male with no risk factor apart metronidazole 500 mg three times daily for 10 days followed 5 by tiliquinol-tilbroquinol two tablets twice daily for 10 days. At from a sexual relationship with a South African woman. follow-up 2 months later, E. histolytica serology was negative. Our patient presented simultaneous intestinal and liver amoe- biasis. Classically, intestinal mucosa invasion leads to an intestinal http://casereports.bmj.com/ infection, which then develops into ulcerations and microab- DISCUSSION scesses, resulting in non-febrile (bloody) diarrhoeas. Then, the Though European cases are quite rare, E. histolytica proto- liver may be infected by invasion of the portal venous system. zoan is cosmopolitan and autochthonous cases may occur in Hepatic tissue necrosis creates hepatitis abscesses resulting in metropolitan France.3–5 A diagnosis of E. histolytica should not pain and fever.1 To our knowledge, there are very few cases of be ruled out only because the patient has not visited travel in simultaneous intestinal and hepatic clinical forms in the liter- endemic areas. Though it is transmitted via the feco-oral route, ature.9 10 Hepatic abscesses are more prevalent in males and it may also be to a lesser extent sexually transmitted from are associated with gastrointestinal symptoms in 10%–35% of healthy carriers. Additional risk factors for amoebiasis infec- patients.1 tion have been identified, such as men having sexual relation- Intestinal amoebiasis is usually confirmed with a parasitic on October 1, 2021 by guest. Protected copyright. ship with men,2 HIV coinfection7 or oro-anal sexual practices,8 stool culture, a PCR-based test or presence of E. histolytica on but our patient confirmed having an exclusively heterosexual colonic mucosal biopsy specimens. Hepatic amoebiasis can be relationship with his female partner.9 Very few heterosexually confirmed with serology (gold standard), but its positivity may be sometimes delayed. Most of time aspiration of the abscess is required to rule out a pyogenic abscess. Occasionally, the abscess may require drainage in patients who fail to respond to drug therapy with a high risk of abscess rupture (cavity with a diam- eter of more than 5 cm) or for pain relief.1 Treatment for intestinal or hepatic amoebiasis consists of a sequence of two antiparasitic therapies. First, a nitroimidazole drug is prescribed, specifically metronidazole (500 mg three times per day for 10 days), followed by a luminal infection cure such as tiliquinol-tilbroquinol (two tablets two times per day for 10 days) or diloxanide furoate. Treatment of the luminal infec- tion is needed to avoid a relapse. Clinical follow-up is associated with a stool culture 3–4 weeks after the end of treatment.2 As amoebiasis can be transmitted via sexual route, it is essential to identify and treat sexual partners to avoid recontamination. This Figure 2 Abdominal CT showing chronic colitis. is important in developed countries like France where, though 2 Billet AC, et al. BMJ Case Rep 2019;12:e228942. doi:10.1136/bcr-2018-228942 Reminder of important clinical lesson BMJ Case Rep: first published as 10.1136/bcr-2018-228942 on 10 May 2019. Downloaded from recent epidemiological data are lacking, it has been suggested Funding The authors have not declared a specific grant for this research from any that 11% of sewer workers and 2% of the general popula- funding agency in the public, commercial or not-for-profit sectors.