found E. histolytica in the discharge from the sinus around the anus in some oases of multiple fistula in ano and suggested that the disease was due to entrance of amoebae in tissues, possibly from an original simple fissure in ano. In 1919 Engman and Heithaus reported a case of deep serpiginous ulcers on body, buttocks and leg. The histological section as well as the pus showed E. hystolyticci. Amoebae were present in the faeces. The same authors reported a case of cutaneous amoebiasis of the dorsal surface of the hand. The pus contained cystic forms of E. histolytica. The case was cured after emetine injections. But there is no evidence that amoebae in the animal host can undergo encystment outside the intestinal tract. Runyan and Herrick in 1925 mentioned two cases of amoebiasis of abdominal and thoracic wall following caecostomy and transthoracic drainage of liver abscess respectively. Penile ulcer of amoebic origin was described by Straub which was cured with emetine. Perianal ulceration resembling malignant condition was described by Tixier et al. (1927). They drew attention to the presence in their case of colonies of amoebae deep down in the CUTANEOUS AMCEBIASIS dermis away from the surface ulceration. L' WITH A CASE REPORT] Van Hoof (1926) described a case of spread- By S. GHOSH, m.b. (Cal.), f.r.c.s. (Eng.) ing ulcer round anus and buttock. Rapidly M.j^ , and spreading ulceration of the abdominal wall or ANJALI m.b. (Cal.) following drainage of appendicular abscess [MUKHERJI, colostomy has from time to time been reported Departvient of Surgery, Campbell Hospital, Calcutta by various authors. Amebic infection of the skin and subcutaneous Cases of cutaneous amoebiasis proved by tissues is much more common than is generally histological section have been reported by realized. Diagnosis is often missed because the Rajam and Rangiah (1939) and Mahadevan possibility is not thought of. Even the- finding (1945). of Entamoeba in the feces may not histolytica McConaghey (1945) reported a case of draw the attention to the of an ulcer possibility mass in the of amoebic to be of amoebic in because amoebic fungating perianal region origin, origin following infection of haemorrhoids. No infection is not in our infrequent country. biopsy was done but the case responded to Cutaneous amoebiasis was originally described emetine treatment. by Nasse as far back as 1892 surrounding Kouri et al. a the discharging sinus of a liver abscess, but he Very recently (1949) reported case of ulcerated in the was not able to see the living amoebae" growth perianal region which was as and radical Menetrier and Touranie reported a case of diagnosed epithelioma necrosis of skin and subcutaneous excision was done including block dissection progressive of the tissue surrounding the incision of a liver abscess. glands. Subsequent biopsy proved The discharge contained active amoebae. No amoebic nature of the growth. Cutaneous amoebiasis is of the .ulcerative but history of dysentery was present. Autopsy con- mainly type firmed the amoebic nature of the liver abscess. an allergic type of dermatitis is also described. Selenew described four cases of desquamative Ulcerative type of cutaneous aviocbiasis.?It and pustular dermatitis of the head, neck and is classified into four different groups : trunk in adult patients, from the discharge of (a) Following drainage of amoebic hepatic which he identified adult amoebae. But there is abscess. no that these were of E. his- proof specimens (b) of Cases of amoebic infection of skin and Following drainage ruptured appendix tolytica. and colostomy. subcutaneous tissue following drainage of liver Cases not concerned with viscera. abscess have been occasionally reported by (c) directly various authors. In 1912 Maxwell read a (d) Perianal amoebiasis. paper before the of the Royal Society ' Tropical The first and the second group comprise Medicine and Hygiene entitled Fistulous bulk of the literature. Various types have been disease of buttocks; a clinical entity \ He described extending from a small area of ulcer 340 THE INDIAN MEDICAL GAZETTE [Aug., 1950 round about a discharging sinus of amoebic A ease of cutaneous amcebic infection closely hepatic abscess to an extensive gangrenous resembling an epidermoid carcinoma came condition spreading over the whole of the under our care recently and is given below : abdominal wall following colostomy. Case report The third group is rare and only one case could be traced in literature where a progressive Complaint.?B. P., an Indian male, aged 42 swelling and ulceration of the abdominal wall years, was admitted to the Campbell Hospital is described, which developed after a bruise with on 10th October, 1949, complaining of a pain- a dirty shovel in a 48-year-old labourer with a ful ulcerative growth accompanied with pruritus history of recurring attacks of dysentery for 20 round the anal orifice of about 2 months' years. The patient came for treatment after duration. 2 years. Biopsy revealed necrotic tissue with numerous amoeba) in the viable tissues. Stool examination showed presence of E. histolytica. The wound healed up with emetine injections and zinc peroxide dressing. The fourth group, to which the case under discussion belongs, is of special importance to the surgeon because of the difficulty in diag- nosis. Usually two types of lesion are seen : (i) Gangrenous type with extensive destruc- tion of skin and subcutaneous tissue, (u) Granulomatous type with the production of a lesion raised above the skin and resembling epidermoid carcinoma. The cutaneous lesion is always secondary to amoebic infection of the intestine. The intestinal infection may be with or without any clinical manifestation. Fig.Fig. 1.?Perianal cutaneouscutaneous amcebiasis.aracebiasis. The amoebae cannot penetrate normal skin History.?The condition started with pain with intact cornified epithelium. In almost all and difficulty during and after defecation. It cases mentioned in literature in which there is was quickly followed by the ulcerative condi- reliable verification of the diagnosis by biopsy tion round the anus. The pain and pruritus all have had cutaneous lesions around the anal were of such severe degree that it interfered in or orifice following fistula ano, fissure, etc., with his sleep and he was in constant agony. from sinus from a liver abscess or leading any Present condition.?An ulcerative other abdominal focus of amoebic infection. growth (figure 1) all round extending for about As to the methods of penetration of E. histo- 3 cm. from the margin of anus with irregular lytica into the tissues there are two views : and everted margins is seen. The floor of the (1) Penetration is effected by the mechanical ulcer shows polypoid masses covered with slough action of the blade-like pseudopodia extruded here and there. The growth extends for about by the amoebae forcing their way between the a centimetre into the anus involving the anal cells in their path. (2) Parasite acts directly mucosa and sub-mucosa. The surrounding area on the tissues by means of a proteolytic secretion is markedly indurated. Proctoscopic examina- which dissolves the cells with which the organism tion is not possible due to pain. comes into contact. view This is accepted by nodes are and tender most workers. Inguinal lymph enlarged on both sides. The role of bacterial infection in production The general condition of the patient is good. of ulcer is of it secondary importance, though Much significance was not attached to the plays an important role in and sloughing previous history of alternate diarrhoea and con- gangrenous changes. stipation as it is a very frequent condition in Allergic type of dermatitis.?This type of our country. From every standpoint, history, skin lesion to which the term amoebides has clinical course and physical findings, the condi- been given, is characterized by obstinate tion was highly suggestive of a malignant growth. urticaria, pruritus, and may be associated with Blood picture.?Hb : 80 per cent, R.B.C.: recurrence of dysentery. It differs from the 4.5 million per c.mm., W.B.C.: 10,000 million other type in that amoebae have never been per c.mm., poly 72 per cent, lympho 22 per demonstrated in the skin lesion. In a consider- cent, eosino 4 per cent and mono 2 per cent. able proportion of cases amoebae can be demon- W.R.?Negative. strated in stool and diagnosis is confirmed by Stool.?Routine stool examination did not t(ieir with emetine. curability reveal any ova or protozoa. Aug., 1950] CUTANEOUS AMEBIASIS : GHOSH AND MUKHERJI 341 Biopsy report.?Ingrowths of papillary pro- tions of emetine the granuloma disappeared cesses in places with suggestion of cell nest completely. formation. The suggests the picture possibility On 19th an of squamous celled carcinoma. December, 1949, extraperitoneal closure of the colostomy was done under nitrous As the clinical and examina- histopathological oxide and oxygen amesthesia. Patient had an tion celled carcinoma from suggested squamous uneventful recovery and was discharged on the anal margin, it was decided to excise the 14th January, 1950. growth after a preliminary inguinal colostomy. On 12th October, 1949, a left inguinal loop Discussion colostomy was performed under nitrous oxide The presence of E. histolytica in the tissues and oxygen. and the dramatic response to emetine leave no In a few days after the colostomy it was doubt about the amcebic nature of the lesion, found that the lesion around the anus showed diagnosis of which was missed in the beginning signs of rapid retrogression. In about three as the possibility was not thought of. The weeks' time the growth completely disappeared. history of attacks of alternate diarrhoea and This caused a doubt about the original diag- constipation which is a common feature in nosis. Rectal examination at that time revealed amcebiasis was ignored in view of the fact that a fissure with a dorsal fistula which was excised the site, progress of the lesion, clinical history on 1 lt-h November.