Amoebiasis an old and important cause of intestinal and liver disease….. © by author ESCMID Online Lecture Library Amoebiasis: Illness caused by infection with Entamoeba histolytica, an unicellular parasite © by author ESCMID Online Lecture Library Fedor Aleksandrevitch Lösch © by author Lösch, F. (1875) Massenhafte Entwickelung von Amöben im Dickdarm. Virchow's Archiv. 65: 196-211. ESCMID Online Lecture Library © by author Phase contrast micrograph of amoebic trophozoite of EntamoebaESCMID histolytica Online (5μ Lecturem /second) Library Trophozoite of © by author Entamoeba histolytica ESCMID Online Lecture Library Transmission of Amoebiasis © by author ESCMID Online Lecture Library © by author ESCMID Online Lecture Library Development of amoebiasis in colon Infection of E. histolytica can be asymptomatic and symptomatic: 4-10% develop disease over a year © by author ESCMID Online Lecture Library Asymptomatic Intestinal Extra-intestinal © by author ESCMID Online Lecture Library Life cycle of E.histolytica © by author ESCMID Online Lecture Library From the CDC web site © by author ESCMID Online Lecture Library Blood on top of feces: blood contains parasites! Amoebic ulcer in intestine © by author ESCMID Online Lecture Library © by author ESCMID Online Lecture Library Severe amoebic colitis with multiple ulcers: mortality is higher than 40% © by author ESCMID Online Lecture Library Typical flask shaped ulcer in amoebiasis of gut (spread laterally in submucosa) Spread of amebiasis from intestine © by author ESCMID Online Lecture Library Yellow necrotic tissue © by author Intact abcess Several liver abcesses ESCMID Online Lecture Library Complications of amoebic abcesses © by author ESCMID Online Lecture Library © by author ESCMID Online Lecture Library Rupture of large amoebic abcess in peritoneal cavity © by author Amoebic liver disease with cutaneous involvement following spontaneous ESCMID Online Lecture Library rupture Diagnosis Intestinal Extra-intestinal © by author ESCMID Online Lecture Library Diagnosis of intestinal parasites S. stercoralis Ascaris C. cayetanensis G. lamblia T. trichiura E. histolytica/ D. fragilis hookworm dispar © by author ESCMID Online Lecture Library Intestinal protozoan parasites observed in routine clinical practice • Entamoeba histolytica • Giardia lamblia • Dientamoeba fragilis • Balantidium coli • Cytoisospora belli pathogens • Cyclospora cayetanensis • Sarcocystis spp. • Cryptosporidium parvum/hominis* • Microsporidia spp* Blastocystis hominis • Entamoeba coli © by author • Entamoeba hartmanni • Iodamoeba butschlii non- pathogens • Endolimax nana •ESCMIDChilomastix mesnili Online Lecture Library New discovery: With microscope Entamoeba histolytica morphological identical Entamoeba dispar But: Entamoeba dispar: non-pathogen ! © by author Entamoeba histolytica: pathogen ESCMID Online Lecture Library New tests necessary for differentiation of Entamoeba histolytica from Entamoeba dispar: i.e. polymerase chain reaction (DNA-studies) E. histolytica © by author E.dispar ESCMID Online Lecture Library WHO/PAHO/UNESCO report. A consultation with experts on amoebiasis. Mexico City, Mexico 28-29 January, 1997. WHO Epidemiol ©Bull by author18: 13- 14. ESCMID Online Lecture Library Buddy Diamond & Graham Clark © by author Diamond,L.S. and Clark,C.G. 1993. A redescription of Entamoeba histolytica Schaudinn, 1903 (Emended Walker, 1911) separating it from Entamoeba dispar Brumpt, 1925. J.Euk.MicrobiolESCMID40: 340-Online344 Lecture Library Entamoeba histolytica and E.dispar We now believe that four, not three species of Entamoeba live in the human large bowel: • Entamoeba hartmanni • Entamoeba histolytica© by author • Entamoeba dispar • Entamoeba coli ESCMID Online Lecture Library There are also a few rare species: • “Atypical,” “low temperature” or “Laredo” strains of E.histolytica are E.moshkovski • E.polecki • E.chattoni • E.gingivalis © by author ESCMID Online Lecture Library Diagnosis Intestinal Extra-intestinal © by author ESCMID Online Lecture Library Temperature chart of patient with amoebic liver abscess © by author The triad of swinging temperature, profuse sweats and ESCMIDleukocytosis Online is indicative Lecture of liver abscess Library © by author ELISA method for detection of specific ESCMIDantibodies Online to Entamoeba Lecture histolyticaLibrary © by author Diagnosis ESCMID Online Lecture Library Ultrasound scan: amoebic liver abcess CT scan of amoebic liver abcess (500-1500 ml) © by author ESCMID Online Lecture Library © by author ESCMID Online Lecture Library Raised right hemidiaphragm due to amoebic liver abcess © by author ESCMID Online Lecture LibraryDrainage of an amoebic liver abcess © by author ESCMID Online Lecture Library © by author Epidemiology ESCMID Online Lecture Library Classic data: • New infections, world-wide, per annum: 480 million; • With disease: 10 – 50 million; • Deaths: 40 – 100,000 (Walsh, 1986) © by author ESCMID Online Lecture Library Reinterpreted - new infections per annum (very approximate) • E.histolytica + E.dispar: 480 million • E.dispar: 450 million? • E.histolytica: 10-50 ©million? by author – with symptoms of invasive amoebiasis: 4 - 10 % • Deaths: 40-100 000 every year? ESCMID Online Lecture Library Therapy # tissue phase: Metronidazol (750 mg tid x 7-10d) # luminal agents: Paromomycin (30 mg/kg x 5-10d) or Diloxanide furoate (500 tid x 10d) © by author Always treatment with a luminal agent after treatment for the tissue phase! Otherwise up to 30% will remain infected ESCMIDand may Online relapse (Irusen Lecture etal. 1192) Library Coccidians Cryptosporidium Cystoisospora belli Cyclospora cayetanensis © by author ESCMID Online Lecture Library © by author ESCMID Online Lecture Library © by author ESCMID Online Lecture Library © by author ESCMID Online Lecture Library © by author ESCMID Online Lecture Library Diagnostic techniques Cryptosporidium Cyclospora cayetanensis Cystoisospora belli sporulation In host weeks days seize 2-5 μm 5-8 μm flask JKJ no uptake no uptake no uptake Acid fast + ©+ by author + Autofluorescence - + + ESCMID Online Lecture Library Auto fluorescence • Prepare direct smear or a smear from Ridley sediment in saline (not JKJ) • Screen smear with fluorescence microscope with excitation filter 340-380 nm (20x10; details 40x10) • oöcyst wall: blue/white© by fluorescent author • Also for SAF preserved samples ESCMID Online Lecture Library © by author ESCMID Online Lecture Library Treatment Cyclospora / Cystoisospora belli • Co-trimoxazol – 2dd TMP 160 mg SMX 800 mg x 7-10 d – Children – 2dd TMP 5 mg/kg SMX 25 mg/kg x 7-10 d © by author ESCMID Online Lecture Library .