• Clinical science

Amebiasis

Summary

Amebiasis is an infectious disease caused by the anaerobic protozoan Entamoeba histolytica. Transmission usually occurs via the fecal-oral route (e.g., via contaminated drinking water) when traveling in an endemic region. Depending on its manifestation, amebiasis is termed either intestinal or extraintestinal. After an incubation period of one to four weeks, symptoms such as loose stools with mucus and fresh blood in combination with painful defecation develop. In extraintestinal amebiasis, amebic abscesses (mostly a single liver abscess in the right lobe of the liver) may form, resulting in pain as well as a feeling of pressure in the right upper quadrant (RUQ). Important diagnostic steps include stool analysis and liver ultrasound to assess extraintestinal amebiasis. Treatment consists of paromomycin to destroy intestinal amebae and metronidazole for invasive disease. Image-guided needle aspiration may be indicated in cases involving complicated liver abscesses.

Epidemiology

  • Occurence: E. histolytica is very common in tropical and subtropical regions (e.g., Mexico; , Southeast Asia, India) and affects more than 50 million people worldwide. Amebic infection is relatively rare in the US.
  • Men and especially immunocompromised individuals have a higher risk of developing liver abscesses.

References:[1][2]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

  • Pathogen: Entamoeba histolytica, a protozoan
  • Transmission
    • Fecal-oral
      • Amebic cysts are excreted in stool and can contaminate drinking water or food
      • Transmission may also occur through sexual contact.
    • Infection typically occurs following travel to endemic regions such as the tropics and subtropics.

References:[1][3]

Pathophysiology

  • Stages
    • Cyst stage: Cysts are very resilient (even against gastric acid) and are able to survive outside the host for months.
    • Vegetative stage: trophozoite formation
      • Trophozoites can produce proteolytic enzymes that allow them to invade the intestinal submucosa. They can then enter the bloodstream where they consume erythrocytes and disseminate to target tissues like the liver via the portal system.

References:[4][1]

Clinical features

Incubation period

  • Intestinal amebiasis: 1–4 weeks
  • Extraintestinal amebiasis: a few weeks to several years

Clinical courses

Intestinal amebiasis (dysentery)

  • Loose stools with mucus and bright red blood
  • Painful defecation, tenesmus, abdominal pain, cramps, weight loss, and anorexia
  • Fever in 10–30% of cases and possible systemic symptoms (e.g., fatigue)
  • High risk of recurrence, e.g., through self-inoculation (hand to mouth)
  • A chronic form is also possible, which is clinically similar to inflammatory bowel disease.

Always consider amebiasis when a patient presents with persistent diarrhea after traveling to a tropical or subtropical destination!

Extraintestinal amebiasis

  • Mostly acute onset of symptoms; subacute courses are rare
  • In 95% of cases: amebic liver abscess, usually a solitary abscess in the right lobe
  • In 5% of cases: abscesses in other organs (e.g., especially the lungs; in rare cases, the brain), with accompanying organ-specific symptoms

Diarrhea precedes only a third of all cases of amebic liver abscess!

References:[5][1][6]

Diagnostics

  • Travel history
  • Intestinal amebiasis
    • Stool analysis
      • Microscopic identification of cysts or trophozoites in fresh stool
      • The following tests confirm the microscopic findings (important since E. histolytica and Entamoeba dispar are morphologically identical ):
        • EIA or copro-antigen ELISA (antigens found in feces)
        • Molecular methods: e.g., PCR
      • Stool microscopy is not sensitive; , especially in later phases, so at least three stool samples should be examined before reporting a negative result.
    • Colonoscopy with biopsy: flask-shaped ulcers
  • Extraintestinal amebiasis

E. histolytica Engulfs Erythrocytes.

References:[3][1]

Treatment

Medical therapy

  • Asymptomatic intestinal amebiasis
    • No treatment in endemic areas
    • In nonendemic areas
  • Symptomatic intestinal amebiasis and invasive extraintestinal amebiasis

Invasive procedures

To ensure successful treatment, the patient's stool must be analyzed regularly!References:[8][1]

Complications

Intestinal amebiasis

Extraintestinal amebiasis

References:[1][9]

We list the most important complications. The selection is not exhaustive.

Prevention

Food and water hygiene

  • Unpeeled fruits or vegetables should not be consumed if there is a potential risk of contamination by Entamoeba histolytica cysts (e.g., endemic region with low hygiene standards).
  • Even chlorinated water can contain high concentrations of amebae; therefore, water should be boiled before use.

The main principles of amebiasis prevention concern consumption of potentially contaminated food and water and can be summarized as follows: "Boil it, cook it, peel it, or forget it."References:[1][5]

  • 1. Dhawan VK. Amebiasis. In: Bronze MS. Amebiasis. New York, NY: WebMD. http://emedicine.medscape.com/article/212029. Updated March 24, 2016. Accessed January 1, 2017.
  • 2. Seeto RK, Rockey DC. Amebic liver abscess: epidemiology, clinical features, and outcome. Western Journal of Medicine. 1999; 170(2): pp. 104–9. pmid: 10063397.
  • 3. CDC (DPDx). Amebiasis . https://www.cdc.gov/dpdx/amebiasis/index.html. Updated November 29, 2013. Accessed January 1, 2017.
  • 4. Author: Stein E Translator: Burgdorf WHC. Anorectal and Colon Diseases: Textbook and Color Atlas of Proctology. Springer; 2002.
  • 5. CDC. Amebiasis. https://www.cdc.gov/parasites/amebiasis/general-info.html. Updated July 20, 2015. Accessed January 2, 2017.
  • 6. Goswami A, Dadhich S, Bhargava N. Colonic involvement in amebic liver abscess: does site matter?. Annals of Gastroenterology. 2014; 27(2): pp. 156–161. url: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3982631/.
  • 7. Bächler P, Baladron MJ, Menias C, et al. Multimodality Imaging of Liver Infections: Differential Diagnosis and Potential Pitfalls. RadioGraphics. 2016; 36(4): pp. 1001–1023. doi: 10.1148/rg.2016150196.
  • 8. Hoenigl M, Valentin T, Seeber K, et al. Amoebic liver abscess in travellers: indication for image-guided puncture?. Wiener klinische Wochenschrift. 2012; 124 (Suppl 3): pp. 31–4. doi: 10.1007/s00508-012-0236-8.
  • 9. Holzheimer RG, Mannick JA, Sayek I, Onat D, Lerut T. Surgical Treatment: Evidence-Based and Problem-Oriented. W. Zuckschwerdt Verlag GmbH.; 2001.
  • Greaney GC, Reynolds TB, Donovan AJ. Ruptured amebic liver abscess. Archives of surgery. 1985; 120(5): pp. 555–61. pmid: 3885916.
  • Garcia LS, Arrowood M, Kokoskin E, et al. Laboratory Diagnosis of Parasites from the Gastrointestinal Tract. Clin Microbiol Rev. 2017; 31(1). doi: 10.1128/cmr.00025-17.
last updated 07/09/2020
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