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AMOEBIASIS Dr.S.Palanivelrajan,M.D (Final Year P.G) Stanley Medical College Chennai
Definition Amoebiasis is an infection with intestinal  protozoa Entamoeba Histolytica.  90% of infection – asymptomatic. 1...
PHYLUM    SARCOMASTIGOPHORA SUBPHYLUM    SARCODINA SUPER CLASS    RHIZOPODA CLASS   LOBOSEA SUB CLASS   GYMNAMOEBIA ORDER ...
HISTORY 1875   LOSCH – RUSSIAN. Differentiated the amoebic dysentery from bacillary  dysentery by describing amoeba in the...
<ul><li>Third most common cause of death from the   parasitic disease. (after schistosomiasis , Malaria) </li></ul><ul><li...
the intestinal lesion  Gut   Minute crypt lesion Extends through the muscularis mucosa and submucosa. “Flask shaped” ulcer...
<ul><li>Tumor like lesion  </li></ul><ul><li>Several cms in length  </li></ul><ul><li>M C in caecum </li></ul><ul><li>Mult...
<ul><li>Asymptomatic infection  </li></ul><ul><li>Mild to moderate colitis (non dysenteric colitis) </li></ul><ul><li>Seve...
DD- Amoebic  Colitis <ul><li>Infective colitis </li></ul><ul><li>Ulcerative colitis </li></ul><ul><li>Colorrectal carcinom...
<ul><li>LABORATORY DIAGNOSIS </li></ul><ul><li>Microscopy And Culture </li></ul><ul><li>Wet Mount Preparation   (i)  mount...
<ul><li>Enzyme Immunoassay </li></ul><ul><li>Indirect Immunoflorescence </li></ul><ul><li>Latex Agglutination </li></ul><u...
500 mg t.i.d  ×  10 days 25 – 30 mg kg -1  day -1  in 3 doses  ×  7-10 days. 650 mg t.i.d  × 20 days 750 – 800  mg.t.i.d  ...
PREVENTION Health Education  Improved water supply Chlorination – not effective Amoebic cysts   Destroyed by  200 parts / ...
Amoebic Liver Abscess
<ul><li>This is the most common  extra intestinal   form of invasive amoebiasis. </li></ul><ul><li>Adults > children ( 10 ...
PATHOGENESIS  Journey of E. Histolytica to the Liver 1.  Direct Extension from the Gut to the Liver 2.  Via the Lymphatics...
Clear 'halo' around an amoeba
Destruction of liver tissue
Congestion of the sinusoids
Pathology
Bulge due to superficial abscess
Shaggy appearance of the walls of the abscesses
Abscess surrounded by a distinct area of severe congestion
Abscess showing a thick fibrous wall
CLINICAL FEATURES   Symptoms  Pain Diarrhoea and / or Dysentery Weight Loss Cough Dyspnoea Physical findings Localized ten...
huge abscess of the inferior surface of the left lobe.
Clinical enlargement of the left lobe of the liver .
Compression Sign
Point tenderness
Intercostal tenderness
Multiple large amoebic abscess seen at autopsy.
COMPLICATONS  Right chest Peritoneum  Pericardium Amoebic brain abscess  - rare Hemobilia – Rupture in to major bileduct  ...
LABORATORY FINDINGS   Normocytic Normochromic anaemia  Leucocytosis -> more than 10× * 10  9  / L  ESR  Stool  Cyst or Veg...
RADIOLOGY  <ul><li>CXR – Elevated Right Hemi diaphragm </li></ul><ul><li>Isotope liver scan  </li></ul><ul><li>USG Abdomen...
Anterior view of 133/Rose Bengal dot liver scan showing a small cold area on the inferior surface of the left lobe .
99m Tc sulphur colloid photo liver scan (anterior view) showing a cold area in the superior surface of the left lobe
X-ray chest showing obliterated costophrenic angle and an elevated right dome of the diaphragm
X-ray chest showing an elevated left dome of the diaphragm
X-ray chest showing a fluid level in a lung abscess in pulmonary amoebiasis .
<ul><ul><li>X-ray chest showing left sided pyopneumothorax </li></ul></ul>
X-ray chest demonstrating the more lateral and vertical spread of an empyema following a liver abscess
CAT SCAN
Peritoneoscopic view of amoebic liver abscess .
TREATMENT 750-800 mg.t.i.d   × 10 days 500 mg t.i.d. ×10   Days 2g/day × 3-5 days 500 mg t.i.d × 10 Days 1-1.5 mg kg-1 day...
Formal Indications To rule out a pyogenic abscess (, particularly with   multiple lesions ) As adjunct to medical therapy ...
Aspiration of flank abscess .
Color   – Anchovy sauce, Chocolate color or pinkish    brown, varying color’s  Odour   – Odourless Consistency   – thick ,...
A bottle of anchovy sauce and amoebic pus.
Bile aspirated from liver abscess
Different coloured pus obtained during a single session by changing the direction of the needle.
Chocolate coloured pus .
Dirty yellowish pus
Ivory or creamy white pus.
Brown coloured pus compared to anchovy sauce.
Pus resembling color of tea. Tea and anchovy sauce placed on either side for comparision .
Specks of necrotic tissue floating in the pus
Thin yellow pus from a 'chronic' abscess
<ul><li>ALA with Secondary infection  </li></ul><ul><li>Left lobe Abscess  </li></ul><ul><li>Bowel perforation </li></ul><...
<ul><li>Haematogenous pulmonary amoebiasis without liver involvement. </li></ul><ul><li>Haematogenous pulmonary amoebiasis...
<ul><li>PERITONEAL AMOEBIASIS </li></ul><ul><li>PERICARDIAL AMOEBIASIS </li></ul><ul><li>CEREBRAL AMOEBIASIS </li></ul><ul...
FREE LIVING AMOEBAE
PRIMARY AMOEBIC MENINGO ENCEPHALITIS <ul><li>Negleria fowleri  </li></ul><ul><li>Swimming -> 2 – 14 days </li></ul><ul><li...
<ul><li>Acanthamoeba – 5 species  </li></ul><ul><li>MC by A.Castellani, A.Polyphaga </li></ul><ul><li>Local propamide and ...
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  1. 1. AMOEBIASIS Dr.S.Palanivelrajan,M.D (Final Year P.G) Stanley Medical College Chennai
  2. 2. Definition Amoebiasis is an infection with intestinal protozoa Entamoeba Histolytica. 90% of infection – asymptomatic. 10% of infection – Clinical syndrome. Ranging from Dysentery to Abscess of the liver or other organs.
  3. 3. PHYLUM SARCOMASTIGOPHORA SUBPHYLUM SARCODINA SUPER CLASS RHIZOPODA CLASS LOBOSEA SUB CLASS GYMNAMOEBIA ORDER AMOEBIDA SUBORDER TUBULINA “ ENTAMOEBA HISTOLYTICA ”
  4. 4. HISTORY 1875 LOSCH – RUSSIAN. Differentiated the amoebic dysentery from bacillary dysentery by describing amoeba in the stool. 1887 KARTULIS – EGYPT. Found amoeba in the pus from a liver abscess. 1881 COUNCILMAN AND COFFLEUR. Described true bowel lesions and used the term Amoebic Dysentery. 1903 SCHAUDINN. Differentiated pathogenic and non pathogenic types of amoeba.
  5. 5. <ul><li>Third most common cause of death from the parasitic disease. (after schistosomiasis , Malaria) </li></ul><ul><li>480 Million people (world) </li></ul><ul><li>12% of world’s population </li></ul><ul><li>High risk groups </li></ul><ul><li>Travellers, immigrants, immunocompromised individual, pregnant women, sexually active male. Mental institutes, prisons, Children in day care centres. </li></ul><ul><li>Cyst carriers </li></ul><ul><li>Sexual transmission also occurs . </li></ul>EPIDEMIOLOGY
  6. 6. the intestinal lesion Gut Minute crypt lesion Extends through the muscularis mucosa and submucosa. “Flask shaped” ulcer Thrombosis of blood vessels “Toxic megacolon” Irreversible coagulation necrosis of bowel wall . PATHOLOGY
  7. 7. <ul><li>Tumor like lesion </li></ul><ul><li>Several cms in length </li></ul><ul><li>M C in caecum </li></ul><ul><li>Multiple </li></ul><ul><li>Histologically tissue edema </li></ul><ul><li> patchy round cell infiltration </li></ul><ul><li>Types intussusceptions </li></ul><ul><li> stricture like </li></ul>AMOEBOMAS
  8. 8. <ul><li>Asymptomatic infection </li></ul><ul><li>Mild to moderate colitis (non dysenteric colitis) </li></ul><ul><li>Severe colitis (dysenteric colitis) </li></ul><ul><li>Localised ulcerative lesions of the colon </li></ul><ul><li>Localised granulomatous lesion of the colon (amoeboma) </li></ul>CLINICAL FINDINGS INTESTINAL AMOEBIASIS
  9. 9. DD- Amoebic Colitis <ul><li>Infective colitis </li></ul><ul><li>Ulcerative colitis </li></ul><ul><li>Colorrectal carcinoma </li></ul><ul><li>Intestinal schistosomiasis </li></ul><ul><li>Trichuris infection </li></ul><ul><li>Balantidiasis </li></ul><ul><li>Crohn’s disease </li></ul><ul><li>Diverticulosis </li></ul><ul><li>Ileoceacal TB </li></ul>
  10. 10. <ul><li>LABORATORY DIAGNOSIS </li></ul><ul><li>Microscopy And Culture </li></ul><ul><li>Wet Mount Preparation (i) mounts in saline solution (ii) mounts in saline + lodine (iii) mounts in saline + methylene blue </li></ul>Gomori,trichrome, Iron haematoxylin Gomori,trichrome Iron haematoxylin PAF Gomori Haematoxylin and eosin Permanently stained slide Permanently Stained slide Wet mount with enzyme digest Permanently stained slide Routine histology <ul><li>-PVA 10 % formalin </li></ul><ul><li>sodium acetate acetic </li></ul><ul><li>acid formalin </li></ul><ul><li>-PVA, schauddins </li></ul><ul><li>fixative </li></ul><ul><li>None </li></ul><ul><li>PVA, Schauddin’s </li></ul><ul><li>Fixative </li></ul><ul><li>Formalin </li></ul>1. Stool 2. Sigmoid colon 3. Aspirate Direct Fixed 4. Biopsy Stain Examination Fixative 2. Sample
  11. 11. <ul><li>Enzyme Immunoassay </li></ul><ul><li>Indirect Immunoflorescence </li></ul><ul><li>Latex Agglutination </li></ul><ul><li>Gel diffusion </li></ul><ul><li>Sensitivity 60 % invasive Bowel disease 100 % with Amoeboma </li></ul>Immunological Test Indirect Haemagglutination
  12. 12. 500 mg t.i.d × 10 days 25 – 30 mg kg -1 day -1 in 3 doses × 7-10 days. 650 mg t.i.d × 20 days 750 – 800 mg.t.i.d × 10 days 500 mg.t.i.d × 10 days 2 g/day 2 -3 days 500 mg .t.i.d × 10 days 25 – 30 mg kg -1 day -1 in 3 doses × 7 – 10 days 1 st Choice Diloxanide Furoate 2 nd Choice Paramomycin (or) Iodoquinol 1 st Choice Metronidazole followed by diloxanide furoate ( or ) Tinidazole followed by diloxanide furoate 2 nd Choice Paramomycin <ul><li>Asymptomahic </li></ul><ul><li>Intestinal carrier </li></ul><ul><li>Intestinal infection </li></ul>Adult Dosage Drugs of Choice Clinical presentation
  13. 13. PREVENTION Health Education Improved water supply Chlorination – not effective Amoebic cysts Destroyed by 200 parts / 10 6 of Iodine 5 – 10 acetic acid. Heating > 68 0 C Removed by sand filtration Boling for 10 minutes kill the cysts
  14. 14. Amoebic Liver Abscess
  15. 15. <ul><li>This is the most common extra intestinal form of invasive amoebiasis. </li></ul><ul><li>Adults > children ( 10 : 1 ) </li></ul><ul><li>Male > female </li></ul><ul><li>20 % with past history of dysentery </li></ul>
  16. 16. PATHOGENESIS Journey of E. Histolytica to the Liver 1. Direct Extension from the Gut to the Liver 2. Via the Lymphatics 3. Along the portal stream Infarction – Enzymatic Dissolution
  17. 17. Clear 'halo' around an amoeba
  18. 18. Destruction of liver tissue
  19. 19. Congestion of the sinusoids
  20. 20. Pathology
  21. 21. Bulge due to superficial abscess
  22. 22. Shaggy appearance of the walls of the abscesses
  23. 23. Abscess surrounded by a distinct area of severe congestion
  24. 24. Abscess showing a thick fibrous wall
  25. 25. CLINICAL FEATURES Symptoms Pain Diarrhoea and / or Dysentery Weight Loss Cough Dyspnoea Physical findings Localized tenderness Enlarged Liver Fever Rales,rhonchi Localized intercostal tenderness Epigatric Tenderness Jaundice
  26. 26. huge abscess of the inferior surface of the left lobe.
  27. 27. Clinical enlargement of the left lobe of the liver .
  28. 28. Compression Sign
  29. 29. Point tenderness
  30. 30. Intercostal tenderness
  31. 31. Multiple large amoebic abscess seen at autopsy.
  32. 32. COMPLICATONS Right chest Peritoneum Pericardium Amoebic brain abscess - rare Hemobilia – Rupture in to major bileduct Portal hypertension
  33. 33. LABORATORY FINDINGS Normocytic Normochromic anaemia Leucocytosis -> more than 10× * 10 9 / L ESR Stool Cyst or Vegetative form of E . Histolytica LFT Bilirubin Transaminases more than 50 % Alkaline phosphatase more than 75 %
  34. 34. RADIOLOGY <ul><li>CXR – Elevated Right Hemi diaphragm </li></ul><ul><li>Isotope liver scan </li></ul><ul><li>USG Abdomen – B mode , Hypoechoic </li></ul><ul><li>CTScan </li></ul>DD <ul><li>Subphrenic Abscess </li></ul><ul><li>Cholecystitis </li></ul><ul><li>Liver Hydatid cyst </li></ul><ul><li>Primary and Secondary carcinoma of liver </li></ul><ul><li>Lesions of the right lung and right pleura </li></ul>
  35. 35. Anterior view of 133/Rose Bengal dot liver scan showing a small cold area on the inferior surface of the left lobe .
  36. 36. 99m Tc sulphur colloid photo liver scan (anterior view) showing a cold area in the superior surface of the left lobe
  37. 37. X-ray chest showing obliterated costophrenic angle and an elevated right dome of the diaphragm
  38. 38. X-ray chest showing an elevated left dome of the diaphragm
  39. 39. X-ray chest showing a fluid level in a lung abscess in pulmonary amoebiasis .
  40. 40. <ul><ul><li>X-ray chest showing left sided pyopneumothorax </li></ul></ul>
  41. 41. X-ray chest demonstrating the more lateral and vertical spread of an empyema following a liver abscess
  42. 42. CAT SCAN
  43. 43. Peritoneoscopic view of amoebic liver abscess .
  44. 44. TREATMENT 750-800 mg.t.i.d × 10 days 500 mg t.i.d. ×10 Days 2g/day × 3-5 days 500 mg t.i.d × 10 Days 1-1.5 mg kg-1 day -1 ( max.90 mg/day ) i.v × 5 days 500 mg t.i.d × 10 days. Metronidazole followed by diloxanide furoate or tinidazole followed by diloxanide furoate dehyderoemetine followed by diloxanide furoate 1st Choice 2nd choice
  45. 45. Formal Indications To rule out a pyogenic abscess (, particularly with multiple lesions ) As adjunct to medical therapy ( No response after 72 hours ) If rupture is believed to be imminent Abscess in the left lobe where the risk of rupture is increased. Possible Indications To reduce the period of disability INDICATIONS FOR ASPIRATION OF AMOEBIC LIVER ABSCESS
  46. 46. Aspiration of flank abscess .
  47. 47. Color – Anchovy sauce, Chocolate color or pinkish brown, varying color’s Odour – Odourless Consistency – thick , Viscosity – thick lubricating Oil , Quantity – Accroding to the size of the abscess Microscopy – Dead and deformed Hepatocytes RBC’S Few Polymorphs Trphozoites of E.Histolytica present in 10 to 25 % cases Microbiology – Sterile PUS IN AMOEBIC LIVER ABSCESS Hepatoma, livercyst, Hemangimoa DD
  48. 48. A bottle of anchovy sauce and amoebic pus.
  49. 49. Bile aspirated from liver abscess
  50. 50. Different coloured pus obtained during a single session by changing the direction of the needle.
  51. 51. Chocolate coloured pus .
  52. 52. Dirty yellowish pus
  53. 53. Ivory or creamy white pus.
  54. 54. Brown coloured pus compared to anchovy sauce.
  55. 55. Pus resembling color of tea. Tea and anchovy sauce placed on either side for comparision .
  56. 56. Specks of necrotic tissue floating in the pus
  57. 57. Thin yellow pus from a 'chronic' abscess
  58. 58. <ul><li>ALA with Secondary infection </li></ul><ul><li>Left lobe Abscess </li></ul><ul><li>Bowel perforation </li></ul><ul><li>Rupture into pericordium </li></ul>SURGERY
  59. 59. <ul><li>Haematogenous pulmonary amoebiasis without liver involvement. </li></ul><ul><li>Haematogenous pulmonary amoebiasis with independent liver abscess. </li></ul><ul><li>Pulmonary amoebiasis extending from a liver abscess. </li></ul><ul><li>Broncho hepatie fistula with pulmonary involvement. </li></ul><ul><li>Empyema entering from a liver abscess </li></ul>PULMONARY AMOEBIASIS
  60. 60. <ul><li>PERITONEAL AMOEBIASIS </li></ul><ul><li>PERICARDIAL AMOEBIASIS </li></ul><ul><li>CEREBRAL AMOEBIASIS </li></ul><ul><li>GENITO URINARY AMOEBIASIS </li></ul><ul><li>CUTANEOUS AMOEBIASIS </li></ul>
  61. 61. FREE LIVING AMOEBAE
  62. 62. PRIMARY AMOEBIC MENINGO ENCEPHALITIS <ul><li>Negleria fowleri </li></ul><ul><li>Swimming -> 2 – 14 days </li></ul><ul><li>Cribriform plate -> olfactory -> sub arachnoid space </li></ul><ul><li>Like meningitis picture </li></ul><ul><li>200 cases since 1965 , young adults and children </li></ul><ul><li>Amphotericin B 1 mg / kg per day </li></ul>
  63. 63. <ul><li>Acanthamoeba – 5 species </li></ul><ul><li>MC by A.Castellani, A.Polyphaga </li></ul><ul><li>Local propamide and neomycin </li></ul><ul><li>Corneal grafting </li></ul><ul><li>Contact lense users – Avoid raw tap water </li></ul><ul><li>Most appropriate – Chlorhexidine and hydrogen peroxide </li></ul>AMOEBIC KERATITIS <ul><li>Balamuthia mandriallaris </li></ul><ul><li>60 cases since 1990 </li></ul><ul><li>Albendazole and itraconazole </li></ul>AMOEBIC MENINGO ENCEPHALITIS
  64. 64. Thank You
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