Amebiasis.

Baba, bayi laki2, 20 bln

Acute (<2wk) dysentry-form diarrhea* :

CC : - Bacterial
Bloody and mucus-laden diarrhea* for 10 days, 6-8x/day  Salmonella  no constipation ×
Fever for 5 days  Shigella  the diarrhea watery and large volume
Others : initially then evolving into frequent, bloody diarrhea.×
abdominal pain  EHEC  usually no fever ×
Tenesmus  Yersinia
History : - Parasitic
Youngest of 4 children  E. Histolytica
Family with low socioeconomic status Abdominal pain + tenesmus : hallmark of dysentry-form diarrhea
Live in crowded condition and poor sanitation

PE :
General : alert,* thirsty,* eager to drink,* 2nd degree of malnutrition
Vital sign :
- BP 90/60  hypotension
- PR 100/min  tachycardia
- RR 30/min  mild-moderate dehydration *)
- T 38  febrila 2nd degree of malnutrition
Head : shunken eyes*, dry mouth*, tear still present* Mild amebic colitis
Conjunctiva : not anemic
Abdomen : skin turgor return to normal slowly*, peristaltic slightly
increase, abominal tenderness localized in lower part abdomen

Lab : Treatment :
Hb 12 g/dl  N?? 3rd day of hospitalization :
- Metronidazole 10 mg/kg/bw PO
Ht 36%  N?? Clinical worsening with sign of peritonitis and
tid
WBC 12.800  leukocytosis toxic megacolon
- Rehydration plan B
Pt 250.000  N - Nutritional support
Fresh stool exam : bloody stool+mucus+fully bad odor D: fulminant amebic colitis with peritonitis
Microscopic exam : fecal leukocytes, erythrocyte abundant
- With normal saline  trophozoite E.histolytica with RBC
ingestion
- With lugol : cyst E.histolytica with nuclei Metronidazole IV for 10 days
Etiology : Entamoeba Histolytica 1. Trophozoite  colonize the lumen of large intestine
Surgery
AMEBIASIS and may invade its mucosal lining.
Supportive treatment
- Mempunyai 2 bentuk :  Bergerak aktif
Definition : adalah infeksi parasit yang disebabkan oleh
 Ø : 10-60µ
Entamoeba Histolytica
  Dapat ditemukan di lumen usus (intraintestinal)
dan luar usus (ekstraintestinal)
 Mengandung beberapa eritrosit di dalamnya
2. Kista  infective form
 Oval/bulat asimetris
 Dinding halus
 Ø : 10-20µ
 Kista muda : berinti 1 dan mengandung
gelembung glikogen dan batang kromatoid
Kista dewasa : berinti 4 dan hanya terbentuk &
dijumpai di lumen usus.
- Siklus Hidup :
Kista dan trophozoite akan keluar bersama feses (kista
biasanya ditemukan pada feses padat, sedangkan
trophozite pada feses yang cair)
 
Kista yang matang termakan oleh manusia
 necrosis of colon
Di usus kecil, kista akan mengalami ekskistasi (dinding
kista hilang dan mengeluarkan amuba dlm stadium
metakista berinti 4, kemudian membelah menjadi 8
trophozoit muda
 imbalance
Parasit terbawa ke usus besar
Trophozoite berkoloni dan Membentuk kista
menginvasi usus besar
Epidemiology
 10% dari populasi dunia terinfeksi oleh spesies
Entamoeba
 Amebiasis terjadi pada 50 juta org tiap tahunnya
dengan kematian mencapai 100.000
 Insidensi amebiasis tinggi pada negara berkembang
 Faktor-faktor yang berpengaruh pada transmisi :
edukasi yang rendah, kemiskinan, populasi penduduk
yang terlalu padat, sumber air yang terkontaminasi.
Manifestasi Klinis
1. Infeksi asimptomatik
2. Intestinal Amebiasis
 Acute amebic colitis
 May occur within 2 wks of infection or be
delayed for months
 Onset is gradual with colicky abdominal pain
and frequent bowel movements (6-8x/day)
 Tenesmus (associated with rectosigmoid
involvement)
 Bloody and mucoid stools with few
leukocytes
 Fever
 Abdominal tenderness may be localized
anywhere in lower abdomen, but usually
over cecum, transverse colon, or sigmoid.
Fulminant colitis
 Is the result of confluent ulceration and
 Bowel is dilated, particularly in transverse
portion
 Patient is extremely febrile and toxic, and
shows signs of hypovolemia and electrolyte
 Ameboma
 A nodular focus of proliferative
inflammation.
 As a result of repeated invasion of the colon
by E.histolytica, complicated by pyogenic
infection.
3. Hepatic Amebiasis (Amoebic Liver Abscess)
 Fever (hallmark in children)
 Abdominal pain, distention, enlargement,
and tenderness of the liver
 Elevation of diaphragm and atelectasis, or
effusion
 Lab findings : slight leukocytosis, moderate
anemia, high ESR, and non-specific elevation
of hepatic enzyme
Diagnosis
1. Stools
- Diagnosis is based on detecting the organisms in
stool samples, sigmoidoscopically obtained
smears, tissue biopsy sample.
- Fresh stools samples should be examined within
30min for detection of trophozoite containing
erythrocyte in saline solution definitive!
2. Serologis
3. Sigmoidoscopy
- Examined for trophozoite in biopsy taken from the
edge of ulcers.
4. Liver aspirate
5. Non-invasive imaging of liver
6. Lab exam
- In mild cases lab test are normal
- May find Leukocytosis
- Anemia is common, esp. In chronic disease.
Differential Diagnosis
 Bacterial diarrhea caused by Campylobacter
 Enteroinvasive E.coli, Shigella, Salmonella, Vibrio
Treatment
- Prinsip managementnya :
 Metronidazole
 DOC for symptomatic invasive disease.
 Dosage : 30-50 mg/kg/day PO/IV divided
in 3 doses for 7-10 days
 Paromomycin
 DOC for non-invasive disease
 Use to cure luminal infection
 Supportive
 Fluid replacement (with plan B for mild-
moderate dehydration)
 Dietetic treatment (for malnutrition)
 Health education
- Class of drugs uses to treat amebiasis
1. Luminal amebicides
 Use to treat asymptomatic or mild
intestinal forms of amebiasis, after
systemic or mixed amebicide to
eradicate infection.
 Contoh :diloxanide furoate, iodoquinol,
and paromomycin
 2. Systemic amebicides
 Against invasive amebiasis
3. Mixed amebicides
 Use for both systemic and intestinal
forms
 Contoh : metronidazole
- Pharmacological properties of Metronidazole
 MOA : nitro group of metronidazole is
chemically reduced in anaerobic bacteria
and sensitive protozoans. The reactive
reduction products is responsible for
microbial activity.
 Clinical uses :
 Amebiasis
DOC for all tissue infection of
E.histolytica. But not effective
against extraluminal parasite
 Giardiasis
 Trichomoniasis
 SE
 Common : Nausea, headache, dry
mouth, or metalic taste
 Infrequent : vomit, diarrhea,
insomnia, weakness, dizziness,
thrush, rash, dysuria, dark urine,
vertigo.
 Should be used with caution in
patients with CNS disease.
- Rehydration plan B :
ORS 700-900 mL in 4 hours + extra fluuid + zinc
Complication
 Bowel perforation
 GI bleeding
 Stricture formation (ameboma)
 Fistula formation
 Intussusceptiopn
 Amebic liver abscess
 Empyema
 Brain Abscess
 Pericarditis
Prevention
- Improved sanitation and clean water supply
- Eating only cooked food or self-peeled fruits in
endemic areas. Avoid eating raw fruits and salads.
- Early treatment in carriers.
Prognosis
- Intestinal infection are respond well to appropriate
therapy. Severity increased in :
 Children, esp. Neonates
 Pregnant and postpartum women
 Those using corticosteroid
 Those with malignancies
 Malnourished individuals
- Mortality rate in pts with uncomplicated amebic liver
abscess <1%
TOXIC MEGACOLON
- clinical term for an acute toxic colitis with dilatation
of the colon
- hallmarks : nonobstructive colonic dilatation larger
than 6 cm and signs of systemic toxicity.
- Criteria :
1. radiographic evidence of colonic dilatation.
2. One of : fever (>101.5°F), tachycardia (>120
beats/min), leukocytosis (>10.5 103/µL), or
anemia
3. One of : dehydration, altered mental status,
electrolyte abnormality, or hypotension.
- icroscopic hallmark of toxic megacolon (toxic colitis)
is inflammation extending beyond the mucosa into
the smooth-muscle layers and serosa.
- nitric oxide appears to be involved in the
pathogenesis of toxic megacolon (toxic colitis).