2020

PARASITOLOGY
Entamoeba Histolytica

introduction ‫علي خالد حلو‬

Morphological features ‫عال حسين علي‬

LIFE CYCLE ‫علي حسين عودة‬

Epidemiology ‫عادل قيس عادل‬

pathogenesis ‫علي حبيب عبد‬

Clinical findings ‫طيبة فالح محمد‬

Laboratory Diagnosis ‫علي حبيب رحيم‬

TREATMENT ‫علي حسن هادي‬

Prevention and Control ‫عباس حيدر نجم‬

SUPERVISED BY DR.HUSSEIN
WRITTEN BY ALI HUSSEIN
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INTRODUCTION
Entamoeba histolytica is an anaerobic parasitic protozoan that infects the digestive tract
of predominantly humans and other primates. It is a parasite that infects an estimated 50
million people around the world and is a significant cause of morbidity and mortality in
developing countries. Infection with E. histolytica may be the cause of a variety of
symptoms, beginning from no symptoms to severe fulminating intestinal and/or life-
threatening extraintestinal disease. Transmission of the parasite occurs when a person
ingests food/water that has been contaminated with infected feces.

Morphological features
(a) Trophozoites Viable trophozoites vary in size from about 10-60μm in diameter.
Motility is rapid, progressive, and unidirectional, through pseudopods. The nucleus is
characterized by evenly arranged chromatin on the nuclear membrane and the presence of
a small, compact, centrally located karyosome. The cytoplasm is usually described as
finely granular with few ingested bacteria or debris in vacuoles. In the case of dysentery,
however, RBCs may be visible in the cytoplasm, and this feature is diagnostic for
E.histolytica.

(b) Cyst

Cysts range in size from 10-20μm. The immature cyst has inclusions namely; glycogen
mass and chromatoidal bars. As the cyst matures, the glycogen completely disappears;
the chromotiodials may also be absent in the mature cyst.

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LIFE CYCLE
Cysts and trophozoites are passed in feces . Cysts are typically found in formed stool,
whereas trophozoites are typically found in diarrheal stool. Infection with Entamoeba
histolytica (and E.dispar) occurs via ingestion of mature cysts from fecally contaminated
food, water, or hands. Exposure to infectious cysts and trophozoites in fecal matter during
sexual contact may also occur.
Excystation occur in the small intestine
and trophozoites are released, which
migrate to the large intestine.
Trophozoites may remain confined to the
intestinal lumen (A: noninvasive
infection) with individuals continuing to
pass cysts in their stool (asymptomatic
carriers). Trophozoites can invade the
intestinal mucosa (B: intestinal disease),
or blood vessels, reaching extraintestinal
sites such as the liver, brain, and lungs
(C: extraintestinal disease). Trophozoites
multiply by binary fission and produce
cysts , and both stages are passed in the
feces . Cysts can survive days to weeks in
the external environment and remain
infectious in the environment due to the
protection conferred by their walls.
Trophozoites passed in the stool are
rapidly destroyed once outside the body,
and if ingested would not survive
exposure to the gastric environment.

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Epidemiology
E.histolytica has a worldwide distribution. Although it is found in cold areas, the
incidence is highest in tropical and subtropical regions that have poor sanitation and
contaminated water. About 90% of infections are asymptomatic, and the remaining
produces a spectrum of clinical syndrome. Patients infected with E.hisolytica pass
noninfectious trophozotes and infectious cysts in their stools. Therefore, the main source
of water and food contamination is the symptomatic carrier who passes cysts.
Symptomatic amebiasis is usually sporadic. The epidemic form is a result of direct
person-to-person faecal-oral spread under conditions of poor personal hygiene.

pathogenesis
Entamoeba histolytica causes intestinal and extraintestinal amoebiasis. The trophozoite
penetrates the epithelial cells in the colon, aided by its movement and histolysin, a tissue
lytic enzyme, which damages the mucosal epithelium. Sometimes, the invasion remains
superficial and heals spontaneously. The ulcers are multiple and are confined to the
colon. The amoebic ulcer is flask shaped in cross-section. Multiple ulcers may coalesce
to form large necrotic lesions with ragged and undermined edges and are covered with
brownish slough. The ulcers generally do not extend deeper than submucosal layer.
Amoebae are seen at the periphery of the lesions and extending into the surrounding
healthy tissues. A granulomatous pseudotumoral growth may develop on the intestinal
wall from a chronic ulcer. This amoebic granuloma or amoeboma may be mistaken for a
malignant tumor. Liver involvement is the most common extraintestinal complication of
intestinal amoebiasis. About 5–10% of patients with intestinal amoebiasis will develop
amoebic liver abscess (ALA). ALA arises from haematogenous spread of amoebic
trophozoites from colonic mucosa or by direct extension. Often, ALA patients do not
present with bowel symptoms. Liver damage may not be directly caused by the amoebae.
The center of the abscess contains thick brown pus (anchovy sauce). The trophozoite is in
the wall of the abscess. Liver abscess may be multiple or more often solitary, usually
located in the upper right lobe of the liver. Jaundice develops only when lesions are
multiple or when they press on the biliary tract. Large, untreated abscess may rupture into
the lungs and pericardium. The incidence of liver abscess is more common in adult
males.

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Clinical findings
Individuals who are infected with E.histolyica can either remain asymptomatic or present
clinically with dysentery or extraintestinal disease.

Asymptomatic :

Roughly 90% of those infected have asymptomatic infections, but they may be carriers,
whose feces contain cysts that can be transmitted to others.

Sypmtomatic :

1-Intestinal amebiasis:

-Acute intestinal amebiasis is presents as dysentery (i.e., bloody, mucus-containing

diarrhea) accompanied by lower abdominal discomfort, flatulence, and tenesmus.

-Chronic amebiasis with low-grade symptoms such as occasional diarrhea, weight loss,
and fatigue also occurs.

In some patients, a granulomatous lesion called an ameboma may form in the cecal or
rectosigmoid areas of the colon. These lesions can resemble an adenocarcinoma of the
colon and must be distinguished from them.

2-Amebic abscess of the liver

is characterized by rightupper-quadrant pain, weight loss, fever, and a tender, enlarged

liver. Right-lobe abscesses can penetrate the diaphragm and cause lung disease. Most
cases of amebic liver abscess occur in patients who have not had overt intestinal
amebiasis. Aspiration of the liver abscess yields brownishyellow pus with the consistency
of anchovy-paste.

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Laboratory Diagnosis
Diagnosis of intestinal amebiasis:

Stool microscopy

Depends on finding either trophozoites in diarrheal stools or

cysts in formed stools. Diarrheal stools should be examined
within 1 hour of collection to see the ameboid motility of the
trophozoite. Trophozoites characteristically contain “ingested
red blood cells, finger like psuedopodia,one nucleus,visible fine
chromatin granule”, while cyst contains “Chromatoid
bars,spherical to round shape,mature cyst with four nuclei”
Mature cysts of E. histolytica are smaller than those of
Entamoeba coli, but E. coli cysts have eight nuclei.

..A complete examination for cysts includes a wet mount in

saline to demonstrate motility of the trophozoites,while iodine
mount clearly demonstrates the internal structures of the cyst,
and a fixed, trichrome-stained preparation, each of which brings
out different aspects of cyst morphology.

Note:sometime,there is both cyst and trophozoite in stool sample to indecate sever

intestinal amebiasis

Molecular diagnosis:

multiplex polymerase chain reaction (PCR) is available targeting small subunit ribosomal
ribonucleic acid (rRNA) genes of E.histolytica .

diagnosis of lnvasive amebasis(liver abscess):

�Microscopy of liver pus can detect trophozoite,liver pus (100% sensitive when tested
before treatment).

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�Molecular diagnosis PCR done on amoebic liver pus approaches sensitivity of 100%
and specifi city of 90–100%.

�Serologic tests, such as IFA, ELISA, for specific antibodies to E. histolytica are very
helpful in diagnosis of invasive amebiasis.

Serologic testing is useful for The indirect hemagglutination test is usually positive in
patients with invasive disease but is frequently negative in asymptomatic individuals who
are passing cysts.

About half of the patients with extraintestinal amebiasis have negative stool examinations

�USG is a accessible, non-invasive imaging modality available at most state hospitals.

Ultrasonography enables the treating clinician to determine the size, site, and type of
abscess present.

TREATMENT
1- For symptomatic intestinal infection and extraintestinal disease,

treatment with: metronidazole Children: 15 mg/kg 3 times daily for 5 days

Adults: 500 mg 3 times daily for 5 days

or tinidazole

Children: 50 mg/kg once daily for 3 days (max. 2 g daily)

Adults: 2 g once daily for 3 days

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should be followed by treatment with iodoquinol or paromomycin.

2- Asymptomatic patients infected with E. histolytica should also be treated with:

iodoquinol or paromomycin, because they can infect others and because 4%–10%
develop disease within a year if left untreated.

3- Oral rehydration salts (ORS) if there is risk of, or if there are signs of dehydration

Note :

In case of amoebic dysentery

• The presence of cysts alone should not lead to the treatment of amoebiasis.

• Amoebiasis confirmed with a parasitological stool examination

– Amoebic liver abscess

Tinidazole PO: same treatment for 5 days

Metronidazole PO: same treatment for 5 to 10 days

Prevention and Control

Introduction of adequate sanitation measures and education about the routes of
transmission. Avoid eating raw vegetables grown by sewerage irrigation and night soil.
Prevention involves avoiding fecal contamination of food and water and observing good
personal hygiene such as handwashing..Purification of municipal water supplies is
usually effective, but outbreaks of amebiasis in city dwellers still occur when
contamination is heavy.The use of “night soil” (human feces) for fertilization of crops
should be prohibited. In areas of endemic infection, vegetables should be cooked.
Avoidance of the ingestion of food and water contaminated with human feces ..Treatment
of asymptomatic persons who pass E.histolytica cysts in the stool may help to reduce
opportunities for disease transmission.Vaccination Till now, there is no effective vaccine

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licensed for human use. However, colonization bloc- king vaccines are under trial
targeting three E. histolytica specific antigens such as: SREHP 170 kDa subunit of lectin
antigen and 29kDa cysteine rich protein..Travelers to endemic areas should
decontaminate drinking water by boiling or filtering it (e.g., with Katadyn filters), not eat
salads,eat only fruit they have peeled themselves and exercise caution when itcomes to
changing their diet. Chemoprophylactic dugs are not available.

References

-medical parasitology.

-CDC

-Levenson mocrobiology.

-Apurba Snakar Sastry parasitology.

-Medical microbiology.