AMEBIASIS

Et. There are 3 common species of Entamoeba which are morphologically

identical but genetically distinct; E. histolytica, the pathogenic one; E.
dispar, the non-pathogenic but more prevalent one that only associated
with asymptomatic carrier state; & Entamoeba moshkovskii, that can
cause diarrhea in infants. In addition, there are 5 other non-pathogenic
species of Entamoeba that are much less common.
Epid. It is the third leading parasitic cause of death worldwide. It infects
up to 10% of the world's population.
Path. Transmission occurs through feco-oral route via food & water
contamination by parasite cysts which can resist many environmental
factors except heating. After ingestion of cysts, they excysts in the small
intestine to form 8 trophozoites which then colonize & invade lumen of
the colon.
Trophozoites can cause destruction of colonic mucosal cells by 2
mechanisms; cytolysis & apoptosis → significant inflammation & flask-
shaped ulcers; as well as they can kill PMN cells.
C.M. It ranges from asymptomatic infection to amebic colitis, amebic
dysentery, ameboma, and extraintestinal disease. Severe disease is
common in malnourished infants and young children & individuals who
take corticosteroids.
Asymptomatic infection represent ≈90% of cases which should be
treated because it may become symptomatic.
Amebic colitis usually present as gradual colicky abdominal pain with
frequent bowel motions that frequently associated with tenesmus, the
stools contain blood & mucus. Generalized constitutional symptoms are
characteristically absent.
Amebic dysentery is associated with sudden onset of fever, chills, and
severe bloody diarrhea which may result in dehydration.
 Amebic liver abscess is a serious extraintestinal Cx of amebiasis but
fortunately it is uncommon in children (<1%); it may appear without a
clear hx of intestinal disease. It is commonly present as fever, abdominal
pain & distention with tender hepatomegaly, there may be changes at
base of the right lung demonstrated by CXR e.g. elevation of the
diaphragm, atelectasis, or effusion.
Cx.
Amebic colitis may result in necrotizing colitis, toxic megacolon, extra-
intestinal extension, local perforation and peritonitis, or ameboma which
is a nodular focus of proliferative inflammation in the colonic wall
develop after chronic amebiasis.
Amebic liver abscess may rupture into the peritoneum, pleural cavity,
or skin.
Extraintestinal dissemination is rare other than the liver but may
include: brain, lungs, kidneys, & skin.

D.Dx.
Amebic colitis & Amebic dysentery may mimic other causes of
dysentery (see D.Dx. of Shigellosis).
Amebic liver abscess may mimic bacterial abscess, hydatid cysts, or
hepatoma.
Inv.
Tests for amebic colitis:-
GSE may show few pus cells & RBC, but Entamoeba may not be found.
Tests to ↑ the sensitivity of detection of Entamoeba as well as to
differentiate between E. histolytica & E. dispar include:-
3 fresh stool samples for microscopy can reveal phagocytosed
erythrocytes in case of E. histolytica which not present with E. dispar.
 ELISA is available for detection of E. histolytica antigens in stool.
PCR.
Serology; Indirect Hemagglutination can detect antiamebic antibodies
in the blood.
Endoscopy with biopsies is only indicated when there is a high suspicion
of amebiasis but negative stool sample.
Tests for amebic liver abscess:-
GSE may be +ve for Entamoeba in only half of patients.
CBP; WBC ↑,ESR ↑,Hb ↓.
LFT; ↑ liver enzymes levels.
Imaging studies e.g. US, CT, or MRI.
Rx.
Invasive amebiasis e.g. colitis or liver abscess should be treated initially
by Metronidazole 35–50 mg/kg ÷ 3 for 7–10 days or Tinidazole
(preferred) 50 mg/kg once for 3 days in colitis & up to 5 days in liver
abscess. - 478 -
Then therapy should be followed by agents active in the gut lumen e.g.
Paromomycin (preferred) 25–35 mg/kg ÷ 3 or Diloxanide furoate (for
children >2 yr) 20 mg/kg ÷ 3 for 1 wk (all drugs are given orally).
Paromomycin or Diloxanide furoate can also be used for Rx of
asymptomatic infection.
Broad-spectrum antibiotics may also be indicated in fulminant colitis.
Image-guided aspiration may be indicated for amebic liver abscess if it
is large or there is poor response to therapy. Chloroquine can be used as
an adjunct Rx in amebic liver abscess.
Intestinal perforation and toxic megacolon are indications for surgery.
The stool exam should be repeated every 2 wk until the result is negative
after completion of antiamebic therapy to confirm cure.
Pg. Death occurs in ≈ 5% of patients with extraintestinal infection,
especially in those who take corticosteroids.
Pv. Proper sanitary measures & regular exam of food handlers-

GIARDIASIS
Epid. Giardia lamblia occurs worldwide; it is the most common intestinal
parasite. Transmission is mainly by contaminated water & less by foods
or animals.
Giardiasis is more common in persons with malnutrition, cystic fibrosis, &
certain immunodeficiencies e.g. hypogammaglobulinemia & IgA
deficiency.
Path. G. lamblia is a flagellated protozoan. Cysts can resist many
environmental factors except heating. After ingestion they excyst to
trophozoites which colonize the lumen of the duodenum and proximal
jejunum.
C.M. The I.P. is 1-2 wk or longer; manifestations are range from
asymptomatic carrier to acute or chronic diarrhea & malabsorption.
Asymptomatic carrier is the most common and highly prevalent among
young children. Most symptomatic patients have a limited period of
acute diarrhea +/_ low-grade fever, nausea, and anorexia, whereas
others may have features of malabsorption e.g. intermittent or
protracted diarrhea (which may alternate with periods of constipation),
abdominal distention and cramps, bloating, malaise, flatulence, nausea,
anorexia, and weight loss or FTT.
The stools initially may be profuse and watery but later become greasy
and foul smelling; it is characteristically contains no blood, mucus or pus
cells (because G. lamblia is not an invasive parasite).
Inv.
 GSE shows no pus cells or RBC; cysts or trophozoites of Giardia may be
seen.
CBP is normal (including eocinophil count) because Giardia do not
invade the intestine.
Radiographic contrast studies of the small intestine may show
nonspecific signs of malabsorption.
Tests to ↑ the sensitivity of detection for Giardia when there is high
suspicion but negative stool sample include:-
Microscopic exam of 3 stool samples.
Endoscopy with aspiration or biopsy of duodenum or upper jejunum.
Entero-Test is an alternate method for obtaining duodenal fluid (without
endoscopy).
Enzyme immunoassay (EIA) or direct fluorescent antibody tests for
Giardia antigens in the stool.
PCR.
Rx.
Recommended drugs are; Tinidazole (for children >3 yr) 50 mg/kg once
or Nitazoxanide 100-200 mg ÷ 2 for 3 days or Metronidazole 15 mg/kg ÷
3 for 5–7 days.
Alternative drugs are; Albendazole (for children >6 yr) 400 mg once for
5 days or Quinacrine 6 mg/kg ÷ 3 for 5 days.
Refractory cases have been treated with Nitazoxanide, prolonged
courses of Tinidazole, or combination of Metronidazole and Quinacrine.
Pv. Improve sanitation including boiling or filtration of water (pore size of
<1 mm is effective in cyst removal). Breast feeding also appear protective
against Giardia lamblia.