Amoebae

• Amoebae are unicellular organisms common in the

environment
• Many are parasitic in vertebrates and invertebrates
• The following species of amoeba are found in/on
humans:
1. Entamoeba histolytica
2. Entamoeba dispar
3. Entamoeba coli
4. Entamoeba hartmanni
5. Entamoeba gingivalis
6. Endolimax nana
7. Iodamoeba buetsschlii
8. Dientamoeba fragillis
 Worldwide incidence
• Has cosmopolitan distribution but more commonly in the
tropics and subtropics

• World prevalence is about 0.2-50%

• Estimated that 10% of world’s population may be infected

• 50 million cases of invasive amoebiasis/year

• 100 000 deaths/year

 Entamoeba histolytica
(tissue destroying)
• No animal reservoir is known

• Facultative pathogens

• Most people clear the infection spontaneously in

6-12 months with mild or no symptoms

• Can cause serious invasive diseases such as

ulcers on the skin and abscesses in the liver,
lungs, spleen and the brain
 Morphology
• E. histolytica exists in 2 forms

– Trophozoite stage

– Cyst stage
 Trophozoite
• This is the actively motile feeding stage
• The organism is oval at the anterior end and
pointed at the posterior end
• They are amoeboid in shape and are constantly
changing
• Has 1 nucleus in the cytoplasm and has chromatin
dot
• Ingested red blood cells may be found in the
cytoplasm of the trophozoite
– indicating the amoebic trophozoites are pathogenic
• Trophozoites form directional pseudopodia
(false feet) and move in one direction in fresh
warm specimen

• The amoebic trophozoites remain actively

motile as long as the environment is favourable,
and the cyst forms when the environmental
temperature or moisture drops

• Trophozoites live in the mucosa and

submucosa of the human large intestine
 Cyst
• The cyst is the dormant, resistant and the
infective stage

• It is round or oval, measuring 10-15 µm

• The immature cyst has 1 or 2 nuclei and

chromatoid bars in the cytoplasm

• The mature cyst has a cyst wall and 4 nuclei.

The nuclei stain brown with iodine preparation
 Life cycle
• The life cycle of amoebae does not involve intermediate
hosts or non-human reservoirs

• After ingestion of the cyst in contaminated food or water,

the cyst passes through the stomach where exposure to
gastric acid in the stomach stimulates the release of the
pathogenic trophozoites in the duodenum

• The trophozoites are carried to the colon where they

mature and reproduce by binary fission

• The trophozoites may lead a commensal life in the crypt

of the colon mucosa

• They may also cause ulceration of the large intestine

• Under desiccation in the colonic region,
the trophozoites encyst and passed out in
the feces

• The cyst is the infective stage and can

survive for several weeks in the
environment
Life cycle of
Entamoeba histolytica
• Successful colonization depends on a
number of factors including

– the size of inoculum ingested

– intestinal motility
– presence of specific intestinal flora
– the host's diet
 Pathogenicity/Clinical
manifestations
• Most people infected with E. histolytica
remains asymptomatic
– However a few people develop clinical
symptoms

• E. histolytica has 3 forms of clinical

manifestation:
– 1. Intestinal
– 2. Extraintestinal
– 3. Cutaneous
 1. Intestinal amoebiasis
• Most people infected with E. histolytica remains
asymptomatic carriers

• However, a few people develop intestinal

amoebiasis

• Only the cyst stage is infectious

• The trophozoite stage dies out readily once passed

out of the body

• The trophozoite will be killed by stomach acids if

ingested
• Clinical presentation of the intestinal infections
depends on degree of ulceration and mucosal
damage

• When ulcerations are small and infrequent,

symptoms may be absent.

• As the involved area of mucosa increases in

size, primary diarrhea with cramping pain occurs
• In the intestine, the trophozoites of the virulent
E.h. are capable of penetrating intact intestinal
mucosa
– by releasing an enzyme that lyses the tissues, hence
their name histolytica (tissue-histo and dissolving-
lysis)

– The histolytic enzyme allows the amoebae to

penetrate into the intestinal mucosa, where
subsurface lesions develop

– These lesions may coalesce into extensive ulcerative

areas, thus leading to severe dysentery with stools
containing bloody mucus
Ulceration Caused by
Entamoeba histolytica
 Symptoms
– Abdominal pains
– Cramping
– Colitis with diarrhea may occur

• In advanced stage
– Numerous bloody stools may be passed in a day
– Vomiting, weakness, and dehydration may also occur

• The stool is usually fowl smelling or fishy

smelling with blood, and/or pus and mucus

• Mortality is high if not treated

2. Extra-intestinal amoebiasis
• In a small percentage of cases, the pathogenic
amoeba or the trophozoite can enter the
bloodstream and be disseminated to various
internal organs

• In such cases, abscesses usually occur in

– the liver
– heart
– brain
– lungs
– or any other organ
 Amoebic pulmonary abscess
• Symptoms
– Fever
– Cough
– Dyspnea (short of breath)
– Pain
• Sudden pain
– Like peptic ulcer (ruptured abscess)
– Vomiting
 3. Cutaneous amoebiasis
• Amoebiasis of the skin occurs when damaged skin
comes in contact with amoeboid trophozoites eg.
– when amoebic liver abscess drains through the
skin as a result of
• spontaneous rupture of the liver abscess
• or through surgical drainage of amoebic liver
abscess
• If not treated, perianal ulcers may occur

• Urogenital ulcers could also occur

– The vagina and the labia could be infected

– Men then become infected with penile

amebiasis after experiencing unprotected sex
with a woman who has vaginal amebiasis

– The penis could be affected, especially

among homosexuals during anal intercourse
 Diagnosis
Intestinal
• Stool examination
– Cysts and trophozoites
• Sigmoidoscopy for mucosal scrapings
– Direct wet mount and iron haematoxylin staining to
demonstrate trophozoites

• Sigmoidoscopy
– Lesions, aspirates, biopsy
• Serodiagnosis
– Serological test is positive only in invasive amoebiasis
• Molecular diagnosis
 Diagnosis
Extraintestinal diagnosis
Microscopic examination
– Demonstration of trophozoites in pus aspirated from
the wall of liver abscess.
• Molecular diagnosis
– PCR of pus aspirated from ALA
• Serodiagnosis
– helpful in diagnosing disseminated amebiasis
•Imaging (ultrasound, X-rays)
– Look for a pleural effusion, and elevation of the right dome of his
diaphragm (80%).
•Abscess aspiration
– Only selected cases
 Microscopy-stool
• Specific diagnosis is made by observing the
trophozoite or cyst of amoeba in the feces
– Take about 1gm of the stool
– emulsified with physiological saline
– put a drop on a slide
– add 1 drop of iodine solution
– cover with coverslip and
– examine under X10
– trophozites are seen with movement and ingested
RBCs
 Prevention and control
• E. histolytica occurs mainly in the tropics and subtropics
where sanitation is very poor

• Human infection results from

– The ingestion of the cyst through hand-to-mouth contamination
and food and water contaminated with human excreta
– E. histolytica may be transferred through unprotected sex
– Flies and cockroaches may also serve as vectors by depositing
infective cysts on unprotected food
– Improper treatment of water supplies is another source of
possible infection
Control methods include
• Avoid fecal-oral route
– Good personal hygiene must be observed
– Proper disposal of human excreta
– Eating of cold food such as salad should be
avoided in endemic areas
– Where there is no potable water, the water
should be filtered or boiled
– Adequate sanitation such as construction of
KVIP and provision of good drinking water
must be pursued by public health authorities
 Non-pathogenic amoebae
1. Entamoeba coli
2. Entamoeba hartmanni
3. Entamoeba gingivalis
4. Endolimax nana
5. Iodamoeba buetsschlii
6. Dientamoeba fragillis

– All these are non-pathogenic

– Their presence is an indication of contamination
with fecal matter
 Treatment

• Nitromidazole derivatives are the drugs of

choice for the treatment of amoebic colitis-
effective against the trophozoite form
• Metronidazole
– (750–800 mg 3 times daily for 5–10 days),
tinidazole and ornidazole act on both sites
CILIATES
 Ciliate protozoan
• Balantidium coli, is the only ciliate in this group
• It is the largest intestinal pathogen of man
• It causes the disease called balantidiasis
• Common in areas where pigs are reared as
scavengers
• Pigs are the reservoir host
– but it affects monkeys, and man
• It is very common in areas where personal and
group hygiene are poor, eg. mental homes,
prisons, etc.
 Morphology
• The organism exists in 2 forms:
– Trophozoite stage
– Cyst stage
 Trophozoite
• The trophozoites are
– Broadly rounded at the posterior end and conical shaped at the
anterior end
– It is about 50-200µm
– At one end of the organism there is a funnel-like structure called
peristome

• Has 2 nuclei:
– a big one shaped like the kidney called macronucleus
– and a smaller one called micronucleus which is close to the
bigger one

• The organism is covered with numerous cilia

• It has food and contractile vacuoles

 Cyst
• The cysts are round (40-60µm in diameter)
• Has a cyst wall
• Has macro- and micronucleus
• Has no food vacuole
 Life cycle
• Human acquires the infection by ingestion of
food or water contaminated with mature cyst

• The cysts are released upon digestion

• Excystation occurs in the small intestine

• The trophozoites invade the mucosal lining of

the large intestine, cecum and terminal ileum

• The actively motile trophozoites undergo

asexual reproduction to produce more
trophozoites.
• The trophozoites use the cilia for motility

• When conditions become unfavourable, the trophozoites

empty their food vacuoles and secrete a cyst wall around
them to become cysts

• The cysts are then passed out in the feces into the
environment

• The cysts may survive several weeks in the environment

and will continue the cycle when ingested through
contaminated food or water
 Clinical manifestations
• Asymptomatic condition can occur

• Symptomatic disease includes:

– Abdominal pain
– tenesmus (inability or difficulty to empty the bowel at
defecation)
– Nausea
– Watery stools with blood and pus
– Ulceration of the intestinal mucosa can occur

• The symptoms are like those of amoebiasis

except
– the lack of extra-intestinal invasion of other organs.
 Laboratory diagnosis
• Microscopic examination of feces for trophozoites
and cysts

• Trophozoites are usually seen in bloody mucoid

diarrhea and cysts are found in formed stool

• A loop full of specimen including the bloody

mucoid stool is taken
– emulsified with saline
– transferred onto the slide
– a drop of iodine is added
– cover with cover slip.
– Examine under X10 and confirm with X40 magnification
 Control and prevention
• Similar to those of amoebiasis.
– Good personal hygiene must be observed
– Proper sanitary disposal of human excreta
– Eating of cold food such as salad should be avoided
in endemic areas.
– Where there is no potable water, bottled water should
be taken, or the water should be filtered or boiled.
– Adequate sanitation such as construction of KVIP and
provision of good drinking water must be pursue by
public health authorities
– Avoid eating unwashed fruits and cold salad

• Pigs should be excluded from human

environment.
 Treatment
• Medications normally used are;
– Tetracycline
– Metronidazole
– Iodoquinol