1.

Brie y discuss what happened in the case

a. Setting — the setting is primarily within the Urology Department of Mexico's General Hospital SSa in Mexico City, D.F. The patients
presented with symptoms related to genital ulcerative lesions following sexual intercourse. The medical care provided involved a
thorough physical examination, diagnostic testing including serological assays, microscopy, and molecular characterization to
identify the causative agent.
b. Pro le — the authors discuss cutaneous amebiasis, a rare form of human amebiasis characterized by Entamoeba histolytica
infection of previously damaged skin. The case described by Nasse in 1892 involved a patient with an amoebic liver abscess, which
led to extensive ulceration and necrosis of abdominal skin, subcutaneous tissue, and muscles after drainage. This represents one of
the earliest documented cases of cutaneous amebiasis.

2. What is the etiologic agent & disease identi ed?

− Etiologic agent identi ed in both cases is Entamoeba histolytica
− Disease identi ed is cutaneous amebiasis

3. What are the signs and symptoms?

PATIENT 1 PATIENT 2

• Preputial and penile edema • Edema of the scrotum and penis

• Areas of induration • Painful ulcer in the scrotal area
• Constant pain • Ulcerated area with an erythematous base and
• Urethral blood discharge irregular borders in the genital region
• Blood clots in the urine • Large necrotic areas covered by brinous and
• Painful and progressively growing ulcer purulent discharge
with an erythematous base and irregular • Looseness of the skin exposing the testes and
borders in the genital region (trunk, penis urethra
shaft, distal portion of the glans, scrotum, and • Inability to urinate due to the severity of the
pubis) ulcerative lesion
• Necrotic appearance of the ulcer covered
by broid material
• Deformation of the penis resembling a
circumcised penis
• Abscess in the suprapubic area draining
purulent material
• Loss of skin involving the entire penis
4. How was it acquired?
o P1 acquired cutaneous amebiasis following sexual intercourse with a male partner, leading to infection of the genital region.
o P2 similarly contracted the infection after sexual intercourse with a female partner, resulting in the development of genital ulcers and
necrosis.

5. What are the laboratory test(s) performed? (Emphasize on serologic tests)

a. Microscopic detection of Entamoeba trophozoites
b. Genotyping of Entamoeba species
c. Molecular Characterization of Entamoeba Species
d. Enzyme-Linked Immunosorbent Assay (ELISA)
e. PCR

LAB TEST P1 P2

Enzyme-Linked Positive for anti-amoebic antibodies Negative for anti-amoebic antibodies

Immunosorbent Assay
(ELISA)

Microscopic Presence of Entamoeba trophozoites observed Presence of Entamoeba trophozoites

Examination of Biopsy observed
Specimens

Molecular Entamoeba histolytica detected Entamoeba histolytica detected

Characterization of
Entamoeba Species
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 PCR E. histolytica and E. dispar detected E. histolytica detected

Genotyping of E. histolytica HM:IMSS genotype E. histolytica HM:IMSS genotype

Entamoeba Species
E. dispar detected (distinct genotype) E. dispar not detected
compared to the reference strain E. dispar
SAW760

6. Describe the importance of these test(s)

a. Microscopic Examination of Biopsy Specimens
o allows for direct visualization of Entamoeba trophozoites in biopsy samples obtained from the lesions.
o Identifying trophozoites in biopsy specimens provides de nitive evidence of amebic involvement in the skin lesions,
guiding appropriate treatment strategies.
b. Molecular Characterization of Entamoeba Species (PCR)
o PCR ampli es speci c DNA sequences of the pathogen, providing sensitive detection and identi cation of Entamoeba
species, including E. histolytica and E. dispar.
o PCR serves as a highly sensitive diagnostic tool, particularly in cases where trophozoites may be scarce or dif cult to
identify microscopically. Detection of Entamoeba DNA in the lesions con rms the presence of the parasite, facilitating
targeted treatment.
c. Genotyping of Entamoeba Species
o Genotyping allows for further characterization of the detected Entamoeba species, determining their genetic variants or
strains.
o Understanding the genetic diversity of Entamoeba species provides insights into their epidemiology, pathogenesis, and
potential drug resistance patterns. It can also help in tracking the sources and routes of transmission of the infection.
d. Enzyme-Linked Immunosorbent Assay (ELISA)
o ELISA was used to detect anti-amoebic antibodies present in serum, indicating exposure to pathogen.
o This was crucial on P1 as P1 tested positive for the speci c antibody.
o However, P2 result was negative on ELISA despite presenting symptoms suggestive of cutaneous amebiasis
▪ This discrepancy in serologic test results between the two patients could indicate variations in their immune
responses to the Entamoeba infection.
▪ Sero tests are valuable diagnostic tools, but their sensitivity and speci city can vary depending on factors such
as the stage of infection, the patient's immune status, and the presence of cross-reactivity with other pathogens.

PATIENT 1 PATIENT 2

• Age: 38-year-old male • Age: 66-year-old male

• Education level: Secondary school • Education level: Primary school
• Risk factors: Chronic smoking and alcoholism • Disease onset: After sexual intercourse with a female partner
• Disease onset: After sexual intercourse with a male partner • Symptoms:
• Symptoms: o Edema of scrotum and penis
o Preputial and penile edema o Painful ulcer in scrotal area
o Induration o Progressively growing ulcerative lesion making urination
o Constant pain dif cult
o Urethral blood discharge • Initial treatment: Surgical debridement, suprapubic drainage of bladder
o Blood clots in urine • Lesion characteristics:
• Initial treatment: Intravenous antibiotics (levo oxacin, ceftriaxone, o Large ulcerated area with erythematous base and irregular
clindamycin) borders
• Lesion characteristics: o Necrotic areas covered by brinous and purulent discharge
o Localized dermatosis affecting the trunk, genital region, o Exposed testes and urethra due to skin looseness
scrotum, and pubis • Diagnostic ndings:
o Painful, progressively growing ulcer with erythematous base o Negative serum anti-amoebic antibodies by ELISA
and irregular borders o Microscopic detection of Entamoeba histolytica in biopsy
o Necrotic appearance, covered by broid material, producing specimen
discharge o Positive PCR for Entamoeba species from purulent material
o Deformation of the penis • Treatment: Metronidazole, ceftriaxone, clindamycin
• Diagnostic ndings: • Clinical outcome: Satisfactory evolution, awaiting reconstructive surgery
o Positive serum anti-amoebic antibodies by ELISA
o Microscopic detection of Entamoeba histolytica/E. dispar in
biopsy specimen
o Positive PCR for Entamoeba species from purulent material
• Treatment: Metronidazole, ceftriaxone
• Clinical outcome: Healing of abscesses, severe skin loss requiring
reconstructive surgery
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