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Extra Intestinal Amoebaisis PowerPoint Presentation

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Description : Overview of amoebaisis, extra intestinal amoebaisis. Considering the risk factors, pathogenesis, diagnostic approach as well as treatment and prevention.

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Published on : Feb 25, 2023 | Views : 1960 | Downloads : 1

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Extra Intestinal Amoebiasis BY ORJI CHIBUEZE FAVOUR DISCUSSANT: SCIENTIST OCHE MAGARETH COORDINATOR: SCIENTIST AKINSOLA PEACE DATE: NOVEMBER, 2022. 1
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OUTLINE Introduction Epidemiology Life cycle of Entamoeba histolytica Pathogenesis Clinical Manifestations Risk Factors Laboratory Diagnosis Treatment Prevention and Control Conclusion Recommendations 2
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INTRODUCTION Amoebiasis: Infection of the intestine by Entamoeba histolytica. Entamoeba histolytica: A protozoan parasite belonging to the genus Entamoeba. Extraintestinal amoebiasis: Amoebiasis that affects organs aside the intestines 3 (Shamsuzzaman & Hashiguchi, 2017)
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EPIDEMIOLOGY Entamoeba histolytica was discovered in 1875 by Losch It has a worldwide prevalence 500 million cases of symptomatic disease, and 40.000-110.000 deaths annually. Amoebiasis is the 3rd leading parasitic cause of death worldwide It is much more common in the tropics than elsewhere, but it has been found wherever sanitation is poor Other industrialised countries including parts of Asia, Europe, North America and Australia have highlighted gay men, bisexual men and other men who have anal sex as a population at higher risk of acquiring amoebiasis than the general population. Amoebic liver abscess (and other extraintestinal disease) is 7 to 10 times more common among adult males than other demographic groups 4 (Knobloch & Mannweiler, 2018)
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EPIDEMIOLOGY CONT’D The epidemiology of E. histolytica infections in Nigeria hence remains unknown because non-molecular methods are still being used in investigations, with prevalence figures ranging from 35.4% to 72%, typically around 40% as estimated by one of the earliest studies some 25 years ago. (Knobloch & Mannweiler, 2018) In FMC Abuja, we have recorded 102 infective cases of Entamoeba histolytica. The data revealed highest occurrence of Ascaris lumbricoides followed by entamoeba histolytica. With a data dated from 04/08/2020 till 05/11/2022. 5
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LIFE CYCLE 6 (Centre for Disease Control [CDC], 2021)
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PATHOGENESIS Ingestion of mature quadrinucleated cyst. Excystation and release of trophozoites. Adherence of trophozoites to the colonic epithelium. Lysis of colonic epithelium by the trophozoites. Trophozoites spreads to distant organs such as the liver, lungs, brain, and other organs through the portal veins. 7 (Anesi & Glukman, 2015)
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8 PATHOGENESIS as described by Modern Clinical microbiology
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CLINICAL MANIFESTATION 9 Asymptomatic Non invasive Symptomatic Invasive Pleuropulmonary abscess Brain abscess Necrotic lesions on Pertianal skin & Genitalia Liver abscess Amoebic colitis Dysentery Peritonitis Perforations Amebic granulomas (ameboma) (Dhawan & Malik, 2015)
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ORGANS AFFECTED IN EXTRA INTESTINAL AMOEBIASIS Liver Lungs Brain Heart Kidney Epithelial Tissues 10 Incubation period for E. histolytica infection is commonly 2-4weeks but may range from a few days to years
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RISK FACTORS It is highly endemic throughout poor and socio-economically deprived communities in the tropics and subtropics. Environmental, socio-economic, demographic, and hygiene-related behavior is known to influence the transmission and distribution of intestinal parasitic infections through; Faecal-oral route i.e Exposure to infected individuals Drinking contaminated or untreated water Vectors such as flies, cockroaches and rodents. Age (elderly or young children) Immunosuppression (example; use of corticosteroids or active malignancy) Individuals with recent sexual history of unprotected anal or oral-anal contact 11 (Lozano et al., 2019)
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Laboratory Diagnosis Stool test: Microscopy smear of fresh stool can show trophozoites of entamoeba. (within 1hr.) Fresh fecal preparation using formol-ether or PVA concentration. Microscopic examination of fecal material from the concentrated specimens by; saline wet mount to detect protozoan trophozoites, and cysts and to reveal the presence of RBCs and WBCs. Iodine wet mount stain glycogen and nuclei of the cysts. Trichrome stain permanent staining can as well be used for cyst and trophozoite identification 12 (Centre for Disease Control [CDC], 2021)
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Laboratory Diagnosis Limitations Concentration method may not be useful for demonstrating trophozoite Microscopy has a low sensitivity if only one stool sample is analysed; Requires personel trained in morphological diagnosis collection and analysis of three consecutive stool samples within ten days improves chances of detection. Also, E. dispar, E. histolytica and E. moshkovskii are not distinguishable based on morphology. 13 (Centre for Disease Control [CDC], 2021)
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14 CYST TROPHOZOITE E. histolytica and E. dispar are morphologically identical having; (Centre for Disease Control [CDC], 2021)
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Trophozoites can also be identified in aspirates or biopsy samples obtained during colonoscopy or surgery. If samples are obtained from the various sites as suspected, they can be stained using various stains such as, trichrome stain, Haematoxylin and eosin stain etc. 15
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IMMUNODIAGNOSIS – Serodiagnosis. Indirect haemagglutination assay (IHA) Enzyme immunoassay (EIA); kits for E.histolytica antibody kits for E.histolytica antigen detection are commercially available 16 Limitations Highly endemic areas are likely to have prior exposure and seroconversion. But is useful on patients in areas with low endemicity. Antigen detection during active infections may be useful as an adjunct to microscopic diagnosis in detecting parasites and distinguish between pathogenic from non pathogenic infections (Centre for Disease Control [CDC], 2021)
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IHA has been replaced by commercially available EIA test kit for routine serodiagnosis of amebiasis. EIA test detects antibody specific for E. histolytica in approximately 95% of patients with extraintestinal amebiasis 70% of patients with active intestinal infection 10% of asymptomatic persons who are passing cyst of E. histolytica . 17 IF, Antibodies are not detected in patient with active or suspected amebic liver abscess, A second specimen should be drawn 7-10days later. If the second specimen doesn’t show seroconversion , other agents should be considered. Detectable E. histolytica- specific antibodies may persist for years after successful treatment, so the presence of antibody doesn’t necessary indicate acute or current infection., (Centre for Disease Control [CDC], 2021)
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Recent studies indicate improve sensitivity and specificity of fecal antigen assays with the use of monoclonal antibodies which can distinguish between E. histolytica and E. dispar infections. Several kits are available which detect E. histolytica antigen in stool but do not exclude E. dispar infection. Commercial kit is available which detects only pathogenic E. histolytica infection in stool. 18 (Centre for Disease Control [CDC], 2021)
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Molecular Polymerase Chain Reaction (PCR); It is the method of choice for detection and differentiation of pathogenic E. histolytica from nonpathogenic E. dispar. Radiography, Ultrasonography, Computer tomography(CT) and Magnetic resonance imaging (MRI) can be used for detection of liver abscess, cerebral amoebiasis. Rectosigmoidoscopy and colonoscopy can provide diagtnostic information in intestinal amoebiasis 19 (Centre for Disease Control [CDC], 2021)
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IMAGE GALLERY of cyst of E. histolytica/ E. dispar 20 A B C D Cyst of E. histolytica/ E. dispar in unstained concentrated wet mount of stool. Cyst of E. histolytica/ E. dispar in iodine stained concentrated wet mount of stool. Cyst of E. histolytica/ E. dispar stained with trichrome. Cyst of E. histolytica/ E. dispar in trichrome stained concentrated wet mount of stool. Chromatoid bodies Chromatoid bodies Chromatoid bodies Chromatoid body Trinucleated Immature cyst of E. histolytica. Specimen was preserved by PVA and stained with trichrome. PCR done to differentiate. DPDx CDC, 2019 [online]
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21 Trophozoite of E. histolytica /E.dispar in direct wet mount stained with iodine E Trophozoite of E. histolytica /E.dispar in direct wet mount stained with trichrome F Single nucleus Single nucleus Trophozoite of E. histolytica. Specimen preserved in PVA, stained with trichrome. PCR done to differentiate. Trophozoite of E. histolytica with ingested erythrocytes. Stained with trichrome Trophozoite of E. histolytica with ingested erythrocytes. Stained with trichrome. ingested erythrocytes appear as dark inclussions. DPDx CDC, 2019 [online]
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22 IMAGE GALLERY Numerous Trophozoites of E. histolytica in a Rectal biopsy, Stained with H&E. Arrows indicate examples of trophozoites with Visible nuclei Trophozoite of E. histolytica with ingested erythrocytes(arrows). Under differential interference contrast(DIC). Microscopy. DPDx CDC, 2019 [online]
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TREATMENT Metronidazole, most preferred drug of choice Tinidazole Diloxanide furoate 23 (Lozano et al., 2019)
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PREVENTION AND CONTROL Eradicating faecal contamination of food and water through improved sanitation Proper hygiene practices Water treatment Detection and treatment of carriers and their exclusion from food handling occupations to limit the spread of infection. Improved water supply Food safety 24 (Anesi & Glukman, 2015)
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CONCLUSION Amoebiasis is a parasitic infection caused by the ingestion of the matured cysts of Entamoeba histolytica. Extraintestinal amoebiasis occurs as a result of the migration of the trophozoites of E. histolytica through the portal veins to other organs of the body such as the liver, lungs, brain and others. Proper hygiene and sanitation measures should be taken to prevent infections. Suspected cases should be rushed down to the hospital for proper medical check up. Metronidazole remains the best drug for treatment. 25
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RECOMMENDATION I recommend that; Fresh stool sample should be analyzed within 1hr of collection for detection of active trophozoites. Stool sample collection for E. histolytica and other parasitic cyst identification should be carried out consecutively for 7-10 days, to be able to capture all incidences. Additional staining techniques be carried out in microbiology for parasite identification. The use of commercially available test kit for the confirmation of E. histolytica after a suspected microscopy examination be practiced in FMC Jabi. faecal examination using ELISA technique for the identification of the pathogenic species of E. histolytica from non pathogenic E. dispar and E. moshkovskii in FMC Jabi. Other body samples should be investigated in cases of extra intestinal amoebiasis e.g sputum, liver abcess, renal, brain etc. using HLA in FMC Jabi. 26
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Community surveys should monitor the local epidemiological situation with regards to extraintestinal amoebiasis. Improvement of case management, for instance, rapid diagnosis and adequate treatment of patients with invasive amoebiasis at all levels of the health services, in FMC Jabi and including the community and health centre levels. Surveillance and control of situations that may encourage the further spread of amoebiasis, example, refugee camps, contaminated public water sources. Health education 27 RECOMMENDATION CONT’D
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REFERENCE Ali, I.K.M., 2015. Intestinal amebae. Clinics in Laboratory Medicine, 35 (2), pp.393-422. Heredia, R.D., Fonseca, J.A. and López, M.C., 2012. Entamoeba moshkovskii perspectives of a new agent to be considered in the diagnosis of amebiasis. Acta Tropica, 123 (3), pp.139-145. Leo, M., Haque, R., Kabir, M., Roy, S., Lahlou, R.M., Mondal, D., Tannich, E. And Petri, W.A., 2006. Evaluation of Entamoeba histolytica antigen and antibody point-of-care tests for the rapid diagnosis of amebiasis. Journal of clinical microbiology, 44(12), pp.4569-4571 Morán, P., Rojas, L., Cerritos, R., Zermeno, V., Valadez, A., de Oca, G.M., Reyes, M.A., González, E., Partida, O., Hernández, E. And Nieves, M., 2013. Cutaneous Amebiasis: the importance of molecular diagnosis of an emerging parasitic disease. The American Journal of Tropical Medicine and Hygiene, 88 (1), pp.186-190. 28
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REFERENCE Acuna-Soto, R., Maguire, H., & Wirth, F. (2000). Gender distribution in asymptomatic and invasive amebiasis. American Journal of Gastroenterology, 95(4), 1277- 1283. Anesi, A., & Gluckman, S. (2015). Amoebic liver abscess. Clinical Liver Disease, 6(2), 41-43. Cameron, J. (2018). The treatment of pleuropulmonary amebiasis with metronidazole. Chest, 73(5), 647-650. Haque, R., Huston, D., Hughes, M., Houpt, E., & Petri, A. (2003). Amebiasis. The New England Journal of Medicine, 348(16), 1565–1573. Hung, C., Ji, D., Sun Y., Lee T., Hsu, Y., Chang, Y., … Colebunders, R. (2008). Increased risk for Entamoeba histolytica infection and invasive amebiasis in HIV seropositive men who have sex with men in Taiwan. Public Library of Science Neglected Tropical Diseases, 2(2), 175. Kantor, M., Abrantes, A., Estevez, A., Schiller, A., Torrent., Gascon, Ochner, C. (2018). Entamoeba histolytica: Updates in clinical manifestation, pathogenesis and vaccine development. Canadian Journal of Gastroenterology, 2018(6), 460-465. Katzenstein, D., Rickerson, V., & Braude, A. (2012). New concepts of amebic liver abscess derived from hepatic imaging, serodiagnosis, and hepatic enzymes in 67 consecutive cases in San Diego. Medicine (Baltimore), 61(7), 237-246. Knobloch, J., & Mannweiler, E. (2018). Development and persistence of antibodies to Entamoeba histolytica in patients with amebic liver abscess: Analysis of 216 cases. American Journal of Tropical Medicine and Hygiene, 32(2), 727-732. Lozano, R., Naghavi, M., Foreman, K., Lim, S., Shibuya, K., Aboyans, V., … Murray, L. (2012). Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: A systematic analysis for the Global Burden of Disease Study 2010. Lancet, 380 (9859), 2095-2128. Lyche, D., & Jensen, A. (2017). Pleuropulmonary amebiasis. Seminars in Respiratory Infections, 12(2),106-112. 29
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30 THANK YOU FOR LISTENING