Entamoeba histolytica

M E RCI LI E G . EB I O , B S N 1 - J O H N S O N
 Overview of the Disease:
 Entamoeba histolytica is a unicellular, protozoan parasite of humans. It
moves by a jelly-like tongue-like protrusion of the cytoplasm
“pseudopodium.” 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.
 It exists in two forms, the trophozoite which is the active, dividing
form, and the cyst which is dormant and can survive for prolonged
periods outside the host.
 Causative Agent:
Amoebiasis is a disease
caused by a one-celled
parasite called Entamoeba
histolytica.
MORPHOLOGIC Characteristics of the Causative Agent:

Entamoeba histolytica exists in 3 morphological forms:

•Trophozoite
•Pre-cyst
•Cyst – uninucleate, binucleate, and quadrinucleate
  It
is also called the feeding stage or free-moving
Trophozoite stage.
 It is the invasive form of the parasite that lives in
the mucosa and sub-mucosa of the large
intestine.
It is variable in shape because of the amoeboid
structure.
 It consists of a distinct nucleus with nuclear
striations radiating out from the centrally located
endosome.
 It shows movement with the help of
pseudopodia.
 It feeds by phagocytosis or pinocytosis and uses
the food vacuole for intracellular digestion.
 Food vacuole contains RBCs being digested.
Pre-cystic  It is the intermediate stage
Stage between trophozoite and cyst.
 It is formed in the lumen of the
large intestine.
It is smaller than the trophozoite
stage and has blunt pseudopodia.
 No RBCs in the endoplasm because
food vacuole is thrust out.
 Smaller in size (10-20μm in diameter)
  Itmay be uninucleate, binucleate, and
Cystic Stage quadrinucleate.
It is the infective stage that is non-feeding and
found in the intestinal lumen.
It becomes round and develops a retractile cyst
wall that is resistant to digestion by enzymes.
It contains glycogen mass and chromatoidal bars
b as storage of food and ribosomes respectively.
It becomes quadrinucleated on maturity and
becomes infective.
 Size – a. small – 6-9μm
b. large – 12-15μm
Life Cycle: Amebiasis
Cysts are passed in feces. Infection by Entamoeba histolytica occurs by ingestion of mature cysts in
fecally contaminated food, water, or hands.  Excystation occurs in the small intestine and trophozoites are
released, which migrate to the large intestine.  The trophozoites multiply by binary fission and produce
cysts, which are passed in the feces.  Because of the protection conferred by their walls, the cysts can
survive days to weeks in the external environment and are responsible for transmission.  (Trophozoites can
also be passed in diarrheal stools, but are rapidly destroyed once outside the body, and if ingested would
not survive exposure to the gastric environment.)  In many cases, the trophozoites remain confined to the
intestinal lumen (: noninvasive infection) of individuals who are asymptomatic carriers, passing cysts in
their stool.  In some patients the trophozoites invade the intestinal mucosa (: intestinal disease), or, through
the bloodstream, extraintestinal sites such as the liver, brain, and lungs (: extraintestinal disease), with
resultant pathologic manifestations.  It has been established that the invasive and noninvasive forms
represent two separate species, respectively E. histolytica and E. dispar, however not all persons infected
with E. histolytica will have invasive disease.  These two species are morphologically indistinguishable. 
Transmission can also occur through fecal exposure during sexual contact (in which case not only cysts,
but also trophozoites could prove infective).
Source of Infection:
 Puts anything into their mouth that has touched the feces (poop) of a
person who is infected with E. histolytica
 Swallows something, such as water or food, that is contaminated
with E. histolytica
 Swallows E. histolytica cysts (eggs) picked up from contaminated
surfaces or fingers.
Mode of Transmission and Portal of Entry:

Transmission can occur through the fecal-oral route (ingestion of food

and water, contaminated with feces containing E. histolytica cysts)
 Eating uncooked vegetables and fruits which have been fertilized with
infected human feces has often led to the occurrence of disease.
 Oral-anal sexual contact with a chronically ill or asymptomatic carrier.

Portal of Entry: Mouth/Ingestion (via the gastrointestinal tract)

Infective Stage ( to man ):
 Cystic stage (Quadrinucleate cyst)

Intermediate Host(s):
 It has no intermediate host or animal reservoir.

Definitive/Final Host:
 Human
Pathogenesis:
 Entamoeba histolytica is an invasive enteric protozoan. Infection typically
begins with the ingestion of mature quadrinucleated cysts found in fecally
contaminated food or water. Excystation occurs in the small intestine with the
release of motile trophozoites, which migrate to the large intestine. Through
binary fission, trophozoites form new cysts, and both stages are shed in feces,
but only cysts have the potential to transmit disease due to the protection
conferred by their wall. Cysts can survive days to weeks in the external
environment, while trophozoites are rapidly destroyed once outside the body
or by gastric secretions if ingested.
Pathogenesis:
 Diagnosis: ( Clinical or Laboratory or both )
It is divided into two parts. One is a diagnosis of intestinal amoebiasis whereas another
diagnosis of extra intestinal amoebiasis.

Lab Diagnosis  of Intestinal Amoebiasis:

Specimen: fresh stool, colonoscopic biopsy, or scraping from the margin of the lesion
Macroscopic examination of stool
Microscopic examination culture – done in an asymptomatic case
Antigen detection
Antibody detection
PCR
Microscopic Examination:

Method: wet mount preparation with Normal saline and iodine

permanent stain- trichrome stain, iron, and hematoxylin stain
Stool leukocytes may be found but in fewer numbers than in shigellosis
trophozoites that contain ingested red blood cells (RBCs) – is diagnostic of E. histolytica infection
Examination of a single stool sample has a sensitivity of only 33-50%; however, examination of 3 stool samples over no more
than 10 days can improve the detection rate to 85-95%.

Diagnosis of Extraintestinal Amoebiasis:

 Demonstration of trophozoite in aspirate taken from a different site

 Blood examination

 Antibody detection

Molecular test- PCR, DNA probe

Intradermal test

Radiological examination- chest X-ray, USG, CT scan, MRI

 Blood tests
Control and Prevention:
 Use of boiled drinking water
 Protection of food and drink from flies, cockroaches, and rats
 Not eating raw vegetables and fruits
 Personal cleanliness and elementary hygiene
 Effective sanitary disposal of feces
 Protection of water supplies from fecal contamination
 Avoidance the use of human excrement as fertilizer
 Detection and isolation of carriers
Treatment:
 There are a number of effective medications. Several antibiotics are
available to treat Entamoeba histolytica. The infected individual will be
treated with only one antibiotic if the E. histolytica infection has not
made the person sick, and will most likely be prescribed two antibiotics
if the person has been feeling sick. Otherwise, below are other options
for treatments.
Metronidazole for the invasive trophozoites PLUS a luminal amoebicide
for those still in the intestine.
 Paromomycin (Humatin) is the luminal drug of choice since Diloxanide
furoate (Furamide) is not commercially available in the USA or Canada
(being available only from the Centers for Disease Control and Prevention).
A direct comparison of efficacy showed that Paromomycin had a higher
cure rate.
 Paromomycin (Humatin) should be used with caution in patients with
colitis, as it is both nephrotoxic and ototoxic. Absorption through the
damaged wall of the intestinal tract can result in permanent hearing loss
and kidney damage.
Recommended Dosage:
Metronidazole 750 mg three times a day orally, for 5 to 10 days FOLLOWED BY
Paromomycin 30 mg/kg/day orally in 3 equal doses for 5 to 10 days or
Diloxanide furoate 500 mg 3 times a day orally for 10 days, to eradicate luminal
amoebae and prevent relapse.