Amebic liver abscess and human immunodeficiency virus infection: a report of three cases.

Invasive amebiasis rarely occurs in homosexual men and human immunodeficiency virus (HIV)-infected individuals and has not been regarded as a beacon for concomitant HIV infection. We encountered a bisexual man with a protracted course of amebic liver abscess and amebic colitis. In the presence of fever, generalized lymphadenopathy, and elevated serum aminotransferase levels, HIV infection was suspected and then confirmed by a de novo seroconversion of HIV antibody. Subsequently, we noted two consecutive patients with amebic liver abscess, also later found to be infected with HIV. The ameba obtained from these three cases was identified as Entamoeba histolytica by amplification of 16S ribosomal RNA by polymerase chain reaction and direct sequencing. This observation suggests that amebic liver abscess and colitis can be presentations for HIV infection in the Far East. Thus, the local patients with invasive amebiasis, especially those with a protracted course or with risk factors of HIV infection, should be tested for HIV.     

Amebic Liver Abscess: A Study of 11 Cases Compared with a Series of 38 Patients with Pyogenic Liver Abscess

Amebic liver abscess is an uncommon disease in the northern states of North America with 11 cases seen among approximately 500,000 Mount Sinai Hospital admissions over a 16-year period. Five of 11 cases originated in, or had recently visited South America. In three of these, and two patients with concomitant intestinal amebiasis, the diagnosis was suspected on admission. Diagnosis after admission was rapid, mean 5 days, compared with a mean of 13 days in pyogenic liver abscess. There was a higher incidence of male patients, nine males versus two females which was greater than the excess found in our pyogenic abscesses, 22 versus 16. Multiplicity was less common than in pyogenic abscess, 27 versus 50%, respectively. All three patients with multiple abscesses survived with surgical drainage and antibiotic therapy despite numerous complicating factors, including secondary bacterial infection. One patient resolved with drug treatment only; all others were treated with drugs and concomitant drainage; surgical drainage in earlier cases, and percutaneous drainage more recently. There was a single postoperative death. Drug treatment is the first therapeutic modality, and if recovery is delayed more than 2 days percutaneous aspiration should be carried out. This was successful in four cases. Surgery should seldom be required with present methods of accurately localizing amebic liver abscess, but is essential for ruptured abscess with peritonitis, and liver abscess with associated intestinal problems such as toxic megacolon, colonic perforation, or fulminating colitis. There has been a significant reduction in mortality of amebic liver abscess over the past 50 years and particularly within the past decade.(ABSTRACT TRUNCATED AT 250 WORDS)     

Use of an enzyme-linked immunosorbent assay to detect anti-adherence protein antibodies in sera of patients with invasive amebiasis in Cairo, Egypt.

We used enzyme-linked immunosorbent assay (ELISA) to detect IgG antibodies to the Entamoeba histolytica galactose-inhibitable adherence protein in the sera of 50 uninfected controls, 50 cases with asymptomatic cyst passage, 100 patients with amebic colitis, and six patients with amebic liver abscess from Cairo, Egypt, and in 50 healthy controls from the United States. When the mean + 3 SD value above that of the controls from the United States was used as a criterion for a positive ELISA result, 100% of those with invasive amebiasis, 80% of those with asymptomatic infection, and 64% of the Egyptian controls had anti-adherence protein antibodies. However, when the mean + 2 SD value of Egyptian control sera (optical density = 0.094) was used as the criterion for positivity, 33 (89%) of 37 sera from individuals with invasive amebiasis having symptoms for at least one week were antibody positive, in contrast to only 12% of asymptomatic cyst passers (P < 0.01). In a highly endemic area such as Cairo, Egypt, detection of serum anti-adherence protein antibodies by ELISA may have greatest diagnostic use in patients with symptomatic invasive amebiasis of greater than one week duration.     

Amebic colitis masquerading as acute inflammatory bowel disease: the role of serology in its diagnosis

Amebic colitis needs to be considered in the differential diagnosis of infectious colitis or inflammatory bowel disease (IBD). Misdiagnosing amebic colitis as idiopathic inflammatory disease may be fatal. Although stool studies remain the initial approach to diagnosis, the incidence of false-negatives associated with this method is high. We report two cases of amebic colitis presenting as inflammatory bowel disease in which the diagnosis of amebic colitis was made by serology. Neither patient had any risk factors for acquiring amebiasis. Paired serology for amebic infections (2-4 weeks apart) should be performed in patients being evaluated for infectious colitis and inflammatory bowel disease.     

Correlation of positive syphilis serology with invasive amebiasis in Japan

Approximately 20% of 52 Japanese males with invasive amebiasis confirmed by gel diffusion precipitin test (GDP) were positive by both Treponema pallidum hemagglutination test (TPHA) and nontreponemal antigen tests, and an additional 20% were positive by TPHA alone. However, none of 109 GDP-negative Japanese males without invasive amebiasis were positive on these serologic tests for syphilis. At least 2 bisexuals and 4 homosexuals were among those with invasive amebiasis. All of these biased males were positive on both TPHA and nontreponemal antigen tests. Four of the biased males had liver abscess and 2 had amebic dysentery or colitis. Bisexual or homosexual males were not found in the negative GDP group. These observations suggest that sexually transmitted amebiasis due to Entamoeba histolytica occurs among sexually biased males in Japan.     

Prevalence and Importance of Amebic Infestation in Patients with Ulcerative Colitis in Two Regions in Turkey

We investigated the prevalence of amebiasis in patients with ulcerative colitis residing in two geographical regions with different socioeconomic status and climatic conditions, and its effect on the age of onset, duration, localization, and activity of disease. Ninety patients from a high socioeconomic location (group I) and 28 cases from a low socioeconomic location (group II) were enrolled. Median age at disease onset was significantly higher in group I compared with in group II. Prevalence of amebiasis in group I was significantly lower than in group II. A considerably number of patients with amebiasis in group I had a history of travel to the cities with a lower socioeconomic level, mainly located in the east of Turkey. There was a strong relationship between presence of amebiasis and history of travel to eastern parts of Turkey among residents from the northwestern part of Turkey. Median age and age at time of diagnosis were significantly lower in patients with amebiasis compared with those without infection. In patients with mild disease activity, prevalence of amebiasis was significantly lower compared with those with moderate or severe disease activity. In conclusion, prevalence of amebiasis was markedly higher in the southeast compared to the northwest of Turkey. Travel to regions with low socioeconomic status may be considered a risk factor for amebiasis in patients with ulcerative colitis. Amebiasis enhances disease activity in ulcerative colitis.     

溃疡性结肠炎合并阿米巴肠病临床特点探讨

目的 探讨溃疡性结肠炎合并阿米巴肠病的临床特点.方法 回顾性分析2003～2010年共104例溃疡性结肠炎患者诊治资料,其中15例确诊合并阿米巴肠病(A组),单纯性溃疡性结肠炎患者89例(B组),统计各患者的腹泻次数、贫血程度、低白蛋白血症程度及结肠病变范围.结果 A、B组患者中腹泻＞6次/d者分别为13例、40例,血红蛋白＜90 g/L患者分别为8例、16例,血清蛋白＜30 g/L患者分别为10例、23例,结肠病变范围超过1/2的患者分别为12例、31例,两组存在统计学差异;15例溃疡性结肠炎合并阿米巴肠病患者中7例为先确诊溃疡性结肠炎,后获得阿米巴感染并致病,其余8例患者无法判断两种疾病的发病先后顺序.所统计病例中溃疡性结肠炎并发阿米巴肠病发病率为14.4％(15/104),高于阿米巴肠病在普通人群中发病率(同地区平均为0.44％,最高2.43％).结论 溃疡性结肠炎合并阿米巴肠病病情较单纯性溃疡性结肠炎患者严重;溃疡性结肠炎患者较普通人群更容易获得溶组织内阿米巴感染并致病.     

Psoas Abscess in Inflammatory Bowel Disease

The inflammatory bowel disease (IBD) is sometimes complicated by the development of a psoas abscess. We recently encountered three patients of IBD with psoas abscess. Two patients had Crohn's ileocolitis and one with ulcerative colitis. During 1979-1984, 23 patients with psoas abscess due to a variety of underlying disease processes were seen at our institution. At the same time period, 483 cases of Crohn's disease and 283 cases of ulcerative colitis were encountered. Therefore, of 766 patients with IBD only three were complicated by psoas abscess (incidence ratio = 0.6%). Thus, psoas abscess was a very rare complication of IBD in patients seen at our institution. In our series of 23 psoas abscess patients, IBD was not a major causative factor. Additionally, to our knowledge, psoas abscess complicating ulcerative colitis has not been reported previously.     

Epidemiologic and clinical features of invasive amebiasis in Bangladesh: a case-control comparison with other diarrheal diseases and postmortem findings

To describe the epidemiologic and clinical features associated with invasive amebiasis in Bangladesh, 85 hospitalized diarrheal patients with hematophagous trophozoites of Entamoeba histolytica in their stools were compared to a control group of 84 hospitalized diarrheal patients without amebiasis. Postmortem examinations were carried out in 22 deaths due to amebiasis. For the patients with amebiasis, there was a bimodal age distribution with peaks at 2-3 years and greater than 40 years, whereas the control patients had a unimodal distribution with the peak at 0-1 year. The sex distribution was equal in childhood but young adults were predominantly female and older adults predominantly male. The clinical features significantly associated with amebiasis were prolonged dysentery, prior measles rash, malnutrition, hyponatremia, hypokalemia, and hypoproteinemia (all P less than 0.05). The case fatality rate in amebiasis was 29%, which was significantly higher than 11% for the controls (P less than 0.05). Postmortem findings included extensive colitis with deep ulcers and complications, including colonic perforation in 2 cases, peritonitis in 4 cases, pneumonia in 9 cases, and septicemia in 5 cases. These results indicate that invasive amebiasis in this population differs from other diarrheal diseases, affecting mainly children greater than 2 years and adults and causing severe and fatal illness characterized by extensive colitis with diverse systemic consequences.     

Analysis of 69 patients with amebic liver abscess

All 69 patients with amebic liver abscess that we treated in 1981–1992 were studied retrospectively. Men predominated by a 101 ratio. Of our 227 patients with amebiasis, some 30% yearly had liver involvement. The incidence peaked in 1988, decreasing later but increasing again in 1992. Most patients were 30–50 years old, the overall mean age being 45 years (range, 22–79), and decreasing with time. Patients with the related factors of travel abroad, positive results of a test forTreponema pallidum hemagglutination, and homosexuality have increased in number in recent years. Fever, abdominal pain, and hepatomegaly were the most frequent findings, and 39 patients had neither bloody stools nor diarrhea. Only 8 patients had had amebiasis previously. A solitary abscess in the right lobe of the liver was found in 40 patients.Eniamoeba histolytica was found in the stool of 31 patients and in the pus of 39 patients. Sixty-one patients had positive results for an amebic serological test(s). The abscesses ruptured into the peritoneal cavity in 4 patients. All patients received metronidazole. Percutaneous or surgical drainage (or both) was done in 62 patients. The outcome was good, with 1 exception, and only 2 patients had recurrences.     

Amebic Liver Abscess

We present a patient with an acute amebic liver abscess with nonreactive serologic tests. Motile hematophagous trophozoites of Entamoeba histolytica were seen microscopically in scrapings from the wall of the abscess. Postoperative serologies revealed rapidly rising then falling titers by SAFA and IHA antibody assays. Serologic tests for amebiasis may be reative in greater than 95% of patients with invasive amebiasis. Nevertheless, a reactive serologic test should not be relied upon exclusively to establish the diagnosis. Sequential serologic testing and surgical intervention to obtain material for microscopic examination, gram stain and bacteriologic culture are warranted in patients with hepatic abscess and nonreactive serologic tests for antibodies to E. histolytica.     

Thoracic amebiasis

Pleuropulmonary amebiasis is the common and pericardial amebiasis the rare form of thoracic amebiasis. Low socioeconomic conditions, malnutrition, chronic alcoholism, and ASD with left to right shunt are contributing factors to the development of pulmonary amebiasis. Although no age is exempt, it commonly occurs in patients aged 20 to 40 years, with an adult male to female ratio of 10:1. Children rarely develop thoracic amebiasis: when it does occur there is an equal sex distribution. The infection usually spreads to the lungs by extension of an amebic liver abscess. Infection may pass to the thorax directly from the primary intestinal lesion through hematogenous spread, however. Lymphatic spread is one possible route. Inhalation of dust containing cysts and aspiration of cysts or trophozoites of E histolytica in the lungs are some other hypothetical routes. The lung is the second most common extraintestinal site of amebic involvement after the liver. Usually the lower lobe, and sometimes the middle lobe of the right lung, are affected, but it may affect any lobe of the lungs. The patient develops fever and right upper quadrant pain that is referred to the tip of the right shoulder or in between the scapula. Hemophtysis is common. The diagnosis of thoracic amebiasis is suggested by the combination of an elevated hemidiaphragm (usually right), hepatomegaly, pleural effusion, and involvement of the right lung base in the form of haziness and obliteration of costophrenic and costodiaphragmatic angles. Infection is usually extended to the thorax by perforation of a hepatic abscess through the diaphragm and across an obliterated pleural space, producing pulmonary consolidation, abscesses, or broncho-hepatic fistula. Empyema develops when a liver abscess ruptures into the pleural space. Rarely, a posterior amebic liver abscess can burst into the inferior vena cava and develop an embolism of the inferior vena cava and thromboembolic disease of the lungs with congestive cardiac failure or corpulmonale. Diagnosis by finding E histolytica in stool specimens is of limited value. In a limited number of cases amebae might be found in aspirated pus or expectorated sputum. "Anchovy sauce-like" pus or sputum may be found. Presence of bile in sputum indicates that the pus is of liver origin. Serological tests are of immense value in diagnosis. Liver enzymes are usually normal and neutrophilic leucocytosis may or may not be found. ESR is invariably elevated. Anti-amebic antibodies can be detected by ELISA, IFAT, and IHA. Amebic antigen can be detected from serum and pus by ELISA. Detection of Entamoeba DNA in pus or sputum may be a sensitive and specific method. Pleuropulmonary amebiasis is easily confused with other illnesses and is treated as pulmonary TB, bacterial lung abscesses, and carcinoma of the lung. A single drug regimen with metronidazole with supportive therapy usually cures patients without residual anomalies. Aspiration of pus from empyema thoracis may be needed for confirmation and therapeutic purposes. The pericardium is usually involved by direct extension from the amebic abscess of the left lobe of the liver, sometimes from the right lobe of the liver, and rarely from the lungs or pleura. An initial accumulation of serous fluid due to reactive pericarditis followed by intrapericardial rupture may develop either (1) acute onset of severe symptoms with chest pain, dyspnea, and cardiac tamponade, shock, and death, or (2) progressive effusion with thoracic cage pain, progressive dyspnea, and fever. Chest radiograph, ultrasound examination, and CT scan usually confirm the presence of a liver abscess in continuity with the pericardium and fluid within the pericardial sac with or without the fistulous tract. Echocardiography may demonstrate fluid in the pericardial cavity. Patients should be cared for in the ICU and ambecides should be started without delay. Pericardiocentesis usually confirms the diagnosis and improves the general condition of the patient. Aspiration of the accumulated fluid should be performed urgently in cardiac tamponade; repeated aspiration may be needed. Surgical drainage should be done if needed. Acanthamoeba, a free-living ameba, may also infect the lungs in the form of pulmonary nodular infiltration and pulmonary edema in association with amebic meningoencephalitis in immunocompromised patients. It usually spreads to the meninges of the brain by way of the blood from its primary lesion in the lung or skin. Early diagnosis and institution of treatment may be life saving for these patients. A literature review shows that HIV/AIDS patients are not prone to infection with E histolytica. It is now clear that there are an increasing number of HIV-seropositive patients among amebic liver abscess patients, however, which suggests that although the incidence of intestinal infection is not high among HIV-seropositive or AIDS patients they are more susceptible to an invasive form of the disease.     

Differences in complement-mediated killing of Entamoeba histolytica between men and women--an explanation for the increased susceptibility of men to invasive amebiasis?

Men are more than 7 times more likely to develop amebic liver abscess or amebic dysentery caused by Entamoeba histolytica than women. Because the complement system could play a key role in controlling amebiasis, we determined whether serum from men and women differ in the ability to kill amebic trophozoites. We found that serum from women was significantly more effective in killing E. histolytica trophozoites than serum from men, and this killing was complement dependent. Our results provide a possible explanation for the differential susceptibility of men and women to amebic liver abscess and amebic colitis.     

Experience with intravenous metronidazole to treat moderate-to-severe amebiasis in Japan

Twenty-eight cases of either intestinal amebiasis, amebic liver abscess, or both, most of which were of moderate-to-severe intensity, were treated with intravenous metronidazole, pioneered by the Research Group on Chemotherapy of Tropical Diseases, Japan. This study was not conducted as a formal clinical trial, and all patients either underwent colectomy for intestinal amebiasis, received oral metronidazole, or both. Despite these limitations, intravenous metronidazole was shown to be well tolerated and seemed to be very effective. This agent should be more widely recommended than previously thought for treating moderate-to-severe amebiasis, especially its intestinal form.     

Incidence and management of anorectal abscess,fistula and fissure,in patients with ulcerative colitis

Summary and Conclusions During a survey of 465 patients with ulcerative colitis, it was learned that 82 (17.6%) had one or more anorectal complications such as abscess, fistula-in-ano, rectovaginal fistula and fissure-in-ano. These complications were associated with attacks of colitis, which generally were severe. The incidence of fissure-in-ano was significantly greater when colitis was extensive, but that of abscess and fistula varied little with the severity and extent of the disease. All complications occurred most frequently during the year of the first attack; after this the duration of symptoms of colitis had little effect on the incidence of anorectal complications. Treatment of each complication is discussed. Perianal abscess requires immediate incision and drainage. Six cases of spontaneous healing of fistula-in-ano are described. Rectovaginal fistula required excisional surgery. Fissure-in-ano was treated by symptomatic measures alone. It is emphasized that treatment of these complications must be accompanied by vigorous treatment of ulcerative colitis itself.     

Perianal skin amebiases

Summary and Conclusions Seven patients with perianal skin amebiasis are discussed; six were men and one was a woman. The ages varied from 28 to 48 years. Grossly, lesions vary from a single ulcer to a massive, fungous, ulcerative lesion; often it may be confused with a simple anal ulcer, lymphogranuloma venereum, condyloma, cancer and other benign anal lesions. Biopsy or scraps of the lesion revealE. histolytica in its trophozoite form. A combination of emetine and other amebicides is the treatment of choice. If untreated, the lesion will grow rapidly and may kill the patient. This happened to one of my patients. In all my cases, the skin infection was due to a previous amebic colitis. Incomplete treatment for amebiasis of the colon may lead to a perianal skin amebiasis. Constipation may be the only symptom. Perianal skin amebiasis is a rare complication of amebic colitis. Read at the meeting of the American Proctologic Society, Minneapolis, Minnesota, June 14 to 16, 1965.     

Amebic liver abscess with bacterial superinfection in a patient with no epidemiologic risk factors.

The amebic liver abscess is uncommon in developed countries like Spain, but the incidence is increasing probably due to the migratory movements of the population. We report a case of an amebic abscess, initially unsuspected due to the absence of epidemiologic risk factors and the negative serology for amebiasis, in the early stages of the disease.     

Rapid diagnostic approach to amebic liver abscess

Summary A Viet Nam veteran was found to have a large liver abscess, almost certainly due toE. histolytica, although the organism was not recovered. A prompt diagnosis was made within 5 days of admission to the hospital, and thus proper chemotherapy and needle aspiration of the abscess were accomplished without undue delay. Confirmation of the clinical suspicion of amebiasis of the liver was achieved by a positive serologic test for amebiasis, and a large defect in the right lobe of the liver shown on radioisotope liver scan.     

Amebic abscess of the liver

Fifteen patients with amebic abscess of the liver were seen at two California county hospitals over a period of 3 1/2 years. Of the 15 patients, 9 diagnoses were proven and 6 were presumptive. Fourteen of the patients had made a recent trip or had ready access to Mexico. The clinical finding of particular note was the high incidence of right lower lung field abnormalities. Useful laboratory studies included the combination of an elevated BSP, alkaline phosphatase, and direct reacting bilirubin. The value of the liver scan is emphasized. The high incidence of secondary infection of the abscesses is stressed. The uncomplicated postoperative courses of those patients treated by surgical drainage and postoperative chemotherapy for amebiasis is of particular importance since this approach has been considered in the past to be most hazardous.The author is indebted to Robert A. O'Reilly, M.D. for his assistance and helpful suggestions. The indirect hemagglutination tests were performed through the courtesy of Dr. John F. Kessel, School of Public Health, University of California, Los Angeles, Calif.     

Perforation of the colon in unsuspected amebic colitis: Report of two cases

Two cases of amebic colitis that resulted in perforation of the colon, an ominous complication, are presented. The first was diagnosed preoperatively as acute ulcerative colitis with toxic megacolon, and the second as peritonitis complicating acute cholecystitis. In both instances the correct diagnosis was made after operation. The first patient recovered after colectomy and antiamebic therapy, but the second patient died in the early postoperative period, in septic shock. Amebic colitis occurs infrequently in the United States, and the diagnosis is rarely considered. In most cases an initial diagnosis of ulcerative or granulomatous colitis is made and the true diagnosis is recognized only after operation for colonic perforation or hepatic abscess. It is suggested that amebic colitis should be considered more frequently in cases of patients who have diarrhea. Stool examination for ova and parasites is often negative in amebic colitis. The IHA is usually positive in emebiasis, and should be performed early in casesof patients who have bloody diarrhea or other clinical symptons when amebiasis is suspected. Rectal biopsy is also a useful diagnostic approach, but failed to reveal amebae in one of our cases. Finally, it is suggested that operation be performed urgently when fulminating amebic colitis is not reversed by antiamebic therapy, when peritonitis occurs even with antiamebic treatment in progess, and for colonic perforation or toxic megacolon even when antiamebic therapy has not been indicated.