Fulminant amebic colitis

Fulminant Amebic Enteritis in the Perinatal Period

Pregnancy is a known risk factor for amebic enteritis, which develops into potentially fatal fulminant amebic enteritis in some cases. We describe a case of a 27-year-old non-immunosuppressed pregnant woman with fulminant amebic enteritis complicated with cytomegalovirus enteritis. She improved with intensive care and intravenous metronidazole and ganciclovir but eventually required subtotal colectomy for intestinal stenosis. It is difficult to diagnose amebic enteritis, especially in a non-endemic area. Amebic enteritis must be considered as a differential diagnosis for refractory diarrhea with bloody stools in women in the perinatal period, even those without immunosuppression.

Interleukin 10 (IL-10) Production and Seroprevalence of Entamoeba histolytica Infection among HIV-Infected Patients in South Africa

Infections by the parasite E. histolytica are increasing in HIV-infected individuals. Interleukin (IL-10) plays an important role in maintaining the mucosal barrier. Therefore, the seroprevalence of E. histolytica was investigated in relation to the IL-10 serum concentration among HIV- infected patients. A total of 647 blood samples were collected from asymptomatic HIV-infected patients. The Entamoeba histolytica antigen (GALNAC lectin) and serum antibodies were assessed using specific ELISAs (TECHLAB, Virginia, USA). IL10 blood levels were measured using a commercial ELISA test, and the results were analyzed using parametric and non-parametric statistical tests. The Gal/GALNAC lectin was detected in only 0.5% (3/647) of individuals, and the antibodies against E. histolytica were detected in 65.2% (422/647) of the samples. A significant increase in IL-10 levels was found in 68.1% of patients who were sero-negative for E. histolytica antibodies compared to patients who were sero-positive. There is a high level of exposure to E. histolytica among HIV patients in South Africa, although the prevalence of amoebic liver abscesses might be low. This study revealed that elevated levels of IL-10 might be associated with a reduced risk of amebiasis.

Updates on the worldwide burden of amoebiasis: A case series and literature review

BACKGROUND

Amoebiasis is an intestinal and tissue parasitic infection caused by the protozoan Entamoeba histolytica. Despite significant medical importance and worldwide dispersion, little is known about the epidemiology and distinct geographical distribution of various clinical forms of amoebiasis in the world. In this study, we present an amoebiasis case series referred to Avicenne Hospital (Bobigny, France) from 2010 to 2022 followed by an overview of the released literature to explore diverse clinico-pathology of amoebiasis and to update the actual epidemiological situation of this parasitosis worldwide.

METHODS

The referred patients underwent a combination of clinical and parasitological examinations and imaging. The study was followed by an overview of released literature performed based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guideline.

RESULTS

A total of 15 patients with amoebiasis were diagnosed with an average age of 48.5 years old at the occurrence time of infection. Men (78%) were the most affected patients. Most of the cases were reported following a trip to endemic regions, such as Mali, India, Nepal, Algeria, Cameroon or Congo. All of the processed patients exhibited a hepatic amoebiasis. Amoebic abscess was observed in all cases with an average size of 6.3 cm. Of these patients, seven cases (46.7%) benefited from drainage following a risk of rupture or superinfection of the abscess. A compilation of findings extracted from 390 scientific publications via seven major medical databases, allowed us to update the main epidemiological and clinical events that has led to the current worldwide expansion of amoebiasis. We presented a clinical and epidemiological overview of the amoebiasis accompanied with a worldwide illustrative map displaying the current distribution of known amoebiasis foci in each geographical ecozone of Asia, Europe, Africa, Americas, and Australia.

CONCLUSIONS

Although Metropolitan France is not known as an endemic region of amoebiasis, amoebic liver abscess was the most frequent clinical form observed among our 15 patients processed. Most of infected patients had a history of travel to or lived-in endemic areas before arriving in France.

Amebiasis and Amebic Liver Abscess in Children

Although rare in the developed world, amebiasis continues to be a leading cause of diarrhea and illness in developing nations with crowding, poor sanitation, and lack of clean water supply. Recent immigrants or travelers returning from endemic regions after a prolonged stay are at high risk of developing amebiasis. A high index of suspicion for amebiasis should be maintained for other high-risk groups like men having sex with men, people with AIDS/HIV, immunocompromised hosts, residents of mental health facility or group homes. Clinical presentation of intestinal amebiasis varies from diarrhea to colitis and dysentery. Amebic liver abscess (ALA) is the most common form of extraintestinal amebiasis. Various diagnostic tools are available and when amebiasis is suspected, a combination of stool tests and serology should be sent to maximize the yield of testing. Treatment with an amebicidal drug such as metronidazole/tinidazole and a luminal cysticidal agent such as paromomycin for clinical disease is indicated. However, for asymptomatic disease treatment with a luminal cysticidal agent to decrease chances of invasive disease and transmission is recommended.

Fulminant Necrotising Amoebic Colitis of Whole of Large Bowel: A Rare Complication of a Common Infectious Disease

Background

Fulminant necrotising amoebic colitis (FulNAC) is an uncommon and grave complication of a very common infectious disease widely prevalent in tropical countries. In most of the cases reported, only a segment of large bowel was gangrenous. The involvement of the whole of the large bowel, as in our case, is very rare and has very high mortality ranging from 55% to 100%. Case Summary. A 50-year-old gentleman presented with an acute abdomen with a history of crampy abdominal pain and passage of blood mixed with mucous and loose stools. After resuscitation and investigations, the patient was taken up for laparotomy and the findings showed that the caecum was sloughed off and the entire large bowel had multiple perforations. Subtotal colectomy with ileostomy was performed. Histopathological examination showed evidence of pancolitis with multiple colonies of amoebic trophozoites. Discussion. Entamoeba histolytica is a protozoon that affects the large intestine and liver in humans. There can be various presentations of amoebiasis: asymptomatic infection (90%), symptomatic noninvasive infection (6–8%), acute amoebic colitis (dysentery), or fulminant colitis with perforation. FulNAC is an uncommon complication, difficult to diagnose and treat, and associated with a high mortality rate, ranging from 55% to 100%.

Conclusion

It is important to consider the possibility of fulminant necrotising amoebic colitis (FulNAC) as an uncommon and fatal complication of amoebiasis, especially in tropical countries, where amoebiasis is prevalent. Early diagnosis and antiamoebic treatment, along with urgent aggressive surgical resection of the involved segment and exteriorization of the proximal and distal bowel ends, are shown to reduce mortality.

Successful surgical drainage with intraoperative ultrasonography for amebic liver abscess refractory to metronidazole and percutaneous drainage: a case report

Background

Metronidazole (MNZ) has been clearly established as a medication for amebic liver abscess. In uncomplicated cases, surgical drainage should be avoided. We report a case of amebic liver abscess refractory to MNZ that was successfully treated using preoperative computed tomography (CT) and percutaneous and surgical drainage with intraoperative ultrasonography (IOUS).

Case presentation

A 53-year-old man with high-grade fever was diagnosed with a cystic lesion on his right hepatic lobe using CT. Percutaneous drainage was performed, and antibacterial drugs were administered. However, the infection and condition of the patient worsened. Entamoeba histolytica was detected from pus within the mediastinal cavity. Hence, the patient was diagnosed with amebic liver abscess. After the diagnosis was established, we administered MNZ for 10 days. Despite this, the patient’s physical condition did not improve. Blood tests suggested impending disseminated intravascular coagulation (DIC). We performed surgical intervention to drain the amebic liver abscess refractory to conservative treatment. During surgery, imaging information from preoperative CT and IOUS enabled us to recognize the anatomical structures and determine the incision lines of the hepatic capsule and hepatic tissue. The patient’s DIC immediately regressed after surgery. Unfortunately, malnutrition and disuse syndrome contributed to the patient’s long recovery period. He was discharged 137 days post-surgery.

Conclusions

We reported a case of amebic liver abscess refractory to conservative treatment. Surgical drainage with preoperative CT and IOUS allowed us to safely and effectively perform complex abscess decompression.

Acute fulminant necrotizing amebic colitis in a pediatric patient: a rare complication of amebiasis with high mortality-a case report

Background

The majority of amebic infections among humans remain asymptomatic. Rarely, the disease takes a fulminant acute course due to the development of necrotizing amebic colitis. This complication is usually found in adult patients. However, on the contrary, this case was diagnosed in a 9-year-old patient. He was transferred to the Sirimavo Bandaranayake Specialized Children’s Hospital (SBSCH), Peradeniya from the District General Hospital, Kilinochchi. To our knowledge, this is the first report of this rare complication in a child in Sri Lanka.

Case presentation

We present a case of acute fulminant necrotizing amebic colitis in a 9-year-old boy. Surgical exploration revealed extensive ulceration and multiple perforations in the entire colon. PAS-Martius Yellow 40 stain highlighted amebae with erythrophagocytosis within the necrotic debris of the ulcers. The polymerase chain reaction (PCR) that was conducted to confirm the diagnosis was positive for Entameba histolytica. The post-operative course was marked with antimicrobial treatment for septicemia and the need for ventilator assistance. Antimicrobial treatment included intravenous metronidazole. The patient progressively recovered and was discharged on a normal diet.

Conclusion

This case reports an acute fulminant necrotizing amebic colitis in a 9-year-old patient. After the treatments, the patient progressively recovered and was discharged on a normal diet. E. histolytica infections in northern Sri Lanka should be given attention as a public health concern. Furthermore, this case highlights that acute fulminant amebic colitis requires early surgical intervention, aggressive supportive and anti-amebic treatments. Clinicians should be cognizant of this potentially fatal complication of amebic colitis.

Fulminant amoebic enteritis that developed in the perinatal period

We present a case of a 30-year-old postpartum woman who delivered by caesarean section at 34 weeks. On postoperative day 9, she was admitted to our hospital in shock. Emergency abdominal surgery was performed. Massive purulent ascites collected in the abdominal cavity and was associated with intestinal necrosis, which extended from the ascending colon to one-third of the descending colon. The necrotic lesion was excised, and an artificial anus was constructed at the ileum end. A histological finding on the 15th day indicated the possibility of amoebic enteritis, and the patient was started on metronidazole therapy. The diarrhoea improved dramatically after metronidazole treatment was started. The patient was able to walk unassisted on the 45th day and was subsequently discharged. Amoebic enteritis has been thought to be epidemic in developing countries, but today, the incidence of amoebic enteritis as a sexually transmitted disease is increasing in developed countries.

Fulminant colitis

Fulminant colitis is an ill-defined entity that is usually viewed as the most severe form of uncomplicated acute colitis. It usually occurs in the course of ulcerative colitis and infectious colitis, but can also be seen in other forms of colitis. Every patient with clinical criteria for severe or fulminant colitis should be approached in a systematic way, based on two premises - intense medical treatment and early surgery in non-responders.

Fulminant amoebic colitis: a rare fierce presentation of a common pathology

We conducted a retrospective study of patients with fulminant amoebic colitis (FAC) over a 20 year period in an urban tertiary care hospital in Pakistan. After consideration for inclusion and exclusion criteria 25 cases were identified as FAC with the most common presentations being abdominal pain (84%). Nineteen (76%) underwent laparotomy for peritonitis with evidence of: colonic perforation in 10 (40%); faecal peritonitis in eight (32%); bowel gangrene in one (4%); and intra-abdominal abscess in two (8%). Nine (36%) deaths were recorded in the series - eight (53%) in the operated group and one (16.6%) in the medically-treated group. The optimal outcome can be achieved in FAC with aggressive resuscitation, intravenous broad-spectrum antibiotics, including metronidazole, and total colectomy without anastomosis in patients with peritonitis.

Amoebic toxic colitis: analysis of factors related to mortality

BACKGROUND

Toxic or fulminant colitis due to Entamoeba histolytica infrequently presents but is very serious. Unfortunately, there are numerous contradictory factors related to mortality.

METHODS

We analyzed several cases of E. histolytica infection to determine the factors related to mortality. We included patients >15 years of age who were histopathologically diagnosed with amoebic toxic colitis and treated from January 2000 through December 2006. We evaluated demographic, clinical, laboratorial, surgical, and histopathological characteristics.

RESULTS

We examined 24 patients and recorded 12 deaths (50%). Twenty patients underwent surgery within a mean time of 24 hours (range: 8-120 hours). Tenesmus and intestinal perforation were determined to be statistically significant (P<0·05) by univariate analysis. Three models of logistic regression were able to determine three statistically significant factors that affected mortality: (1) tenesmus and a lymphocyte count <1·5×10(3) cell/μl; 2) depth of invasion beyond the mucosa and a lymphocyte count <1·5×10(3) cell/μl; 3) time spent with symptoms and perforation.

CONCLUSIONS

The mortality rate determined in this study is similar to previously reported series. A low lymphocyte count, significant depth of invasion, and intestinal perforation were determined to be the factors related to increased mortality, while tenesmus and limited amount of time spent with symptoms were associated with survival. Quick diagnosis and appropriate treatment are important factors that reduce mortality.

Development of perianal ulcer as a result of acute fulminant amoebic colitis

We report a case of acute fulminant amoebic colitis that resulted in the development of a perianal ulcer in a 29-year-old Japanese homosexual man with acquired immunodeficiency syndrome (AIDS). The patient was admitted to our hospital with a persistent perianal abscess that was refractory to antibiotic therapy administered at another hospital. On admission, we observed a giant ulcer in the perianal region. At first, cytomegalovirus colitis was suspected by blood investigations. Ganciclovir therapy was initiated; however, the patient developed necrosis of the skin around the anus during therapy. We only performed end-sigmoidostomy and necrotomy to avoid excessive surgical invasion. Histopathological examination of the surgical specimen revealed the presence of trophozoite amoebae, indicating a final diagnosis of acute fulminant amoebic colitis. The patient’s postoperative course was favorable, and proctectomy of the residual rectum was performed 11 mo later. Amoebic colitis is one of the most severe complications affecting patients with AIDS. Particularly, acute fulminant amoebic colitis may result in a poor prognosis; therefore, staged surgical therapy as a less invasive procedure should be considered as one of the treatment options for these patients.

Fulminant amebic colitis in an HIV-infected homosexual man

We present a case of fulminant amebic colitis in a human immunodeficiency virus (HIV)-infected homosexual man. The patient developed colonic perforation over a short time despite empirical therapy with metronidazole, and underwent right hemicolectomy. Amebic colitis was pathologically diagnosed by identifying invasive trophozoites of Entamoeba in a surgical specimen. Amebic colitis is one of the important differential diagnoses of acute abdomen in HIV-infected patients and/or homosexual men, especially in East Asia. Although fulminant amebic colitis is a rare manifestation of amebiasis, early diagnosis and treatment are thought to be important to improve the outcome of this highly fatal complication.

Amebiasis

Amebiasis is an important cause of death from parasitic disease worldwide. The causative organism is Entamoeba histolytica, which has an infective cyst stage and a pathogenic and motile trophozoite stage. The clinical presentation can vary from an asymptomatic carrier state to fulminant colitis and colonic perforation. The majority of patients can be managed medically. However, a small percentage of patients require urgent exploration and resection with an associated high mortality rate. Early recognition and initiation of medical therapy including treatment of asymptomatic carriers are vital to preventing catastrophic outcomes.

Acute fulminant necrotizing amoebic colitis: a rare and fatal complication of amoebiasis: a case report

Acute Fulminant Necrotizing Amoebic Colitis is a rare complication of amoebiasis that is associated with high mortality. Only one to four such cases are seen per year in large hospitals of India, and only few such cases have been reported in the literature. The condition requires early diagnosis and surgical intervention. We recently cared for a patient who presented with acute abdomen with history of intermittent abdominal pain and diarrhea. Before presenting to our institution he was misdiagnosed as a case of inflammatory bowel disease and had been treated with steroids. On emergency exploration, extensive necrosis and multiple perforations in retroperitoneum involving entire colon were seen. Total colectomy with ileostomy was performed. Postoperative course was marked by septicaemia and multi-organ failure followed by death. This case report emphasizes the importance of early diagnosis and treatment of acute FAC, and associated high mortality.

Acute fulminant necrotizing amoebic colitis: a rare and fatal complication of amoebiasis: a case report

Acute Fulminant Necrotizing Amoebic Colitis is a rare complication of amoebiasis that is associated with high mortality. Only one to four such cases are seen per year in large hospitals of India, and only few such cases have been reported in the literature. The condition requires early diagnosis and surgical intervention. We recently cared for a patient who presented with acute abdomen with history of intermittent abdominal pain and diarrhea. Before presenting to our institution he was misdiagnosed as a case of inflammatory bowel disease and had been treated with steroids. On emergency exploration, extensive necrosis and multiple perforations in retroperitoneum involving entire colon were seen. Total colectomy with ileostomy was performed. Postoperative course was marked by septicaemia and multi-organ failure followed by death. This case report emphasizes the importance of early diagnosis and treatment of acute FAC, and associated high mortality.

Fulminant amoebic colitis during chemotherapy for advanced gastric cancer

A 52-year-old man had bloody stools during chemotherapy for gastric cancer. A colonoscopy revealed necrotizing ulcer-like changes. A biopsy confirmed the presence of amoebic trophozoites. Subsequently, peritonitis with intestinal perforation developed, and emergency peritoneal lavage and colostomy were performed. After surgery, endotoxin adsorption therapy was performed and metronidazole was given. Symptoms of peritonitis and colonitis resolved. However, the patient’s general condition worsened with the progression of gastric cancer. The patient died 50 d after surgery. Fulminant amoebic colitis is very rarely associated with chemotherapy. Amoebic colitis should be considered in the differential diagnosis of patients who have bloody stools during chemotherapy.

Fulminant amoebic colitis following loperamide use

Toxic megacolon is a rare consequence of infection with Entamoeba histolytica. We present such a patient in whom the course of disease may have been influenced by heavy loperamide use. Loperamide and other anti-motility agents have been implicated previously in the pathogenesis of toxic megacolon in patients with infectious gastroenteritis.

Amebic perforation of the colon: rare and frequently fatal complication

Amebic colitis perforation is a rare clinical form of amebiasis characteristically associated with high morbidity and mortality. We here present our series of eight patients with amebic colitis perforation. These patients represent 5% of 150 patients hospitalized during the same period for chronic amebic colitis. Only 50% of our patients had a correct preoperative diagnosis, and signs of generalized peritonitis such as rebound tenderness or muscular rigidity were not as common as might have been expected. Our mortality rate was 50% despite aggressive surgical treatment. Every effort should be made to have an early diagnosis, which would lead to early treatment with antiamebic agents, earlier and more limited surgery, and improved survival of these patients.

Laboratory diagnosis of amebiasis

The detection of Entamoeba histolytica, the causative agent of amebiasis, is an important goal of the clinical microbiology laboratory. To assess the scope of E. histolytica infection, it is necessary to utilize accurate diagnostic tools. As more is discovered about the molecular and cell biology of E. histolytica, there is great potential for further understanding the pathogenesis of amebiasis. Molecular biology-based diagnosis may become the technique of choice in the future because establishment of these protozoa in culture is still not a routine clinical laboratory process. In all cases, combination of serologic tests with detection of the parasite (by antigen detection or PCR) offers the best approach to diagnosis, while PCR techniques remain impractical in many developing country settings. The detection of amebic markers in serum in patients with amebic colitis and liver abscess appears promising but is still only a research tool. On the other hand, stool antigen detection tests offer a practical, sensitive, and specific way for the clinical laboratory to detect intestinal E. histolytica. All the current tests suffer from the fact that the antigens detected are denatured by fixation of the stool specimen, limiting testing to fresh or frozen samples.

Amoebiasis

Amoebiasis is the second leading cause of death from parasitic disease worldwide. The causative protozoan parasite, Entamoeba histolytica, is a potent pathogen. Secreting proteinases that dissolve host tissues, killing host cells on contact, and engulfing red blood cells, E histolytica trophozoites invade the intestinal mucosa, causing amoebic colitis. In some cases amoebas breach the mucosal barrier and travel through the portal circulation to the liver, where they cause abscesses consisting of a few E histolytica trophozoites surrounding dead and dying hepatocytes and liquefied cellular debris. Amoebic liver abscesses grow inexorably and, at one time, were almost always fatal, but now even large abscesses can be cured by one dose of antibiotic. Evidence that what we thought was a single species based on morphology is, in fact, two genetically distinct species--now termed Entamoeba histolytica (the pathogen) and Entamoeba dispar (a commensal)--has turned conventional wisdom about the epidemiology and diagnosis of amoebiasis upside down. New models of disease have linked E histolytica induction of intestinal inflammation and hepatocyte programmed cell death to the pathogenesis of amoebic colitis and amoebic liver abscess.

Fatal amoebic colitis in a patient with SLE: a case report and review of the literature

Colitis in systemic lupus erythematosus (SLE) poses a diagnostic challenge as clinical, radiological and laboratory findings are often non-specific. Fulminant amoebic colitis is a rare cause of death in SLE. Early diagnosis coupled with timely surgery can reduce the mortality. The demonstration of haematophagous trophozoites in the stool is diagnostic but insensitive. Early endoscopy with adequate specimen collection is an important part of the diagnosis. Serology is both sensitive and specific but can take up to 2-4 weeks for seroconversion making it less useful in a disease that takes a rapid downhill course if treated inappropriately. We report a fatal case of colitis in a patient with SLE due to invasive amoebiasis which was complicated by Salmonella bacteraemia, disseminated intravascular coagulation, acute oliguric renal failure and adult respiratory syndrome. We also reviewed the literature on the clinical features and diagnosis of fulminant amoebic colitis. Amoebic colitis, although rare, should be considered in the differential diagnosis of lupus patients with colitis.

Recent advances in amebiasis

Advancements in our understanding of amebiasis have been rapid over the decade that I have followed this field. What was identified morphologically for years as Entamoeba histolytica has been redescribed with modern techniques as a complex of two species, the commensal parasite E. dispar and the pathogenic parasite E. histolytica that is the cause of colitis and liver abscess. Antigen detection tests are now available for the rapid detection in stool of the pathogenic species E. histolytica. New understandings of the importance of luminal as well as tissue-active antimebic medications in the treatment of invasive disease have been reached. The groundwork is being laid for an understanding of the protective immune responses to infection, and at the lab bench DNA transfection of the parasite has opened studies of pathogenesis to genetic analysis. While necessarily an incomplete sketch of the field, I have attempted here to highlight some recent and important developments of interest to clinicians and microbiologists.

Mesenteric ischemia. Acute arterial syndromes

Acute mesenteric ischemia represents one to two percent of all gastrointestinal illnesses. There are three possible causes of acute arterial mesenteric ischemia: embolism, thrombosis, and nonocclusive mesenteric insufficiency. The key to early diagnosis is a high index of suspicion. The classic clinical picture of obvious cardiac disease, sudden onset of severe abdominal pain and gastrointestinal emptying, is not always present. Serum markers and plain films are often nondiagnostic but may suggest acute arterial mesenteric ischemia. Angiography establishes the diagnosis and allows for planning of aortomesenteric bypass, if indicated. Papaverine is immediately instilled to decrease splanchnic vasoconstriction. Embolic and thrombotic disease is treated by laparotomy with re-establishment of visceral perfusion. Only after blood flow is restored is nonviable bowel resected. Clinical methods of assessing intestinal viability include Doppler scanning, intravascular dyes, and tissue oximetry. The decision to perform a second-look laparotomy is made prior to closure of the abdomen. Pharmacologic treatment is the mainstay of nonocclusive ischemia. Surgery is reserved for clinical deterioration. Survival is dependent on the cause and extent of occlusion as well as the rapidity of diagnosis and therapy. Bowel necrosis results in mortality rates between 80 percent and 95 percent.

Persisting diarrhoea and malabsorption

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