A case of amoebic colitis with Crohn-like endoscopic and histopathological features.

Amoebic colitis represents a common parasitic infection in developing countries. In western world, it is encountered only sporadically. The clinical presentation is usually non-specific, non-invasive laboratory tests are often false negative and endoscopic and histopathological appearance may mimic other illnesses, especially Crohns disease. The disease therefore harbours a huge risk of misdiagnosing and a proper diagnosis is usually challenging. We present a case of an amoebic colitis with Crohn-like features and negative parasitological testing in a 53-years-old woman, in which the final diagnosis was established on the basis of its histopathological examination.

[Eficacia del tinidazol en la profilaxis terapéutica de la colitis amebiana en pacientes con leucemia aguda de novo que reciben quimioterapia intensiva].

INTRODUCTION: In Mexico, seroprevalence of Entamoeba histolytica is 8.4%. The intestinal amebiasis in patients with acute leukemia of novo, after the start of chemotherapy (CT) in the Hematology Service of the CMN 20 de Noviembre is 12%, even if patients show a negative baseline coprological test. OBJECTIVE: To find out if the administration of tinidazole, in patients with acute leukemia and negative coprological test, at the beginning of the CT, decreases the incidence of amoebic colitis during the induction to remission. METHOD: Prospective and not comparative study. Patients with de novo diagnosis of acute leukemia who initiate induction and initial coprological CT. Tinidazole was indicated, 2 g/day for 5 days in the first week of CT started. They were monitored until the induction was concluded and hematopoietic recovery started. RESULTS: 38 patients, 15 women and 23 men with a mean age of 44 years (16-72), with acute lymphoblastic leukemia 19, myeloblastic 16 and promyelocytic 3. Cases without and with intestinal amebiasis were 35 and 3, respectively. Patients with amebiasis only received tinidazole for 3 days and it was given 2 days after the CT started. CONCLUSION: Tinidazole, in patients with acute de novo leukemia who initiate induction CT, is effective in the prevention of intestinal amebiasis, during the induction stage, if administered at 2 g/day, for five days, starting on day 1 of the CT.

INTRODUCCIÓN: En México la seroprevalencia de la Entamoeba histolytica es del 8.4%. La amebiasis intestinal en pacientes con leucemia aguda de novo posterior al inicio de quimioterapia (QT), en el Servicio de Hematología del CMN 20 de Noviembre, es del 12%, aún si muestran test coprológico negativo basal. OBJETIVO: Averiguar si la administración de tinidazol, en pacientes con leucemia aguda y coprológico negativo, al principio de la QT, disminuye la incidencia de colitis amebiana durante la inducción a la remisión. MÉTODO: Prospectivo y no comparativo. Enfermos con diagnóstico de leucemia aguda de novo que inician QT de inducción y coprológico inicial. Se indicó tinidazol, 2 g/día durante 5 días en la primera semana de comenzada QT. Se vigilaron hasta que la inducción concluyó y se inició la recuperación hematopoyética. RESULTADOS: 38 pacientes, 15 mujeres y 23 hombres con edad media de 44 años (16-72). Con leucemia aguda linfoblástica 19, con mieloblástica 16 y con promielocítica 3. Casos sin y con amebiasis intestinal, 35 y 3, respectivamente. Los pacientes con amebiasis solo recibieron tinidazol durante 3 días y se dio después de 2 días de empezada la QT. CONCLUSIÓN: El tinidazol, en pacientes con leucemia aguda de novo que inician QT de inducción, es efectivo en la prevención de la amebiasis intestinal, durante la etapa de inducción, si se administra a 2 g/día, durante cinco días, a partir del día 1 de la QT.

[A Case of Peristomal Cutaneous Ulcer Following Amebic Colitis Caused by Entamoeba histolytica].

A 66-year-old Japanese male with a history of a rectal ulcer and rectovesical fistula following brachytherapy and radiotherapy for prostate cancer, who had undergone colostomy and vesicotomy presented with a painful peristomal ulcer of approximately 5 x 2.5cm adjacent to the direction of 6 o'clock of the stoma in his left lower abdomen. Although he was admitted to be treated with intravenous antibiotics and topical debridement, the ulcer was rapidly increasing. In the laboratory findings, WBC was 12,400/µL, CRP was 16.9 mg/dL, ESR was 105mm in the first hour. Contrast enhanced CT images showed a wide high density area of skin and subcutaneous tissue around the stoma and dillitation of the transverse and descending colon. Colonoscopy showed furred profound ulcers in the rectum. A biopsy from the ulcer floor submitted to histopathology showed necrotic tissue with a mixed inflammatory infiltrates mainly composed of neutrophils and lymphocytes in the dermis. We suspected pyoderma gangrenosum with an inflammatory bowel disease in the beginning. Although he was started on oral prednisolone 60 mg daily, the ulcer did not respond to treatment. Additional methylprednisolone pulse therapy, intravenous cyclosporine and granulocytapheresis were also ineffective. A biopsy specimen from the skin ulcer margin showed erythrophagocytosis by trophozoites of amebae which were identified on PAS stained slides. The PCR method and stool examination showed positive for Entamoeba histolytica (E. histolytica), but serum antibodies were negative. Within two weeks of treatment with oral metronidazole 2,250 mg/day and topical metronidazole ointment, resolution of the ulcer was observed, then the prednisolone dosage was tapered. A split-thickness skin graft was used to cover the ulcer with a successful result. Even though we originally misdiagnosed this case, we finally reached a diagnosis of amebiasis. It is important to take account of amebiasis in the differential diagnosis of intractable ulcers which can be contaminated by feces.

Burden of major diarrheagenic protozoan parasitic co-infection among amoebic dysentery cases from North East India: a case report.

Intestinal diarrheagenic polyparasitic infections are among the major public health concerns in developing countries. Here we examined stool specimens by microscopy, DNA dot blot and polymerase chain reaction (PCR) to evaluate the co-infection of four principal protozoans among amoebic dysentery cases from Northeast Indian population. The multiplex PCR confirmed Entamoeba histolytica (8.1%), Entamoeba dispar (4.8%) and mixed infection of both the parasites (3.4%) in 68 of 356 stool specimens that were positive in microscopy and/or HMe probe based DNA dot blot screening. The prevailing parasite that co-exists with E. histolytica was Giardia duodenalis (34.1%), followed by Enterocytozoon bieneusi (22.0%), Cryptosporidium parvum (14.6%) and Cyclospora cayetanensis (7.3%, P = 0.017). Symptomatic participants (odds ratio (OR) = 4.07; 95% confidence interval (CI) = 1.06, 15.68; P = 0.041), monsoon season (OR = 7.47; 95% CI = 1.40, 39.84; P = 0.046) and participants with family history of parasitic infection (OR = 4.50; 95% CI = 1.16, 17.51; P = 0.030) have significant association with overall co-infection rate. According to molecular consensus, comprehensive microscopy yielded 3.4% (12/356) false-negative and 7.6% (27/356) false-positive outcome, suggesting an improved broad-spectrum PCR-based diagnostic is required to scale down the poor sensitivity and specificity as well as implementation of integrated control strategy.

Fulminant amoebic colitis: a clinicopathological study of 30 cases.

AIMS: To review the clinical and pathological factors associated with fulminant amoebic colitis (FAC) requiring colonic resection and its outcome. METHODS: We retrospectively identified adult patients admitted to our centre between June 2007 and December 2011 with FAC who underwent colonic resection and were diagnosed with amoebic colitis based on the presence of trophozoites on histological examination. The clinical details were extracted from the medical notes and correlated with the pathological findings. RESULTS: Thirty patients (18 men and 12 women) met the inclusion criteria. Their mean age was 50.1 years (range 21-89). The most frequent symptoms were abdominal pain, vomiting and fever. More than half the patients (16/30) had underlying conditions associated with immunosuppression including diabetes mellitus and tuberculosis. Pathological investigation of colonic resections showed predominantly right-sided involvement with geographic colonic ulcers covered with a creamy-white pseudomembrane, perforations, gangrenous changes, amoeboma and lesions mimicking inflammatory bowel disease. All showed basophilic dirty necrosis with abundant nuclear debris and amoebic trophozoites on histological examination. 21/30 patients (70%) had involvement beyond the caecum. 17/30 patients (57%) died. Those with involvement beyond the caecum were more likely to die (15/21, 71.4%) than those with less extensive disease. CONCLUSIONS: FAC presents as acute abdomen and can mimic appendicitis, ischaemic bowel disease, tuberculosis and malignancy. Comorbidities causing immunosuppression frequently associated. Mortality remains high despite surgery, so FAC should be suspected in every case of acute abdomen with colonic perforation if associated with typical gross and microscopic findings and a history of stay in an endemic area.

Varied Clinical Manifestations of Amebic Colitis.

Invasive amebiasis is common worldwide, but infrequently observed in the United States. It is associated with considerable morbidity in patients residing in or traveling to endemic areas. We review the clinical and endoscopic manifestations of amebic colitis to alert physicians to the varied clinical manifestations of this potentially life-threatening disease. Copyright ©Most patients present with watery or bloody diarrhea. Less common presentations of amebic colitis include abdominal pain, overt gastrointestinal bleeding, exacerbation of inflammatory bowel disease, or the incidental association with colon cancer. Amebic liver abscesses are the most frequent complication. Rectosigmoid involvement may be found on colonoscopy; however, most case series have reported that the cecum is the most commonly involved site, followed by the ascending colon. Endoscopic evaluation should be used to assist in the diagnosis, with attention to the observation of colonic inflammation, ulceration, and amebic trophozoites on histopathological examination.

[HIV-associated nephropathy with amoebic enteritis: a case report and literature review].

We herein describe a case of HIV-associated nephropathy (HIVAN) in a 64-year-old HIV antibody-positive man presenting with proteinuria. Laboratory examinations showed positive proteinuria, a high ß2-microglobulin level and decreased creatinine clearance. He underwent a percutaneous renal biopsy, and a pathologic evaluation revealed a collapsing form of focal sclerosing glomerulosclerosis. Histologically, HIVAN is a collapsing form of focal sclerosing glomerulosclerosis (FSGS), which can be distinguished from idiopathic FSGS by the presence of microcystic tubular dilatation and interstitial inflammation. The patient was diagnosed with HIV-associated nephropathy and was started on ART. The HIV-associated nephropathy did not progress to acute renal failure, and long-term survival has been observed for over 12 years.

Intestinal amebiasis in a group of patients with ulcerative colitis: influence on clinical course of the disease.

INTRODUCTION: Ulcerative colitis (UC) is a common disease with a chronic and relapsing presentation requiring regular clinical follow up. Epidemiological and microbiologic studies suggest that enteropathogenic microorganisms play a substantial role in the clinical presentation and extent of inflammatory bowel disease. GOAL: To evaluate the presence of intestinal infections by Entamoeba hystolitica in patients with ulcerative colitis, their impact on clinical outcome, and to identify associated risk factors. MATERIAL AND METHODS: A total of 31 patients hospitalized on Gastroenterohepatology Department with patohystologically proved ulcerative colitis were studied. Fresh feces samples taken from 20 patients were examined immediately using Eosin and Lugol-staining methods and analyzing the presence of vegetative and MIFC (Meriolat and Iod staining). RESULTS: A total of 16 female and 15 male hospitalized UC patients were analysed in a period of two years (2010-2011). The mean age at diagnosis was 43 years. We analyzed relation of amoeba infection with localization of ulcerative colitis. Our results indicate that amoeba infection is related to extent of disease (they were mostly present in pancolitis). Presence of amoeba is not related to age nor gender. Furthermore, presence of amoeba was not associated with more severe clinical course of disease. Similarly, higher value of serum marker of inflammation was not associated with amoeba infection. DISCUSSION AND CONCLUSION: Amoeba infections in UC patients treated at Gastroenterohepatology Department was not related to the grade of disease activity, and other clinical variables such as gender, age and parameters of inflammation. These microorganisms could be a contributing cause of extended localization of disease.

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.

A case of fulminant amoebic colitis during systemic chemotherapy for gastric cancer.

Amoebiasis is a parasitic infection caused by the protozoan, Entamoeba histolytica. At times, amoebiasis is activated under immunosuppressive conditions such as chemotherapy. We report a case of fulminant amoebic colitis resulting from an asymptomatic Entamoeba histolytica infection, which was activated by chemotherapy for gastric cancer. The patient developed diarrhea and fever after three courses of chemotherapy for gastric cancer and was diagnosed with acute enteritis. A colonoscopy and biopsy were performed because of the bloody stool. Histopathological findings revealed amoebic invasion of the rectum. Therefore, the patient was diagnosed with amoebic colitis and was treated with metronidazole. Emergency surgery was performed because intestinal perforation was suspected after which his general condition improved and was discharged. Subsequently, gastric cancer surgery was performed and the patient was discharged without postoperative complications. Hence, amoebic colitis should be listed as a differential diagnosis, and a colonoscopic biopsy should be performed when colitis occurs during chemotherapy for cancer.

Fulminant amoebic colitis co-infection in a patient with COVID-19.

A woman in her 80s who presented with sudden abdominal pain and bloody stool associated with fever, dry cough and malaise, was found to be COVID-19 RT-PCR positive with fulminating necrotising amoebic colitis. She underwent right extended hemicolectomy with ileostomy and survived despite an unpredictable post-operative course, the need for aggressive intensive care and other major risk factors, and was discharged home after the twentieth day of her presentation.This case summarises the survival of a geriatric patient diagnosed with two lethal complications - amoebic colitis and COVID-19 respiratory infection with the aid of prompt surgical intervention and appropriate critical care.

Fulminant amoebic colitis mimicking intestinal vasculitis in a patient with systemic lupus erythematosus.

Colitis in patients with systemic lupus erythematosus (SLE) is quite rare. It can be caused by intestinal vasculitis, mesenteric vascular thrombosis, concomitant inflammatory bowel disease or infectious colitis. It is important to make an accurate and early diagnosis as the treatments for each condition differ and a delayed diagnosis can result in life-threatening complications. However, non-specific gastrointestinal symptoms make a timely diagnosis challenging. Amoebic colitis is a rare condition in patients with SLE. Here we present a case of fulminant amoebic colitis in a patient with SLE which was initially misdiagnosed as ischemic colitis due to intestinal vasculitis. Her colitis was complicated with multiple intestinal perforations, disseminated intravascular coagulation and acute respiratory distress syndrome; but in the end, the patient was successfully treated with metronidazole and paromomycin.

An unusual cause of unilateral hydronephrosis: invasive colonic amebiasis.

A 62-year-old man was admitted to our hospital with complaints of abdominal pain and rectal bleeding. Although the colonoscopic examination was highly suggestive of a carcinoma, the histopathological examinations were consistent with chronic inflammation. CT examination revealed a solid lesion from cecum to the ascending colon with right urethral invasion. Percutaneous right nephrostomy was performed for grade 2-3 hydronephrosis. Three days after hospitalization, ileus developed and right hemicolectomy was performed. During surgery we observed that the lesion had invaded the middle part of ureter. So the middle part of ureter was removed with side-to-side urethral anastomosis and 6F double-J catheter was placed. The histopathological findings of resected specimen were consistent with ameboma. Reviewing the literature unilateral hydronephrosis due to colonic amebiasis has not been reported.

[Amebic colitis and liver abscess complicated by high serum procalcitonin in acute myeloid leukemia].

We present a case of amebic colitis and liver abscess complicated by acute myeloid leukemia (AML) with high serum procalcitonin (PCT). A 61-year-old Japanese man seen at our hospital for severe diarrhea and high fever was found to have multiple ulcers in the transverse and sigmoid colon and rectum by colonoscopy and biopsies were conducted. Immature leukocytes with mild anemia and thrombocytopenia were seen in peripheral blood, necessitating bone marrow aspiration and biopsy that yielded a diagnosis of AML (FAB M4Eo). Serum C-reactive protein and PCT were extremely elevated. Blood cultures for bacteria and fungi were negative. Multiple low-density areas in the liver were found in abdominal computed tomography. Histological colon biopsy findings revealed amebic colitis, strongly suggesting amebic liver abscess. Metronidazole treatment was initiated for amebiasis and subsequent standard chemotherapy for AML was followed after fever was lowered. Hematological and cytogenetic CR was maintained with good clinical condition. Few case reports have been published in Japan to date on amebic colitis and liver abscess complicated by AML and no reports have been made on PCT elevation caused by amebiasis. In conclusion, differential diagnosis of amebiasis is necessary in addition to that of bacterial or fungal infection in serum PCT elevation.

Fulminant necrotizing amoebic colitis presenting as acute appendicitis: a case report and comprehensive literature review.

Intestinal amoebiasis is a parasitic infection caused by Entamoeba histolytica. It is commonly found in developing countries with poor hygiene. A rare, life-threatening complication of amoebiasis is fulminant necrotizing amoebic colitis (FulNAC). We report a 59-year-old male with acute lower right abdominal pain. Before coming to our institution, he was diagnosed with acute appendicitis. Extensive necrosis near the caecum involving the appendix and colon was observed intraoperatively. The patient underwent a right hemicolectomy, followed by an ileostomy and colostomy. Histopathologic examination confirmed the diagnosis of FulNAC. After the surgery, the patient was transferred to the high care unit and treated with metronidazole after histopathologic findings confirmed the etiology. The patient showed excellent response to the antibiotic prescribed, and the symptoms subsided. He was discharged from the hospital on day nine. Additionally, we reviewed fifty-one existing case reports on invasive intestinal amoebiasis worldwide, confirmed by histopathological examination following their preoperative diagnosis, surgery, pharmacology treatment, and outcomes. The learning point of this case is that intestinal amoebiasis should be considered a differential diagnosis for patients around fifty years old with bowel symptoms and travel history or living in tight quarters. Blood tests, radiological examinations, and serological evaluations are valuable diagnostic modalities. Metronidazole should be given as early as possible, and health promotion is recommended to prevent this disease in the population.

A case of intestinal amoebiasis mimicking intestinal Behçet's disease.

Intestinal amoebiasis is caused by Entamoeba histolytica (E. histolytica) and is characterised by cecal lesions, multiple lesions, aphthae, and multiple exudative erosions. Intestinal Behçet's disease (BD) is a chronic inflammatory disorder that is characterised by multiple ulcers. Although the aetiologies of these two bowel diseases are unrelated, they are difficult to distinguish because they present similarly with inflammation and ulcers, especially if evidence of specific pathogens is not detected. Herein, we report a case of intestinal amoebiasis in a patient with BD. The patient underwent colonoscopy four times before intestinal amoebiasis was diagnosed. As intestinal BD was initially suspected, she received high-dose glucocorticoid therapy, which exacerbated her condition. Following exacerbation, she underwent colonoscopy, and E. histolytica was revealed. Deliberate care should be taken to distinguish between intestinal amoebiasis and intestinal BD, as the appropriate treatments for these diseases are entirely different.

[Fulminant amebic colitis with fatal outcome in a patient with probable SARS-CoV-2 infection]. / Colitis amebiana fulminante con desenlace fatal en un paciente con probable infección por SARS-CoV-2.

We report the case of a 62-year-old male with cough and abdominal pain for two weeks, associated with pulmonary tomographic findings compatible with probable infection by SARS-CoV-2, and who received high doses of early corticotherapy as an outpatient. The patient showed clinical deterioration, was hospitalized and died in the immediate postoperative period due to acute surgical abdomen. The anatomopathological study showed parasitic structures with characteristics compatible with amebae, which was pointed to as the cause of a complicated acute fulminant colitis, with multiple perforations and acute peritonitis. Acute fulminant colitis due to intestinal amebiasis in the context of a patient with probable COVID-19 had not been previously reported in Peru. It is important to highlight the fulminant presentation with fatal outcome of this prevalent parasitic infection, in the context of corticosteroids use in a probable SARS-CoV-2 pulmonary infection.

Se reporta el caso de un varón de 62 años quien presentó tos y dolor abdominal por dos semanas, con hallazgos tomográficos pulmonares compatibles con probable infección por SARS-CoV-2, que recibió tempranamente corticoterapia a dosis altas y de manera ambulatoria. El paciente presentó evolución tórpida, fue hospitalizado y falleció en el posoperatorio inmediato por un cuadro de abdomen agudo quirúrgico. El estudio anatomopatológico mostró estructuras parasitarias con características compatibles con amebas, como causa de una colitis aguda fulminante complicada, con perforación múltiple y peritonitis aguda. La colitis aguda fulminante por amebiasis intestinal en el contexto de un paciente con probable COVID-19 no había sido reportada en el Perú. Resulta importante resaltar la presentación fulminante con desenlace fatal de esta infección parasitaria prevalente en nuestro medio, en el contexto del uso de corticoides ante una probable infección pulmonar por COVID-19.

Intestinal protozoan infections in relation to nutritional status and gastrointestinal morbidity in Colombian school children.

While Giardia duodenalis infection has been consistently associated with nutrient malabsorption and stunting in children, the effects of other protozoans on nutritional status or gastrointestinal morbidity are less clear. We sought to determine whether infection with common intestinal protozoans including Giardia duodenalis, Entamoeba coli and Blastocystis hominis was associated with anthropometric and micronutrient status, gastrointestinal symptoms, visits to the doctor or school absenteeism in children 5-12 years of age from Bogotá, Colombia. We obtained stool samples from 442 children enrolled in primary schools in 2006 and examined the presence of intestinal protozoans in relation to height, body mass index, plasma concentrations of vitamins A and B12, ferritin and zinc and erythrocyte folate. In addition, we examined the associations between protozoan infections and the incidence of common gastrointestinal symptoms, which were registered prospectively in morbidity diaries. The prevalence rates of G. duodenalis, E. coli and B. hominis infection were 6.3, 23.1 and 22.4%, respectively. Giardia infection was associated with lower height-for-age z-score (p = 0.04), whereas E. coli infection was associated with low erythrocyte folate (p = 0.04), and B. hominis infection was related to higher vitamin A levels (p = 0.05). Infection with E. coli was also associated with a significantly higher incidence of fever but fewer visits to the doctor, while B. hominis infection was associated with significantly less diarrhea, diarrhea with vomiting, doctor visits and school absenteeism. In conclusion, G. duodenalis and E. coli infections were associated with indicators of poor nutritional status in this population, while B. hominis was related to apparently decreased morbidity.

A case of fulminant amebic colitis with multiple large intestinal perforations.

Amebic colitis normally causes mucous and bloody diarrhea stool as predominant symptoms, thus leading to a course of chronic colitis. However, though rare, there exists a fulminating type that causes intestinal perforations due to wide necrosis of the large intestine. We encountered a case of fulminant amebic colitis that lead to death due to multiple large intestinal perforations. The patient was a 72-year-old female. The patient was admitted to our hospital with symptoms of fever, abdominal pain, and diarrhea. She continued to have a fever of over 38 degrees C and increased left abdominal pain. An abdominal computed tomography scan revealed free gas on the abdominal side of the kidney. Therefore, gastrointestinal perforations were diagnosed and surgery was performed. In surgery, many perforated parts were observed from the appendix to the descending colon, and subtotal colectomy was performed. However, sepsis and disseminated intravascular coagulation occurred, and the patient died on the eighth postoperative day.

Endolimax nana and urticaria.

Endolimax nana is a commensal protozoan of the colon. We report a case of chronic urticaria associated with E. nana in a 34-year-old Italian woman. The patient suffered from abdominal pain, diarrhoea and weight loss. The disease appeared after a trip to Vietnam. Laboratory examinations showed mild blood eosinophilia. Three coproparasitological examinations were positive for cysts of E. nana. The patient was successfully treated with two courses of metronidazole (2 g/day for 10 days each). No antihistamines were used. Three coproparasitological examinations, carried out at the end of the therapy, were negative. Follow up (six months) was negative. E. nana can be responsible for very rare cases of abdominal pain, diarrhoea, polyarthritis and urticaria.