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July, 29, 2016

PARASITIC AND COMMENSAL AMOEBA


Dra. Ma. Cielo Malijan

Department of Parasitology

TOPIC OUTLINE
I.
Amoeba Parasitic Biology
a. Morphology
b. Life Cycle and Reproduction
c. Intestinal and Oral Amoebas
II.
Entamoeba hystolytica
a. General Features
b. Life Cycle
c. Pathogenesis and Clinical Manifestations
d. Diagnosis
e. Treatment, Prevention, and Control
III.
Dentamoeba fragilis
a. General Features
b. Pathogenesis
c. Diagnosis
d. Treatment
IV.
Commensals
a. General Features
b. Entamoeba dispar
c. Entamoeba hartmanii
d. Entamoeba coli
e. Entamoeba gingivalis
f. Entamoeba polecki

o
o

g. Endolimax nana
AMOEBA PARASITIC BIOLOGY

Morphology
Cytoplasm
o Ectoplasm

Outer, thin layer for movement, ingestion,


excretion, respiration, protection
o Endoplasm

Voluminous inner which contains nucleus


Nucleoplasm
o Nuclear membrane enveloping a fine reticulum
filled with nuclear sap and chromatin

Vesicular concentrated in a single mass

Granular diffused
o Karyosome: centrally, deeply stained for
promitosis
Life Cycle and Reproduction
Reproduction is asexual/ binary fission
Trophozoite INVASIVE
o Pathologic state and mature form
o Vegetative, destroyed by unfavorable
environment
o Has the ability to colonize and/or invade the
large bowel (cysts dissolve in the alkaline SI
and hatches in the LI)
o Present in diarrheal stool
Cyst INFECTIVE
o Inactive trophozoite inside a shell
o Survives in any environment; resistant to
gastric acidity and desiccation

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Quadrinucleated
Present in formed stool

Intestinal and Oral Amoebas


Intestinal Amoebas
o Have trophozoite and cyst stages except
Dientamoeba fragilis (only cyst stage)
o Found in the large intestine
o Mode of transmission:

Oral-fecal route

Venereal transmission

Contaminated instruments (forceps)

Via intestinal roundworms (D. fragilis: thru


eggs or adults of E. vermicularis and A.
lumbricoides)
o Examples:

Entamoeba histolytica

Entamoeba coli

Entamoeba dispar

Endolimax nana

Iodamoeba butschii

Dientamoeba fragilis
Oral Amoeba
o No cyst stage; Needs direct passage for
survival
o Found in the oral cavity
o Mode of transmission:

Kissing

Sharing of utensils, toothbrush


o Example:

Entamoeba gingivalis

ENTAMOEBA HYSTOLYTICA

General Features
Most in invasive of the Entamoeba family
Pseudopod-forming, non-flagellated
Eukaryotic with 1-4 nuclei
o undergoes nuclear division followed by
cytoplasmic divisions to form 8 trophozoites
Causes intestinal amebiasis, colitis and Amoebic
Liver Abscess (ALA)
Unusual features
o Presence of nuclear-encoded mitochondrial
genes such as pyridine nucleotide
transhydrogenase and HSP 60
o Lack of organelles that morphologically
resemble mitochondria
o No rough ER and no Golgi apparatus
o Tunicamycin inhibits protein glycosylation
o Lack of glutathione metabolism
o Use of pyrophosphate instead of ATP at several
steps in glycolysis

Lecture Title
o
o

Inability to synthesize purine nucleotides


de novo
End product of CHO metabolism are
ethanol and CO2, and under aerobic
conditions, acetate

Life Cycle
1. Cysts are passed in feces.
2. Infection of E. histolytica occurs by ingestion of
mature cysts in focally contaminated food, water,
or hands.
3. Since cyst is resistant to stomach acid, it passes
to small intestine where excystation occurs,
releasing trophozoites which migrate to the large
intestine.
4. Trophozoite multiply by binary fission and
produce cysts, both stages passed in the feces.
5. Trophozoite passed in the stool are rapidly
destroyed once outside the body, and if ingested
would not survive exposure to gastric environment
6. In many cases, trophozoites remain confined to
the intestinal lumen (noninvasive infection) of
asymptomatic carriers, passing cysts in their stool.
In others, trophozoites invade intestinal mucosa
(intestinal disease) or through bloodstream,
extraintestinal sites such as liver, brain, and lungs
(extraintestinal disease)

Fig1. Life cycle of E. hystolytica.


Pathogenesis and Clinical Manifestations
1. Sites

Cecum

Ascending colon

Hepatic flexure

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Liver
o Via portal vein (Hematogenous
spread) periportal inflammation and
amoebic hepatitis
o Via direct extension from intestinal
ulcer (flask-shaped ulcers when
trophozoite erode through lamina and
extend laterally): Amoebic Liver
Abscess

necrotic

proteinaceous debris

anchovy sauce-like aspirate

odorless (may not be contaminated)


2. Invasion due to virulence factors

Gal/ GalNac lectin


o Mediates adherence to host cells

Amebapores
o Form spores on host cell membranes

Cysteine proteinases
o Cytopathic for host tissues
3. Types of invasion

Direct extension liver, lungs, skin

Hematogenous liver, lungs, brain, heart,


etc.
4. Signs and Symptoms

Liver: tenderness, hepatomegaly, right


upper quadrant pain

Blood: fever

Lungs: dyspnea, hemoptysis

Intestine: diarrhea, hyperperistalsis,


ulcerations

Brain: headache, convulsion, paralysis

Lecture Title

5. Signs and Symptoms of Complications

Asymptomatic
o Majority of the cases
o Cyst carrier state (passed out in stools)
o In endemic communities

Amebic colitis
o Most common and serious form of
disease
o Intestinal perforation
o Secondary bacterial peritonitis
o Occurs in 60% fulminant colitis
o Gradual onset of the abdominal pain
o Diarrhea with/without blood
o Mucus in the stool
o Fever occur in 1/3 of patients
o Diarrhea alternating with constipation
o Children: fulminant colitis with severe
bloody diarrhea, fever and abdominal
pain

Ameboma
o Occur in less than 1% of the cases
o Mass-like lesion with abdominal pain
o History of dysentery
o Mistaken for carcinoma
o May also be asymptomatic

Amebic Liver Abscess (ALA)


o Most common form of extra-intestinal
amebiasis
o Rupture into the pericardium (most
serious; 70% mortality rate), pleura,

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superinfection, intraperitoneal rupture


(second most common)
o Only 30% with concurrent diarrhea
o Invasive process of trophozoite
o Cardinal manifestations

Acute cases (<2weeks): fever, right


upper quadrant pain

Pain: local and referred to the right


shoulder

Liver: tender (esp. in acute cases)

Hepatomegaly (50% of cases)

Chronic (>2 weeks): wasting disease


with weight loss rather than fever
Secondary Amebic
Meningoencephalitis
o Occurs in 1-2% ; Considered in cases of
amebiasis with abnormal mental status
Renal involvement (rare)
o Caused by extension of ALA or
retroperitoneal colonic perforation
Genital involvement
o Caused by fistulae from ALA and colitis
o Primary infection through sexual
transmission

Diagnosis
1. Microscopic Examination (Standard)

3 consecutive stool examinations in 3 days

Detection of trophozoite in fresh stool 30


min after defecation

Highly motile trophozoites with


unidirectional movement

Detection of E. histolytica trophozoites with


ingested RBCs is diagnostic of amoebiasis
2. Direct Fecal Smear

NSS

Saline and methylene blue stain

Entamoeba species stains blue


differentiating them from WBC

NSS and iodine: nucleus and karyosome


obserbed to differentiate pathogenic from
nonpathogenic species
3. Concentration Techniques

More sensitive than DFS for detection of


cysts

Formalin Ether Concentration Test

Merthiolate Iodine Formaline Concentration


Test
4. Stool Culture

Robinsons and Inokis Medium more


sensitive than microscopy but is not
routinely available
5. PCR

Expensive

Lecture Title

Helps differentiate one species from another


(E. histolytica vs E. dispar)
6. ELISA

80-90% accuracy

Assays for Amebic Gal/GalNac lectin


antigens
7. Liver Ultrasound

Trophozoites surround liver abscesses

Right upper lobe of the liver most infected


8. Serology

Indirect hemagglutination

Counter immunoelectrophoresis

Agar gel diffusion

Indirect fluorescent antibody test

Enzyme-linked immunosorbent assay


9. Colonoscopy

Done in ascending colon and cecum

Wet preparations from aspirations and


scrapings from ulcers
10. Radiographic studies

CT scan, MRI, and ultrasound


11. Aspiration of the tissue

Periphery (ALA)

Treatment, Prevention, and Control

Percutaneous drainage of abscess for


nonresponders
Environmental sanitation
Health education and promotion
Boiling of drinking water for 20mins
Avoidance of night soil
Prompt diagnosis and treatment
Vaccine (experimental)- serine rich E.
hystolitica protein (SREAP), adherence
lectins (GAL/GALNAC lectins), 29kDa
cysteine rich amoebic antigen

DENTAMOEBA FRAGILIS

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Host Defense Mechanism


1. Nonspecific Defense
o First line mucin
o Second line complement system
2. Specific Defense
o Third line cellular mediated
immunity

Against trophozoite

Activated T cells kill E.


histolytica

direct lysis

cytokines

helper effect from antibody


prod.
Drug of Choice (DOC) - Metronidazole
Cyst removal through filtration and boiling
(not chlorination)

[Transcriber 1, Transcriber 2, and so on...]

General Features
Flagellated with only trophozoite stage
known
Rosette nucleus, nuclear membrane has
no chromatin
Binucleated, resembles Trichomonas
Infrequently found in association with
other parasitic intestinal pathogens with
the exception of pinworm infestations,
where the prevalence of infections with
both organisms is ninefold greater than
would be expected based on just a random
association
Also found in Ascaris and Enterobius
Neither its epidemiology nor its route of
transmission is completely known
Mode of Transmission:
o Believed to be transmitted between
human hosts inside helminth eggs or
larvae, particularly those of Enterobius
vermicularis
o
Evidence: frequent association
between the two organisms and the
presence of bodies inside the helminth
eggs, which resemble D. fragilis
Pathogenesis
Irritation of mucosal lining with excretion
of excess mucus and hypermotility of
bowel
Colicky abdominal pain and abdominal
tenderness
Bloating sensation and flatulence
Intermittent diarrhea with excess mucus
Anal pruritus (E. vermicularis)
Non-invasive: no bleeding
Mistaken for irritable bowel syndrome (IBS)
Diagnosis
Microscopic stool exam (same as in E.
histolytica )

Lecture Title

Treatment
Drug of Choice (DOC) - Iodoquinol for
20 days
Treat also E. vermicularis
Proper sanitation
Alternative Treatments
o Tetracycline
o Metronidazole

COMMENSALS

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General Features
No need for treatment, just indicative of
food contamination
Entamoeba dispar
Non-invasive protozoan
Morphologically similar to E. histolytica
In controlled in numbers or if
immunocompromised can cause colitis
Commonly found in captive primates
Live and multiply in intestinal crypts of the
large intestine mucosa and feed on starches
and mucus secretions
Entamoeba hartmanii
Similar to E. histolytica but much smaller
Does not ingest RBC
More sluggish in movement
Mature cysts measures from 5-10 um,
quadrinucleate and have coarse cytoplasm
Immature cysts have chromatoidal bars
which may be short with tapered ends or
thin and bar-like
Entamoeba coli
Largest intestinal amoeba
Survives putrefaction
Feed on bacteria, other protozoa, yeasts
and blood cells
Endosomes eccentrically arranged
Cysts has chromatoidal bars that have
splintered ends
May have as much as 8-16 nuclei
Used to determine whether water sources
are contaminated with fecal wastes
Entamoeba gingivalis
Only found in mouth
First amoeba in humans to be described
Only found in trophozoite form and do not
form cysts
Move quickly because of blunt
pseudopodia

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Central endosome
Chromatin concentrated in the inner
surface of inner surface
Food vacuoles contain cellular debris,
bacteria and blood cells
Lives in the surface of teeth and gums
even at crypt of tonsils
Entamoeba polecki
Usual parasites of pig and monkeys rarely
in humans
Nonpathogenic in humans
Have on nucleus
Cysts have one nucleus but may reach
binucleate stage
Endolimax nana
Smallest amoebas
Live both in vertebrates and invertebrates
Vesicular nucleus
Endosome comparatively large and
irregular
Endosome attached to the nuclear
membrane via achromatic threads
Lives in the human large intestine near the
cecum
Feeds on the bacteria
Pseudopodia are short and blunt
Food vacuoles contain bacteria, plant cells
and debris
Undergoes encystment

Fig2. Morphology of trophozoite and cyst stage of


E. hystolytica, E. hartmanii, E. coli, E. polecki,
Endolimax nana, Iodamoeba butschlii.

Lecture Title

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