Amoebiasis

[Dr. S Sen, IIMSAR, Haldia]

Amoebiasis is a parasitic infection due to the intestinal protozoa Entamoeba

histolytica. Transmission is faecal-oral, by ingestion of amoebic cysts from food or water
contaminated with faeces. Usually, ingested cysts release non-pathogenic amoebae and 90%
of carriers are asymptomatic.
In 10% of infected patients, pathogenic amoebae penetrate the mucous of the colon:
this is the intestinal amoebiasis (amoebic dysentery). The clinical picture is similar to that of
shigellosis, which is the principal cause of dysentery.
Occasionally, the pathogenic amoebae migrate via the blood stream and form peripheral
abscesses. Amoebic liver abscess is the most common form of extra-intestinal amoebiasis.
Clinical features
– Amoebic dysentery
• diarrhoea containing red blood and mucus
• abdominal pain, tenesmus
• no fever or moderate fever
• possibly signs of dehydration

– Amoebic liver abscess

• painful hepatomegaly; mild jaundice may be present
• anorexia, weight loss, nausea, vomiting
• intermittent fever, sweating, chills; change in overall condition
Laboratory
– Amoebic dysentery: identification of mobile trophozoites (E. histolytica histolytica) in fresh
stool samples
– Amoebic liver abscess: indirect haemoagglutination and ELISA
Treatment
– Amoebic dysentery
• The presence of cysts alone should not lead to the treatment of amoebiasis.
• Amoebiasis confirmed with a parasitological stool examination:
tinidazole PO
Children: 50 mg/kg once daily for 3 days (max. 2 g daily)
Adults: 2 g once daily for 3 days
or metronidazole PO
Children: 15 mg/kg 3 times daily for 5 days
Adults: 500 mg 3 times daily for 5 days
• If there is no laboratory, first line treatment for dysentery is for shigellosis. Treat for
amoebiasis if correct treatment for shigellosis has been ineffective.
• Oral rehydration salts (ORS) if there is risk of, or if there are signs of dehydration.
– Amoebic liver abscess
• tinidazole PO: same treatment for 5 days
• metronidazole PO: same treatment for 5 to 10 days

Shigellosis
 Shigellosis is a highly contagious bacterial infection resulting in bloody diarrhoea. There are
4 serogroups of shigella: S. dysenteriae, S. sonnei, S. flexneri, S. boydii.
– S. dysenteriae type 1 (Sd1) is the only strain that causes large scale outbreaks. It has the
highest case fatality rate (up to 10%). 
– Patients at risk of death are children under 5 years, malnourished patients, children after
measles, adults over 50 years.
Clinical features
– Diarrhoea with bright red blood visible in stool1 , with or without fever 
– Abdominal and rectal pain frequent
– Signs of serious illness: fever above 39 °C; severe dehydration; seizures, altered mental
status
– Complications (more frequent with Sd1): febrile seizures (5 to 30% of children), rectal
prolapse (3%), septicaemia, intestinal obstruction or perforation, moderate to severe
haemolytic uraemic syndrome
Laboratory
Shigellosis in an epidemic context:
– Confirm the causal agent (stool culture) and perform antibiotic sensitivity tests.
– Perform monthly culture and sensitivity tests (antibiotic resistance can develop rapidly,
sometimes during the course of an outbreak).
Treatment
– Patients with signs of serious illness or with life-threatening risk factors must be admitted
as inpatients.
– Treat patients with neither signs of serious illness nor risk factors as outpatients.
– Antibiotherapy:

First-line treatment

ciprofloxacin PO for 3 days • if the strain is sensitive

Children: 15 mg/kg 2 times daily (max. • if there is no antibiotic sensitivity test
1 g daily) • if oral administration is possible
Adults: 500 mg 2 times daily

ceftriaxone IM for 3 days • in patients with severe infection and/or oral

Children: 50 to 100 mg/kg once daily administration is not possible
(max. 1 g daily) • in pregnant women
Adults: 1 to 2 g once daily
If resistance or contra-indication to ciprofloxacin or if no improvement within 48 hours
of starting first-line treatment:
azithromycin PO for 5 days
Children: one dose of 12 mg/kg on D1 then 6 mg/kg once daily from D2 to D5
Adults: one dose of 500 mg on D1 then 250 mg once daily from D2 to D5
or
cefixime PO for 5 days
Children: 8 mg/kg once daily (max. 400 mg daily)
Adults: 400 mg once daily
If there is no improvement 48 hours after starting second-line treatment, treat
for amoebiasis.
– For pain and/or fever:
paracetamol PO. All opioid analgesics are contra-indicated as they slow peristalsis.
– Supportive therapy:
• nutrition: nutritional supplement with frequent meals 
+ 2500 kcal daily during hospitalisation 
+ 1000 kcal daily as outpatients 
• rehydration: administration of ORS according to WHO protocols.
• zinc supplement in children under 5 years.
– Never give loperamide or any other antidiarrhoeal.
– Management of complications: rectal prolapse reduction, septicaemia, etc.