Pleural empyema secondary to rupture of amoebic liver abscess

Amoebiasis is a worldwide parasitic infection although it is more prevalent in the subtropical and tropical countries. Extraintestinal amoebic infections currently have been reported in increased numbers of male homosexuals and immunocompromised patients. Here, we present an interesting case of a 27-year-old homosexual man with pleural empyema secondary to rupture of amoebic liver abscess. Using chest tube and percutaneous liver abscess drainage, the patient was treated with metronidazole followed by iodoquinol. His general condition improved dramatically. After one-year of follow-up, there was no evidence of relapse on plain chest radiography and abdominal CT scan.

Differentiating amoebic ulcero-haemorrhagic recto-colitis from idiopathic inflammatory bowel disease: still a diagnostic dilemma

The colon responds monomorphically to a variety of insults thus making it difficult to differentiate invasive amoebic colitis and inflammatory bowel disease (IBD). The authors present a case with chronic dysentery, haematochezia, anaemia and hypoproteinaemia. The endoscopic findings were suggestive of IBD. The stool examination was negative for trophozoites or cysts of parasites. The recto-colonic biopsy specimens showed mucosal inflammation with exudates containing amoebic trophozoites. The patient was successfully treated with metronidazole and iodoquinol. He recovered within two weeks and repeat colonoscopy four weeks after the treatment showed a normal rectum and colon. Clinicians should have a high level of suspicion for amoebic colitis in cases of colitis especially in regions where amoebiasis is still present. Efforts should be made to find the amoebic trophozoites in multiple stool and colonic biopsy specimens.

Efficacy of saccharomyces boulardii with antibiotics in acute amoebiasis

AIM

To compare the efficacy of antibiotics therapy alone with antibiotics and saccharomyces boulardii in treatment of acute amebiasis.

METHODS

In a double blind, random clinical trial on patients with acute intestinal amoebiasis, 57 adult patients with acute amoebiasis, diagnosed with clinical manifestations (acute mucous bloody diarrhea) and amebic trophozoites engulfing RBCs found in stool were enrolled in the study. Regimen 1 included metronidazole (750 mg Tid) and iodoquinol (630 mg Tid) for 10 days. Regimen 2 contained capsules of lyophilized saccharomyces boulardii (250 mg Tid) orally in addition to regimen 1. Patients were re-examined at two and four weeks after the treatment, and stool examination was performed at the end of week 4. Student's t-test, chi(2) and McNemar's tests were used for statistical analysis.

RESULTS

Three patients refused to participate. The other 54 patients were randomized to receive either regimen 1 or regimen 2 (Groups 1 and 2 respectively, each with 27 patients). The two groups were similar regarding their age, sex and clinical manifestations. In Group 1, diarrhea lasted 48.0+/-18.5 hours and in Group 2, 12.0+/-3.7 hours (P<0.0001). In Group 1, the durations of fever and abdominal pain were 24.0+/-8.8 and 24.0+/-7.3 hours and in Group 2 they were 12.0+/-5.3 and 12.0+/-3.2 hours, respectively (P<0.001). Duration of headache was similar in both groups. At week 4, amebic cysts were detected in 5 cases (18.5 %) of Group 1 but in none of the Group 2 (P<0.02).

CONCLUSION

Adding saccharomyces boulardii to antibiotics in the treatment of acute amebiasis seems to decrease the duration of clinical symptoms and cyst passage.

Intestinal amebiasis: a diagnosis not to be missed

Entamoeba histolytica is a well-recognized cause of infectious colitis and disseminated amebic abscesses. Most prevalent in the tropics and subtropics, E. histolytica infections may also occur in the developed world. We describe a case of a North American traveler with intestinal amebiasis, a diagnosis first made by colonic biopsy. We review the available diagnostic tools and the role of the surgical pathologist in the detection of this infection.

Gastric wall erosion by an amebic liver abscess in a 3-year-old girl

The occurrence of an amebic liver abscess (ALA) rupturing into the stomach is reported. ALAs in children can have atypical presentations, resulting in delayed diagnosis and increased morbidity and mortality. Timely treatment is usually followed by complete recovery.

Severe vaginal infection with Entamoeba histolytica in a woman who recently returned from Mexico: case report and review

Genital amebiasis is a rare complication of infection with Entamoeba histolytica, even in areas where the pathogen is endemic. We describe a patient who apparently contracted intestinal amebiasis on a trip to Mexico and who presented with ulcerative vulvovaginitis 2 months later. Her condition rapidly progressed to severe necrotizing vulvovaginitis that required a radical vulvectomy. Histopathologic examination of the surgical specimen revealed the presence of E. histolytica trophozoites. The patient recovered after surgery and antiamebic therapy. We review the epidemiology and pathogenesis of genital amebiasis as well as therapy for this rare infection.

Blastocystis hominis in hospital employees

Several reports have appeared that either support or deny the importance of the protozoan Blastocystis hominis as an intestinal pathogen in humans. In this report, we describe the clinical characteristics of B. hominis and its response to therapy in hospital employees found to have the parasite on routine screening of stools. During the study, 49 patients with B. hominis were identified, and 413 stools were examined from these patients. Twenty-nine patients were asymptomatic (59%), and 20 had symptoms of bloating, flatulence, soft/loose stools, or constipation. Of these 20 patients, 10 had symptoms that correlated with the presence or absence of B. hominis, four had symptoms that were independent of B. homonis, and six had other intestinal parasites that could account for their symptoms. Nineteen percent of patients without treatment had eradication of B. hominis from stool on follow-up examination. Metronidazole did not increase this rate. Iodoquinol treatment eradicated the organism in 41% of patients (p less than 0.05), and resulted in the reduction or eradication of the parasite in 62%, as determined by follow-up examination.

Amebic colitis. Preventing morbidity and mortality from fulminant disease

Uncomplicated amebic colitis is readily treated and has a mortality rate of less than 0.5%. Complications necessitating surgical intervention develop in only 6% to 11% of patients with symptomatic disease. However, the mortality rate in these patients ranges from 40% to 100% and stems in part from delays in diagnosis and treatment. Patients with known amebic colitis who show signs of systemic toxicity or of localized or generalized peritonitis are at high risk for complications; surgical consultation should be obtained. Patients who are thought to have acute appendicitis, diverticulitis, or obstructive or perforative carcinoma but have a history of dysentery atypical of that in these conditions should also be evaluated for amebiasis. Such patients should be treated presumptively until the diagnosis of amebic colitis can be excluded.

Rectal ameboma

Although rare, invasive amebiasis should be considered in the differential diagnosis of rectal disease suggesting carcinoma. In the case reported, rectal ameboma was responsible for the patient's rectal pain, hematochezia and weight loss.

Dientamoeba fragilis, a protozoan parasite in adult members of a semicommunal group

Dientamoeba fragilis is an intestinal protozoan parasite associated with gastrointestinal symptoms. This study was undertaken in a semicommunal group reported to have a high prevalence of this parasite. Stools were collected from 81 adult group members. Intestinal parasites were observed in stool specimens of 45 (56%) of the 81 adults; D. fragilis was found in 33 (41%) subjects. This paper describes the clinical findings and treatment of 26 adults with D. fragilis alone or with a commensal. Gastrointestinal symptoms were observed in 22 (85%) of infected subjects; abdominal pain and excessive flatus were significantly more common in this group. diiohydroxyquin 650 mg three times a day for 20 days eliminated the parasite in 10 (83%) of the 12 treated, although three subjects required a second course of therapy. Parasitic infection should be considered in patients with vague gastrointestinal symptoms, especially those living in endemic areas, in close proximity, or with a history of foreign travel.

Dientamoeba fragilis: a gastrointestinal protozoan infection in adults

Dientamoeba fragilis is a protozoan parasite of the large intestine of man. Individuals with infection may be asymptomatic or have gastrointestinal and systemic symptoms. We report a patient with symptomatic D. fragilis infection and negative extensive laboratory and radiological workup, with resolution of symptoms after diiodohydroxyquin therapy. No parasites were detected in three follow-up stool examinations. We then undertook retrospective study to define and describe further clinical symptoms in adults with this infection by analysis of data from medical records of 50 subjects with this parasite.

Malignant melanoma and dermatofibrosarcoma in a 60-year-old patient with lifelong acrodermatitis enteropathica

The life course of acrodermatitis enteropathica is recorded in a 62-year-old white man. Initially saved in infancy by breast-feeding and good medical care, later in his twenties he responded well to diiodohydroxyquinoline (Diodoquin) therapy, his only residua being dermatitis, hoarseness, and short stature. Subsequently untreated, this patient years later developed not only a dermatofibrosarcoma but also a large amelanotic malignant melanoma. Both were successfully excised. Subsequently, oral zinc therapy initiated for the first time cleared his acrodermatitis, which had been present for 60 years. It is suggested that this patient's malignancies developed as a result of an immune deficiency state typically found in acrodermatitis enteropathica. On this basis, acrodermatitis enteropathica may be viewed as having a malignant potential over the long term. The zinc-dependent nature of the immune deficit, however, suggests that lifelong daily zinc supplementation is an appropriate prophylactic measure.

Parasitic disease control in a residential facility for the mentally retarded

Asymptomatic infection with either Entameba histolytica or Giardia lamblia was found in 61 per cent of the residents of a dormitory in an institution for the mentally retarded; two other dormitories had rates of 20 per cent and 22 per cent. Drug therapy was successfully undertaken in all three dormitories, and environmental improvements were introduced in the heavily infected dormitory. A one-year follow-up showed a reduction in parasitic disease in two dormitories but, in the most heavily infected dormitory, infection had returned to pretreatment levels.

Therapeutic trial of four amoebicide regimes in rural Zaire

A prospective comparative trial of four amoebicide regimes was carried out with protozoological control using 300 patients presenting with symptomatic intestinal amoebiasis at a tropical rural hospital during a five month period. 195 (76.2%) of 256 treated supplied three follow-up stools. Of those treated with Metronidazole and Oxytetracycline 10.9 per cent continued to excrete Entamoeba histolytica while with Di-iodohydroxyquinoline and Oxytetracycline the figure was 25.5 per cent falling to 20.0 per cent when Dehydroemetine was added and with Clioquinol and Oxytetracycline 27.5 per cent continued to excrete Entamoeba histolytica. These figures with the absolute numbers of patients involved do not show any one of the regimes used to be significantly more effective than the others in unclassified symptomatic intestinal amoebiasis. We conclude therefore that in the rural situation the cheapest regime should be preferred as the standard one, namely Clioquinol and Oxytetracycline. However, in view of the reported serious side-effects of Clioquinol, Di-iodomydroxyquinoline and Oxytetracycline could be considered as the second cheapest and with slightly better results.

Dientamoeba fragilis. An intestinal pathogen in children?

A retrospective study was conducted of 35 children in whom Dientamoeba fragilis was the only parasite found in the gastrointestinal (GI) tract. Gastrointestinal symptoms were present in 32 (91%) of these children; diarrhea was the most common finding in patients with acute symptoms, whereas abdominal pain was more common in children with chronic symptoms. Peripheral eosinophilia was present in half of the children examined and was statistically more significant in patients with D fragilis than in a control group of children admitted for elective surgery. Therapy with diiodohydroxyquin or metronidazole was effective; children's symptoms were diminished or were eliminated on follow-up evaluation after treatment. From this association between therapy and symptomatic relief, D fragilis should be considered pathogenic in those children with GI symptoms.

Seborrheic dermatitis: practical therapy

A discussion of seborrheic dermatitis is presented, including the clinical picture, etiology, pathology, histochemistry, and therapy regimen and rationale.

Treatment of pulmonary aspergillosis with di-iodohydroxyquinoline

Thirteen patients with a clinical diagnosis of pulmonary aspergillosis were treated with the anti-amoebic drug di-iodohydroxyquinoline, 1500-1800 mg/day orally, for 20 days. All were precipitin positive before treatment and all but one became negative after treatment. Sputum became negative in all of the 10 patients in whom it had been positive before treatment. Clinical improvement was marked in four patients, moderate in three, and slight in three, no change occurring in the remaining three. These results suggest that di-iodohydroxyquinoline may be of value in the treatment of pulmonary aspergillosis.

Zinc and di-iodohydroxyquinoline therapy in acrodermatitis enteropathica

A 25-year-old patient with acrodermatitis enteropathica who had been treated with di-iodohydroxyquinoline for 20 years was changed to zinc sulphate therapy and studied under full metabolic balance control for zinc, calcium, magnesium, and inorganic phosphorus. The results obtained indicate that there is only a small overall deficit of body zinc stores in this disease and that the function of di-iodohydroxyquinoline is to increase the amount of zinc absorbed and retained by the body.

Clinical, biochemical and histochemical studies on infants with Acrodermatitis enteropathica chronica

7 infants diseased with Acrodermatitis enteropathica and 10 normal controls were included in this study. The values of anthranilic acid glucuronide, 6- aminohippuric, anthranilic acid, N-acetyl Kneurine, Kneurine and 30 H Kneurenine, were estimated in mg/24 hours urine, both basal and after tryptophane load. In addition, histopathological and histochemical studies for lactase, succinic dehydrogenase, alkaline phosphatase, acid phosphatase, and alpha-non-specific esterases activities were done for the intestinal mucosal biopsies. All the previous investigations were then repeated after two months treatment with 500 mg/day diiodohydroxyquinoline. The tryptophan metabolites were significantly low in the diseased infants, both basal and after tryptophan load. Moreover, the intestinal enzymes activities were altered. After 2 months treatment with diiodohydroxyquinoline the diseased infants became clinically improved, tryphtophan metabolites became normal, but the activities of the intestinal enzymes were not altered. The biochemical and histochemical findings were discussed, giving the possibility of competitive inhibition of the diiodohydroxyquinolines and the by-product 8 OH Quinololic acid resulting in more degradation of Kneurine and 3 OH Kneurenine to nicotinamide adenine dinucleotide.