7 Amebae

Intestinal Ameba
Entamoeba histolytica
Scientific name
Common name

Entamoeba histolytica
Ameba

Entamoeba histolytica is the only pathogenic

intestinal amoeba of the Entamoeba species to
infect humans.
Approximately 10% of the world population is
infected with E. histolytica/dispar, but only a tenth
of those people are infected with E. histolytica

Geographical Distribution
Endemic (tropical and subtropical region)

o
South America
o
Africa
o
China
o
Asia
o
Mexico

Prevalence of amebiasis in the Philippines is low

(about 1.5%)

Endemic areas in the Philippines

o
Baguio
o
Davao
Iloilo
o
o
Cagayan de Oro
o
Cebu
Transmission and Life Cycle
Transmission

o
Ingestion of infective matured cysts thru:
Contaminated food

Water

Hands contaminated with feces

From the lack of personal hygiene among
o
cyst carrier
o
Flies feeding from feces containing cysts
and subsequently contaminating food
E. histolytica exists in the body as the fragile motile
trophozoite and the hardy infective cyst.
Man ingests
tetranucleated cysts in
food and drink

Cysts excyst in the

alkaline juices of the small
intestines where the
tetranucleated
trophozoites are liberated

Divide into four

metacystic trophozoites

Pass down to the caecum

where they colonize in
glandular crypts (of
Lieberkuhn)

Develop into normal sized

trophozoites and multiply
by fission

Trophozoites invade the

large intestines, sigmoid
and rectum.

Transform into precystic

stages in lumen of the
large gut
Trophozoites passed out
in diarrheic stools

Stools passed out

Morphological Characteristics

Immature cyst
o Have a vacuole
o Few nuclei

Mature cyst
o 10-20 microns
o 4 nuclei
o Rounded or cigar shaped chromatoidal bars
o Infective stage to host

Trophozoites
o Size 12-30 microns
o Possesses one nucleus
o With a fine even peripheral chromatin
o Punctuate karyosome is usually central in
location sometimes off central
o Cytoplasm usually contains little debris with
fine outer membrane

Size
Motility
Pseudopodia
Inclusions
Nucleus

8-30 um
Active, progressive, directional
Finger-shaped, hyaline, glass-like;
rapidly extruded
Red blood corpuscles;
no bacteria in fresh specimens
Usually invisible

Vegetative or trophozoite stage, unstained

Develop into
monunucleated cysts in
formed stools

Cysts mature
rainwater@mymelody.com || 2nd semester, AY 2011-2012

Nuclear membrane
Karyosome

Delicate; lined with single layer

of chromatin dots
Minute; central

Cyst stage, iodide smear preparation

Vegetative or trophozoite stage, iron hematoxylin stain

Habitat

Intestinal (large intestine)

o Most frequent sites

Cecum

Terminal ileum
o Less frequent sites

Ascending colon

Rectum

Sigmoid

Appendix
Extra intestinal
o Liver
o Lungs
o Brain
o Skin
o Other organs

Pericardium

Spleen

Genitalia

Kidney and urinary bladder

Clinical Manifestation and Pathology

90% of persons infected with E. histolytica are

asymptomatic

Disease is caused by pathogenic strains of amoeba

invading the wall of the intestine.

Multiply in submucosa, forming large flask-shaped

ulcers which contain necrotic tissues

Development of invasive amoebiasis depends on

the level of immunity, nutrition and intestinal
environment of the host.

It is the only invasive amoeba of the Entamoeba

species
Characteristic pathology flasklike primary ulcer
1. Crateriform appearance
2. Wide base and narrow opening
3. Irregular, slightly elevated, overhanging edges

Size
Shape
Cytoplasm
Glycogen Mass
Nuclei

10-20 um
Usually spherical
Bright greenish-yellow
Diffuse; reddish brown
1 to 4; minute central karyosome refractile;
nuclear membrane beaded

Complications of intestinal amebiasis

1. Appendicitis
2. Intestinal perforation
3. Hemorrhage
4. Stricture
5. Granulomas
6. Pseudopolyposis
Pathogenic activities depend upon:
1. Resistance of the host
a. Innate immunity
b. State of nutrition
c. Freedom from infections and debilitating
diseases
2. Virulence and invasiveness of the amebic strain
3. Conditions in the intestinal tract
rainwater@mymelody.com || 2nd semester, AY 2011-2012

Symptomatology
Intestinal
Asymptomatic infection

Healthy carriers or cyst passers most common

1. Vague abdominal discomfort
2. Weakness
3. Neurasthenia
Symptomatic infection
1. Nondysenteric colitis
a. Moderate malaise
b. Alternating diarrhea and constipation
c. Irregular colicky abdominal pain
d. With or without local abdominal tenderness
2. Dysenteric
a. Acute intestinal amebiasis
1. Incubation period 1-14 weeks
2. Severe dysentery with numerous
small stools containing blood,
mucus and shreds of necrotic
mucosa
3. Acute abdominal pain and
tenderness
4. Fever (38 to 39)
5. Dehydration, prostration and
toxemia
b. Chronic amebiasis
1. Recurrent attacks of dysentery
2. Intervening periods of mild or
moderate gastrointestinal
disturbances and constipation
3. Localized abdominal tenderness
4. Liver may be enlarged
5. Psychoneurotic disturbances
6. Marked weight loss and cachexia
Differential diagnosis
1. Ulcerative colitis
2. Carcinoma of the large intestine
3. Diverticulitis
Extraintestinal
Hepatic amebiasis
1. Most common complication; a grave manifestation of
intestinal amebiasis
2. Due to metastasis of the infection from the intestinal
mucosa by way of the portal blood stream
3. Includes:
a. amebic hepatitis
b. abscess of the liver
Amebic hepatitis
1. Enlarged tender liver
2. Pain in the upper right hypochondrium that radiates
to the right shoulder
Abscess of the liver
1. Symptoms similar to amebic hepatitis but more
severe
2. Fever is common and chills may occur
3. Mild jaundice

Pulmonary amebiasis
1. Chills and fever
2. Evidence of pulmonary consolidation
Amebic infections of the brain
1. Signs and symptoms of brain abscess or tumor
2. Diagnosed only at autopsy
Differential Diagnosis
1. Intestinal amebiasis
a. Other dysenteries and intestinal diseases
2. Hepatic abscess
a. Viral and bacterial hepatitis
b. Hydatid cyst
c. Gallbladder infections
d. Malignancy
e. Pulmonary disease

Onset
Signs/ symptoms
Odor (feces)
Blood and mucus
pH
Pus cells/
PMN neutrophils
Cellular exudates
Pyknotic residues
Charcoat Leyden
crystals
Pathogenic amoebae
(motile amoebae
containing red cells
Bacteria
Macrophages

Amoebic
dysentery
Gradual
No significant
fever or vomiting
Offensive
(+)
Acidic
Few

Bacillary
dysentery
Acute
Fever and
usually vomiting
Odorless
Often watery
and bloody
Alkaline
Numerous

Scant
Numerous
Present

Massive
Few
Absent

Present

Absent

Few
Absent

Numerous
Present

Prevention
1. Treat all infections and examine contacts.
2. Remove carriers from the food handling occupations.
3. Institute sanitary methods of sewage disposal.
4. Screening of latrines.
5. Store feces used as fertilizers for an appropriate
length of time.
6. Use properly safeguarded filtered water supply.
7. Boil drinking water and ice should be made from
boiled water.
8. Treat small quantities with iodine compound tablets.
9. Screen and protect food from dust contamination.
10. Control of insects with insecticides
11. Uncooked vegetables should be washed with water
treated with iodine tablets or scalded at 80 C for at
least 30 seconds.
12. Inform the public regarding methods of avoiding
infection.
13. Development of a vaccine.

rainwater@mymelody.com || 2nd semester, AY 2011-2012

E. histolytica

Trophozoites

Cyst

Nucleus

E. coli

E. nana

I. buetschlii

Entamoeba coli

A non-pathogen amoeba
Morphological Characteristics

Cysts
o Size (12 25 microns)
o Larger than E. histolytica
o Consists of 8 nuclei with very diffuse
karyosomes
o May also contain needle-like chromatoidal
bodies with irregular fragmented ends

Trophozoites
o Size (18-28 microns)
o Larger than E. histolytica
o Has one nucleus containing a large diffuse
karyosomes
o Peripheral chromatin is usually dense and
irregular
o Cytoplasm is usually rough and contain few
to many ingested debris
Size
Motility
Pseudopodia
Inclusions
Nucleus

Nuclear membrane

Thick; lined with coarse chromatin

dots and bars
Large; location is eccentric

Karyosome

Vegetative or trophozoite stage, iron hematoxylin stain

15-50 um
Sluggish, rarely progressive and directional
Short and blunt; granular; slowly extruded
Bacteria and other material;
no blood corpuscles
Rarely visible

Vegetative or trophozoite stage, unstained

In the wet mount it is usually impossible to differentiate
between E. coli trophozoites and those of E. histolytica. A
stained smear is required.

Entamoeba gingivalis

The first human amoeba to be described

Found in all populations

Found only in the mouth: on the surface of teeth,

gingival pockets and tonsils

95% of unhygienic mouths, 50% of healthy

No cyst forms
Size
Average
Range
Inclusions
RBC
Bacteria and
other material
Vacuoles
Pseudopodia
Motility

15
5-35
Present at times
Present, abundant

Nucleus

Numerous
Usually blunt, hyaline,
often formed rapidly
Moderately active, progressive

rainwater@mymelody.com || 2nd semester, AY 2011-2012

Endolimax nana

A non-pathogen.

Most frequently recovered intestinal parasite.

Associated with unsanitary conditions.

The nucleus of E. nana may appear in many forms

making it sometimes difficult to differentiate
between other organisms such as Entamoeba
hartmanni and at times Dientamoeba fragilis.

The trophozoite of Endolimax nana typically has 1

nucleus with a large blob like karyosome, however,
it is not uncommon for a trophozoite to have 2
nuclei.

Surrounding the karyosome is a clear area called

the perikaryosomal space. A small amount of
peripheral chromatin may appear to be present but
it is not typical.

The cysts of E. nana are small, refractive cells with

4 nuclei containing large karyosomes and a
relatively clear cytoplasm.
Size
Motility
Pseudopodia
Inclusions
Nucleus

6-15 um
Sluggishly progressive
Blunt and hyaline; rapidly extruded
Bacteria; no blood corpuscles
Rarely visible

Vegetative or
trophozoite stage,
unstained

Size
Shape
Cytoplasm
Glycogen mass
Nuclei

Iodamoeba butschlii

Non-pathogenic.

Trophozoite size: 8 - 20 microns

The trophozoite of Iodamoeba buetschlii contains 1

nucleus with a large karyosome.

Typically chromatic granules are seen between the

karyosome and nuclear membrane often giving it a
cloudy appearance.

The nuclei do not appear to contain peripheral

chromatin.
Size
Motility
Pseudopodia
Inclusions
Nucleus

8-20 um
Sluggishly progressive
Blunt and hyaline; slowly extruded
Bacteria; no blood corpuscles
Invisible

Nucleus
Vegetative or trophozoite stage, unstained
Nuclear membrane
Karyosome

Thick; often lined with chromatin dots

Large and granular; location is central
or somewhat eccentric

Vegetative or trophozoite stage, iron hematoxylin stain

5-14 um
Spherical or ovoid
Pale green with refractile vacuoles
Usually diffuse; brownish
1 to 4, indistinct

Cyst stage, iodine smear preparation

Nucleus

Cyst size: 6 - 16 microns. The cysts contains 1

nucleus with chromatic granules and usually a large
vacuole making identification even in the wet
mount easy.
As with most amoeba, improved sanitary
conditions will reduce infection with this organism.
Most common amoeba of swine

Size
Shape
Cytoplasm
Glycogen Mass
Nuclei

5-20 um
Irregular
Yellowish green
Usually present;
dark brown; definite
1; indistinct but
usually evident
Cyst stage, iodine smear preparation

rainwater@mymelody.com || 2nd semester, AY 2011-2012

Entamoeba hartmanni

Entamoeba hartmanni is considered

nonpathogenic.

At one time literature incorrectly referred to as

being a sub-species of E. histolytica.

The cyst is very similar to E. histolytica but is

smaller, less than 10 microns. It very often contains
less than 4 nuclei but 4 nuclei are characteristic of
the species. The cyst also contains chromatoidal
bars, however, they are slightly smaller and more
numerous.

The trophozoite of E. hartmanni measuring 5 - 12

microns is smaller than that of E. histolytica and
often contains hyperparasites.

The size of the trophozoite is altered by the

presence of hyperparasites. Care must be taken
when differentiating the trophozoites of E.
hartmanni and E. histolytica.

Although E. hartmanni is considered

nonpathogenic it should be considered an indicator
of fecal contamination.

Free Living Amebas

Trophozoite

Trophozoite

Size range
Motility
Number of nuclei
Karyosome
Peripheral chromatin
Cytoplasm
Cytoplasmic inclusions

5 to 15 m
Nonprogressive/fingerlike
pseudopods
One
Small and central
Fine and evenly distributed
Finely granular
Ingested bacteria

Free-living Amebas Causing Meningoencephalitis and Keratitis

1. Species of Naegleria;
Naegleria fowleri has both an ameboid and
flagellate stage
2. Species of amebas called Acanthamoeba
Naegleria
Naegleria fowleri

Commonest pathogenic species causing amoebic

menigoencephalitis and keratitis
Transmission and Life Cycle

Nasal entry thru bathing in stagnant fresh water

lakes, pools contaminated with sewage or other
decaying matter and under chlorinated swimming
pools

After nasal entry, the amoebas penetrate the

cribiform plates and multiply along the base of the
brain

Size range
Motility
Number of nuclei
Karyosome
Peripheral chromatin
Cytoplasm
Cytoplasmic inclusions

8 to 22 m
Sluglike/blunt pseudopods
One
Large and usually centrally
located
Absent
Granular, usually vacuolated
Ingested bacteria

Cyst

Flagellate
Form

Size range
Shape
Number of nuclei
Karyosome
Peripheral chromatin
Cytoplasm
Cytoplasmic inclusions

5 to 12 m
Spherical
One to four
Small and central
Fine and evenly distributed
Finely granular
Chromatoid bars/ rounded ends
Diffuse glycogen mass

Symptomatology
a. Severe frontal headache
b. Fever
c. Blocked nose
d. Signs of CNS involvement
e. Altered taste and smell
f. Stiff neck and Kernigs sign

rainwater@mymelody.com || 2nd semester, AY 2011-2012

Laboratory findings
a. Peripheral white count leukocytosis with
preponderance of neutrophils
b. Cerebrospinal fluid analysis
1. presence of neutrophils
2. protein moderately elevated
3. glucose moderately reduced
4. CSF culture
c. Amebas can be recovered by:
1. Intracerebral inoculation of mice
2. Growth in non-nutrient agar in conjunction
with coliform growth
d. At autopsy
1. Amebas abundant in the involved areas of
the brain; rare in other organs
2. Trophozoites, without cysts, are seen in the
tissues
Treatment
1. Amphotericin
2. Amphotericin plus miconazole and rifampicin
Acanthamoeba
Trophozoite

Acanthamoeba: most common amoeba of freshwater and soil

Amebic encephalitis
a. Do not necessarily involve contact with soil or
stagnant water
b. Hematogenous spread to the CNS after initial
invasion via the respiratory tract or skin
c. Occurs in people who are debilitated from other
diseases or immunocompromised
d. Subacute clinical course with a variety of CNS
manifestations
e. Symptoms
1. meningeal signs
2. alteration of mental status
3. neurologic deficits mimicking brain
abscess or tumors
f. Pathologic process is a granulomatous amebic
encephalitis
g. Characteristic cycle with wrinkled walls present
in the affected tissues
h. Treatment
a. Sulfadiazine in experimental animals
b. 5 fluorocytosine and pentamidine has in
vitro activity; no cures for human infections
Amebic Keratitis
Acanthamoeba castellani
Acanthamoeba polyphaga
a.
b.

Size range
Motility
Number of nuclei
Karyosome
Peripheral chromatin
Cytoplasm

12 to 45 m
Sluggish/spinelike pseudopods
One
Large
Absent
Granular and vacuolated

Cyst

Preceded by some type of minor trauma resulting to

corneal ulceration
Associated with the use of contaminated contact
lenses

Clinical Features
1. Unilateral location
2. Severe ocular pain
3. A characteristic stromal infiltrate in the shape of a
complete or partial ring
4. Recurrent breakdown and healing of the overlying
epithelium
Laboratory Diagnosis
1. Microscopy
a. Giemsa or Periodic acid Schiff stained
smears from Giemsa Scrapings or corneal
biopsy specimens
b. Staining with immunofluorescent antibody
2. Culture in nutrient agar plates seeded with bacteria
Treatment
1. Long term application of agents such as propamidine,
miconazole and neomycin
2. Corneal grafting with enucleation

Size range
Shape
Number of nuclei
Karyosome
Peripheral chromatin
Cytoplasm
Other features

8 to 25 m
Rounding with ragged edges
One
Large and central
Absent
Granular, sometimes vacuolated
Double cell wall

Prevention
1. Do not swim or dive in small lakes and ponds that
have warm water and algal growth.
2. Adequate chlorination of swimming pools
3. Adhere closely to recommended procedures for use
and care of contact lenses

rainwater@mymelody.com || 2nd semester, AY 2011-2012

Flagellates and Ciliates

Flagellates

Intestinal
o Giardia lamblia
o Chilomastix mesnili
o Trichomonas hominis
o Dientamoeba fragilis

Urogenital
o Trichomonas vaginalis

Oral
o Trichomonas tenax
Ciliates

Intestinal
o Balantidium coli

Viability

May survive in water from 1-3 months

Killed at 50C
Survives at -20C for 10 hours
Killed by 1.0% cresol and 0.3% caustic soda

Pathogenesis

Incubation period - (pre-patent) period 10-36

days

Irritative; mechanical, toxic action in the

intestinal mucosa

Variable findings on biopsies

Ranges from blunting of villi, hypercellularity of

lamina propria to even villous atrophy, some
manifests denudation or ulcerations

Giardia lamblia
Habitat

Upper small intestine

Gall bladder and biliary drainage

Morphology

Trophozoite (9-21 X 5-15 um)

o Bilateral symmetry, 2 nuclei
o Sucking disc
o 4 pairs of flagella
o Median bodies, axonemes
o Falling leaf motility

Cyst
o Ovoid (8-14 X 7-10 um)
o 4 nuclei, 4 median bodies

Symptomatology

Acute diarrhea, flatulence, anorexia, abdominal

pain steatorrea and malabsorption,
hypoproteinemia, hypogammaglobulinemia,
fat-soluble vitamin deficiencies, lactose intolerance
Epidemiology

Water borne

Causes travelers diarrhea

More common in children than adults (day care

centers)

Reservoir in wild and domestic animals

Sexual transmission
Diagnosis

Fecalysis (concentration technique) alternating

high and low excretion of cyst
Enterotest
Duodenal aspiration techniques and
duodenoscopy,
Flouroscopy - mucosal defects

Treatment

Metronidazole, Albendazole, Mebendazole

Prevention

Purification/iodination of water
rainwater@mymelody.com || 2nd semester, AY 2011-2012

Dientamoeba fragilis

Considered recently to have closer affinity to

flagellates by virtue of electron microscope studies
Habitat

Mucosal crypts of the colon

Morphology

3-18 mm, hyaline broad and leaflike pseudopodia,

binucleate (arrested telophase), no cyst form

Clinical Manifestation

Mucoid diarrhea

Anal pruritus

Abdominal pain

Clinical Manifestations

Females
o Vaginal discharge profuse, watery, mucoid
or grayish, occasionally bubbly, mucosa
hyperemic with punctate hemorrhages
o Vulvar itchiness; burning sensation, urinary
frequency and dysuria

Males
o Infection frequently asymptomatic, may
involve the prostate, seminal vesicles and
urethra

Epidemiology

Oral transmission have not been proven

Transmission via nematode ovum

Prevalence 1-20% of population, higher in

institutional groups
Treatment

Iodoquinol

Tetracycline

Paromomyin
Trichomonas vaginalis
Morphology

5-15 um, Habitat uro-genital tract

Differs from T. hominis by its shorter undulating

membrane
Pathogenesis

Incubation period 4-28 days

Contact dependent cytopathic effect

Cell detaching factor that may cause sloughing of

vaginal epithelium (maybe influenced by estrogen
level)

Epidemiology

Sexually transmitted disease

Maybe transmitted to infants

Peak incidence (16-35 years) more among those

with other venereal diseases

Prevalence of 3-15% in asymptomatic ; 50-75%

among prostitutes

Females have 100% chance of getting the infection

from infected man
Diagnosis

Fresh vaginal smear or prostatic secretions

Sedimented urine
Culture Diamonds medium
Antigen Detection (EIA, DFA, LA, DNA probe)

Treatment

Metronidazole

Treatment of sexual partners

rainwater@mymelody.com || 2nd semester, AY 2011-2012

Chilomastix mesnilli

Commensal, cyst and trophozoite

10-20 um

Lemon shaped cyst, single large nucleus

Trophozoite, anterior flagella and spiral groove,

anterior nucleus

Ciliates
Balantidium coli

Only ciliate that parasitize humans

Habitat

Colon, cecum and

terminal ileum

Morphology

Trophozoite
o
Ovoid
o
35X50(small); 70 X 110(large) variety
o
With funnel shaped cytostome, body
covered with cilia; macro and micro nucleus
Cysts

o
50-75 long

Trichomonas hominis

Commensal, trophozoite only (7-15 um)

No cyst form

4 anterior flagella, one recurrent flagella, single

nucleus with small karyosome, a costa and axostyle

Binary fission; conjugation

Symptoms and Pathogenesis

Tissue invasion

Produces enzyme hyaluronidase

Many asymptomatic carriers

Mimics amoebic dysentery

Rarely may produce extraintestinal infection

Epidemiology

May cause epidemics in institution

Reservoir in hogs; transfer of porcine to human

host
Treatment

Oxytetracycline, Iodoquinol
rainwater@mymelody.com || 2nd semester, AY 2011-2012