Definition

Amoebiasis is an infection with intestinal

protozoa Entamoeba Histolytica.

90% of infection asymptomatic.

10% of infection Clinical syndrome.

Ranging from Dysentery to Abscess of the
liver or other organs.

PATHOLOGY
the intestinal lesion
Gut
Minute crypt lesion
Extends through the muscularis mucosa and submucosa.
Flask shaped ulcer
Thrombosis of blood vessels
Toxic megacolon
Irreversible coagulation necrosis of bowel wall.

CLINICAL FINDINGS
INTESTINAL AMOEBIASIS
Asymptomatic infection
Mild to moderate colitis (non dysenteric colitis)
Severe colitis (dysenteric colitis)
Localised ulcerative lesions of the colon
Localised granulomatous lesion of the colon
(amoeboma)

LABORATORY DIAGNOSIS
Microscopy And Culture
1. Wet Mount Preparation
(i) mounts in saline solution
(ii) mounts in saline + lodine
(iii) mounts in saline + methylene blue
2. Sample
Fixative
Examination
1. Stool

2. Sigmoid
colon
3. Aspirate
Direct
Fixed
4. Biopsy

Stain

-PVA 10 % formalin
-sodium acetate acetic
acid formalin
-PVA, schauddins
fixative

Permanently stained
slide

Gomori,trichrome,
Iron haematoxylin

Permanently
Stained slide

Gomori,trichrome
Iron haematoxylin

None

Wet mount with

enzyme digest
Permanently stained
slide
Routine histology

PVA, Schauddins
Fixative
Formalin

PAF Gomori
Haematoxylin and
eosin

Immunological Test
Indirect Haemagglutination
Enzyme Immunoassay
Indirect Immunoflorescence
Latex Agglutination
Gel diffusion
Sensitivity
60 % invasive Bowel disease 100 % with
Amoeboma

Clinical
presentation
Asymptomahic
Intestinal carrier

Intestinal infection

Drugs of Choice

Adult Dosage

1st Choice
Diloxanide Furoate

500 mg t.i.d 10 days

2nd Choice
Paramomycin
(or)
Iodoquinol

25 30 mg kg-1 day-1 in 3
doses 7-10 days.
650 mg t.i.d 20 days

1st Choice
Metronidazole
followed
by diloxanide furoate
( or )
Tinidazole followed by
diloxanide furoate
2nd Choice
Paramomycin

750 800 mg.t.i.d 10

days
500 mg.t.i.d 10 days
2 g/day 2 -3 days
500 mg .t.i.d 10 days
25 30 mg kg-1 day-1 in 3
doses 7 10 days

PREVENTION
Health Education
Improved water supply
Chlorination not effective
Amoebic cysts
Destroyed by
200 parts / 106 of Iodine 5 10 acetic acid.
Heating > 680C
Removed by
sand filtration
Boling for 10 minutes kill the cysts

This is the most common extra intestinal

form of invasive amoebiasis.
Adults > children ( 10 : 1 )
Male > female
20 % with past history of dysentery

PATHOGENESIS
Journey of E. Histolytica to the Liver
1. Direct Extension from the Gut to the Liver
2. Via the Lymphatics
3. Along the portal stream
Infarction Enzymatic Dissolution

Clear 'halo' around an amoeba

Destruction of liver tissue

Congestion of the sinusoids

Bulge due to superficial abscess

CLINICAL FEATURES
Symptoms
Pain
Diarrhoea and / or Dysentery
Weight Loss
Cough
Dyspnoea

Physical findings
Localized tenderness
Enlarged Liver
Fever
Rales,rhonchi
Localized intercostal tenderness
Epigatric Tenderness
Jaundice

COMPLICATONS
Right chest
Peritoneum
Pericardium
Amoebic brain abscess - rare
Hemobilia Rupture in to major bileduct
Portal hypertension

RADIOLOGY
1. CXR Elevated Right Hemi diaphragm
2. Isotope liver scan
3. USG Abdomen B mode , Hypoechoic
4. CTScan

DD

1. Subphrenic Abscess
2. Cholecystitis
3. Liver Hydatid cyst
4. Primary and Secondary carcinoma of liver
5. Lesions of the right lung and right pleura

TREATMENT
1st Choice

Metronidazole followed
by
diloxanide furoate
or
tinidazole followed by
diloxanide furoate

750-800 mg.t.i.d
10 days
500 mg t.i.d. 10
Days
2g/day 3-5 days
500 mg t.i.d 10
Days

2nd choice

dehyderoemetine followed by

1-1.5 mg kg-1 day -1

(max.90 mg/day ) i.v
5 days

diloxanide furoate

500 mg t.i.d 10 days.

INDICATIONS FOR
ASPIRATION OF AMOEBIC
LIVER ABSCESS
Formal Indications
To rule out a pyogenic abscess (, particularly with
multiple lesions )
As adjunct to medical therapy ( No response after 72 hours )
If rupture is believed to be imminent
Abscess in the left lobe where the risk of rupture is increased.
Possible Indications
To reduce the period of disability

Ivory or creamy white pus.

Brown coloured pus compared to

anchovy sauce.

ASCARIASI
S
A COMMON ROUND WORM DISEASE

INTRODUCTION

Ascaris lumbricoides is the

largest nematode
(roundworm) parasitizing the
human intestine.
Ascaris lumbricoides is an
intestinal worm found in the
small intestine of man.
They are more common in
children then in adult.
As many as 500 to 5000
adult worms may inhabit a
single host.

The Egg of Ascaris

LIFE CYCLE

Symptoms of Ascariasis

No symptoms
Stage 1:
worm larvae in the bowels attach to bowel walls
Stage 2:
worm larvae migrate into the lungs:
Fever and breathing difficulty
Coughing and pneumonia
Stage 3:
worms enter the small intestine and mature into worms
and remain there to feed
Abdominal symptoms
Abdominal discomfort
Intestinal blockage - may be partial or complete
Partial intestinal blockage
Total intestinal blockage
Severe abdominal pain
Vomiting
Restlessness
Disturbed sleep
Worm in stool
Worm in vomit

Treatment
Infections with A.lumbricoides are easily treated
with a number of Anthelmintic drugs:
Pyrantel pamoate given as a single dose of 10
mg/kg.
Levamisole given as a single dose of 2.5 mg/kg.
Mebendazole given as a single dose of 500 mg.
Albendazole given as a single dose of 400 mg.

PREVENTION
Keeping good sanitation conditions is the only way to
prevent the infection of Ascaris.
Pollution of soil with human faeces should be avoided.
Vegetable should be thoroughly washed in a mild
solution of Pottasium permanganate and properly
cooked before use.
Finger nails should be regularly cut to avoid the
collection of dirt and eggs below them.
Hands should be properly washed with some antiseptic
soap before touching edibles or eating.

Lymphatic Filariasis

Lymphatic Filariasis
Infection with 3 closely related Nematodes
Wuchereria bancrofti
Brugia malayi
Brugia timori
* Transmitted by the bite of infected mosquito
responsible for considerable sufferings/deformity and
disability
* All the parasites have similar life cycle in man
* Adults seen in Lymphatic vessels
* Offsprings seen in peripheral blood during night

Disease Manifestation
Disease manifestation range from
None
Acute-Filarial fever
Chronic-Lymphangitis, Lymphadenitis,
Elephantiasis of genitals/legs/arms
Tropical Pulmonary Eosinophilia (TPE)
Filarial arthritis
Epididimoorchitis
Chyluria

Lymphatic Filariasis
Diagnostic Methods

Diagnosis of Lymphatic
Filariasis
Lymphatic Filariasis can be diagnosed clinically
and through laboratory techniques.
Clinically, diagnosis can be made on
circumstantial evidence with support from
antibody or other laboratory assays as most of
the LF patients are amicrofilaraemic and in the
absence of serological tests which is not
specific other than CFA (ICT). In TPE, serum
antibodies like IgG & IgE will be extremely high
and the presence of IgG4 antibodies indicate
active infection.

Laboratory Diagnosis
1. Demonstration of microfilarae in the
peripheral blood
a. Thick blood smear: 2-3 drops of free flowing
blood by finger prick method, stained with JSB-II
b. Membrane filtration method: 1-2 ml
intravenous blood filtered through 3m pore size
membrane filter
c. DEC provocative test (2mg/Kg): After
consuming DEC, mf enters into the peripheral
blood in day time within 30 - 45 minutes.

2. Immuno Chromatographic Test (ICT):

Antigen detection assay can be done by Card
test and through ELISA. Circulating Filarial
Antigen detection is regarded as Gold Standard
for diagnosing Wuchereria bancrofti infection.
Specificity is near complete, sensitivity is greater
than all other parasite detection assays, will
detect antigen in amicrofilaraemic as well as with
clinical manifestations like lymphoedema,
elephantiasis.

3. Quantitative Blood Count (QBC):

QBC will identify the microfilariae and will help in studying
the morphology. Though quick it is not sensitive than blood
smear examination.

4. Ultrasonography:
Ultrasonography using a 7.5 MHz or 10 MHz probe can
locate and visualize the movements of living adult worms
of W.b. in the scrotal lymphatics of asymptomatic males
with microfilaraemia. The constant thrashing movements
described as Filaria dance sign can be visualized.

5. Lymphoscintigraphy:
Structure

and function of the lymphatics of the involved

limbs can be assessed by lymphoscintigraphy after
injecting radio-labelled albumin or dextran in the web
space of the toes. The structural changes can be imaged
using a Gamma camera. Lymphatic dilation & obstruction
can be directly demonstrated even in early clinically
asymptomatic stage of the disease.

6. X-ray Diagnosis:
X-ray are helpful in the diagnosis of Tropical pulmonary
eosinophilia.
Picture will show interstial thickening, diffused nodular
mottling.
7. Haematology : Increase in eosinophil count

Lymphatic Filariasis
Clinical Manifestations

Clinical Manifestations

Manifestations are 2 types

1. Lymphatic Filariasis (Presence of Adult
worms)
2. Occult Filariasis (Immuno hyper
responsiveness)

Stages in Lymphatic
Filariasis

There are 4 stages :

1.
2.
3.
4.

Asymptomatic Amicrofilariaemic stage

Asymptomatic Microfilariaemic stage
Stage of Acute manifestation
Stage of Obstructive (Chronic) lesions

Lymphatic Filariasis
Management

Management of Lymphatic
Filariasis
1. Treating the infection
2. Treatment and prevention of Acute ADL
attacks
3. Treatment and prevention of Lymphoedema

 Treating the infection:

Remarkable advances in the treatment of
LF have recently been achieved focusing not
on individual but on community with infection,
with the goal of reducing mf in the community,
to levels below which successful transmission
will not occur.

Chemotherapy of Filariasis
Drugs effective against filarial parasites
1.
2.
3.
4.

Diethyl Carbomazine citrate (DEC)

Ivermectin
Albendazole
Couramin compound
Treatment of microfilaraemic patients may
prevent chronic obstructive disease and
may be repeated every 6 months till mf
and/or symptoms disappears.

Surgical Treatment
Hydrocele: Excision
Scrotal Elip: Surgical removal of Skin &
Tissue, preserving penis and testicles.
Lymphoedema
(Elephantiasis):
Excision of redundant tissue, Excision
of subcutaneous and fatty tissues,
Postral drainage and physiotherapy

Echinococcus granulosus

Morphology

Only 2-8 mm long

Usually comprises of Scolex: with four suckers and 2 circular

rows of hooks
neck
immature proglottid
mature proglottid
gravid proglottid

The eggs of E. granulosus and Teania spp. are

indistinguishable

 Hydatid Cyst:
Round & cystic
Wall cuticle layer, germinal layer
Contents
cystic fluid, brood capsules, protoscolex, daughter
& grand daughter cysts (hydatid sands)

Hydatid cyst
Cuticle layer
Germinal layer
Daughter cyst
Granddaugher cyst
Protoscolex

Brood capsule

Brood capsule

Hydatid cyst

Pathogenesis

Cause Hydatid Disease (Hydatidosis)

Sites of hydatid cyst: liver, lungs,
abdominal cavity, spleen, kidney, heart,
bones, brain etc
Analysis of 15,289 cases in Xinjiang,China
Liver 69.97%
Lung 19.3%
Abdominal cavity 3%

Clinical menifestations
Depends on the size, the location and the
number of cyst.
Pressure by tremendous size of the cyst. results in
disfunction of liver, lung or nervous system
Allergy -due to rupture of cyst, may cause severe
allergic reaction
Regeneration due to rupture of cyst, intracystic
protoscolex or germinal layer may be transplanted
and result in multiple secondary infection
Secondary regeneration 5.3%

Toxicosis by secretion of worm

Diagnosis
History of contacting with sheep & dogs
Clinical symptoms of a slow-growing tumor
accompanied by eosinophilia are suggestive
Parasitological examination for finding scolexes,
brood capsules & daughter cysts
Cysts in organs or calcified cysts can be
visualized using x-rays, CT & B-ultrasound
examination
Biopsy are forbidden unless during operation

 Serological examination for specific Ab or

Cag.
Intradermal (Casoni) test with hydatid fluid is
useful.
Antibodies against hydatid fluid antigens
have been detected in a sizable population
of infected individuals by ELISA or indirect
hemagglutination test.

B-ultrasound, liver

CT, liver

CT, brain

X-ray, lung

Control and treatment

Regular treatment of infected dogs to reduce worm
load.
Prevention of dogs from eating infected offals of
domestic animals(sheep,etc) in the endemic areas.
Health education and strict personal hygiene.
Avoidance of unnecessary contact with infected
dogs.
Surgery is still remains the mainstay of the
treatment of hydatid disease.
Albendazole have proved to be effective against
hydatid cyst(for median or small size cysts).