Question 1 of 10

    Amebiasis (Amebiases)

    Amebiasis is an infectious disease caused by the protozoan parasite, Entamoeba histolytica. The disease occurs in two forms: intestinal and extra-intestinal amebiasis.  

    Amebiasis arises due to the following process: infectious.

    Presentation

    Persons with amebiasis may or may not manifest the disease. Symptoms, if any, include flatulence, alternating diarrhea and constipation, and abdominal cramps. In advanced cases, the patient may complain of fever, abdominal tenderness and passage of bloody, mucoid stools (frank dysentery). Dehydration is imminent. The patient is emaciated and possibly anemic from chronic infection and malnutrion. A large mass  (ameboma) may obliterate the intestines. 

    Colonies of trophozoites can cause ulcers and perforate the intestinal wall, resulting in severe abdominal pain and peritonitis needing urgent medical intervention.

    Extraintestinal amebiasis can cause suppurative infection of the liver parenchyma (abscess), fever, chills, sweating, general debility, nausea, vomiting, and pain in the upper right quadrant. Amebas may spread to other organs, including the lungs or brain, the skin, especially around the buttocks, genitals, or wounds from abdominal surgery or injury.

    Complications of amebic colitis include ameboma, toxic megacolon, fulminant or necrotizing colitis, and rectovaginal fistula. Hepatic amebiasis or liver abscess may lead to intrapericardial, intrathoracic, or intraperitoneal rupture, with or without secondary bacterial infection; invasion of the pleural or pericardial cavity; and migration to the brain via blood route and development of brain abscess. Other complications include GI bleeding, bowel perforation, peritonitis, stricture formation, empysema and intussusception [11] [12].

    gastrointestinal
    Diarrhea
    • In fact, most traveler's diarrhea is bacterial or viral in origin.[en.wikipedia.org]
    • Entamoeba histolytica is a common pathogen leading to chronic bloody diarrhea in developing countries .[journalmc.org]
    • May not present with diarrhea, but will usually have a preceding history of diarrhea.[us.bestpractice.bmj.com]
    • Soft stools or diarrhea may alternate with constipation.[thirdworldtraveler.com]
    • Typically, this diarrhea is watery or contains blood and mucus.[drugs.com]
    Abdominal Pain
    • The patient attended to our clinic with nonspecific abdominal pain and intermittent bloody diarrhea.[journalmc.org]
    • Examples of causes of abdominal pain in adults include learn more Abdominal Pain in Children Abdominal pain in children can range from trivial to life-threatening.[emedicinehealth.com]
    • pain, a painful contracted feeling around the anal sphincter, blood and mucus in the stools but without the presence of fever), or amoebic liver abscesses (fever, chills, abdominal pain, weight loss, hepatomegaly) that can be fatal if not immediately[orpha.net]
    • Extra-intestinal amoebiasis Patients show symptoms of fever and right upper abdominal pain.[webhealthcentre.com]
    • When present, symptoms include crampy abdominal pain , flatulence, and intermittent diarrhea/constipation.[mdguidelines.com]
    Abdominal Cramps
    • The symptoms and signs include loose stools , mild abdominal cramping, frequent, watery, and/or bloody stools with severe abdominal cramping (termed amoebic dysentery) may occur, flatulence , appetite loss , and fatigue .[medicinenet.com]
    • However, the most common symptoms are abdominal cramps and loose stools.[simcoemuskokahealthstats.org]
    • Symptoms include diarrhea, abdominal cramping and pain, nausea, bloody stools, loose stools, fever, weight loss and in severe cases intestinal damage can occur. credit: C f O'kane/Hemera/GettyImages Homeopathic Cure For Amoebiasis In Descriptive Medicine[leaf.tv]
    • Additional symptoms may include fever, and abdominal cramping and pain.[healthcentral.com]
    • Mild symptoms: Abdominal cramps Diarrhea: Passage of 3 to 8 semiformed stools per day, or passage of soft stools with mucus and occasional blood Fatigue Excessive gas Rectal pain while having a bowel movement ( tenesmus ) Unintentional weight loss Severe[scripps.org]
    Abdominal Tenderness
    • Abdominal tenderness and weight loss are common with amebic colitis.[us.bestpractice.bmj.com]
    • Abdominal tenderness and weight loss are common with amoebic colitis.[bestpractice.bmj.com]
    • Examination of the abdomen can show enlargement of the liver or abdominal tenderness.[byebyedoctor.com]
    • The mild form of Amebiasis includes nausea, diarrhea, weight loss, abdominal tenderness and occasional fever.[algomapublichealth.com]
    • More severe illness (amebic dysentery) is characterized by fever, bloody diarrhea, generalized abdominal tenderness, vomiting, and much greater toxicity.[thirdworldtraveler.com]
    Tenesmus
    • Mild symptoms: Abdominal cramps Diarrhea: Passage of 3 to 8 semiformed stools per day, or passage of soft stools with mucus and occasional blood Fatigue Excessive gas Rectal pain while having a bowel movement ( tenesmus ) Unintentional weight loss Severe[scripps.org]
    • Mild symptoms may include: Abdominal cramps Diarrhea: passage of 3 to 8 semiformed stools per day, or passage of soft stools with mucus and occasional blood Fatigue Excessive gas Rectal pain while having a bowel movement ( tenesmus ) Unintentional weight[uichildrens.org]
    • In 10% of patients with the disease amoeba, the most common symptoms are usually abdominal pain , tenesmus (painful evacuate) and aqueous massive diarrhea with several bowel movements per day, and weight loss .[tabletsmanual.com]
    Malnutrition
    • […] spread: Through food or water contaminated with stools Through fertilizer made of human waste From person to person, particularly by contact with the mouth or rectal area of an infected person Risk factors for severe amebiasis include: Alcohol use Cancer Malnutrition[uichildrens.org]
    • Symptoms of these more severe infections include: anemia appendicitis (inflammation of the appendix) bloody diarrhea fatigue fever gas (flatulence) genital and skin lesions intermittent constipation liver abscesses (can lead to death, if not treated) malnutrition[parasitesinhumans.org]
    • Among the risk factors for symptomatic amebiasis include: Pregnancy Use of immunosuppressive drugs The use of corticoids Alcoholism Age of extremes (infants and the elderly) HIV Cancer Malnutrition As already said, more than 90% of patients infected with[tabletsmanual.com]
    Loss of Appetite
    • But sometimes, it invades the lining of the large intestine, causing bloody diarrhea , stomach pains, cramping, nausea, loss of appetite, or fever .[kidshealth.org]
    • But sometimes, it invades the lining of the colon, causing stomachache, cramping, nausea, loss of appetite, bloody diarrhea, or fever.[bimcbali.com]
    • You may experience fatigue, loss of appetite, and some weight loss.[thirdworldtraveler.com]
    • If the infection spreads to your liver, which is rare, you may develop a fever, pain in your upper-right abdomen, nausea, vomiting, loss of appetite, weight loss, and fatigue.[consumer.healthday.com]
    • […] of appetite Fulminant or necrotising colitis can develop Amoebic liver abscess Most commonly presents as fever, pain in the right upper quadrant of the abdomen, and tenderness Jaundice can occur 60-70% of patients with amoebic liver abscess do not have[dermnetnz.org]
    Chronic Diarrhea
    • This potentially serious illness is caused by parasites that invade the wall of the large intestine, causing either acute dysentery or chronic diarrhea of variable severity.[thirdworldtraveler.com]
    • Usually caused by the amoeba Entamoeba histolytica, infection can result in chronic diarrhea in humans and canines.[dogcare.dailypuppy.com]
    • In some cases, it invades the colon wall, causing colitis , acute dysentery, or long-term (chronic) diarrhea.[scripps.org]
    Severe Abdominal Pain
    • If you have severe abdominal pain, especially in the right upper side, and a fever, visit a doctor the same day.[drugs.com]
    • Fulminant infection with high grade fever, severe abdominal pain and profuse diarrhoea occurs in children and in patients receiving steroids.[webhealthcentre.com]
    • So, symptoms of amoebic dysentery include severe abdominal pain and diarrhoea which can contain blood and mucus.[patient.info]
    • Individuals with more severe amebiasis may also experience fever , weakness, nausea , vomiting, abdominal bloating, severe abdominal pain, and weight loss.[mdguidelines.com]
    • In more severe cases, symptoms can include: watery diarrhoea that contains blood or mucus nausea or vomiting (feeling or being sick) severe abdominal pain stomach cramps a high temperature (fever) of 38C (100.4F) or over Amoebic dysentery Dysentery that[your.md]
    Acute Abdomen
    • abdomen Cases where symptoms develop months after infection may occur Young children may develop intussusception or necrotizing colitis that may lead to perforation Rare complications are toxic megacolon or colonic amebomas Amebic liver abscesses are[pathologyoutlines.com]
    • Keywords: Amebiasis; Colonic lymphoma; Intussusception Introduction Intussusception is one of the most common causes of acute abdomen in childhood.[journalmc.org]
    • When patients fail medical treatment and undergo open surgery for acute abdomen, gastrointestinal bleeding, or toxic megacolon ( 64 ), mortality is extremely high and broad-spectrum antibiotics should probably be added for bacterial spillage into the[antimicrobe.org]
    Mucus in Stool
    • Sometimes blood and mucus in stools may also be present.[surgerydoor.co.uk]
    • Symptomatic patients initially have lower abdominal pain and diarrhoea and later develop dysentery (with blood and mucus in stool).[webhealthcentre.com]
    Tenderness in the Right Upper Quadrant
    • Fever and tenderness in the right upper quadrant of the abdomen are common symptoms of amebic liver disease.[epainassist.com]
    Acute Diarrhea
    • In Egypt, 38% of individuals presenting with acute diarrhea to an outpatient clinic were found to have amebic colitis. [4] A study in Bangladesh indicated that preschool children experienced 0.09 episodes of E histolytica -associated diarrhea and 0.03[emedicine.medscape.com]
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  • Entire body system
    Fever
    • Instead, they may note fever, upper abdominal pain, and an enlarged, tender liver.[thirdworldtraveler.com]
    • Amoebic liver abscess presents with fever and right upper quadrant abdominal pain.[who.int]
    • In about one third of cases, fever is present. * parasites are creatures that live in and feed on the bodies of other organisms.[humanillnesses.com]
    • ), or amoebic liver abscesses (fever, chills, abdominal pain, weight loss, hepatomegaly) that can be fatal if not immediately treated.[orpha.net]
    • Associated symptoms include a yellow-brown coating on the tongue, a low-grade fever and watery stools.[leaf.tv]
    Weight Loss
    • Sweating, chills, weight loss, and fatigue may also be present.[thirdworldtraveler.com]
    • Often there are no symptoms, but, sometimes it causes diarrhea (loose stool/poop), nausea (a feeling of sickness in the stomach), and weight loss.[health.ny.gov]
    • Symptoms include: fever, cough, dull abdominal pain, nausea, diarrhea, ulcers, constipation, gas, hepatomegaly, cough, and weight loss.[web.stanford.edu]
    • Chronic amoebiasis can present with gastrointestinal symptoms plus fatigue, weight loss and occasional fever.[who.int]
    • Eventually, you may have profuse, bloody diarrhea along with a fever, intense abdominal pain, and rapid weight loss.[consumer.healthday.com]
    Chills
    • […] manifestations that may range from an asymptomatic state to amoebic colitis (violent abdominal pain, a painful contracted feeling around the anal sphincter, blood and mucus in the stools but without the presence of fever), or amoebic liver abscesses (fever, chills[orpha.net]
    • More severe cases may experience fever, chills and/or diarrhea with blood or mucous.[simcoemuskokahealthstats.org]
    • Sweating, chills, weight loss, and fatigue may also be present.[thirdworldtraveler.com]
    • Severe diarrhea (loose poop) Stomach pain Fever Chills Weight loss Most people infected do not show any symptoms at all.[wechu.org]
    • Identification – an intestinal protozoan parasitic infection in two forms 1) hardy infective cyst 2) fragile, potentially pathogenic trophozoite that can invade tissues - severe infection – amoebic dysentery – acute fever, chills and bloody or mucoid[the-travel-doctor.com]
    Malnutrition
    • […] spread: Through food or water contaminated with stools Through fertilizer made of human waste From person to person, particularly by contact with the mouth or rectal area of an infected person Risk factors for severe amebiasis include: Alcohol use Cancer Malnutrition[uichildrens.org]
    • Symptoms of these more severe infections include: anemia appendicitis (inflammation of the appendix) bloody diarrhea fatigue fever gas (flatulence) genital and skin lesions intermittent constipation liver abscesses (can lead to death, if not treated) malnutrition[parasitesinhumans.org]
    • Among the risk factors for symptomatic amebiasis include: Pregnancy Use of immunosuppressive drugs The use of corticoids Alcoholism Age of extremes (infants and the elderly) HIV Cancer Malnutrition As already said, more than 90% of patients infected with[tabletsmanual.com]
    Anemia
    • Symptoms of these more severe infections include: anemia appendicitis (inflammation of the appendix) bloody diarrhea fatigue fever gas (flatulence) genital and skin lesions intermittent constipation liver abscesses (can lead to death, if not treated)[parasitesinhumans.org]
    • Specialty Infectious disease Symptoms Abdominal pain , diarrhoea , bloody diarrhea [3] Complications Severe colitis , intestinal perforation , anemia [3] Causes Amoebas of the Entamoeba group [3] Diagnostic method Stool examination , antibodies in the[en.wikipedia.org]
    • Emaciation as well as anemia can happen in individuals with long-lasting infection.[byebyedoctor.com]
    • Between relapses, symptoms diminish to recurrent cramps and loose or very soft stools, but emaciation and anemia may develop.[merckmanuals.com]
    Malaise
    • Capacity: Individuals with amebiasis may have temporarily reduced work capacity due to intermittent diarrhea, crampy abdominal pain , and, in some cases, fever and malaise.[mdguidelines.com]
    • Diagnosis - can mimic appendicitis or present with weight loss and malaise - stools essentially blood and mucous - only 40% are febrile - liver abcess usually presents within 5 months of travel - only 1/3 have diarrhea - can get a fistula to the lung[the-travel-doctor.com]
    Constitutional Symptom
    • Onset of constitutional symptoms is often insidious, but pain may begin abruptly.[emedmd.com]
    Unsafe Sexual Practices
    • Transmission of amebiasis can happen by taking fecal contaminated food or water or it can also spread from person to person contact like unsafe sexual practices or when changing diapers of baby infected with amebiasis.[epainassist.com]
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  • Liver, Gall & Pancreas
    Hepatomegaly
    • […] the liver 484 Parasitic infections and the liver 498 Mycotic infections and the liver 518 Liver abscess 524 Alcoholinduced liver damage 532 Druginduced liver damage 556 Mehr Scintigraphic diagnostics 200 Neurological and psychological diagnostics 208 Hepatomegaly[books.google.de]
    • […] asymptomatic state to amoebic colitis (violent abdominal pain, a painful contracted feeling around the anal sphincter, blood and mucus in the stools but without the presence of fever), or amoebic liver abscesses (fever, chills, abdominal pain, weight loss, hepatomegaly[orpha.net]
    • Symptoms include: fever, cough, dull abdominal pain, nausea, diarrhea, ulcers, constipation, gas, hepatomegaly, cough, and weight loss.[web.stanford.edu]
    • Presentation of liver abscess may be acute with fever and abdominal pain, tachypnea, and liver tenderness and hepatomegaly, or chronic with weight loss, vague abdominal symptoms, and irritability.[meddean.luc.edu]
    • When a liver abscess is present, the liver may be enlarged (hepatomegaly).[mdguidelines.com]
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  • Course
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  • Workup

    The diagnosis of amebiasis requires collection of fecal sample from the patient for subsequent tests [13]. Microscopic examination may not always reveal the presence of the amebas (trophozoites and/or cysts). Two methods are currently available:

    1. In vitro reaction of parasite protein (antigen) with specific antibody and
    2. Polymerase chain reaction (PCR)

    Molecular diagnostic technique to identify ameba's genetic material. PCR amplifies the ameba's genetic material when present and makes detection possible even with minute quantities of reagents. Both tests are sensitive and specific. Routine microscopy examination may require three to six repeat ed stool examinations and differential diagnosis of ameba species is difficult based on gross morphology.

    Colonoscopy can reveal the presence of ulcers or other signs of infection in the large intestine. Tissue samples may be obtained for further evaluation.

    Parasites may not be found in the stool in extraintestinal amebiasis. Appropriate diagnostic methods are ultrasonography, CT scan, or MRI, with serological test for anti-ameba antibodies to confirm liver abscess or infection in other sites. Given a strong index of suspicion, the physician may initiate treatment with an amebicidal drug and if the patient responds well, the disease is presumed to be amebiasis. 

    Laboratory

    Serum
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  • Microbiology
    Entamoeba Histolytica
    • Life cycle of Entamoeba histolytica Warning: do not confuse the Entamoeba histolytica with other harmless amoeba like dispar Entamoeba, Entamoeba moshkovskii, Endolimax nails or Entamoeba coli.[tabletsmanual.com]
    • Human Infection by Entamoeba histolytica.[els.net]
    • "The immunopathogenesis of Entamoeba histolytica.".[librepathology.org]
    • Factors associated with the detection of Entamoeba histolytica in homosexual men.[mja.com.au]
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  • Imaging

    X-ray
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  • Test Results

    Proctoscopy
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  • Colonoscopy
    Colitis
    • Amoebic colitis is a type of infectious colitis , more common in tropical and subtropical areas.[radiopaedia.org]
    • Severe amoebic colitis is known as 'fulminant' or 'necrotising' colitis.[patient.info]
    • Atypical clinical manifestations of amebic colitis.[ijpmonline.org]
    • Patients with amoebic colitis usually present with bloody diarrhea, abdominal pain, and abdominal tenderness.[journals.lww.com]
    Colonic Ulcer
    • In the early stages the colonic ulcers have a narrow neck and thus appear as small nodules with a minute surface opening (5 mm in diameter).[histopathology-india.net]
    • A , Colonic ulcers of 1 mm diameter.[academic.oup.com]
    • Arrows indicate the colonic ulcers. b) Large bowel necropsy specimen from a case of fulminant amoebic colitis.[pubmedcentralcanada.ca]
    • Demonstration of E. histolytica trophozoites in tissue from a biopsy of a colonic ulcer (see Figure 2 ) is the gold standard for diagnosis.[antimicrobe.org]
    • Amoebic colitis with dysentery Dysentery, the passage of loose or diarrhoeal stools containing fresh blood, occurs when there is generalized colonic ulceration or when more localized lesions occur in the rectum or rectosigmoid.[emedmd.com]
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  • Treatment

    The current drug of choice for amebiasis is metronidazole or tinidazole [14], which kills the trophozoites in the intestine and other organs. Metronidazole is taken daily for several days, whereas tinidazole is given as a single large dose, with fewer side effects. Dehydrated patients are given fluids. Alcoholic drink is contraindicated since it may cause nausea, vomiting, flushing and headaches. These drugs are not to be taken by pregnant women.

    Metronidazole and tinidazole do not kill ameba cysts that are in the large intestine. A second drug (such as diloxanide, paromomycin, or iodoquinol) is prescribed to eliminate the cysts, thus prevent a relapse. These drugs may be taken by asymptomatic individuals who are positive for cysts both for prophylaxis and for eliminating the source of contamination of the environment with the infective stage of the parasite.

    Prognosis

    Amebiasis is among the leading causes of morbidity in developing countries. Susceptibility to infection and fatality rates vary with age, nutritional status, immune status , and involvement of extraintestinal foci. Severity of amebiasis is more pronounced in young children, especially neonates; malnourished individuals; pregnant and postpartum women; those on corticosteroids and those with immune deficiencies and/or malignancies.

    Treatment of intestinal amebiasis with appropriate drugs is straightforward but there is no immunity following previous infections nor guarantee against reinfections. Complete elimination of the intestinal forms can prevent the occurrence of extraintestinal amebiasis. Ninety percent (90%) of persons with intestinal amebiasis are asymptomatic and only 4-10% of them developed colitis or extraintestinal amebiasis after a one year follow-up period. 

    Effective treatment with amebicidal drugs has kept mortality rates below 1% for patients with uncomplicated liver abscess. On the other hand, hepatic amebiasis can be complicated by intraperitoneal rupture in 2-7% of patients and higher mortality rates can result from this [2].

    Complications

    Ileus
    • As the result of this suppuration, it may obstruct, or he may develop ileus.[meb.uni-bonn.de]
    Fever
    • Instead, they may note fever, upper abdominal pain, and an enlarged, tender liver.[thirdworldtraveler.com]
    • Amoebic liver abscess presents with fever and right upper quadrant abdominal pain.[who.int]
    • In about one third of cases, fever is present. * parasites are creatures that live in and feed on the bodies of other organisms.[humanillnesses.com]
    • ), or amoebic liver abscesses (fever, chills, abdominal pain, weight loss, hepatomegaly) that can be fatal if not immediately treated.[orpha.net]
    • Associated symptoms include a yellow-brown coating on the tongue, a low-grade fever and watery stools.[leaf.tv]
    Shock
    • The skin may turn pale and cold if shock develops.[mdguidelines.com]
    • Aspiration is largely being replaced by percutaneous catheter drainage. [ 13 ] In patients unsuitable for percutaneous drainage (elderly, frail, septic shock, multilocular cysts) laparoscopy is the preferred option. [ 14 ] Laparotomy is usually required[patient.info]
    • […] balance and prevention of complications resulting from abnormal or undesired fluid levels Hypovolemia Management: Rationale: Reduction in extracellular and/or intracellular fluid volume and prevention of complications in a patient who is fluid overloaded Shock[rnpedia.com]
    • Suppression of NF-kappaB activation by Entamoeba histolytica in intestinal epithelial cells is mediated by heat shock protein 27.[frontiersin.org]
    • Pericardial amebiasis, an unusual but serious complication, usually presents with fever and abdominal pain with progression to substantial chest pain and signs of congestive heart failure although acute perforation with cardiac tamponade and shock can[antimicrobe.org]
    Liver Abscess
    • Amoebic liver abscess Antibiotics are also needed to treat an amoebic liver abscess.[patient.info]
    • "First case of amebic liver abscess 22 years after the first occurrence" .[en.wikipedia.org]
    • Amebic liver abscess and its complications.[antimicrobe.org]
    • Fulminant colitis and liver abscess rupture are associated with higher mortality rates.[dermnetnz.org]
    Brain Abscess
    • Rare cause of brain abscess.[us.bestpractice.bmj.com]
    • Complications bowel perforation extraintestinal disease, including amoebic liver abscess (most common), brain abscess , peritonitis, pleuropulmonary and/or genitourinary disease, and pericarditis 1 other infectious colitides (e.g.[radiopaedia.org]
    • Codes A06 Amebiasis A06.0 Acute amebic dysentery A06.1 Chronic intestinal amebiasis A06.2 Amebic nondysenteric colitis A06.3 Ameboma of intestine A06.4 Amebic liver abscess A06.5 Amebic lung abscess A06.6 Amebic brain abscess A06.7 Cutaneous amebiasis[icd10data.com]
    • The offending parasite may invade other organs via blood and lead to liver abscess, lung abscess, brain abscess or in extremes instances inflammation of lining of heart which is called pericarditis.[surgerydoor.co.uk]
    Malnutrition
    • […] spread: Through food or water contaminated with stools Through fertilizer made of human waste From person to person, particularly by contact with the mouth or rectal area of an infected person Risk factors for severe amebiasis include: Alcohol use Cancer Malnutrition[uichildrens.org]
    • Symptoms of these more severe infections include: anemia appendicitis (inflammation of the appendix) bloody diarrhea fatigue fever gas (flatulence) genital and skin lesions intermittent constipation liver abscesses (can lead to death, if not treated) malnutrition[parasitesinhumans.org]
    • Among the risk factors for symptomatic amebiasis include: Pregnancy Use of immunosuppressive drugs The use of corticoids Alcoholism Age of extremes (infants and the elderly) HIV Cancer Malnutrition As already said, more than 90% of patients infected with[tabletsmanual.com]
    Dehydration
    • An ORS may also be recommended for your child if they are dehydrated or at risk of dehydration.[your.md]
    • Dehydration can be very dangerous, especially for children and older adults.[summitmedicalgroup.com]
    • Dehydration means there is a lack of fluid in your body.[patient.info]
    • Therefore, to prevent dehydration, you should remember to drink lots of fluids during the day.[vkool.com]
    • It is important to drink lots of fluids in order to prevent dehydration due to vomiting and diarrhea.[home-remedies-for-you.com]
    Ulcerative Colitis
    • colitis - steroids make it worse 2.[the-travel-doctor.com]
    • However, clinical amebiasis occurs when the parasite penetrates the colon wall, causing ulcerative colitis, or disseminates into other organs, most commonly the liver, leading to abscess formation.[cdipd.org]
    • Reglonal enteritis and ulcerative colitis must be considered in the younger patient.[thirdworldtraveler.com]
    • Correlations between defined sigmoidoscopic appearances and other measures of disease activity in ulcerative colitis.[ijpmonline.org]
    • Amebic dysentery may be confused with shigellosis, salmonellosis, schistosomiasis, or ulcerative colitis.[merckmanuals.com]
    Anemia
    • Symptoms of these more severe infections include: anemia appendicitis (inflammation of the appendix) bloody diarrhea fatigue fever gas (flatulence) genital and skin lesions intermittent constipation liver abscesses (can lead to death, if not treated)[parasitesinhumans.org]
    • Specialty Infectious disease Symptoms Abdominal pain , diarrhoea , bloody diarrhea [3] Complications Severe colitis , intestinal perforation , anemia [3] Causes Amoebas of the Entamoeba group [3] Diagnostic method Stool examination , antibodies in the[en.wikipedia.org]
    • Emaciation as well as anemia can happen in individuals with long-lasting infection.[byebyedoctor.com]
    • Between relapses, symptoms diminish to recurrent cramps and loose or very soft stools, but emaciation and anemia may develop.[merckmanuals.com]
    Appendicitis
    • Appendicitis — Condition characterized by the rapid inflammation of the appendix, a part of the intestine.[medical-dictionary.thefreedictionary.com]
    • Diagnosis - can mimic appendicitis or present with weight loss and malaise - stools essentially blood and mucous - only 40% are febrile - liver abcess usually presents within 5 months of travel - only 1/3 have diarrhea - can get a fistula to the lung[the-travel-doctor.com]
    • Symptoms of these more severe infections include: anemia appendicitis (inflammation of the appendix) bloody diarrhea fatigue fever gas (flatulence) genital and skin lesions intermittent constipation liver abscesses (can lead to death, if not treated)[parasitesinhumans.org]
    Traveler's Diarrhea
    • E. histolytica is not a common cause of travelers' diarrhea, and gastrointestinal infection is uncommon in travelers who have spent less than one month in endemic areas.[uptodate.com]
    • In fact, most traveler's diarrhea is bacterial or viral in origin.[en.wikipedia.org]
    Amebic Liver Abscess
    • Amebic Liver Abscess Amebic liver abscess is ten times more commonly observed in men than in women, while at the same time it is very rare in children.[news-medical.net]
    • Pleural empyema secondary to amebic liver abscess.[emedicine.medscape.com]
    • Amebic liver abscess is 10 times more common in men than women.[academic.oup.com]
    • Amebic liver abscess and its complications.[antimicrobe.org]
    Amebic Lung Abscess
    • Codes A06 Amebiasis A06.0 Acute amebic dysentery A06.1 Chronic intestinal amebiasis A06.2 Amebic nondysenteric colitis A06.3 Ameboma of intestine A06.4 Amebic liver abscess A06.5 Amebic lung abscess A06.6 Amebic brain abscess A06.7 Cutaneous amebiasis[icd10data.com]
    • lung abscess A06.6 Amebic brain abscess A06.7 Cutaneous amebiasis A06.8 Amebic infection of other sites A06.82 Other amebic genitourinary infections A06.89 Other amebic infections A06.9 Amebiasis, unspecified A07 Other protozoal intestinal diseases A07.1[icd10data.com]
    • Lung Abscess; Amebic Abscess of Lung, Liver 006.5 - Amebic Brain Abscess; Amebic Abscess of Brain, Liver, Lung 006.6 - Amebic Skin Ulceration; Cutaneous Amebiasis 006.8 - Amebic Infection of Other Sites; Amebic Appendicitis; Amebic Balanitis; Ameboma[mdguidelines.com]
    Colitis
    • Amoebic colitis is a type of infectious colitis , more common in tropical and subtropical areas.[radiopaedia.org]
    • Severe amoebic colitis is known as 'fulminant' or 'necrotising' colitis.[patient.info]
    • Atypical clinical manifestations of amebic colitis.[ijpmonline.org]
    • Patients with amoebic colitis usually present with bloody diarrhea, abdominal pain, and abdominal tenderness.[journals.lww.com]
    Colonic Perforation
    • Intestinal amoebiasis may rarely be complicated by: granuloma of the large intestine colitis, colonic perforation and haemorrhage perianal ulceration.[www2.health.vic.gov.au]
    • Most cases of amebiasis is mild to moderate intensity, but rarely, in about 0.5% of the cases, the disease can present in fulminant with intestinal necrosis, colonic perforation and severe peritonitis.[tabletsmanual.com]
    • Evolution of surgical treatment of amebiasis-associated colon perforation.[emedicine.medscape.com]
    • Acute colonic perforation in the absence of diffuse colitis or ruptured amoebic appendicitis may be amenable to local repair.[emedmd.com]
    Leukocytosis
    • […] fever, cough, and dull, achy right upper quadrant pain that may also include referred pain in the right chest or shoulder Only 1/3 have gastrointestinal symptoms Symptoms usually develop over two to four weeks The liver is usually enlarged and tender Leukocytosis[pathologyoutlines.com]
    • High fever, leukocytosis and high CRP were associated with extraluminal amebic diseases.[journals.plos.org]
    • Leukocytosis without eosinophilia is noted in 80% of cases and mild anemia in more than half.[antimicrobe.org]
    • Investigations FBC (leukocytosis), raised ESR, abnormal LFTs (raised alkaline phosphatase and transaminases). [ 2 ] Stool examination: Microscopic stool examination for trophozoites should be performed in patients with diarrhoea..Examination of 3 to 6[patient.info]
    • With regards to laboratory investigations, leukocytosis can happen, but eosinophilia is not seen.[tsijournals.com]
    Eosinophilia
    • The complete blood count showed a leukocyte count of 7800 μ L with eosinophilia of 7%.[hindawi.com]
    • With regards to laboratory investigations, leukocytosis can happen, but eosinophilia is not seen.[tsijournals.com]
    • […] cryptitis or crypt abscesses): graded as mild, moderate, or severe for cryptitis and few or many for crypt abscesses Chronic inflammation in the superficial and deep lamina propria (mild, moderate, or severe) and submucosa Presence of edema, fibrosis, eosinophilia[ijpmonline.org]
    • Laboratory Studies Laboratory diagnosis of amebiasis is made by demonstrating the organism or by employing immunologic techniques. [48, 49 , 50, 51 , 52] Findings from basic blood tests may include the following: Leukocytosis without eosinophilia (80%[emedicine.medscape.com]
    • Leukocytosis without eosinophilia is noted in 80% of cases and mild anemia in more than half.[antimicrobe.org]
    Proctocolitis
    • Colonic manifestations comprise a spectrum of disease, including 1-2 : acute proctocolitis (dysentery) perianal ulceration fulminant colitis leading to colonic wall perforation toxic megacolon chronic (nondysenteric) colitis ameboma CT appearances of[radiopaedia.org]
    • Symptomatic amoebiasis is manifested by symptoms such as mild diarrhea, severe dysentery (proctocolitis), abdominal discomfort, bloody diarrhea and colic pain.[tsijournals.com]
    • Intestinal conditions resulting from E histolytica infection include the following: Asymptomatic infection Symptomatic noninvasive infection Acute proctocolitis (dysentery) Fulminant colitis with perforation Toxic megacolon Chronic nondysenteric colitis[emedicine.medscape.com]

    Etiology

    Amebiasis is infection with the protozoan parasite, Entamoeba histolytica, which has two clinical manifestations i.e., intestinal amebiasis  (colitis. diarrhea, dysentery) and extraintestinal amebiasis (liver abscess, pleuropulmonary, cardiac, and cerebral involvement).

    Other species of Entamoeba are: E coli, E dispar, E moshkovskii, E polecki, E coli, and E hartmanni. These too reside in the human intestinal lumen as commensals (non-pathogenic) and should be differentiated from E histolytica as the only potentially pathogenic species. E dispar and E moshkovskii have been recovered from patients with gastrointestinal (GI) symptoms; however, their role in the pathogenesis of amebiasis remains to be verified.

    E dispar and E histolytica are indistinguishable from each other by light microscopy. Molecular techniques have shown them as two different species, with E dispar being the commensal (as in patients with HIV infection) and E histolytica, the pathogenic species.

    Co-infections with E histolytica and E dispar have been reported in many individuals, with E dispar being 10 times more common than E histolytica. In Brazil and Egypt, E dispar and E histolytica infections are equally prevalent [2]. In Western countries, E dispar has been isolated from 20%-30% of MSM (men having sex with other men).

    Transmission of E histolytica is primarily through the ingestion of fecally contaminated food and water containing cysts, or through the hands of food handlers. Sexual transmission occurs via oral-anal practices (anilingus). Malnutrition, resulting in immune deficiency , is a risk factor in amebiasis [3].

    Causes

    Dehydration
    • An ORS may also be recommended for your child if they are dehydrated or at risk of dehydration.[your.md]
    • Dehydration can be very dangerous, especially for children and older adults.[summitmedicalgroup.com]
    • Dehydration means there is a lack of fluid in your body.[patient.info]
    • Therefore, to prevent dehydration, you should remember to drink lots of fluids during the day.[vkool.com]
    • It is important to drink lots of fluids in order to prevent dehydration due to vomiting and diarrhea.[home-remedies-for-you.com]
    Protozoan Infection
    • Infection with E. histolytica is the fourth leading cause of death and the third leading cause of morbidity due to protozoan infections worldwide.[cdipd.org]
    • .: Amebiasis Entamoeba histolytica Additional relevant MeSH terms: Amebiasis Dysentery, Amebic Protozoan Infections Parasitic Diseases Intestinal Diseases, Parasitic Dysentery Gastroenteritis Gastrointestinal Diseases Digestive System Diseases Intestinal[clinicaltrials.gov]
    • The study documented the presence of enteropathogenic bacteria, parasites, and viruses in mixed infections, and highlighted the importance of diarrheal disease associated with protozoan infections.[pubmedcentralcanada.ca]
    • Recent studies have suggested that the intestinal bacterial microbiota may influence the outcome of protozoan infections ( 48 , 49 ).[frontiersin.org]
    Plasmodium
    • Therefore, Entamoeba histolytica is second only to the Plasmodium parasite (responsible for malaria) as a protozoan cause of death.[news-medical.net]
    • Two Plasmodium rhomboid proteases preferentially cleave different adhesins implicated in all invasive stages of malaria.[frontiersin.org]

    Epidemiology

    Amebiasis in the United States is approximately 4% of the total population. Of these, only 10% of E histolytica infections are invasive, and only 1% of those positive for E histolytica by stool examination actually develop symptomatic amebiasis. Asymptomatic E dispar infection is 10 times more prevalent than E histolytica.

    About 50 million cases of amebiasis due to E histolytica are reported each year, with 100,000 deaths worldwide. This is presumed to be an underestimation, representing as it is, the so-called tip of the iceberg, since only 10%-20% of infected individuals become symptomatic [4] [5]. Amebiasis is among the leading causes of morbidity in developing countries [6].

    Sex distribution
    Age distribution

    Pathophysiology

    Infection with the protozoan parasite E histolytica is associated with  proteolysis, tissue damage and host-cell apoptosis in humans and presumably nonhuman primates. Ingested E histolytica cysts from contaminated food and water or oral-anal sex undergo excystation in the terminal ileum or colon. Each mature cyst can give rise to four highly motile trophozoites which will colonize the intestinal mucosa, causing tissue lysis and ulcerations. Meanwhile,  trophozoites may find their way in the bloodstream and migrate to the liver, lung, and other sites, causing further damage thereat. With physiological changes in conditions in the intestinal lumen, the amebas may transform into cysts that are excreted in the feces. Excreted cysts when ingested by the next susceptible host will initiate a new infectious cycle.

    The trophozoite's ability to invade the colonic epithelium is facilitated by a 260-kd surface protein, galactose/N -acetylgalactosamine (GAL/GalNAc)–specific lectin, containing a 170-kd subunit and a 35-kd subunit [7] [8]. IgA antibody binds to this lectin receptor, killing the ameba thus, preventing reinfection [9].

    Amebapores, which are peptides capable of forming pores in bimolecular lipid layers of cell membranes are responsible for cytolysis and apoptosis of the parasite. Trophozoite-induced apoptosis in liver abscess was observed with a non-Fas and non–tumor necrosis factor (TNF)-α1 receptor pathway in experimental animal models [10]. Amebapores can also induce apoptosis at sublytic concentrations.

    Cysteine proteinases are involved in colonization of the gut and may amplify interleukin (IL)-1–mediated inflammation just as human IL-1–converting enzyme would cleave IL-1 precursor to its active form [11]. The anaphylatoxins C3a and C5a and immunoglobulins, IgA and IgG are likewise cleaved and inactivated by cysteine proteinases [12].

    E histolytica is equipped with 100 putative transmembrane kinases (TMKs), of which there are 9 subgroups. EhTMKB1-9 is found in proliferating trophozoites and is induced by serum. This was shown to be involved in phagocytosis and virulence of E histolytica in amebic colitis. Thus, TMKs such as EhTMKB1-9 may serve as potential targets for future drug development.

    Prevention

    • The only lasting control of amebiasis is in breaking the cycle of transmission through sanitary human waste disposal, keeping food and water free from contamination with infective cysts, and good personal hygiene practices especially among food handlers. Treat all infected persons with amebicidal drugs for both trophozoite and cystic forms of the parasite.
    • Amebiasis vaccine is in the developmental stage, with prospective candidates in the pipeline, expected to be available soon.
    • The choice of vaccine material and its efficacy in ensuring long-term protective immunity are important considerations both for clinical and public health applications [15].

    Summary

    Amebiasis is an infectious disease of the large intestine, liver and other organs that is caused by the protozoan parasite, Entamoeba histolytica [1]. The parasite undergoes two developmental stages, namely:

    1. A motile, vegetative, and tissue-invasive form, trophozoite and
    2. A dormant, infective form, cyst.

    The infective stage or cyst is transmitted directly from one person to another, or through food and water. The trophozoite or vegetative stage invades the intestinal mucosa, causing diarrhea or fulminant dysentery in intestinal amebiasis. Involvement of the liver and other organs such as the skin or brain is called extra-intestinal amebiasis.

    Affected persons may be asymptomatic or may experience a variety of clinical manifestations such as alternate diarrhea and constipation, abdominal tenderness, cramps, malaise, and fever. Asymptomatic persons may be cyst-passers that is, cysts are found in their stools. Cyst is the infective stage to man. Trophozoites are found in the stools of patients with diarrhea or dysentery. These are motile amebas, usually seen with ingested red blood cells under the microscope.

    Diagnosis is by routine microscopic examination of fecal smears or liver aspirate, and if needed, colonoscopy or ultrasonography, and blood tests. Oral anti-trophozoite drugs are taken by patients with diarrhea or dysentery, with another amebicide to eliminate the cysts.

    Amebiasis is common in areas where fecal contamination of food and water is rampant due to poor sanitation. These are in Africa, the Indian subcontinent, parts of Central and South America, and Asia. In the United States, there are cases among immigrants and sometimes in travelers who might have acquired the infection from developing countries.

    Patient Information

    Amebiasis is an infectious disease primarily of the intestines caused by the protozoan parasite, Entamoeba histolytica. The ameba can reside in the large intestine (colon) with other species of amebas as commensals without causing disease. When conditions permit as when the innate immunity of the human host is impaired, the parasite may invade the intestinal wall, cause ulcers or perforations, and manifest clinically as colitis, chronic diarrhea, or at its worst, acute dysentery.  

    From the intestines the amebas can migrate via the blood route to the liver, causing liver abscess. In severe cases the lungs, brain, skin and other organs may become involved.

    Infection with Entamoeba histolytica cysts is acquired from ingestion of ameba cysts from contaminated food or water, through the unwashed hands of food handlers, through oral-anal sex, or in some places, when human waste is used as fertilizer.  

    Symptoms

    The symptoms of amebiasis range from mild to severe. Mild symptoms are:

    Severe symptoms include:

    Diagnosis

    • Microscopic examination of Direct Fecal Smears for trophozoites and/or cysts, repeated over several days
    • Serological examinations for ameba antigens using specific antibody especially for extraintestinal amebiasis
    • Colonoscopy or sigmoidoscopy (internal examination of the lower large intestine) 
    • Microscopic examinatiion of tissues from infected organs such as liver aspirate

    Treatment

    • Amebicidal drug, metronidazole (kills the trophozoites) for symptomatic case; other amebicide such as diloxanide, for asymptomatic case or cyst-passer 
    • Supportive treatment and drugs to control  vomiting
    • Drink plenty of fluids, water for dehydrated patients
    • Antibiotics (if co-existing bacterial infection is suspected)

    Other symptoms

    Colon Carcinoma
    • Paucity of WBC's in stools Ameboma An ameboma is an annular lesion of the cecum or ascending colon that may be mistaken for colonic carcinoma or as a tender extrahepatic mass mimicking a pyogenic abscess.[meddean.luc.edu]
    • On the other hand, colonoscopy detects the presence of lesions related to the mentioned severe forms of intestinal amoebiasis and allows for differential diagnosis of other pathologies, such as inflammatory bowel disease or colon carcinoma. a) Intestinal[pubmedcentralcanada.ca]

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    References

    1. Pritt BS, Clark CG. Amebiasis. Mayo Clin Proc. 2008 Oct; 83(10):1154-9; quiz 1159-60.
    2. Stanley SL Jr. Amoebiasis. Lancet. 2003 Mar 22; 361(9362):1025-34.
    3. Verkerke HP, Petri WA Jr, Marie CS. The dynamic interdependence of amebiasis, innate immunity, and undernutrition. Semin Immunopathol. 2012 Nov; 34(6):771-85.
    4. Valenzuela O, Morán P, Gómez A, et al. Epidemiology of amoebic liver abscess in Mexico: the case of Sonora. Ann Trop Med Parasitol. 2007 Sep; 101(6):533-8.

    5. Van Hal SJ, Stark DJ, Fotedar R, et al. Amoebiasis: current status in Australia. Med J Aust. 2007 Apr 16; 186(8):412-6.

    6. Stauffer W, Abd-Alla M, Ravdin JI. Prevalence and incidence of Entamoeba histolytica infection in South Africa and Egypt. Arch Med Res. 2006 Feb; 37(2):266-9.

    7. Ravdin JI, Stanley P, Murphy CF, et al. Characterization of cell surface carbohydrate receptors for Entamoeba histolytica adherence lectin. Infect Immun. 1989 Jul; 57(7):2179-86.

    8. Ximénez C, Cerritos R, Rojas L, et al. Human amebiasis: breaking the paradigm?. Int J Environ Res Public Health. 2010 Mar; 7(3):1105-20.

    9. Haque R, Mondal D, Duggal P, et al. Entamoeba histolytica infection in children and protection from subsequent amebiasis. Infect Immun. 2006 Feb; 74(2):904-9.

    10. Seydel KB, Stanley SL Jr. Entamoeba histolytica induces host cell death in amebic liver abscess by a non-Fas-dependent, non-tumor necrosis factor alpha-dependent pathway of apoptosis. Infect Immun. 1998 Jun; 66(6):2980-3.
    11. Rao S, Solaymani-Mohammadi S, Petri WA Jr, et al. Hepatic amebiasis: a reminder of the complications. Curr Opin Pediatr. 2009 Feb; 21(1):145-9.

    12. Sodhi KS, Ojili V, Sakhuja V, et al. Hepatic and inferior vena caval thrombosis: vascular complication of amebic liver abscess. J Emerg Med. 2008 Feb; 34(2):155-7.
    13. Abd-Alla MD, Jackson TF, Gathiram V, et al. Differentiation of pathogenic Entamoeba histolytica infections from nonpathogenic infections by detection of galactose-inhibitable adherence protein antigen in sera and feces. J Clin Microbiol. 1993 Nov; 31(11):2845-50.
    14. Kimura M, Nakamura T, Nawa Y. Experience with intravenous metronidazole to treat moderate-to-severe amebiasis in Japan. Am J Trop Med Hyg. 2007 Aug; 77(2):381-5.
    15. Parija SC. Progress in the research on diagnosis and vaccines in amebiasis. Trop Parasitol. 2011 Jan; 1(1):4-8.

    • Acute fulminant necrotizing colitis caused by amebiasis: report of a case - S Shimada, T Mizumoto, R Nishioka, K Fukami - Surgery today, 2002 - Springer
    • A growing spectrum of surgical disease in patients with human immunodeficiency virus/acquired immunodeficiency syndrome: Experience with 120 major cases - NA Diettrich, JC Cacioppo, G Kaplan - Archives of , 1991 - Am Med Assoc
    • A PROTOZOAL SURVEY OF ONE THOUSAND PRISONERS WITH CLINICAL DATA ON NINETY-TOW CASES OF AMEBIASIS - HG Johnstone, NA David, AC Reed - Journal of the American , 1933 - Am Med Assoc
    • " Association Bulletin: All India Institute of Hygiene and Public Health, Calcutta, 2: 12, 1956. - SN BAsu - Ind. J. Pediat, 1956 - Springer
    • Amebiasis - DL Longo, DL Kasper, JL Jameson - Harrison's™ , 2012 - accessmedicine.com
    • Amebiasis - DJ Krogstad, HC Spencer Jr - New England Journal of , 1978 - Mass Medical Soc
    • Amebiasis - JI Ravdin - Clinical Infectious Diseases, 1995 - JSTOR
    • [Autochthonous and imported amebiasis: description of 2 clinical cases] - F De Lalla, R Esposito, G Orlando - Annali Sclavo; rivista di , 1980 - ukpmc.ac.uk
    • Amebic liver abscess - SF Abuabara, JA Barrett, T Hau, O Jonasson - Archives of Surgery, 1982 - Am Med Assoc
    • Of the micro enzyme-linked immunosorbent assay, indirect hemagglutination and indirect fluorescence antibody techniques for serodiagnosis of amebiasis. - P Das, S Pal, SC Pal - Journal of diarrhoeal diseases research, 1984 - books.google.com
    • [Diagnosis of intestinal amebiasis] - B Reichlin, K Gyr, M Giger, AL Blum - Schweizerische medizinische , 1981 - ukpmc.ac.uk
    • Amebiasis - R Haque, CD Huston, M Hughes - New England journal , 2003 - Mass Medical Soc
    • Acute fulminant necrotizing amoebic colitis: a rare and fatal complication of amoebiasis: a case report - SS Gupta, O Singh, S Shukla, MK Raj - Cases journal, 2009 - ncbi.nlm.nih.gov
    • Trichuris suis therapy for active ulcerative colitis: A randomized controlled trial - RW Summers, DE Elliott, JF Urban, RA Thompson - Gastroenterology, 2005 - Elsevier
    • Amebiasis: an update - SL Reed - Clinical infectious diseases, 1992 - cid.oxfordjournals.org
    • Acute appendicitis caused by amebiasis - N Gotohda, S Itano, Y Okada, S Horiki, A Endo - Journal of , 2000 - Springer
    • A rare cause of acute appendicitis: parasitic infection - S Yildirim, TZ Nursal, A Tarim - journal of infectious , 2005 - informahealthcare.com
    • Amebic liver abscess: 1966–1976 - JM Shabot, M Patterson - Digestive Diseases and Sciences, 1978 - Springer
    • [Autochthonous and imported amebiasis: description of 2 clinical cases] - F De Lalla, R Esposito, G Orlando - Annali Sclavo; rivista di , 1980 - ukpmc.ac.uk
    • Abscess (see also Amebiasis) Abscess Perinephric (Thorley, JD) 53 (6) 441 Acanthosis Nigricans: A Study of 90 Cases (Brown, J.) 47 (1) 33 - II WA - Amyloid - journals.lww.com
    • Adenocarcinoma of the large bowel in Nigerians: a clinicopathologic study - OO Adexunle, AA Abioye - Diseases of the Colon & Rectum, 1980 - Springer
    • Flagellar export and synthesis machinery differentially alters virulence of Salmonella enterica serovar Typhimurium in models of typhoid fever, survival in macrophages - CK Schmitt, JS Ikeda, SC Darnell, PR Watson - Infection and , 2001 - Am Soc Microbiol
    • Anorectal diseases in Western Nigerian adults - AN Ani - Diseases of the Colon & Rectum, 1983 - Springer
    • Acute infectious diarrhea - NM Thielman, RL Guerrant - New England Journal of Medicine, 2004 - Mass Medical Soc
    • Amebic liver abscess - MA Hughes, WA Petri - Infectious disease clinics of North America, 2000 - Elsevier
    • Autologous polymorphonuclear leukocyte abdominal scanning, and quantitative fecal indium-111 excretion in acute gastroenteritis and enteropathogen carriage - T Kordossis, AEA Joseph, JN Gane, CE Bridges - Digestive diseases and , 1988 - Springer
    • Amebiasis: epidemiologic studies in the United States, 1971-1974. - DJ Krogstad, HC Spencer Jr, GR Healy - Annals of Internal , 1978 - ukpmc.ac.uk
    • Acute benign pericarditis and the Coxsackie viruses - RL Gillett - New England Journal of Medicine, 1959 - Mass Medical Soc
    • Amebiasis - R Haque, CD Huston, M Hughes - New England journal , 2003 - Mass Medical Soc
    • Amebiasis - DJ Krogstad, HC Spencer Jr - New England Journal of , 1978 - Mass Medical Soc
    • ABC of diseases of liver, pancreas, and biliary system: Liver abscesses and hydatid disease - JEJ Krige, IJ Beckingham - BMJ: British Medical Journal, 2001 - ncbi.nlm.nih.gov
    • A randomized double-blind placebo-controlled trial of rifaximin in patients with abdominal bloating and flatulence - AI Sharara, E Aoun, H Abdul-Baki, R Mounzer - The American journal of , 2006 - nature.com
    • Acute appendicitis caused by amebiasis - N Gotohda, S Itano, Y Okada, S Horiki, A Endo - Journal of , 2000 - Springer
    • Amebiasis in goldfish - FA Voelker, MR Anver, AE McKee - Veterinary Pathology , 1977 - vet.sagepub.com
    • Acute amebic colitis - K Juniper - The American journal of medicine, 1962 - Elsevier
    • Amebiasis - R Haque, CD Huston, M Hughes - New England journal , 2003 - Mass Medical Soc
    • A clinical report on amebiasis in infants under one year of age - C Goldenberg, WH Shlaes, S Mintzer - The Journal of Pediatrics, 1952 - Elsevier
    • Acute appendicitis in children: emergency department diagnosis and management - SG Rothrock, J Pagane - Annals of emergency medicine, 2000 - sygdoms.com
    • AGA technical review on the evaluation and management of chronic diarrhea - KD Fine, LR Schiller - Gastroenterology, 1999 - Elsevier
    • Abses Amebiasis Hati - A Rahmad, L Winaga - Ebers Papyrus, 2010 - journal.tarumanagara.ac.id
    • Amebiasis - J Kerrison Juniper - psmid.org.ph
    • Acute and Chronic Diarrhea: A distillation - B Smith - bwhirim.org
    • [Subacute forms of hepatic amebiasis in Indochina; their clinical, anatomic and bacteriologic aspects; concerning 37 observations.] - MF ANDRE - Bulletin de la Societe de pathologie exotique et de ses , 1956 - ukpmc.ac.uk
    • ACTH and cortisone therapy in ulcerative colitis - A Richman, I Sternlieb, A Winkelstein - Digestive Diseases and Sciences, 1956 - Springer
    • Amebiasis - R Haque, CD Huston, M Hughes - New England journal , 2003 - Mass Medical Soc
    • Amebiasis - R Haque, CD Huston, M Hughes - New England journal , 2003 - Mass Medical Soc
    • A case of endemic amebic colitis: Diagnosis with colonoscopic biopsy - LR Kaplan, JM Pries - Diseases of the Colon & Rectum, 1979 - Springer
    • Technique for the diagnosis of parasitic diseases in persons returning from the tropics. I. Immunofluorescence antibody test for malaria and amebiasis]. - V Suter-Kopp, P Giacometti - Schweizerische , 1971 - ncbi.nlm.nih.gov
    • AIDS and sexual behavior reported by gay men in San Francisco. - L McKusick, W Horstman - American Journal of , 1985 - ajph.aphapublications.org
    • Amebiasis - DJ Krogstad, HC Spencer Jr - New England Journal of , 1978 - Mass Medical Soc
    • Acute fulminant necrotizing colitis caused by amebiasis: report of a case - S Shimada, T Mizumoto, R Nishioka, K Fukami - Surgery today, 2002 - Springer
    • Agents of apocalypse: Epidemic disease in the colonial Philippines - K De Bevoise - 1995 - books.google.com
    • A new look at toxic megacolon: an update and review of incidence, etiology, pathogenesis, and management - SI Gan, PL Beck - The American journal of gastroenterology, 2003 - nature.com
    • Absence of intestinal parasites in asthma - RG Van Dellen, JH Thompson Jr - New England Journal of , 1971 - Mass Medical Soc
    • A review of the parasite cellular mechanisms involved in the pathogenesis of amebiasis - JI Ravdin, RL Guerrant - Review of Infectious Diseases, 1982 - cid.oxfordjournals.org
    • A new acid-fast trichrome stain for simultaneous detection of Cryptosporidium parvum and microsporidial species in stool specimens. - R Ignatius, M Lehmann, K Miksits - Journal of clinical , 1997 - Am Soc Microbiol
    • AMEBIASIS: COMMENTS ON VARIOUS AMEBACIDES REPORT OF CASE - HH Anderson, AC Reed - California and western medicine, 1931 - ncbi.nlm.nih.gov
    • A Redescription of Entamoeba Histolytica Schaudinn, 1903 (Emended Walker, 1911) Separating It From Entamoeba Dispar Brumpt, 19251 - LS Diamond, CG Clark - Journal of Eukaryotic Microbiology, 1993 - Wiley Online Library

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