Invasive Amoebiasis in a Child:

A Case Report in Aceh Provincial Referral Hospital

Reno Keumalazia Kamarlis

1,2

Department of Anatomical Pathology, Universitas Syiah Kuala Banda Aceh, Indonesia

Department of Anatomical Pathology, Zainoel Abidin Hospital, Banda Aceh, Indonesia

Keywords: Amoebiasis, Enterocolitis, Histopathology

Abstract: Amoebiasis is throught to occur intraveller, immigrant from endemic areas and among men who have sex

with men. Amoebiasis, caused by parasite Entamoeba histolytica, has a worlwide distribution, with an

estimated 50 million people being infected. We present case of amoebic anal in a boy, 4 years-old with

diagnosed Enterocolitis until a punch biopsy disclosed a diagnosis Ameboetic. According to microscopic

result, the findings were typical characteristic of amoebiasis. This technique can detect the presence of dots

in the mucosa that contain many trophozoites and perform biopsy specimens for histopathological

examination to establish a definitive diagnosis.

1 INTRODUCTION

Amoebiasis is a common infectious disease in the

human digestive tract caused by a parasite infection,

Entamoeba histolytica. These parasites are generally

apathogenic microorganisms that live in the large

intestine of humans and some animals, but in certain

numbers can become pathogens by forming colonies

in the intestinal wall and penetrating the intestinal

wall causing ulceration.

Amoebiasis has a worldwide distribution with an

estimated 50 million people being infected. With

40.000-100.000 deaths reported annually, it is the

second leading cause of death from parasitic

diseases worldwide. High-risk areas include South

Asia, Southeast Asia, the Middle East, and South

America. According to (Shahrul Anuar et al., 2012),

amoebiasis prevalence in ethnic group in Malaysia,

as a developing country, is 18.6%. North Eastern

states of India has amoebiasis prevalence of 23.2%

(Nath et al., 2015). Indonesia as a fellow developing

country has a high incidence of amoebiasis, which is

10-18% (Andayasari, Lelly, 2011). The death rate

due to infectious diseases caused by amoebiasis was

ranked second after malaria. Diarrhea prevalence is

13% higher in rural areas compared to urban areas

(Balitbang Kesehatan Kemenkes RI, 2007).

In this report, the reviewed case is a 4-year-old

child diagnosed with enterocolitis, yet due to further

examination, it was found that the cause was

amoebiasis, infection of Entamoeba histolytica.

2 CASE REPORT

A boy, 4 years old, with fever, right upper quadrant

pain and has been diagnosed with enterocolitis. He

got medical treatment but the clinical manifestation

not better and he referred to pediatric surgery. In

physical examination there was a fistula near anal

and biopsy taken to confirm the diagnosis.

The macroscopic result, a gray white soft tissue

fragmented volume ± 0,5 cc, was received. Formalin

fixed paraffin embedded and Hematoxylin and Eosin

stained.

According to microscopic result, amoeba burrow

in lamina propria and cause tissue necrosis with

inflammation with scattered neutrophils. Ulceration

and the trophozoites of E. histolytica are resemble

macrophages sections revealed areas underlying

granulation tissue and focal collections of

histiocytes. Other findings were the subepithelium

clustered of spherical organisms showing a single

nucleus with prominent karyosome and cytoplasm

containing ingested red blood cells.

Kamarlis, R.

Invasive Amoebiasis in a Child: A Case Report in Aceh Provincial Referral Hospital.

DOI: 10.5220/0008788902010204

In Proceedings of the 2nd Syiah Kuala International Conference on Medicine and Health Sciences (SKIC-MHS 2018), pages 201-204

ISBN: 978-989-758-438-1

201

Figure 1. Tissue necrosis with inflammation with scattered

neutrophils, ulceration and the trophozoites of Entamoeba

histolytica are resemble macrophages sections revealed

areas underlying granulation tissue and focal collections of

histiocytes (100x magnification).

Figure 2. Single nucleus with prominent karyosome

containing ingested red blood cells (400x magnification).

Figure 3. Single nucleus with cytoplasm containing

ingested red blood cells (400x magnification).

3 DISCUSSION

Amoebiasis is an infection caused by protozoa

Entamoeba histolytica. Predominant spectrum of the

disease constitutes amoebic colitis and liver abscess.

This disease is strongly associated with poor

personal hygiene and environmental sanitation. The

socio-economic level of the community is one of the

factors that influence the sanitary conditions.

Research conducted by Shahrul Anuar et al. (2012)

in developing country, Malaysia, also stated that

housing conditions is a risk factor because it

indicates environmental sanitation in the area. The

risk of children infected by E. Histolytica will be

higher if the parents are carriers. This is in line with

the high prevalence of amoebiasis in children under

15 years old (Shahrul Anuar et al., 2012). E.

histolytica is second only to malaria as a protozoal

cause of death.

Worldwide the prevalence of amoebic infections

is estimated at 40-50 million with 40,000-110,000

deaths occurring annually. Most parts of Asia and

Africa are endemic for amoebic infection. In

developed countries infection occurs primarily

among travellers and immigrants to endemic

regions, homosexual males, immunosuppressed and

institutionalized individuals. Transmission is

predominantly by oro-faecal route (Dhingra et al.,

2007).

Some cases of Entamoeba histolytica infection is

asymptomatic, but there are also some cases that

show symptoms such as diarrhoea, dysentery,

fulminant colitis to extra intestinal amoebiasis which

can infect other organs such as liver, cardiac, lung,

cerebral, kidneys and other organs. According to

Pritt & Clark (2008), the life cycle of Entamoeba

histolytica begins with the entry of active cysts that

originate from feces into the human intestine, either

through contaminated food or drink or oral sexual

behaviour. In the large intestine, the cyst develops

and multiplies itself asexually into an active

trophozoite form and enters the mucosa of the large

intestine. Some active trophozoites are out with

feces and can survive in humid conditions for

several weeks or months. Active cysts that are

outside the human body are susceptible to

contamination with food, drinks or even other

humans so that the chain of infection continues to

repeat itself. Trophozoites that are still in the

intestinal mucosa are carried along with the blood

circulation system to the organs outside the large

intestine. This is what causes extraintestinal

amoebiasis. Extraintestinal amoebiasis often occurs

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in the liver causing damage to the liver because liver

parenchymal cells are eaten by active trophozoites.

Mostly, people who infected with E. histolytica

is asymptomatic, the disease may occur within days,

months, or years after the infection, but the

condition will be worsen and can lead to colitis,

swelling and resembling a tumor in the large

intestine. Symptoms caused by E. histolytica

infection will be more progressive, begin from

abdominal pain, diarrhoea, bloody diarrhoea to

colitis. E. histolytica infection also occurs outside

the large intestine. The most common infected organ

is liver. Parasites are carried along with the

bloodstream. This causes pain in the right upper

quadrant pain and fever.

E. histolytica transmitted primarily through

ingestion of food or water contaminated with faecal

cysts. Transmission through faecal-oral can be

directly by person to person or indirectly by

consuming food or drink that contaminated by

faecal. Entamoeba histolytica can also communicate

through contamination of food or drinks through

vectors such as flies, cockroaches, and rodents.

Beside faecal-oral transmission, Entamoeba

histolytica has been recently recognised as an

emerging sexually transmissible pathogen in

homosexual (Escolà-Vergé et al., 2017). It often

found in the stool of homosexual men (Shelton).

Sexual transmission has also been reported,

particularly via contact with commercial sex

workers or in men who have sex with men (Gilroy et

al., 2018). This caused sporadic outbreaks in

countries where it is not endemic (Escolà-Vergé et

al., 2017). According to Shahrul Anuar et al., (2012)

the possibility of family members being infected by

Entamoeba histolytica is higher if the family

members themselves are the one who carried the

cyst and the transmission occurs between the family

members, because the cyst is more likely to become

infective.

Diagnosis can be done in several ways, including

faecal examination, culture, biopsy and

sigmoidoscopy, radiology and serology (Maryatun,

2008). Diagnosis with faecal examination is done to

find eggs, larvae and protozoa cysts using

concentration techniques. Culture is also one of the

techniques for diagnosing amoebiasis by making a

layer of liquid that is located on top of the basic

nutrient in a partial anaerobic state. Another

technique to diagnose amoebiasis is biopsy. This

technique can detect the presence of dots in the

mucosa that contain many trophozoites and perform

biopsy specimens for histopathological examination

to establish a definitive diagnosis. Radiology

techniques performed with the use of barium.

However, this technique cannot be used to examine

eggs and parasites. Another technique is serology,

which is primarily aimed for extraintestinal

amoebiasis diagnosis when stool examination shows

negative results.

Gross description discrete ulcers with normal

intervening mucosa may show areas of colitis or

inflammatory polyps. Histopathological examination

result of the fistulous tract and the curetted

granulation tissue shown the presence of multiple

trophozoites of E. histolytica exhibit

erythrophagocytosis in the background of mixed

inflammatory infiltrate.

Necrotic material admixed with mucin,

proteinaceous exudate and blood clot lining ulcers,

significant surface epithelial changes such as

shortening and tufting adjacent to sites of ulceration.

Mild chronic inflammation extending into the deep

mucosa and mild architectural alteration were

features of amebiasis. Trophozoite forms of amoeba

were seen in the necrotic material lining sites of

ulceration or lying separately, as well as over intact

mucosa.

Necrotic material lining ulcers was less common

in inflammatory bowel disease. The chronic

inflammation crypt abscess formation and

architectural alteration were more severe (Singh et

al., 2015). Typically, the parasites are surrounded by

an artifactually clear space. They are round or ovoid,

measure 6-40 nm in diameter, and contain abundant

cytoplasm with a distinctive vacuolated appearance

and relatively small. They also perfectly round

nuclei with prominent nuclear borders and central

karyosome. Erythrocytosis by trophozoites is usually

present (Rosai, 2004). The cytoplasm is vacuolated

which leads to confusion with macrophages

(Dhingra et al., 2007). The presence of trophozoites

containing red blood cells is indicative of tissue

invasion Adequate sampling and step sections are

very important to get true diagnosis.

4 CONCLUSION

A boy, 4 years old, with fever, right upper quadrant

pain confimed as a case of amoebiasis. Diagnosis

can be done in several ways, including biopsy.

According to microscopic result, amoeba burrow in

lamina propria and cause tissue necrosis with

inflammation with scattered neutrophils. Ulceration

and the trophozoites of E. histolytica are resemble

macrophages sections revealed areas underlying

granulation tissue and focal collections of

Invasive Amoebiasis in a Child: A Case Report in Aceh Provincial Referral Hospital

203

histiocytes. Other findings were the subepithelium

clustered of spherical organisms showing a single

nucleus with prominent karyosome and cytoplasm

containing ingested red blood cells. This technique

can detect the presence of dots in the mucosa that

contain many trophozoites and perform biopsy

specimens for histopathological examination to

establish a definitive diagnosis.

ACKNOWLEDGEMENTS

Department of pathology and anatomical Zainoel

Abidin Hospital, Banda Aceh, Indonesia.

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