LECTURE No. 11. Amoebiasis. Balantidiasis. Etiology, epidemiology, clinic, diagnostics, treatment

1. Amoebiasis

Amebiasis is a protozoal disease characterized by ulcerative lesions of the large intestine, with the formation of abscesses in the liver, lungs and other organs and a tendency to a protracted and chronic course.

Etiology. The causative agent is dysenteric amoeba, which can be found in three forms. Cysts are highly resistant to environmental factors; in moist feces and water they are viable for up to 1 month; in darkened and moist soil they live for up to 8 days. High temperatures have a detrimental effect; low temperatures can be tolerated for up to several months. Drying effect is immediate. The large vegetative form (tissue form, erythrophage) phagocytoses red blood cells and is detected only in the patient’s body. The luminal form and stage of the cyst can also be found in carriers.

Epidemiology. The way of transmission of infection is alimentary, fecal-oral, water, and also contact-household. Amoeba cysts are spread by flies, cockroaches.

Pathogenesis. A person becomes infected when cysts enter the digestive system. In the large intestine, the cyst transforms into a luminal form, and carriage occurs. Clinical manifestations appear only when the luminal form transitions to the tissue form. The formation of ulcers in the intestinal mucosa is a consequence of the proliferation of the tissue form in the intestinal wall. In this case, small abscesses first appear in the submucosal layer, which then break into the intestinal lumen. By hematogenous route, dysenteric amoeba can reach the liver, less often - other organs, and cause the formation of specific abscesses in them. As ulcers scar, narrowing of the intestines may occur.

Clinic. The incubation period lasts from 1 week to 3 months. The disease begins acutely. Symptoms are manifested in the form of weakness, headache, moderate abdominal pain, the appearance of loose stools with the presence of vitreous mucus and blood, low-grade fever. After the end of the acute period, a long remission may occur, then the disease resumes and takes on a chronic course. Without the appointment of etiotropic antiparasitic treatment, the disease can occur for 10 years or more in the form of recurrent or continuous forms. In this case, there are pains in the abdomen, loose stools, alternating with constipation, sometimes there may be blood in the stool. With a long course of the disease, an asthenic condition develops, weight loss, hypochromic anemia.

Diagnosis is carried out on the basis of epidemiological data and clinical examination of patients. Sigmoidoscopy reveals ulcers up to 10 mm in diameter, deep, with undermined edges. The bottom of the ulcers is covered with a purulent coating. The ulcers are surrounded by a rim of hyperemic mucous membrane. A biopsy of the intestinal mucosa, ultrasound of the liver, and laparoscopy are performed. The main and decisive factor in the diagnosis is the detection of the vegetative form of amoeba in feces, abscess contents, and material from the bottom of ulcers. The study should be carried out no later than 20 minutes after defecation or collection of material. Complications of amebiasis include peritonitis due to intestinal perforation, amoeba, and intestinal bleeding. Liver abscess (extraintestinal complication) can develop both during the acute period and after a long time, when there are no longer significant intestinal lesions. The acute course of an abscess is manifested by hectic fever, chills, and pain in the right hypochondrium. An x-ray reveals a high position of the diaphragm (or its local protrusion). Even minor abscesses can be detected with a liver scan. Mild intoxication and fever are observed with chronic abscess. The possibility of an amoebic abscess breaking into surrounding organs can lead to the formation of a subphrenic abscess, peritonitis, and purulent pleurisy. Laboratory diagnosis is confirmed when a large vegetative form of amoeba with phagocytosed red blood cells is detected in the stool. Serological diagnostic methods are available. Amebiasis must be differentiated from dysentery, balantidiasis, ulcerative colitis, and neoplasms of the large intestine.

Treatment. Prescribe a 2% solution of emetine hydrochloride, 1,5-2 ml IM 2 times a day for 5-7 days. A week later the cycle is repeated. In the intervals between zmetin cycles, khingamin (delagil) is prescribed 0,25 g 3 times a day, quiniophone 0,5 g 3 times a day. Metronidazole (Trichopolum, Flagyl) is considered the most effective and non-toxic drug for the treatment of patients with both intestinal and extraintestinal manifestations of amebiasis. It is prescribed 0,5-0,75 g 3 times a day for 5-7 days. Antibacterial therapy is prescribed as an adjunct in order to change the microbial biocenosis in the intestine. For amoebic liver abscesses, the drug is prescribed for a longer period - until the abscess resolves (based on the results of a liver scan). For large liver abscesses, surgical treatment methods are used.

The prognosis for intestinal amebiasis is favorable. Possible residual effects in the form of narrowing of the intestine. With an amoebic abscess of the liver or brain, a fatal outcome is possible, but modern therapy has made the prognosis more favorable.

Prevention. Isolation, hospitalization and treatment of patients. Amoeba carriers are not allowed to work in the public catering system. General preventive measures are the same as for dysentery.

2. Balantidiasis

Balantidiasis is a protozoal disease characterized by ulcerative lesions of the colon and symptoms of general intoxication, severe course and high mortality in late therapy.

Etiology. The causative agent - balantidia - belongs to the class of ciliates, occurs in a vegetative form and in the form of cysts that are stable in the external environment. The natural carriers of balantidia are pigs.

Epidemiology. The route of transmission is fecal-oral. The reservoir of pathogens are pigs.

Pathogenesis. Infection occurs when balantidia enter the human digestive tract, mainly in the small intestine, where they stay for a long time without causing a clinical picture of the disease. Some of the infected balantidia enter organs and tissues. At the same time, ulcers, foci of necrosis, and hemorrhages are formed there. The ulcers are irregular in shape, the edges are thickened and indented. Their bottom is uneven, with a purulent-bloody coating. Perforation of ulcers may occur and the development of peritonitis is not excluded.

Clinic. The incubation period lasts 1-3 weeks. Acute forms of the disease are characterized by fever, symptoms of general intoxication and signs of intestinal damage (abdominal pain, diarrhea, flatulence, tenesmus is possible). The stools are characterized by an admixture of mucus and blood. Spasm and soreness of the large intestine, enlargement of the liver are characteristic. In severe cases, general intoxication, high fever, stools up to 20 times a day with an admixture of mucus and blood with a rotten smell are observed. Patients quickly lose weight, sometimes there are symptoms of irritation of the peritoneum. Chronic balantidiasis occurs with mild symptoms of intoxication, body temperature is normal, stools - up to 2-3 times a day, liquid, with mucus, sometimes with an admixture of blood. On palpation, pain is found predominantly in the blind and ascending colon.

Diagnosis is based on epidemiological data and clinical examination data of patients. Sigmoidoscopy reveals a focal infiltrative-ulcerative process or extensive ulcerative lesions. The diagnosis is confirmed by the detection of parasites in feces, biopsy specimens of the edge of ulcers, and in smears of ulcerative contents.

Treatment. Etiotropic drugs are used in the form of 2-3 5-day cycles. Assign monomycin 0,15 g 4 times a day, oxytetracycline 0,4 g 4 times a day, metronidazole 0,5 g 3 times a day. The interval between cycles is 5 days.

The prognosis for modern therapy is favorable. Without the use of antiparasitic therapy, mortality reached 10-12%.

Prevention. Compliance with hygiene measures when caring for pigs. Identification and treatment of people with balantidiasis. General preventive measures are the same as for dysentery.

Author: Gavrilova N.V.

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