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Prevalence of Amebiasis among Histologically Confirmed Colitis Patients

Rasha I Salama, Mohamed H Emara, Ibrahim Fathi Amer, Shimaa Elsharawy

Rasha I salama, Department of Tropical Medicine, Faculty of Medicine, Zagazig University, Zagazig, Egypt
Mohamed H Emara, Ibrahim Fathi Amer, Department of Hepatology Gastroenetrology and Infectious Diseases, Faculty of Medicine, Kafrelsheikh University, Kafrelsheikh, Egypt
Shimaa Elsharawy, Department of Tropical Medicine, Faculty of Medicine, Tanta University, Tanta, Egypt

Conflict-of-interest statement: The author(s) declare(s) that there is no conflict of interest regarding the publication of this paper.

Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http: //creativecommons.org/licenses/by-nc/4.0/

Correspondence to: Mohamed H Emara, MD, Hepatology, Gastroenetrology and Infectious Diseases Department, Faculty of Medicine, Kafrelsheikh University, Kafrelsheikh, Egypt.
Email: emara_20007@yahoo.com
Telephone: +201002724482

Received: April 14, 2018
Revised: May 28, 2018
Accepted: June 1, 2018
Published online: June 21, 2018

ABSTRACT

AIM: Amebiasis is a prevalent infection worldwide and is associated with colitis that may mimic different types of colitis. The aim of this study is to determine the prevalence of amebiasis among patients with endoscopically and histologically confirmed colitis n the Egyptian community.

PATIENTS AND METHODS: This study was carried out in the period from June 2017 to March 2018. Patients in the final analysis were divided into 2 groups according to their histopathologic features: Group I: Inflammatory bowel disease (IBD) patients comprised 60, 49 patients diagnosed as ulcerative colitis (UC) and 11 patients diagnosed as Crohn’s disease (CD). Group II: Non-specific colitis. Comprised a total of 100 patients.

RESULTS: The prevalence of Entamoeba histolytica cysts and trophozoits among the study patients was 9.37% (15/160). They were 11 patients with IBD (6.87%) and 4 patients with non- specific colitis (2.5%). Patients with non- specific colitis are younger in age, had less blood levels of CRP and lower prevalence rates of amebiasis when compared with IBD patients. When patients with IBD were compared as ulcerative colitis and Crohn’s disease it seem that the younger age CD did not show different prevalence rates of amebiasis when compared with UC (P value 1).

CONCLUSIONS: The prevalence of amebiasis in histologically confirmed colitis is 9.37% (15/160). They were 11 patients with IBD (6.87%) and 4 patients with non- specific colitis (2.5%). Regarding IBD the prevalence of amebiasis was 11 patients/out of 60 (18.3%) and prevalence was higher in ulcerative colitis when compared with Crohn’s disease with figure of 9 patients (15%) and 2 patients (3.3%) respectively. Further studies are needed to clarify the impact of amebiais on the course of IBD and non-specific colitis.

Key words: Amebiasis; Inflammatory bowel disease; Non-specific colitis

© 2018 The Author(s). Published by ACT Publishing Group Ltd. All rights reserved.

Salama RI, Emara MH, Amer IF, Elsharawy S. Prevalence of Amebiasis among Histologically Confirmed Colitis Patients. Journal of Gastroenterology and Hepatology Research 2018; 7(3): 2609-2611 Available from: URL: http://www.ghrnet.org/index.php/joghr/article/view/2313

INTRODUCTION

Amebiasis is a highly prevalent disease. It is assumed that it affects around 50 million people (10% of the world’s population) and kills more than 100,000 people annually[1]. Certain regions around the world had higher prevalence rates including India, Africa, Mexico, and parts of Central and South America. Some areas with higher prevalence may have amebic infection as high as 50%[2].

Amebic colonic affection had diverse manifestations ranging from watery diarrhea, dysentery, abdominal pain and tenderness[3]. These diverse clinical manifestations frequently lead to confusing it with other types of colitis[4]. Sometimes is difficult to differentiate between amebiasis and idiopathic inflammatory bowel disease (IBD) even with the available sophisticated investigative procedures[5]. Of notice the rising incidence IBD and the use of immunosuppressants for IBD could precipitate fulminant disease or dissemination of infection in individuals with amebiasis which is higher in IBD patients[6].

The aim of the current study was to investigate the prevalence of amebiasis among patients with histologically confirmed colitis in our Egyptian community.

PATIENTS AND METHODS

This multicenter study was carried out in the period from June 2017 to March 2018. Patients were picked up from the outpatient clinics and they referred for completing their work up. Patients in the final analysis were divided into 2 groups according to their histopathologic features:

Group I: Inflammatory bowel disease (IBD) patients. IBDs were diagnosed in 60 patients by clinical presentation, laboratory and serological, endoscopic and histopathology examinations. There were 49 patients diagnosed as ulcerative colitis (UC) and 11 patients diagnosed as Crohn’s disease (CD).

Group II: Non-specific colitis. Comprised a total of 100 patients. They were diagnosed by clinical presentation, endoscopic and histopathology examinations as well.

All patients were subjected to: (1) Through history taking; (2) Complete clinical examination; (3) Fresh stool analysis: If native microscopy was found Entamoeba hystolitica cysts or trophozoits, immunochromatographic rapid assay “RIDA®QUICK Entamoeba test” is used to confirm diagnosis. Fresh faeces samples taken from people were examined immediately using the wet mount, Lugol’s iodine and physiological solution[7]. Serial samples were collected before the sample was considered negative.

Method

(1) A drop of saline was placed at each end of the slide; (2) An applicator stick was used to select a piece of fecal material at the size of a small pea and emulsification of the feces was done in the two drops of saline on the slide then a drop of Lugol’s iodine was added to the right- hand suspension; (3) A cover slip was placed on each suspension, and the slide was examined using the 10× and 40× objectives; (4) Blood examination including: CBC, ESR, CRP; (5) Pan-colonoscopy with multiple biopsies taken for histopathology; (6) Histopathologic examination of the endoscopy retrieved mucosal biopsies; (7) All patients with IBD and amebiasis were treated and followed up according the current guidelines.

Statistical analysis of the data

Data were fed to the computer and analyzed using IBM SPSS software package version 20.0. (Armonk, NY: IBM Corp) .The Kolmogorov-Smirnov test was used to verify the normality of distribution. Comparisons between groups for categorical variables were assessed using Chi-square or Fisher test. Student t-test was used to compare two groups for normally distributed quantitative variables. Significance of the obtained results was judged at the 5% level.

RESULTS

The prevalence of Entamoeba histolytica cysts and trophozoits among the study patients was 9.37% (15/160). They were 11 patients with IBD (6.87%) and 4 patients with non- specific colitis (2.5%). Table 1 shows the major differences between the two study groups. Patients with non- specific colitis are younger in age, had less blood levels of CRP and lower prevalence rates of amebiasis when compared with IBD patients.

When patients with IBD were compared as ulcerative colitis and Crohn’s disease it seem that the younger age CD did not show different prevalence rates of amebiasis when compared with UC as shown in Table 2.

Table 1 Comparison between the two studied groups according to different parameters.
  Non-specific (n = 100)IBD (n = 60)P
Age (years)39.9 ± 944.7 ± 7.80.001*
Sex
Male90 (90%) 57 (95%)0.374
Female10 (10%) 3 (5%)
E. histolytic in the stool
Negative96 (96%)49 (81.7%)0.003*
Positive4 (4%)11 (18.3%)
CRP
Negative93 (93%)46 (76.7%)0.003*
Positive7 (7%)14 (23.3%)
* Significance.

Table 2 Relation between endoscopic evidence and different parameters in IBD group (n = 60).
IBD groupEndoscopic evidenceP
UC (n = 49)CD (n = 11)
Age (years)45.9 ± 7.739.4 ± 6.20.011*
Sex
Male47 (95.9%)10 (90.9%)0.462
Female2 (4.1%)1 (9.1%)
E. histolytic in the stool
Negative40 (81.6%)9 (81.8%)1
Positive9 (18.4%)2 (18.2%)
CRP
Negative37 (75.5%)9 (81.8%)1
Positive12 (24.5%)2 (18.2%)
* Significance.

DISCUSSION

Both amebiasis and colitis are prevalent diseases and frequently encountered in the daily medical practice not only in gastroenterology clinics but also in GP and family medicine clinics particularly in developing countries like our community.

In fact the relation between amebiasis and IBD has been illustrated in the literature with sometimes conflicts. One study by Ustun et al[8], studied the prevalence of amebiasis among IBD patients in Turkey and they found ameba cyts and trophozoytes among 14 (8.75%) of a total of 160 cases, 13 (10.0%) of the 130 patients with ulcerative colitis and 1 (3.3%) of the 30 patients with Crohn’s disease. When these figures compared with our results of 11 patients/out of 60 IBD cases (18.3%) including 9 patients out of 49 with UC (18.4%) and 2 patients out of 11 with CD (18.2%) it seems that our prevalence rates are higher and this can be explained by 2 points. First, the small number of patients in our IBD group (60 patients versus 130 in their study). Second, our Egyptian community is a subtropical community and may be less developed than Turkey and prevalence of amebiasis may be higher in Egypt than in Turkey.

Another study from Bosnia[9] found that Entamoeba histolytica/dispar were found in 19 (16.0%) of a total of 119 cases with IBD, 12 (14.3%) of the 84 patients with ulcerative colitis and 7 (20.0%) of the 35 patients with Crohn’s disease. Although the prevalence rates reported in this study regarding all IBD and UC patients were similar to our figures yet the prevalence rates they reported for CD is high (20%) when compared to us (18.2%) and this ultimately is a result for low prevalence rated of Crohn’s disease in Egypt and this represented in the current study by the small number of CD patients we enrolled. Another point is that CD commonly affects the small bowel and the natural habitat of amebiasis is the colon making it more logic to be associated with lesions affecting the colon rather than the small bowel.

However, the relations between amebiasis and IBD in the literature were not limited to the prevalence studies. A more offensive relation have been reported by Addib et al[5], they reported invasive amebiasis flaring a stable UC patient on aminosalysilates after her return from developing country and the patient condition improved only after she received her anti-amebic drugs. The relation also extends to the confusion that may occur in the diagnosis because both conditions have some similarities in the endoscopic and histopathologic features and are considered as differential diagnosis to each other[6].

Another important and even conflicting relation between amebiasis and UC has been reported from one of our institutions. In the study by Saad et al[10], they found deleterious impact for the treatment of intestinal parasites (including Ascaris lumbricoides Blastocystis hominis, Entamoeba histolytica, Giardia lamblia, Hymenolepis nana, Trichostrongylus, Trichuris trichura, Enterobius vermicularis) on the course of UC. In their study patients who received specific treatment for their parasitic infestations (including amebiasis) showed deterioration in their clinical, laboratory and colonoscopic features when compared with UC patients who were not treated for their parasitic infestations. The authors attributed this to the protective role of parasites on the course of UC probably through an immune mechanism.

To the best of our knowledge no study in the literature focused prevalence of amebiasis among histologically confirmed colitis. Making this article unique in that point and to shade the light on the possible relation between amebiasis and non-specific colitis. It is known that amebiasis is associated with production of multiple ulcers in the caecum or recto-sigmoid regions and the term non-specific colitis is a transional stage in the course of colitis. This is supported by the findings in the current study. Non-specific colitis patients in this study are of younger age, had low CRP levels and low prevalence rates of amebiasis when compared with IBD patients. Based on the evidence proposed by Saad et al[10], in 2013, treatment of amebiasis (with assumed protective role in IBD) may convert non-specific colitis to active IBD. We cannot confirm this but we think that this point needs further prospective studies to delineate the relation between amebiasis and non-specific colitis.

The current study had some limitations. First, the small number of patients in IBD group. Second, lack of follow up regarding the impact of amebiasis on the course of histologically confirmed colitis with and without treatment for amebiasis. But our aim was primarily to focus on the prevalence and this could be a research question for further studies.

In conclusion, the prevalence of amebiasis in histologically confirmed colitis is 9.37% (15/160). They were 11 patients with IBD (6.87%) and 4 patients with non- specific colitis (2.5%). Regarding IBD the prevalence of amebiasis was 11 patients/out of 60 (18.3%) and prevalence was higher in ulcerative colitis when compared with Crohn’s disease with figures of 9 patients (18.4%) and 2 patients (18.2%) respectively. Further studies are needed to clarify the impact of amebiasis on the course of IBD and non-specific colitis.

REFERENCES

1 Bercu TE, Petri WA, Behm JW. Amebic colitis: new insights into pathogenesis and treatment. Curr Gastroenterol Rep 2007; 9: 429. [PMID: 17991346]

2 Peterson KM, Singh U, Petri WA Jr. Enteric Amebiasis. In: Tropical Infectious Diseases: Principles, Pathogens and Practice, 3rd ed, Guerrant R, Walker DH, Weller PF (Eds), Saunders Elsevier, Philadelphia 2011. p.614.

3 Haque R, Huston CD, Hughes M, Houpt E, Petri WA. Amebiasis. N Engl J Med. 2003; 348: 1565-1573. [PMID: 12700377]; [DOI: 10.1056/NEJMra022710]

4 Patel AS, DeRidder PH. Amoebic colitis masquerading as acute inflammatory bowel disease: the role of serology in its diagnosis. J Clin Gastroenterol 1989; 11(4): 407-410. [PMID: 2547865]

5 Addib O, Ziglam H, Conlong P. Invasive amoebiasis complicating iflammatory bowel disease. Libyan J Med. 2007; 2(4): 214-5. [PMID: 21503247]; [PMCID: PMC3078255]; [DOI: 10.4176/070905]

6 Singh R, Balekuduru A, Simon EG, Alexander M, Pulimood A. The differentiation of amebic colitis from inflammatory bowel disease on endoscopic mucosal biopsies. Indian J Pathol Microbiol. 2015; 58(4): 427-32. [PMID: 26549061]; [DOI: 10.4103/0377-4929.168880]

7 Carleton HM, Drury RAB, Wallington EA. Carleton’s histological techniques, 5th edition, volume 243. Carleton HM, Drury RAB, and Wallington EA. (editors). Oxford University Press, New York, 1980 p. 417.

8 Ustun S, Dagci H, Aksoy U, Guruz Y, Ersoz G. Prevalence of amebiasis in inflammatory bowel disease in Turkey. World J Gastroenterol 2003; 9(8): 1834-1835. [PMID: 12918132]; [PMCID: PMC4611555]

9 Babić E, Bevanda M, Mimica M, Karin M, Volarić M, Bogut A, Barišić T, Pravdić D, Šutalo N et al. Prevalence of amebiasis in inflammatory bowel disease in University Clinical Hospital Mostar. Springer Plus 2016; 5: 1586

10 Saad EA, Mourad AA, Mahmoud AM, Hussien HI, Elhawari SA. Emara MH, Mohamed SM. Impact of Treatment of Intestinal Parasites on the Activity of Ulcerative Colitis. Afro-Egypt J Infect Endem Dis 2013; 3(3): 96-104.

Peer Reviewer: Michael Lim

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