in brief
In Brief
Amebiasis
Diagnosis and Management of Amebia-
sis. Petri WA Jr, Singh U. Clin Infect
Dis. 1999;29:1117–1125
Amebiasis. Hotez PJ, Strickland AD. In:
Feigin RD, Cherry JD, eds. Textbook
of Pediatric Infectious Diseases. 4th
ed. Philadelphia, Pa: WB Saunders;
1998:2389 –2397
Amebiasis. American Academy of Pedi-
atrics. In: Pickering LK, ed. 2000 Red
Book: Report of the Committee on
Infectious Diseases. 25th ed. Elk
Grove Village, Ill: American Academy
of Pediatrics; 2000:164 –166
Invasive amebiasis probably is second
only to malarial disease as a cause of
protozoan-mediated death. Worldwide,
500 million people are carriers of Enta-
moeba histolytica or E dispar, 50 mil-
lion people have active disease, and
50,000 to 100,000 persons die per year.
Amebiasis follows a bimodal age distri-
bution. One peak is at age 2 to 3 years,
with a case fatality rate of 20%, and
the other peak is at more than 40 years,
with a case fatality rate of 70%.
Amebiasis is especially common in
Africa, Indochina, and Central and
South America. Up to 5% of diarrheal
illness in Mexico is due to Entamoeba
disease. In the United States, it is much
less common. The prime risk groups in
the United States include recent immi-
grants from endemic areas and people
who live in institutions. Small children
are capable of infecting entire families.
In the past, homosexual males also
constituted a risk group, but their risk
has decreased in recent years, presum-
ably due to increased safe-sex prac-
tices.
Two major species of amoebae in-
fect humans. E dispar is associated with
an asymptomatic carrier state and not
with disease. E histolytica is the species
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responsible for all forms of invasive
disease. The life cycle of E histolytica
includes infective cysts and invasive
trophozoites. The quadrinucleate cysts
can last for days in a dried state at
temperatures of 30°C and for weeks in
a moist environment. The cysts resist
the pH of gastric acid and are stimu-
lated to form trophozoites in the alka-
line pH of the bowel. Trophozoites are
found in the colon and feces of humans
and other mammals. Humans are the
reservoir, and transmission occurs by
ingesting food and water contaminated
with amebic cysts, although person-to-
person contact does occur. The incuba-
tion period is usually 1 to 4 weeks.
Untreated asymptomatic individuals
may shed cysts for years.
Invasive amebiasis covers a range of
diseases from amebic dysentery to met-
astatic abscesses. Amebic dysentery, or
amebic colitis, is the most common
form of invasive disease. It begins when
trophozoites invade and induce apopto-
sis in the colonic mucosa cells, leading
to the development of “buttonhole”
ulcers with undermined edges. These
ulcers are sometimes seen with Crohn
lesions, but trophozoites can be found
on the edge of the ulcers.
Clinically, 70% to 80% of individu-
als who have amebic colitis experience
a gradual onset of symptoms over 3 to
4 weeks. Symptoms include weight loss,
increasingly severe diarrhea, abdominal
pain, and stools containing blood and
mucous. In children, diarrhea almost
always is associated with abdominal
pain that can be so severe that it
mimics an acute abdomen. Fever is
uncommon, occurring in 8% to 38% of
cases. In young children, complications
include intussusception, perforation
with peritonitis, and necrotizing en-
terocolitis. The differential diagnosis of
bloody diarrhea includes infection with
Shigella, Salmonella, Campylobacter,
and enterohemorrhagic Escherichia
coli, but these conditions usually have a
more acute onset. Arteriovenous mal-
formation, inflammatory bowel disease,
and tuberculous colitits also should be
considered.
Another intestinal manifestation of
amebiasis is the ameboma, a ball of
granulation tissue containing tropho-
zoites capable of causing colonic ob-
struction and mimicking colon cancer.
Extraintestinal manifestations of
amebiasis include liver abscesses and
metastatic amebiasis. Liver abscesses
occur following metastasis of the par-
asite to the liver via the portal vein and
represent the most common extraintes-
tinal site of amebiasis, occurring in 1%
to 7% of children (equally in males and
females) and 10% to 50% of adults
(usually males) who have invasive dis-
ease. Alcohol consumption frequently is
associated with abscesses. Symptoms
include fever, right upper quadrant
pain, and increased liver size. Jaundice
is rare, but leukocytosis and elevations
in alkaline phosphatase levels can oc-
cur. Fewer than 30% of affected pa-
tients have diarrhea. Serum transami-
nase levels usually are normal. Children
present with high fever, abdominal dis-
tention, irritability, tachypnea, and
hepatomegaly, but abdominal pain and
liver tenderness is infrequent. Because
the diagnosis is unsuspected, up to
80% of children younger than 5 years
of age who have liver abscesses die,
usually due to rupture.
Metastatic amebiasis usually ex-
tends directly from liver abscesses and
less often from the intestine. Thoracic
amebiasis (including empyema, bron-
Pediatrics in Review Vol.23 No.8 August 2002 293
in brief
chohepatic fistulas, and pleuropulmo-
nary abscess) is the most common,
followed by pericardial amebiasis
(acute pericarditis with tamponade).
Cerebral amebiasis has been found in
up to 8% of autopsy studies. These
patients frequently are severely ill from
other sites of infection, but seizures can
develop.
Amebiasis should be considered in
any child who is passing stools that
contain mucus or blood. When colitis is
present, wet mount preparations of
stool samples reveal trophozoites 30%
of the time with one sample and 70%
with three samples. Liver abscesses are
associated with positive stool samples
in 40% to 50% of cases. Ingested
erythrocytes can be seen in E histo-
lytica, which distinguishes it from E
dispar. Some authors recommend test-
ing the stool for E histolytica antigen,
but this test is not widely available.
Serum antibodies are positive in 85% of
cases of invasive colitis, and 99% of
patients who have liver abscesses.
In Brief
Tachypnea
Do Published Guidelines Predict Pneu-
monia in Children Presenting to an
Urban ED? Rothrock G, Green S,
Fanelli JM, et al. Pediatr Emerg Care.
2001;17:240 –243
The Rational Clinical Examination: Does
This Infant Have Pneumonia?
Margolis P, Gadomski A. JAMA.
1998;279:308 –313
Establishing Clinically Relevant Stan-
dards for Tachypnea in Febrile Chil-
dren Younger Than Two Years.
Taylor J, Beccaro M, Dune S, et al.
Arch Pediatr Adolesc Med. 1995;149:
283–287
Evaluation of Simple Clinical Signs for
the Diagnosis of Acute Respiratory
294 Pediatrics in Review Vol.23 No.8 August 2002
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However, countries in which there is a
high prevalence of amebas also have a
high prevalence of positive serologies in
asymptomatic individuals. Therefore,
serologies can be helpful in excluding
the diagnosis only in appropriately cho-
sen populations. Patients who have E
dispar infection have negative serolo-
gies. Biopsies should be taken from the
edge of ulcers or from the capsule of an
abscess, where trophozoites are re-
vealed with periodic acid-Schiff stain.
Ultrasonography is equally effective to
magnetic resonance imaging (MRI) or
computed tomography (CT) for diag-
nosing liver abscesses. MRI or CT can be
used to diagnose cerebral abscesses.
Barium enemas should be avoided be-
cause of the risk of perforation, except
in the case of intussusception.
Treatment for asymptomatic pa-
tients who excrete cysts requires a
luminal agent, usually iodoquinol. Paro-
momycin or diloxanide furoate also
may be used. For patients who have
colitis or extraintestinal disease, met-
ronidazole for 10 days followed by a
Tract Infection. Cherian T, John TJ,
Simoes E, et al. Lancet. 1988;2:
125–128
Through the course of maturation from
infancy to adulthood, human anatomy
and physiology undergo many normal
changes that interact to sustain
breathing and maintain homeostasis.
Both the size and number of the air-
ways and alveoli increase about ten-
fold, thus decreasing airway resistance
and increasing the surface area avail-
able for gas exchange. The chest wall
increases in size and strength. At birth,
the ribs are primarily cartilaginous and
luminal agent is recommended. For
those who have invasive disease and
have a failed a course of treatment,
dehydroemetine followed by a luminal
agent can be considered. Liver ab-
scesses can be treated alternatively
with chloroquine phosphate and dehy-
droemetine followed by metronidazole.
Steroids and antimotility agents may
worsen symptoms. Large liver abscesses
should be drained or aspirated to pre-
vent rupture. Patients who have necro-
tizing enterocolitis and perforation
should undergo emergent surgical re-
section.
Spread of amebiasis is prevented by
appropriate disposal of feces, steriliza-
tion of water, and hand washing. Sur-
veillance for infection and early treat-
ment also helps to contain spread.
Travelers should buy only unpeeled fruit
and drink water that is boiled or treated
with iodine.
Jon Yost, MD
Childrens National Medical Center
Washington, DC
project at right angles from the verte-
bral column. As a result, the ribcage is
rather circular and lacks mechanical
efficiency. When an infant is able to
maintain an upright position, the forces
of gravity act on the muscles and ribs,
causing a relative lengthening of the
thoracic cavity. In addition, the ribcage
mineralizes, becoming less compliant
and more resistant to the forces of each
respiratory cycle. The skeletal muscles
of respiration and the diaphragm con-
tinue to develop after birth, increasing
the number and strength of their fibers.
Tidal volume is the amount of air
that moves in and out of the lung with
 Amebiasis
Jon Yost
Pediatrics in Review 2002;23;293
DOI: 10.1542/pir.23-8-293

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 Amebiasis
Jon Yost
Pediatrics in Review 2002;23;293
DOI: 10.1542/pir.23-8-293

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pedsinreview.aappublications.org/content/23/8/293

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