AMOEBA

An amoeba, sometimes written as "ameba", is a term generally used to

describe a single celled eukaryotic organism that has no definate shape and that moves
by means of pseudopodia. Pseudopodia or pseudopods are temporary projections of the
cell and the word literally means "false feet". The cell uses the pseudopodia as a means
of locomotion. The plural of amoeba is "amoebae", not "amoebas". Although the word
"amoeba" or "amoeboid" is often used to refer to all protozoa that move using
pseudopodia, the word Amoeba (written in italics and with a capital letter) refers to a
specific genus of protozoa of which Amoeba proteus is the best-know species.

The cytoplasm of an amoeba contains the organelles and is enclosed by a cell

membrane. An amoeba uses a process called phagoctyosis to obtain food. This is a
process in which projections of the cell membrane of the amoeba extend and surround
the food particle, totally enclosing it. The food particle is thus internalized in a sort of
"bubble" called a vacuole. The food particle can then be digested in the vacuole. The
amoeba reproduces via mitosis.

Who is at risk for amebiasis?

Amebiasis is common in tropical countries with underdeveloped sanitation. It’s
most common in the Indian subcontinent, parts of Central and South America,
and parts of Africa. It’s relatively rare in the United States.

People with the greatest risk for amebiasis include:

 people who have traveled to tropical locations where there’s poor sanitation
 immigrants from tropical countries with poor sanitary conditions
 people who live in institutions with poor sanitary conditions, such as prisons
 men who have sex with other men
 people with compromised immune systems and other health conditions
What causes amebiasis?
E. histolytica is a single-celled protozoan that usually enters the human body
when a person ingests cysts through food or water. It can also enter the body
through direct contact with fecal matter.

The cysts are a relatively inactive form of the parasite that can live for several
months in the soil or environment where they were deposited in feces. The
microscopic cysts are present in soil, fertilizer, or water that’s been
contaminated with infected feces. Food handlers may transmit the cysts while
preparing or handling food. Transmission is also possible during anal sex, oral-
anal sex, and colonic irrigation.

When cysts enter the body, they lodge in the digestive tract. They then release
an invasive, active form of the parasite called a trophozite. The parasites
reproduce in the digestive tract and migrate to the large intestine. There, they
can burrow into the intestinal wall or the colon. This causes bloody
diarrhea, colitis, and tissue destruction. The infected person can then spread
the disease by releasing new cysts into the environment through infected
feces.

What causes amebiasis?

E. histolytica is a single-celled protozoan that usually enters the human body
when a person ingests cysts through food or water. It can also enter the body
through direct contact with fecal matter.

The cysts are a relatively inactive form of the parasite that can live for several
months in the soil or environment where they were deposited in feces. The
microscopic cysts are present in soil, fertilizer, or water that’s been
contaminated with infected feces. Food handlers may transmit the cysts while
preparing or handling food. Transmission is also possible during anal sex, oral-
anal sex, and colonic irrigation.

When cysts enter the body, they lodge in the digestive tract. They then release
an invasive, active form of the parasite called a trophozite. The parasites
reproduce in the digestive tract and migrate to the large intestine. There, they
can burrow into the intestinal wall or the colon. This causes bloody
diarrhea, colitis, and tissue destruction.

What treatments are available for

amebiasis?
Treatment for uncomplicated cases of amebiasis generally consists of a 10-day
course of metronidazole (Flagyl) that you take as a capsule. Your doctor may
also prescribe medication to control nausea if you need it.

If the parasite is present in your intestinal tissues, the treatment must address
not only the organism but also any damage to your infected organs. Surgery
may be necessary if the colon or peritoneal tissues have perforations.

What is the outlook for people

with amebiasis?
Amebiasis generally responds well to treatment and should clear up in about 2
weeks. If you have a more serious case where the parasite appears in your
internal tissues or organs, your outlook is still good as long as you get
appropriate medical treatment. If amebiasis is left untreated, however, it can
be deadly.

How can I prevent amebiasis?

Proper sanitation is the key to avoiding amebiasis. As a general rule,
thoroughly wash hands with soap and water after using the bathroom and
before handling food.

If you’re traveling to places where the infection is common, follow this

regimen when preparing and eating food:

 Thoroughly wash fruits and vegetables before eating.

 Avoid eating fruits or vegetables unless you wash and peel them yourself.
 Stick to bottled water and soft drinks.
 If you must drink water, boil it or treat it with iodine.
 Avoid ice cubes or fountain drinks.
 Avoid milk, cheese, or other unpasteurized dairy products.
 Avoid food sold by street vendors.

There, it starts destroying brain tissue. But, as Laura Sanders reports for Science News,
the brain eating might not actually be the thing that kills you when you get an N. fowleri
infection. Stomach acid is deadly to the amoeba, so the nose is the its only a shot at a
successful colonization of its host.

Amoebiasis) Amebiasis is an infection of the large intestine and sometimes the liver
and other organs that is caused by the single-celled protozoan parasite Entamoeba histolytica,
an ameba. The amebas may be spread from person to person or through food or water.

Gastrointestinal amebiasis is an infection of the large intestine caused by microscopic one-

celled parasites commonly known as amoebas (Entamoeba histolytica). ... E. histolytica can
live in the intestine without causing symptoms, but it also can cause severe disease.
 Drug treatment can cure amebiasis within a few weeks. However, because medication cannot
keep you from getting infected again, repeat episodes ofamebiasis may occur if you continue to
live in or travel to areas where amoebas are found

Exploring Virulence Determinants

of Filamentous Fungal Pathogens
through Interactions with Soil
Amoebae
Silvia Novohradská1,2, Iuliia Ferling1,2 and Falk Hillmann1*

 1Evolution of Microbial Interactions, Leibniz Institute for Natural Product Research and
Infection Biology-Hans Knöll Institute, Jena, Germany
 2Institute of Microbiology, Friedrich Schiller University Jena, Jena, Germany

Infections with filamentous fungi are common to all animals, but attention is
rising especially due to the increasing incidence and high mortality rates
observed in immunocompromised human individuals. Here, Aspergillus
fumigatus and other members of its genus are the leading causative agents.
Attributes like their saprophytic life-style in various ecological niches
coupled with nutritional flexibility and a broad host range have fostered the
hypothesis that environmental predators could have been the actual target for
some of their virulence determinants. In this mini review, we have merged
the recent findings focused on the potential dual-use of fungal defense
strategies against innate immune cells and soil amoebae as natural
phagocytes. Well-established virulence attributes like the melanized surface
of fungal conidia or their capacity to produce toxic secondary metabolites
have also been found to be protective against the model
amoeba Dictyostelium discoideum. Some of the recent advances during
interaction studies with human cells have further promoted the adaptation of
other amoeba infection models, including the wide-spread
generalist Acanthamoeba castellanii, or less prominent representatives
like Vermamoeba vermiformis. We further highlight prospects and limits of
these natural phagocyte models with regard to the infection biology of
filamentous fungi and in comparison to the phagocytes of the innate immune
system.
Environmentally Acquired Fungal Pathogens
Fungi are ubiquitous in nature, inhabiting various ecological niches. Even
among those which thrive as saprophytes and do not exhibit any host
requirement for survival, there are pathogens which cause devastating
diseases in humans and animals resulting in thousands of deaths every year
(Brown et al., 2012). Classical examples include filamentous fungi
like Aspergillus fumigatus and Fusarium sp., but also several dimorphic fungi
such as Blastomyces dermatitidis or Histoplasma capsulatum, and the
yeast Cryptococcus neoformans, have environmental reservoirs. One of the
most prevalent groups of fungi in the environment is represented by the
aspergilli (Shelton et al., 2002). With several hundred species, only a few of
them have a considerable impact on human health: A. fumigatus, A. flavus, A.
terreus, A. nidulans, and A. niger.

Aspergillus fumigatus is one of the most important air-borne fungal

pathogens, living ubiquitously in terrestrial environments. This fungus
disseminates by releasing thousands of asexual spores (conidia) from each
conidiophore which, upon inhalation, pass through the nasal cavity and reach
the alveoli. Most of them are expelled by mucocilliary clearance while the
residual ones are eliminated by macrophages and neutrophils of an
immunocompetent host. In the case of an immunodeficient host, conidia swell
and grow into a mycelium. Once the fungus overcomes the natural immune
barrier, it can cause asthma-associated allergies, sinusitis, allergic
bronchopulmonary aspergillosis (ABPA) and, in the worst case, life-
threatening invasive aspergillosis (IA), occasionally reaching mortality rates
even beyond 50% due to rapid progression and misdiagnosis (Brown et al.,
2012). Aspergilli can also infect wild and domestic animals nearly
encompassing all major phyla including corals, honey bees, reptiles, and
warm-blooded animals such as birds, mammals, and non-human primates
(reviewed by Seyedmousavi et al., 2015). Another group of environmental
filamentous fungi represent exclusively entomogenous pathogens, such
as Metarhizium anisopliae or Beauveria bassiana. Microscopic examination
and phagocytosis assays with these fungi suggested that their ability to adhere
to the insect cuticle, penetrate through the haemocoel using hydrolyzing
enzymes, and ultimately survive phagocytic haemocytes may be a consequence
of adaptations that have been acquired early in evolution to avoid predation by
soil amoebae (Bidochka et al., 2010).

Unlike Aspergillus, C. neoformans is not ubiquitous in the soil; rather it has

been isolated from areas frequented by pigeons, chickens, turkeys, and other
avian species. After inhalation of infectious particles, Cryptococcus resides in
the lung alveoli where it can persist and replicate while a thick polysaccharide
capsule surrounding the yeast cell helps to avoid its killing by macrophages.
Other studies have shown that Cryptococcus is also able to survive
intracellularly, even a few hour after phagocytosis (Feldmesser et al., 2000).
Dissemination to the brain results in severe meningoencephalitis, especially in
immunocompromised patients. On the other hand, C. gatii which has been
isolated from trees, mainly causes pulmonary infections in an
immunocompetent host (García-Rodas and Zaragoza, 2012; Kwon-Chung et
al., 2014).

Among other environmentally acquired pathogenic fungi, thermally dimorphic

fungi such as Histoplasma capsulatum, Blastomyces dermatitidis,
and Coccidioides immitis are especially clinically relevant and classified as
Biosafety Level 3 (BSL3) organisms. Despite their divergent phylogeny, they
all share similar patterns of existence: temperature-dependent morphological
dimorphism, pulmonary infectivity, and endemism. After the inhalation of
conidia, transformation into a yeast-form is crucial to promote pathogenicity
through escape from phagocytosis, modulation of the cytotoxic environment
of the phagolysosome or enhanced degradation of reactive oxygen species
(Boyce and Andrianopoulos, 2015).

Considering the diversity of environmental niches and strategies to survive

and replicate within a variety of mammalian hosts, the aforementioned
virulence attributes may confer a dual-use capability to defend against
phagocytes in both animal hosts and the environment. Moreover, such
parallels gave rise to the idea that selective pressures in the environment have
led to the emergence and maintenance of these traits that have later supported
virulence in higher eukaryotes. Although the filamentous life style of aspergilli
suggests little need for any specific attributes to avoid or withstand any
phagocytes, their infectious and reproductive stage is formed by small,
unicellular conidia which are easily ingested by such cells. A number of
profound studies over the last years have uncovered a multitude of
mechanisms which aid in the escape and defense of these fungi against their
opponents of human or environmental origin (Table 1).

Fungal Resistance to Innate Immune Cells and

Soil Amoebae
Macrophages and neutrophil granulocytes are the most prominent
representatives among innate immune cells which counteract fungal
pathogens. Alveolar macrophages are the first line of defense against IA by
killing inhaled conidia and initiating the pro-inflammatory response that
recruits neutrophils to the site of infection (reviewed by Brakhage et al., 2010).
As a consequence, patients with reduced numbers of macrophages have long
been known to be at a higher risk to develop IA (Brakhage, 2005). A number
of in-vitro studies suggest that even macrophages from immunocompetent
individuals show variable killing efficiencies of ingested fungal conidia ranging
from 10 to 90% as summarized in Philippe et al. (2003). The same study
demonstrated that fungal conidia are especially resistant to killing when
remaining in a dormant state or when the confronting macrophages are
derived from immunosuppressed donors. Overall, most of these results are
based on counts of colony forming units (CFUs) and certain methodological
issues, such as the time of co-incubation, conidial aggregation or the
incomplete experimental removal of non-ingested conidia, could have also
contributed to the heterogeneous killing rates that have been reported. A
similar assay with Dictyostelium discoideum revealed that conidia were
readily ingested but remained viable over more than 24 h based on the
number of CFUs (Hillmann et al., 2015). Even the comparably robust
pathogen Acanthamoeba castellanii ingested conidia within the first hour of
their interaction, but no signs of digestion were observed at any stage (Van
Waeyenberghe et al., 2013). Along this line, co-incubation of A.
fumigatus or Fusarium oxysporum conidia with the common water
contaminant Vermamoeba vermiformis did not result in any reduction of
viable conidia, but instead phagocytic uptake promoted filamentation and
growth of the fungus (Cateau et al., 2014; Maisonneuve et al., 2016).

Recognition and Processing of Fungal Conidia

by Human and Environmental Phagocytes
Given their role as a first line of defense, studies on the recognition and
phagocytic processing of fungal conidia by macrophages have a long-standing
history, mainly with regard to aspergilli. The surface of their conidia
represents the immediate interface and pathogen-associated molecular
patterns (PAMPs) include cell wall constituents like α- and β-glucans, chitins,
galactomannans, and other polysaccharides. However, these are usually
masked by a proteinaceous, hydrophobic rodlet layer which is
immunologically inert and diminishes the recognition by immune cells
(Aimanianda et al., 2009). The green-gray dihydroxynapthalene (DHN)-
melanin pigment coating dormant conidia is another surface component
assumed to play a similar role in A. fumigatus (Jahn et al., 1997; Tsai et al.,
1998; Chai et al., 2010). These protective layers are lost during swelling and
subsequent germination of the conidia (Figure 1), exposing the PAMPs and
allowing recognition, as demonstrated for strains of A. fumigatus lacking the
DHN melanin pigment which were ingested by macrophages at higher rates
than wild type strains (Luther et al., 2007). Interestingly, nearly identical
ratios were observed with D. discoideum. Conidia of the wild-type, covered by
green DHN-melanin, were taken up, but at least threefold less efficiently than
the white conidia of the melanin deficient mutant (Hillmann et al., 2015).
These data suggest that hiding “prey”-associated molecular patterns could be
an asset to escape also from environmental predators and hence, well suited to
be studied in an amoeba model.

Amoebae Predation as an Evolutionary

Training Ground for Filamentous Fungal
Pathogens
Free living amoebae (FLA) are ubiquitous unicellular protozoa, distributed
worldwide in various environments such as soil, water, or air. Mycophagous
species, either opportunists or specialists, are widespread and have been
isolated over the past 60 years (Olive and Stoianovitch, 1960; Old and
Darbyshire, 1978; Chakraborty et al., 1983; Old et al., 1985; Chakraborty and
Old, 1986). One of the first mycophagous amoebae ever described
was Protostelium mycophagum (Olive and Stoianovitch, 1960). It has been
isolated alongside the pink-pigmented yeast Rhodotorula mucilaginosa, but it
can also feed on Phoma sp., Ustilago violacea, Sporobolomyces sp.,
and Cryptococcus laurentii (Spiegel et al., 2006). Other mycophagous soil
amoebae from the genera Thecamoeba, Arachnula, and Vampyrella have
been shown to suppress the growth of the plant pathogenic
fungus Gaeumannomyces graminis var. tritici and therefore significantly
contribute to the reduction of “take-all” wheat crops disease caused by this
fungus (Chakraborty et al., 1983).

In environments where fungi have encountered constant protozoal predation

and competition for nutrients, they must have developed strategies to
counteract phagocytic uptake or intracellular passage. Consequently, the same
determinants that were effective against amoeba predation, could have later
promoted the survival of fungi in a human host. The coincidental evolution
hypothesis suggests that virulence factors have evolved as a response to more
ordinary selection pressures than for virulence per se(Erken et al., 2013).
Several studies using free-living amoeba A. castellanii and more recently D.
discoideum have supported this hypothesis for yeast-like fungi and have
underlined the suitability of these models to study basic fungal virulence
determinants (Steenbergen et al., 2001, 2004; Chrisman et al.,
2010; Derengowski et al., 2013; Koller et al., 2016; Rizzo et al., 2017, see
Table 1 for an overview).

Aspergillus fumigatus requires no obvious residence inside the mammalian

host to survive and replicate; it appears to lack classical virulence factors and
its pathogenicity primarily depends on host impairment. Therefore, it is
conceivable that the ability to counteract the compromised immune system
was partially tuned from the long-term interplay between fungi and their
predators in their natural environment. Such fungivorous organisms are by no
means limited to amoebae, but also include higher animals like nematodes,
mites, or insects. For instance, a primary study on A. nidulans demonstrated
that the multitude of fungal low-molecular-mass compounds known as
secondary metabolites could present a selective advantage against predation
by the fungivorous springtail Folsomia candida (Rohlfs et al., 2007).

Such defensive actions could also provide protection against microscopic

predators, as active components have been shown to diffuse from the non-
germinating spores and inhibit certain functions of phagocytosis (Slight et al.,
1996). The anti-amoebae effects of diffusates from clinical and environmental
isolates of A. fumigatus and A. terreus have been described on Naegleria
gruberi, proposing it as a primary function of such metabolites (Hobson,
2000). Even at the early stages of a direct interaction, mycotoxins are
encountered immediately by the ingesting phagocytes, as it has recently been
shown for the amoebicidal polyketide trypacidin which resides primarily on
the surface of the A. fumigatus spore (Gauthier et al., 2012; Mattern et al.,
2015, Figure 1). Following germination and escape, further potent, soluble
toxins are synthesized.

Among them, the sesquiterpene fumagillin was one of the first for which
amoebacidal properties were observed and has initially been used for the
treatment of infections caused by Entamoeba histolytica (Killough et al.,
1952). Fumagillin (Figure 1) and its synthetic analogs thereby irreversibly
inhibit the methionine aminopeptidase-2 (MetAP2), making them promising
therapeutic candidates against malaria parasites, trypanosomes, or other
amoebae (Arico-Muendel et al., 2009). When using D. discoideum as a model,
however, cytotoxic effects on the phagocytes could largely be attributed to the
non-ribosomal peptide gliotoxin (Hillmann et al., 2015). The toxic and
immunosuppressive properties of gliotoxin, the prototype of the
epidithiodioxopiperazine (ETP)-type mycotoxins, are directed toward the
host's immune effector cells via the activity of its unusual intramolecular
disulfide bridge (Figure 1). Several target molecules for gliotoxin have been
well described, including the NADPH oxidase of polymorphonuclear
leukocytes or central regulatory hubs like the phosphatidylinositol 3,4,5-
trisphosphate metabolism and the transcription factor NFκB (Pahl et al.,
1996; Tsunawaki et al., 2004; Schlam et al., 2016). Among these studies,
Schlam and colleagues have shown that gliotoxin further prevents integrin
activation in immortalized and primary macrophages and interferes with actin
dynamics. As both of these are essential instruments during phagocytosis and
membrane ruffling, such pathways may be attractive targets in the defense
against FLA. Previously it was thought that gliotoxin production is restricted
only to clinical isolates of A. fumigatus; however, it was demonstrated recently
that the vast majority (>96%) of both environmental and clinical isolates of
aspergilli are able to produce this mycotoxin (Kupfahl et al., 2008; Scharf et
al., 2012). Consequently, it is only plausible to suspect that fungi have
maintained their whole repertoire of active secondary metabolites to
counteract not only their numerous competitors, but also predators in their
natural environment whose numbers and diversity have long been
underestimated. A recent study supports this conclusion by demonstrating
that mycophagous protists are abundant, taxonomically widespread, and
central ecological players in the soil food web (Geisen et al., 2016).

Perspectives
Long before bacteria infected humans, they infected amoebas, which remain a potentially
important reservoir for human disease. Diverse soil amoebas
including Dictyostelium and Acanthamoeba can host intracellular bacteria. Though the internal
environment of free-living amoebas is similar in many ways to that of mammalian macrophages,
they differ in a number of important ways, including temperature. A new study in PLOS Biology by
Taylor-Mulneix et al. demonstrates that Bordetella bronchiseptica has two different gene suites
that are activated depending on whether the bacterium finds itself in a hot mammalian or cool
amoeba host environment. This study specifically shows that B. bronchiseptica not only inhabits
amoebas but can persist and multiply through the social stage of an amoeba host, Dictyostelium
Environmental amoebas came before animals as
discoideum.

hosts to bacteria
The bacteria that most concern us are those that make us sick, but we are

sometimes so preoccupied with our battle with them that we forget they

have been waging a much longer war. More than a billion (109) years before

the first animals, bacteria were evolving strategies first to resist being killed

by protozoan predators and then to actually infect their former predators [1].

These strategies are likely to have laid the groundwork for the later evolution

of animal–bacteria interactions, so understanding how they function

provides an essential context for understanding modern-day bacterial

pathogens in humans. This is particularly true for the bacteria that invade

animals through macrophages [2]. Further, environmental amoebas are still

ubiquitous in modern soil and water, so they may act as important reservoirs

from which emerging human diseases can arise [3]. Many amoebas,
including Acanthamoeba castellanii, D. discoideum, Hartmannella

vermiformis, and Naegleria gruberi, have been found to harbor bacteria [4].

Bacteria that can defeat amoebas’ defenses gain a refuge in which to proliferate, where

they are protected from hostile external conditions by their unwitting hosts [5–8].

It is worth pointing out that amoebas do not fall into a monophyletic group but instead

share a life form and a diet based on phagocytosis. The bacteria that can evade

amoeba defenses are called amoeba-resistant bacteria [3,4]. In these amoebas,

resistant bacteria can survive, proliferate, and be protected in adverse situations,

particularly when the host amoeba forms a hardy cyst with the bacteria inside.

Glossary
Glossary

Amoeba-resistant bacteria: Bacteria that have evolved to resist being killed by free-
living amoebas.

Bacterial secretion system: The mechanisms by which bacterial pathogens evolved to

export various virulence factors across the phospholipid membrane and cell envelope.

Ejectosome: A peripheral cellular organelle responsible for ejecting cytosolic bacteria

from the cell without lysing that cell.

Fruiting body: A multicellular structure on which spore-producing structures are borne.

Free-living amoebas: Widely distributed protozoa that have the ability to alter their
shape and feed on bacteria, algae, fungi, and small organic particles.

Lysosome: A membrane-bound organelle that contains hydrolytic enzymes that can

break down biomolecules.

Phagocytosis: The process by which a cell engulfs a solid particle to form an internal
compartment known as a phagosome.

Phagosome: A vacuole formed around a particle engulfed by phagocytosis.

Symbiosis: A relationship between individuals of different species that live closely
together.

Two-component regulatory system: One kind of mechanism of signal transduction

that allows organisms to sense and respond to a changing environment.

Spore: A unit of sexual or asexual reproduction that is able to disperse and survive in
unfavorable conditions.

Virulence factor: Molecules produced by pathogens that can increase their fitness in
interactions with the host.

The parasite lives only in humans and is passed in the feces (poop) of an infected
person. A person gets amebiasis by putting anything in their mouth that has touched
infected feces or by eating or drinking food or water contaminated with the parasite. It
can also be spread sexually by oral-anal contact.

Transmission
Amebiasis is spread person to person by eating or drinking food or water contaminated with the
stools of persons infected with E. histolytica. It can also be spread through sexual contact with
an infected person. While anyone can get this illness, it is most common in people who live in or
travel to developing countries that have poor sanitary conditions.

For most persons, staying home from work or school is not necessary. However, persons who
work as food handlers, child care providers, and those involved with patient care, should not
serve or handle food until given permission to do so by their doctor or the Department of Health.

Diagnosis
If you have symptoms of amebiasis, your health care provider may conduct a stool specimen
test.

Treatment
A doctor can prescribe medicine to treat amebiasis.

Immunity
http://health.hawaii.gov/docd/disease_listing/amebiasis/
VEpidemiologic Notes and Reports Pseudo-outbreak of Intestinal
Amebiasis -- California

In October 1983, the Los Angeles County (California) Department of Health Services
was notified by a local medical laboratory of a large increase in the laboratory's
diagnoses of intestinal amebiasis (Entamoeba histolytica infection). Thirty-eight cases
were identified from August to October. The laboratory staff estimated that, before
August, they had diagnosed approximately one E. histolytica infection per month.

A preliminary investigation failed to identify a common source of the infection. There

had been no increase in the number of specimens examined, and although the
laboratory served several health facilities, there was no clustering of cases in
particular facilities. Finally, most patients did not belong to groups recognized to be at
high risk for acquiring amebiasis (such as male homosexuals, tourists to or
immigrants from developing countries, or institutionalized persons). The most
common complaint of patients was gastrointestinal symptoms, and most improved
after treatment with metronidazole. A review of amebiasis diagnoses from other
laboratories in Los Angeles County did not reveal other instances of increased
reporting.

To evaluate the accuracy of E. histolytica diagnoses, 71 slides from the 38 patients

were reexamined by the University of California at Los Angeles Clinical Laboratory
or the Los Angeles County Public Health Laboratories. Only four slides from two
(5.3%) patients were found to contain E. histolytica. Of specimens from the 36
patients found not to have E. histolytica, 34 contained polymorphonuclear neutrophils
and/or macrophages, and two contained nonpathogenic protozoa.

The laboratory reporting the increase follows approved procedures for the collection
and examination of stools for protozoa. Permanent slides are prepared from fecal
material preserved in polyvinyl alcohol and stained by the Gomori-trichrome method
(1). One technician was responsible for reading parasitology slides and had performed
that job for the preceding 4 years. The technician's supervisor reviewed all positive
slides. The only change in procedure that had been recently introduced was the
assignment of a different person to the preparation of the initial smears. This person
prepared slides that were "less dense," and the slides were "easier to read." Reported
by L Garcia, MT, University of California at Los Angeles Medical Laboratory, F
Sorvillo, MPH, M Epstein, MD, K Mori, B Agee, MD, R Barnes, PhD, Los Angeles
County Dept of Health Svcs, J Chin, MD, State Epidemiologist, California Dept of
Health Svcs; Protozoal Diseases Br, Div of Parasitic Diseases, Center for Infectious
Diseases, Laboratory Program Office, CDC.
Editorial Note

Editorial Note: This pseudo-outbreak of intestinal amebiasis serves as a reminder that

identification of E. histolytica is difficult. Although E. histolytica can be confused
with other intestinal protozoa, a more common problem is that leukocytes or
macrophages in stool specimens are identified as E. histolytica (2). In 1981, the
College of American Pathologists (CAP) conducted a proficiency survey using a stool
specimen, which contained many leukocytes, from a patient with inflammatory bowel
disease (3). None of 15 referee laboratories but 100 (16.7%) of 599 participating
laboratories reported one or more intestinal protozoa, most commonly E. histolytica.
Similarly, as shown in a report of seven suspected outbreaks of amebiasis in the
United States between 1971 and 1974, three laboratories might have mistakenly
diagnosed amebiasis in as many as 1,200 patients a year for 20 years (2).

A summary of proficiency surveys for parasites conducted by the CAP from 1973 to
1977 showed that E. histolytica infections are also often overlooked (4). Twenty-
seven percent of participating laboratories overlooked trophozoites, and 37%
overlooked cysts of E. histolytica in stool specimens.

Results of CDC's Proficiency Testing Program in Parasitology closely paralleled those

reported by the CAP. In 1982, CDC conducted a parasitology proficiency testing
survey using a stool specimen that contained no parasites and numerous leukocytes.
None of the 17 reference or referee laboratories reported the presence of intestinal
parasites; however, 74 (14.0%) of the 528 participant laboratories incorrectly reported
one or more intestinal parasites, most commonly E. histolytica cysts. A summary of
CDC proficiency testing surveys in parasitology from 1973-1977 also demonstrated
that E. histolytica is often overlooked. Twenty-nine percent of participating
laboratories overlooked E. histolytica trophozites, and 33% overlooked E. histolytica
cysts in stool specimens.

To avoid errors when attempting to diagnose parasitic diseases, physicians should

identify laboratories in their areas whose staffs are experienced in diagnostic
parasitology and who participate in and score well on proficiency testing for parasitic
diseases.

References

1. Garcia LS, Ash LR. Diagnostic parasitology clinical laboratory manual. St.
Louis, Missouri: CV Mosby, 1975:16-7.
2. Krogstad DJ, Spencer HC Jr, Healy GR, Gleason NN, Sexton DJ, Herron CA.
Amebiasis: epidemiologic studies in the United States, 1971-1974. Ann Intern
Med 1978;88:89-97.
 3. College of American Pathologists. Special parasitology survey (critique
specimen P-12), 1981.
4. Smith JW. Identification of fecal parasites in the special parasitology survey of
the College of American Pathologists. Am J Clin Pathol 1979;72:371-3.

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In a visit on Wednesday, villagers told The Star they were fearful.

Mainda Mathina, 95, from Lairang'i died yesterday afternoon while his wife and son were
admitted at Isiolo hospital with vomiting, abdominal pains and diarrhea. Lairang'i sub-location
manager Norman Mwiti said most families do not have access to water and that Mburanaro
stream and a borehole in Buuri constituency were "very contaminated'.

Mwiti, sub-county health officials and area sub-chief Kawira Mwenda visited affected families
and found both adults and children were sick.

Administrators warned locals against visiting their friends and relatives and sharing food and
water at public gatherings.

County public health director Ephantus Kariuki ruled out cholera and said a laboratory report
showed most residents were suffering from amoebiasis, a bacterial infection that also results
form the contamination of food and water.

The officer said they visited several parts and believed the outbreak was worsened by festivities.

"This resulted from contamination of food during the festive season. I have been to Ruiri where
some of affected people are drunkards," he said.

"Most cases were reported on Friday when the holiday began. The lab analysis shows this is
amoebiasis."

Kariuki said Mathina may have died from dehydration after refusing to drink water or eat.

"He refused to eat and drink and due to vomiting and diarrhea, I suspect the mzee died from
dehydration. His age is also a factor to consider."
The Cebu Provincial Health Office reported Friday only one patient from Barangay Calmante
remains confined in the hospital, while the others were asked to self-medicate at home.

Dr. Cristina Giango, Cebu provincial health officer, told reporters that while the diarrhea and
amoebiasis cases in Barangay Calmante in Tudela increased to 44, the situation is "already under
control."

She added that it was not alarming, since only three percent of the barangay's population of
1,323 residents was affected.

Admissions have increased due to fears among residents that they may be suffering from an
outbreak of cholera in their area, she said.

However, Giango denied reports the residents have cholera, citing results of tests on their stool
samples.

Dr. Susana Madarieta, DOH Central Visayas director, said it was the first time the agency heard
that Barangay Calmante reported mass admissions due to diarrhea and amoebiasis.

She applauded local health officials for their quick assessment and response.

She also asked the local government of Tudela to examine a well in the barangay and check its
water quality, to make sure the water is safe to drink.

As diarrhea and amoebiasis are food and water-borne, a thorough check on what the residents ate
or drank since the incident began will be needed.

As of Friday, the Provincial Epidemiology and Surveillance Unit (Pesu) brought some supplies
of chlorine tablets, medicines and Oresol, a solution of sugar, salt and water, to Barangay
Calmante.

The team from the Capitol also monitored the hospital fees of the affected residents, so they
won't be paying a single centavo while being treated, said Giango. Some of the residents were
admitted to the Ricardo Maningo Memorial Hospital in San Francisco, Camotes since Tuesday.

Dr. Giango also revealed Cebu Governor Gwendolyn Garcia has ordered the Provincial Water
Task Force to check on the barangay's well, which was believed to be the source of the residents'
ailments.

Amoebiasis is an infection of the bowels whose symptoms include diarrhea and abdominal
cramps.

In an administrative order in December 2007, the DOH national office listed diarrhea among the
10 leading causes of death among children. A DOH field survey in 2006 found that 707 out of
every 100,000 children younger than five years suffered from acute watery diarrhea that year.

The agency recommended oral rehydration salts and zinc supplements to prevent severe
dehydration, which can prove fatal, and recurrence of the disease. (JKV of Sun.Star Cebu)