Eficacia del tinidazol en la profilaxis terapéutica de la colitis amebiana en pacientes con leucemia aguda de novo que reciben quimioterapia intensiva / Efficacy of tinidazole in the therapeutic prophylaxis of amoebic colitis in patients with de novo acute leukemia receiving intensive chemotherapy

Resumen Introducción: En México la seroprevalencia de la Entamoeba histolytica es del 8.4%. La amebiasis intestinal en pacientes con leucemia aguda de novo posterior al inicio de quimioterapia (QT), en el Servicio de Hematología del CMN 20 de Noviembre, es del 12%, aún si muestran test coprológico negativo basal. Objetivo: Averiguar si la administración de tinidazol, en pacientes con leucemia aguda y coprológico negativo, al principio de la QT, disminuye la incidencia de colitis amebiana durante la inducción a la remisión. Método: Prospectivo y no comparativo. Enfermos con diagnóstico de leucemia aguda de novo que inician QT de inducción y coprológico inicial. Se indicó tinidazol, 2 g/día durante 5 días en la primera semana de comenzada QT. Se vigilaron hasta que la inducción concluyó y se inició la recuperación hematopoyética. Resultados: 38 pacientes, 15 mujeres y 23 hombres con edad media de 44 años (16-72). Con leucemia aguda linfoblástica 19, con mieloblástica 16 y con promielocítica 3. Casos sin y con amebiasis intestinal, 35 y 3, respectivamente. Los pacientes con amebiasis solo recibieron tinidazol durante 3 días y se dio después de 2 días de empezada la QT. Conclusión: El tinidazol, en pacientes con leucemia aguda de novo que inician QT de inducción, es efectivo en la prevención de la amebiasis intestinal, durante la etapa de inducción, si se administra a 2 g/día, durante cinco días, a partir del día 1 de la QT.

Abstract Introduction: In Mexico, seroprevalence of Entamoeba histolytica is 8.4%. The intestinal amebiasis in patients with acute leukemia of novo, after the start of chemotherapy (CT) in the Hematology Service of the CMN 20 de Noviembre is 12%, even if patients show a negative baseline coprological test. Objective: To find out if the administration of tinidazole, in patients with acute leukemia and negative coprological test, at the beginning of the CT, decreases the incidence of amoebic colitis during the induction to remission. Method: Prospective and not comparative study. Patients with de novo diagnosis of acute leukemia who initiate induction and initial coprological CT. Tinidazole was indicated, 2 g/day for 5 days in the first week of CT started. They were monitored until the induction was concluded and hematopoietic recovery started. Results: 38 patients, 15 women and 23 men with a mean age of 44 years (16-72), with acute lymphoblastic leukemia 19, myeloblastic 16 and promyelocytic 3. Cases without and with intestinal amebiasis were 35 and 3, respectively. Patients with amebiasis only received tinidazole for 3 days and it was given 2 days after the CT started. Conclusion: Tinidazole, in patients with acute de novo leukemia who initiate induction CT, is effective in the prevention of intestinal amebiasis, during the induction stage, if administered at 2 g/day, for five days, starting on day 1 of the CT.

Perfuração do colo por colite amebiana invasiva durante terapia anti-TNF para espondiloartrite / Colonic perforation due to invasive amebic colitis during anti-TNF therapy for spondyloarthritis

O bloqueio do TNF tem tido sucesso no tratamento de algumas doenças reumáticas, como a espondiloartrite. Relatam-se muitas complicações infecciosas com a terapia anti-TNF, principalmente infecções bacterianas, micobacterianas, virais e fúngicas. A Entamoeba histolytica é um protozoário extracelular que causa principalmente colite e abscesso hepático, sendo que a perfuração intestinal é uma complicação rara, com alta mortalidade. O TNF é considerado o principal mediador da imunidade celular contra a amebíase. Inicialmente, é quimiotático para a E. histolytica, potencializando sua adesão ao enterócito por meio da lectina galactose-inibível, e depois ativando os macrófagos para matarem a ameba pela liberação de NO; assim, o bloqueio do TNF poderia ser prejudicial, aumentando a virulência amebiana. Descreve-se o caso de uma mulher de 46 anos com espondiloartrite que apresentou uma perfuração do colo por colite amebiana invasiva durante uso de anti-TNF.

TNF blockade has been successful in the treatment of some rheumatic diseases such as spondyloarthritis. Many infectious complications have been reported with anti-TNF therapy, mainly bacterial, mycobacterial, viral and fungal infections. Entamoeba histolytica is an extracellular protozoan parasite that mainly causes colitis and hepatic abscess; bowel perforation is an uncommon complication with high mortality. TNF is considered the principal mediator of cell immunity against amebiasis. Initially, it is chemotactic to E. histolytica, enhancing its adherence to enterocyte via galactose inhibitable lectin, and then activating macrophages to kill ameba though the release of NO, so that TNF blocking could be harmful, increasing amebic virulence. We describe the case of a 46-year-old woman with spondyloarthritis who presented a colonic perforation due to invasive amebic colitis during anti-TNF use.

Perforación intestinal secundaria a amebiasis / Amebiasis intestinal perforation secondary

La amebiasis intestinal es una enfermedad frecuente en países en desarrollo, que es común en regiones tropicales y subtropicales, así como en regiones con servicios sanitarios deficientes. Presentamos el caso de un paciente de 74 años de edad, sexo masculino, originario y residente de la ciudad de Guatemala, quién cursó una diarrea y dolor abdominal. Fue intervenido quirúrgicamente por abdomen agudo, con resección intestinal extensa por perforaciones. En el estudio de anatomía patológica se realizó el diagnóstico de colitis amebiana con perforaciones y peritonitis.

Intestinal amoebiasis is a disease common indeveloping countries, which is common in tropicaland subtropical regions, as well as in regions withpoor sanitation. We report the case of a 74-year-oldmale, resident of Guatemala City, who presented withdiarrhea and abdominal pain. He had a laparatomy foracute abdomen, undergoing wide intestinal resectiondue to perforations. The pathology diag-nosis wasamoebic colitis with perforations and peritonitis.

Fulminant amebic colitis a life threatening rare entity

To present two uncommon cases of Fulminant Amebic Colitis. Retrospective study. Surgical and Medical Department at Salmaniya Medical Complex. From March to September 2008, two cases of fulminant Amebic Colitis were seen and reviewed as far as their presenting features, investigation, characteristic histopathologic picture, and management. Two cases of Amebic Colitis were found in the hospital records during the last ten years. Both presented to the clinic within the last six months. Both patients were males, young, from poor socio-economic class and are originally from Indian subcontinent. Both had vague and mild presentation. One progressed to massive lower GI bleeding and the other one progressed to colonic perforation and peritonitis. The second case had CT scan, which showed signs of colitis and suspected perforation but was not diagnostic of Amebic Colitis. The first case had subtotal colectomy and primary anastomosis; while, the second case had limited colectomy with proximal colostomy and distal mucus fistula. The diagnosis was based on histopathology of the resected specimens. Serology was confirmatory in only one patient. Fulminant Amebic Colitis is a rare entity. Clinical awareness and early surgical intervention are very important in the outcome. Two cases of fulminant Amebic Colitis have been managed by colonic resection of the affected part, in addition to Metronidazole and broad-pectrum antibiotic

Colitis amebiasis with symptom of occasional dripped anal bleeding.

Colitis amebiasis is usually characterized by bloody and mucous diarrhea, abdominal pain and anal discomfort. However, there is unusual manifestation of colitis amebiasis, such as occasional dripped anal bleeding, which sometimes spouted. Therefore, we often do not suspect such symptoms for colitis amebiasis. Laboratory examination includes complete laboratory test, coagulation and hematologic test, ICT TBC and colonoscopy. The pathology anatomy examination reveals positive results of trophozoites. Treatment by using metronidazole tablet provides good result for this disease.

Colonic perforation due to necrotizing amoebic colitis.

A seriously ill woman with the history of fever for 14 days and severe pain in abdomen with frequent passage of blood and mucous mixed loose stool for 11 days was admitted in the Surgery Unit-3 of Mymensingh Medical Collage Hospital. On examination the patient was toxic, moderately anaemic and dehydrated and there was diffuse abdominal tenderness with a palpable tender cystic intra abdominal lump in right lower abdomen. Fluidthril was present with absent bowel sound. Digital rectal examination revealed bulged anterior rectal wall. X-ray abdomen revealed multiple gas and fluid leveled loops of intestine with increased haziness of the film. On emergency laparotomy it revealed huge amount of faecal matter with fluid in peritoneal cavity. The greater omentum was adherent to caecum with multiple friable necrotic areas in the caecum, transverse and splenic flexure of the colon with multiple small perforations, Subtotal colectomy and end to end anastomosis was done. Histopathological examination of the resected gut revealed features compatible with amoebic ulcer perforations. On 13th post operative day the patient was discharged without any post operative complication and in the 1st follow up after one month the patient was found without any complication.

Ruptured liver abscess with fulminant amoebic colitis: case report with review.

Amoebic liver abscess is the commonest extra intestinal manifestation of amoebiasis. Intraperitoneal rupture of liver abscess and fulminant necrotizing amoebic colitis are rare occurrences which complicate a severe form of invasive disease caused by Entamoeba histolytica. These complications are associated with a high morbidity and mortality. Synchronous pathological lesions in colon and liver are rare. Still rare is the occurrence of complicated colonic and hepatic invasive amoebiasis presenting as an acute abdomen. One such presentation of ruptured liver abscess and necrotizing amoebic colitis in a 70 year old male which was successfully managed is being reported.

Toxic amebic colitis coexisting with intestinal tuberculosis

A patient with a fulminant amebic colitis coexisting with intestinal tuberculosis had a sudden onset of crampy abdominal pain, mucoid diarrhea, anorexia, fever and vomiting with signs of positive peritoneal irritation. Fulminant amebic colitis occurring together with intestinal tuberculosis is an uncommon event and may present an interesting patho-etiological relationship. The diagnosis was proven by histopathologic examination of resected specimen. Subtotal colectomy including segmental resection of ileum, about 80 cm in length, followed by exteriorization of both ends, was performed in an emergency basis. Despite all measures, the patient died on the sixth postoperative day. The exact relationship of fulminant amebic colitis and intestinal tuberculosis is speculative but the possibility of a cause and effect relationship exists. Fulminant amebic colitis may readily be confused with other types of inflammatory bowel disease, such as idiopathic ulcerative colitis, Crohn's disease, perforated diverticulitis and appendicitis with perforation. This report draws attention to the resurgence of tuberculosis and amebiasis in Korea, and the need for the high degree of caution required to detect it.

Comparative study of the efficacy and tolerability of Secnidazole suspension (single dose) and Tinidazole suspension (two days dosage) in the treatment of amebiasis in children

Amebiasis caused by Entamoeba histolytica may be considered the most aggressive parasitic disease affecting human intestine, causing acute amoebic colitis and extra-intestinal diseases of high morbidity and mortality. 5-nitroimidazoles are the drugs of choice. In this multicenter, open and randon clinical trial, the efficacy and tolerability of secnidazole suspension in a single oral dose of 1ml/kg was compared with 0.5ml/kg doses of tinidazole suspension given for 2 consecutive days to 303 Entamoeba histolytica-positive children aged 2 to 13. Patients with extra-intestinal complications were excluded from the study. Clinical and parasitological follow-up using the Faus and Kato-Katz method were carried out 7, 14, and 21 days after treatment. Clinical improvement/cure was observed in 93 percent of the patients in the secnidazole group and 91 percent in the tinidaloze group. Parasitological sucess was reported for 77 percent and 63 percent of the secnidazole and tinidazole patients, respectively, showing a significant statistical difference between the two groups (p=0.007). Both drugs were well tolerated, and the adverse effects reported were mild, consisting mainly of digestive disturbances. This comparative study showed that a single oral dose of 1ml/kg of secnidazole produced a significantly higher parasitological cure rate than 2 doses of tinidazole. Secnidazole is a safe and effective drug for the treatment of uncomplicated intestinal amebiasis.

Profile of lower gastrointestinal bleeding in children from a tropical country.

Eighty five children were evaluated endoscopically for recurrent lower gastrointestinal (GI) bleeding. The male: female ratio was 2.4:1 with a mean age of 6 years (range 8 months to 2 years). After adequate bowel preparation endoscopic evaluation was done using olympus CF 101 colonoscope. Sedation was given only in two patients. Full length colonoscopy had been done in 16 cases only, to look for extent of disease in 8 cases and to ascertain site of bleeding when no lesion could be seen on sigmoidoscopy. Juvenile polyps were seen in 40 cases, amoebic ulcer in 20, solitary rectal ulcer in 4 and polyposis syndrome in 5 cases. Sigmoidoscopy alone could establish the diagnose in 76 cases. We conclude that flexible sigmoidoscopy alone is safe and adequate in ascertaining the cause of prolonged recurrent lower GI bleeding.

Absceso hepático amibiano en el hospital San Juan de Dios de Armenia

Las manifestaciones clínicas siguen siendo el pilar diagnóstico del absceso hepático amibiano (AHA), a comprobarse por la sumatoria de análisis de imágenes hepáticas y de estudios serológicos para detectar anticuerpos con la Entamoeba histolytica o, en su defecto, la prueba terapéutica con derivados imidazólicos. El análisis retrospectivo de 64 casos de AHA en el Hospital San Juan de Dios de Armenia, recopilados durante un período de 12 años, muestra la presentación clínica típica de la entidad, cursando con mayor frecuencia en hombres, entre 20 y 39 años de edad, con dolor en el hipocondrio derecho en la totalidad de los casos, curso agudo o subagudo, acompañado de fiebre en 94 por ciento de los casos, y manifestaciones respiratorias en 50 por ciento de los pacientes. La presentación con disentería amibiana concomitante fue rara y las complicaciones se presentaron en 4.6 por ciento de casos, representadas fundamentalmente por ruptura del absceso a la cavidad torácica. Los pacientes con ocupaciones agrícolas fueron los más afectados, sin poder determinar correlaciones con la procedencia y estrato socioeconómico. La mortalidad por AHA fue de 1.56 por ciento, que representa un solo caso, asociada a ruptura del absceso al tórax. El manejo quirúrgico no aumentó la mortalidad.

Necrotising arteritis in amoebic colitis.

Massive intestinal haemorrhage rarely occurs in amoebic colitis. We report a case of caecal amoebic ulcer in a 61 year old diabetic male who presented with massive lower intestinal haemorrhage requiring blood transfusion and emergency surgical intervention. Histologically, trophozoites of Entamoeba histolytica were seen invading the wall of the submucosal arteries, causing necrotising arteritis. Rupture of a necrosed artery probably caused massive haemorrhage.

Spastic colitis and irritable bowel syndrome: which expression is prevalent? (A review of 120 cases).

Spastic Colitis (SC) of the fifties has been deleted and included in the Irritable Bowel Syndrome, as inflammation is not present, and the disturbed intestinal motility may involve the small and large intestine. With the advent of colonoscopy, we could investigate this generalized common term. Between 1983 and 1988 we have studied 120 documented cases of SC by colonoscopy with multiple biopsies. In every patient, we relied on consecutive procedures to confirm the diagnosis. They included: Stool examination, barium enema, small bowels series, colonoscopy with multiple biopsies. Serological diagnosis of Amebiasis has been applied to 41 patients only. With a normal small bowels, barium enema revealed a severe spasm of the whole colon, or a segmental spasm in one part of the colon. In 53 cases (44%,) we have noted virtual absence of haustra in the tubular descending colon. Colonoscopy in all cases has revealed an active contraction with some congestion of the mucosa or hyperemia. Different degrees of inflammatory reaction shown on multiple biopsies make the diagnosis of SC in these cases more relevant. In the Afro-Asiatic countries where amebiasis is endemic, SC is to be considered, as colonoscopy is proving the prevalence of congested or inflammatory process in the colonic mucosa, even when stool examination is repeatedly negative for amebiasis.

Atypical clinical manifestations of amebic colitis

Amebic colitis is a disease revealing diverse clinical manifestations and endoscopic gross features and often confused with other types of colitis. In case of misdiagnosis as an idiopathic inflammatory bowel disease or delayed recognition of intestinal amebiasis, an undesirable outcome may occur resulting from erroneous administration of steroids or delayed antiamebic treatment. To demonstrate the pitfalls in the diagnosis and treatment of intestinal amebiasis, 3 cases of amebic colitis with atypical clinical manifestations are presented in this paper. In conclusion, despite the low sensitivities of routine stool examination for parasite and histopathologic confirmation in biopsy specimen, every effort must be made to find amebic trophozoites either in fresh stool or biopsy specimens for prompt and correct diagnosis of amebic colitis when we manage patients with chronic intestinal ulcerations, even though their clinical course and endoscopic findings are not typical of amebiasis. Moreover, following initial successful anti-amebic therapy, more careful clinical, endoscopical, and parasitological follow-up should be done for the early detection of recurrence.

Megacolon tóxico amebiano / Amebic toxic megacolon

Se estudiaron en forma prospectiva 27 casos de megacolon tóxico amebiano (MCTA), en nuestro Hospital, desde el año 1977 a la fecha. Se presenta como complicación de la colitis ulcerosa amebiana con una frecuencia estimada entre 0,6 al 0,9 de los casos. Anatomopatológicamente, corresponde a una dilatación del colon por destrucción de los plexos mientéricos y que, unida a las ulceraciones de la pared intestinal termina por perforarla. El cuadro clínico inicial corresponde al de una gastroenteritis aguda corriente, pero que en las siguientes horas de su evolución presenta manifestaciones propias de un cuadro abdominal agudo, con características de sepsis violenta. El diagnóstico inicial, por tanto, es difícil. Todos los pacientes fueron intervenidos practicando cirugía resectiva de los segmentos comprometidos. La morbilidad es extraordinariamente alta y su mortalidad alcanza casi al 50%. La sobrevida, por consiguiente, dependerá de la precocidad del diagnóstico y tratamiento quirúrgico y, fundamentalmente, de manejo pre y postoperatorio en las unidades respectivas

Colon tóxico amibiano con y sin perforación: conducta quirúrgica / Amoebic toxic colon with and without perfuration: surgical management

Se trataron quirúrgicamente 47 pacientes de colon tóxico amibiano en el Instituto Nacional de Pediatría, 27 con perforación del colon y 20 sin perforación durante un período de 12 años (enero de 1972 a diciembre de 1984). En los 27 pacientes perforados, las zonas más afectadas fueron el colon ascendente, transverso y descendente; en 4 pacientes estuvo afectada la totalidad del colon. A 18 se les practicó colectomía subtotal, a 4 hemicolectomía, a otros 4 colectomía total y en 1 caso colostomia. A los pacientes no perforados sólo se les practicó derivación fecal mediante ileostomía. En ambos grupos hubo un número importante de complicaciones posoperatorias, de todas ellas una de las más frecuentes fue la estenosis en el colon desfuncionalizado (40% de los pacientes que sobrevivieron). La reintervención quirúrgica que ocupó el primer lugar fue el cierre de la ileostomía; otro grupo importante fue la resolución quirúrgica de las zonas de estenosis incluyendo 3 pacientes a quienes se practicó rectoplastía sagital posterior sin que se alterara la continencia fecal. La mortalidad global fue de 47%

Chronic diarrhoea: a prospective study in Thai patients at Chulalongkorn University Hospital, Bangkok.

Fifty-five Thai patients with chronic diarrhoea were prospectively studied to find out the underlying causes. The aetiology was identified in 38.2%, uncertain in 29.1%, and unknown in 32.7% of the patients. In the group with a definitive aetiologic diagnosis, parasitic and infective causes were commoner than non-infective causes. Amoebiasis and giardiasis were more frequent than expected, such that empirical therapeutic trial with an antiprotozoal may be justified if initial routine investigations fail to uncover the cause of the diarrhoea. No significant clinical features were noted between the infective and the non-infective groups. Overall, repeated stool microscopy using the concentration technique was the most useful single investigation in approaching the chronic diarrhoea problem.