A rare case of invasive amoebiasis requiring emergency subtotal colectomy in an HIVpositive man Dr Robert Ball 1 Dr Fiona Campbell 2, Dr Steven Woolley 1,3, Mr Richard Heath 4, Dr Nick Beeching 1,5, Dr Lance Turtle 1,6, Dr Tom Wingfield 1,6,7 Tropical and Infectious Disease Unit Royal Liverpool University Hospital 1. Tropical and Infectious Disease Unit, Royal Liverpool University Hospital 2. Department of cellular pathology, Royal Liverpool University Hospital 3. Institute of Naval Medicine, Alverstoke, Hampshire 4. Department of colorectal surgery, Royal Liverpool University Hospital 5. Liverpool School of Tropical Medicine, Liverpool 6. Institute of Infection and Global Health, University of Liverpool 7. Department of Public Health Sciences, Karolinska Institutet, Stockholm
Presentation 56 year old male, MSM 2 months in Indonesia, Vietnam and Malaysia Presented on return to UK 2 weeks watery diarrhoea >10 stools/day, occasional fresh blood HIV +ve, CD4 194 cells/mm 3, viral load undetectable Tenofovir, emtricitabine, nevirapine
Investigations Observations: Heart rate 103 bpm Blood pressure 155/78 mmhg Temperature 37.0 o C Respiratory rate 19 breaths/min Raised inflammatory markers CRP 282 mg/l (<5) Neutrophils 12.9 x10 9 /L (2-10) Prothrombin time 19.8 s (9-13) Alanine Aminotransferase 55 U/L (<35) Considered likely bacterial gastroenteritis Commenced oral azithromycin
Day 3 of admission Morning consultant ward round Acute abdominal distension, generalised peritonitis Commenced IV ceftriaxone and metronidazole Urgent CT abdomen with contrast Severe pancolitis Perforations of the caecum and sigmoid colon Two small hypoechoic lesions in the liver
Day 4 of admission Emergency laparotomy Gangrenous necrotic caecum Serosal evidence of colitis with rectal sparing Faecal contamination of the peritoneal cavity Subtotal colectomy Spouting end ileostomy formation
Day 1 post-op Recovery in Intensive Therapy Unit (ITU) Intra-abdominal drains Lactobacillus rhamnosusin, Streptococcus milleri (anginosus) Surgical wound swabs Enterococcus gallinarum, Escherichia coli Continues ceftriaxone and metronidazole
Week 1-2 post-op Laparotomy on day 4 Transferred to High Dependency Unit (HDU) 3500 3000 Increasing cholestatic LFTs 2500 2000 Gamma GT (U/L) Repeat CT abdomen No change in the hypoechoic lesions Likely haemangiomas U/L 1500 1000 Alkaline phosphatase (U/L) Alanine Aminotransferase (U/ L) MRCP Normal biliary tree 500 0 1 2 3 4 8 9 10 11 12 13 14 15 17 Day of admission Ceftriaxone changed to tigecycline
3500 3000 Ceftriaxone changed to tigecycline day 17 2500 Laparotomy on day 4 2000 U/L Gamma GT (U/L) 1500 Alkaline phosphatase (U/L) Alanine Aminotransferase (U/L) 1000 500 0 1 2 3 4 8 9 10 11 12 13 14 15 17 18 21 24 27 29 30 35 37 47 Day of admission
Day 8 post-op Discrete ulcers within the colon
Flask-shaped ulcers Normal colon Normal colon 1. Images from www.google.com
Foamy cytoplasm E. histolytica trophozoite Ingested RBC 27 days post-op Amoebic IFA positive - 1:512 Amoebae latex test - positive 60um
Case - outcome Turbulent post-operative recovery Ileus requiring Total Parental Nutrition (TPN) Abdominal wound dehiscence Coagulopathy Weight loss, deconditioning and immobility Recovered and discharged home on week 5 No anti-retroviral therapy missed during admission Total antimicrobial therapy: Metronidazole 14 days Tigecycline 42 days (completed as outpatient IV therapy) Oral paromomycin 7 days
Case 5 months post-op Good recovery Using stoma independently Good wound healing Planning ileorectal anastomosis For further 7 days oral paromomycin
Fulminant amoebic colitis (FAC)
Fulminant amoebic colitis (FAC) Virulent host response to amoebae causing fulminating reaction Necrotising colitis, perforation and peritonitis Uncommon (1:200) 1 Male=Female Presents as surgical emergency 1. Acuna-Soto R, Wirth DF et al. Am J Gastroenterol 2000; 95:1277-83
Fulminant amoebic colitis (FAC) Mumbai 2014 2 Amoebiasis considered pre-operatively 5/30 28 required emergency surgery Mortality 17/30 (57%) 2. Chaturvedi R, Joshi AS et al. Postgrad Med J 2015; 91:200-5
Key questions 1. Could we have made an earlier diagnosis? 2. Does being MSM help our diagnosis? 3. Does being HIV +ve help our diagnosis? 4. Does he need lumicidal treatment after bowel re-anastamosis?
1. Could we have made an earlier diagnosis? Investigations Stool microscopy 3x negative Enzyme-linked immunosorbent assay (ELISA) Indirect fluorescent assay (IFA) took 27 days post-op Could we have done better? Hot stool for microscopy? Request urgent IFA? Could we have treated empirically?
2. Does being MSM help our diagnosis? China 2010 3 602 MSM 42% of MSM seropositive on ELISA for Entamoeba histolytica Higher seropositivity in receptive anal sex Taiwan 2007 4 HIV positive patients 70% were MSM MSM at significantly higher risk of amoebiasis 3. Zhou F, Gao C et al. PLoS NTD 2013; e22324 4. Hung CC, Colebunders R et al. PLoS NTD 2008; e175
3. Does being HIV +ve help our diagnosis? Mexico 2005 5 Entamoeba histolytica cysts on microscopy and PCR No increase in HIV +ve compared to -ve Japan 2013 6 21.3% of HIV +ve on IFA for Entamoeba histolytica Titres x 400 predictive of invasive disease Link unproven 7 Confounded by MSM 5. Moran P, Ximénez C et al. Exp Parasitol 2005; 110: 331-4 6. Watanabe K, Gatanaga H et al. J Infect Dis 2014; 209: 1801 7 7. Hung CC, Ji DD et al. Lancet Infect Dis 2012; 12: 729-36
4. Does he need lumicidal treatment after bowel re-anastamosis? Eradicate colonic carriage and prevent recurrence Paromomycin 25-35mg/kg/day for 7 days Or diloxanide furoate, iodoquinol Rectal stump untreated due to ileostomy No rectal preparations No evidence/ guidelines
Key questions 1. Could we have made an earlier diagnosis? q Possibly 2. Does being MSM help our diagnosis? q Possibly 3. Does being HIV +ve help our diagnosis? q Probably not 4. Does he need lumicical treatment after bowel re-anastamosis? q Probably
Questions?