A rare case of invasive amoebiasis requiring emergency subtotal colectomy in an HIV-positive man DrRobertBall1DrFionaCampbell2,DrStevenWoolley1,3,MrRichardHeath4,DrNickBeeching1,5,DrLanceTurtle1,6,DrTomWingfield1,6,7

TropicalandInfectiousDiseaseUnitRoyalLiverpoolUniversityHospital

1.  TropicalandInfectiousDiseaseUnit,RoyalLiverpoolUniversityHospital2.  Departmentofcellularpathology,RoyalLiverpoolUniversityHospital3.  InstituteofNavalMedicine,Alverstoke,Hampshire4.  Departmentofcolorectalsurgery,RoyalLiverpoolUniversityHospital5.  LiverpoolSchoolofTropicalMedicine,Liverpool6.  InstituteofInfectionandGlobalHealth,UniversityofLiverpool7.  DepartmentofPublicHealthSciences,KarolinskaInstitutet,Stockholm

Presentation

•  56yearoldmale,MSM

•  2monthsinIndonesia,VietnamandMalaysia•  PresentedonreturntoUK

•  2weekswaterydiarrhoea•  >10stools/day,occasionalfreshblood

• HIV+ve,CD4194cells/mm3,viralloadundetectable

•  Tenofovir,emtricitabine,nevirapine

Investigations •  Observations:

•  Heartrate 103bpm•  Bloodpressure 155/78mmHg•  Temperature 37.0oC•  Respiratoryrate 19breaths/min

•  Raisedinflammatorymarkers•  CRP 282mg/L(<5)•  Neutrophils 12.9x109/L(2-10)•  Prothrombintime 19.8s (9-13)•  AlanineAminotransferase55U/L(<35)

•  Consideredlikelybacterialgastroenteritis

•  Commencedoralazithromycin

Day 3 of admission

• Morningconsultantwardround•  Acuteabdominaldistension,generalisedperitonitis

• CommencedIVceftriaxoneandmetronidazole

• UrgentCTabdomenwithcontrast•  Severepancolitis•  Perforationsofthecaecumandsigmoidcolon•  Twosmallhypoechoiclesionsintheliver

Day 4 of admission

•  Emergencylaparotomy•  Gangrenousnecroticcaecum•  Serosalevidenceofcolitiswithrectalsparing•  Faecalcontaminationoftheperitonealcavity

•  Subtotalcolectomy•  Spoutingendileostomyformation

Day 1 post-op

• RecoveryinIntensiveTherapyUnit(ITU)

•  Intra-abdominaldrains•  Lactobacillusrhamnosusin,Streptococcusmilleri(anginosus)

•  Surgicalwoundswabs•  Enterococcusgallinarum,Escherichiacoli

• Continuesceftriaxoneandmetronidazole

Week 1-2 post-op •  TransferredtoHighDependencyUnit(HDU)

•  IncreasingcholestaticLFTs

•  RepeatCTabdomen•  Nochangeinthehypoechoiclesions•  Likelyhaemangiomas

•  MRCP•  Normalbiliarytree

•  Ceftriaxonechangedtotigecycline

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Laparotomyonday4

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Alkalinephosphatase(U/L)

AlanineAminotransferase(U/L)

Ceftriaxonechangedtotigecyclineday17

Laparotomyonday4

Day 8 post-op

Discreteulcerswithinthecolon

Flask-shapedulcers

Normalcolon

Normalcolon

1.  Imagesfromwww.google.com

IngestedRBC

“Foamy”cytoplasm

E.histolyticatrophozoite

27dayspost-op

AmoebicIFApositive-1:512Amoebaelatextest-positive

60um

Case - outcome •  Turbulentpost-operativerecovery

•  IleusrequiringTotalParentalNutrition(TPN)•  Abdominalwounddehiscence•  Coagulopathy•  Weightloss,deconditioningandimmobility

•  Recoveredanddischargedhomeonweek5

•  Noanti-retroviraltherapymissedduringadmission

•  Totalantimicrobialtherapy:•  Metronidazole14days•  Tigecycline42days(completedasoutpatientIVtherapy)•  Oralparomomycin7days

Case – 5 months post-op

• Goodrecovery•  Usingstomaindependently•  Goodwoundhealing

• Planningileorectalanastomosis•  Forfurther7daysoralparomomycin

Fulminant amoebic colitis (FAC)

Fulminant amoebic colitis (FAC)

• Virulenthostresponsetoamoebaecausingfulminatingreaction•  Necrotisingcolitis,perforationandperitonitis

• Uncommon(1:200)1

• Male=Female

• Presentsassurgicalemergency

1.Acuna-SotoR,WirthDFetal.AmJGastroenterol2000;95:1277-83

Fulminant amoebic colitis (FAC)

• Mumbai20142•  Amoebiasisconsideredpre-operatively5/30•  28requiredemergencysurgery•  Mortality17/30(57%)

2.ChaturvediR,JoshiASetal.PostgradMedJ2015;91:200-5

Key questions 1.  Couldwehavemadeanearlierdiagnosis?

2.  DoesbeingMSMhelpourdiagnosis?

3.  DoesbeingHIV+vehelpourdiagnosis?

4.  Doesheneedlumicidaltreatmentafterbowelre-anastamosis?

1. Could we have made an earlier diagnosis?

•  Investigations•  Stoolmicroscopy–3xnegative•  Enzyme-linkedimmunosorbentassay(ELISA)•  Indirectfluorescentassay(IFA)–took27dayspost-op

• Couldwehavedonebetter?•  “Hotstool”formicroscopy?•  RequesturgentIFA?•  Couldwehavetreatedempirically?

2. Does being MSM help our diagnosis?

• China20103•  602MSM•  42%ofMSMseropositiveonELISAforEntamoebahistolytica•  Higherseropositivityin“receptiveanalsex”

•  Taiwan20074

•  HIVpositivepatients•  70%wereMSM•  MSMatsignificantlyhigherriskofamoebiasis

3.ZhouF,GaoCetal.PLoSNTD2013;e223244.HungCC,ColebundersRetal.PLoSNTD2008;e175

3. Does being HIV +ve help our diagnosis? • Mexico20055

•  EntamoebahistolyticacystsonmicroscopyandPCR•  NoincreaseinHIV+vecomparedto-ve

•  Japan20136•  21.3%ofHIV+veonIFAforEntamoebahistolytica•  Titresx400predictiveofinvasivedisease

•  Linkunproven7•  ConfoundedbyMSM

5.MoranP,XiménezCetal.ExpParasitol2005;110:331-46.WatanabeK,GatanagaHetal.JInfectDis2014;209:1801–77.HungCC,JiDDetal.LancetInfectDis2012;12:729-36

4. Does he need lumicidal treatment after bowel re-anastamosis? •  Eradicatecoloniccarriageandpreventrecurrence

•  Paromomycin25-35mg/kg/dayfor7days•  Ordiloxanidefuroate,iodoquinol

• Rectalstumpuntreatedduetoileostomy•  Norectalpreparations

• Noevidence/guidelines

Key questions 1.  Couldwehavemadeanearlierdiagnosis?

q  Possibly

2.  DoesbeingMSMhelpourdiagnosis?q  Possibly

3.  DoesbeingHIV+vehelpourdiagnosis?q  Probablynot

4.  Doesheneedlumicicaltreatmentafterbowelre-anastamosis?q  Probably

Questions?