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CASE REPORT Table of Contents   
Year : 2010  |  Volume : 53  |  Issue : 4  |  Page : 767-768
Acute amebic appendicitis: Report of a rare case


Department of Pathology, Al-Jahra Hospital, Jahra, Kuwait

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Date of Web Publication27-Oct-2010
 

   Abstract 

Acute appendicitis of amebic origin is considered a rare cause of acute appendicitis. We report a case of amebic appendicitis presenting with fever, severe pain in the right lower quadrant of the abdomen and rebound tenderness. Lab investigations revealed neutrophilic leukocytosis. The patient underwent appendectomy. Histopathological examination revealed numerous Entameba histolytica trophozoites in the mucosa of the appendix. Acute appendicitis of amebic origin does not appear frequently. Appendicular amebiasis can give the clinical features of acute appendicitis and should be treated accordingly.

Keywords: Ameba, appendicitis, GIT

How to cite this article:
Singh NG, Rifat Mannan A, Kahvic M. Acute amebic appendicitis: Report of a rare case. Indian J Pathol Microbiol 2010;53:767-8

How to cite this URL:
Singh NG, Rifat Mannan A, Kahvic M. Acute amebic appendicitis: Report of a rare case. Indian J Pathol Microbiol [serial online] 2010 [cited 2019 Dec 16];53:767-8. Available from: http://www.ijpmonline.org/text.asp?2010/53/4/767/72080



   Introduction Top


Acute appendicitis is considered the most common cause of emergency surgery. Enterobius vermicularis and Entameba histolytica are responsible for the majority of intestinal parasitic infections. [1],[2] It is known that these organisms rarely cause acute appendicitis, but the nature of the relationship between parasitic infection and acute appendicitis has been debated for years. [1],[2] Here, we report a rare case of acute appendicitis, which, on examination, reveals colonies of Entameba histolytica trophozoites in the lumen as well as in the mucosa of the appendix with evidence of acute appendicitis.


   Case Report Top


A 35-year-old male presented to the emergency department for acute abdomen in the right lower compartment with associated nausea, vomiting and fever. There was no preceeding history of diarrhea. Abdominal examination revealed signs of tenderness in the right iliac fossa with rebound tenderness and guarding. Lab investigations revealed hemoglobin of 135 g/L and total leucocyte count of 23 x 10 9 /L with neutrophilia. A clinical diagnosis of acute appendicitis was made. The patient underwent laparoscopic appendectomy. An inflamed appendix without any perforation was found. No other abnormalities were found and the patient made an uneventful recovery.

Gross and Microscopic Examination

Specimen of the appendix was received in 10% buffered formalin. The appendix measured 6 cm in length. The serosa was focally congested. On longitudinal section at the tip, the lumen was filled with fecal matter and the mucosa was ulcerated and focally purulent. The sections were routinely processed, paraffin-embedded and 4-micron-thick sections were prepared. On microscopy, there was mucosal ulceration with numerous trophozoites of Entameba histolytica infiltrating the ulcerated mucosa [Figure 1]. Many of the trophozoites revealed erythropagocytosis. There was follicular hyperplasia. The wall of the appendix was inflamed and showed mixed acute and chronic inflammatory infiltrates, including few eosinophils [Figure 2]. There was no evidence of periappendicitis. Special stain (periodic acid Schiff) revealed better morphology of the trophozoites. Thus, a diagnosis of acute amoebic appendicitis was made.
Figure 1 :Photomicrograph showing trophozoites (arrow) of Entameba histolytica in the ulcerated mucosa of the appendix (H and E, ×200) with mixed inflammatory infiltrate in the wall. Trophozoites in the colony (inset) in the luminal aspect of the appendix (H and E, ×100).

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Figure 2 :Photomicrograph displaying the presence of mixed acute and chronic inflammatory infiltrate in the muscle coat of the appendix (H and E, ×200). Inset shows appendicular mucosa with adjacent dense acute inflammatory infiltrate (H and E, ×200).

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   Discussion Top


There is practically no area in the world completely free of amebiasis, but the degree of affection varies markedly. [3] Acute appendicitis is the most frequently noted surgical entity in patients arriving in the emergency department complaining of abdominal pain. [4] Acute appendicitis due to Entameba histolytica is relatively rare and when it does occur, it usually develops as an extension of caecal infection. [5] In most cases of systemic amebiasis, parasites in the appendix lumen do not invade the mucosa or the submucosa or cause acute inflammation. [5] The literature contains only a few reports of amebic appendicitis and the exact frequency of this lesion is not known. A study by Gupta and colleagues [6] regarding the incidence of rare appendicitis described appendicitis of amebic origin and reported a frequency of 0.5%. [6] Guzman et al.,[7] however, in a study of 4,093 cases, revealed a higher frequency of amebic appendicitis (2.3%). [7] It is thought that the inflammation of the appendix is secondary to the obstruction of its lumen due to mucosal edema caused by the presence of trophozoites, which is the active form of Entameba histolytica. [8] Therefore, the presentation shares the same physiopathology already seen in other forms of acute appendicitis.

Under precarious hygiene, humans ingest the parasite in the form of a cyst, which then gives rise to trophozoites. The latter remain in the lumen of the colon or may even invade the wall and form a chronic inflammatory lesion known as an ameboma, which itself may resemble acute appendicitis. [9] Alternatively, the cyst can travel via the portal vein to the liver and then to other organs.

Stool examination, serological test, culture and non-invasive imaging of the liver are the most important procedures in the diagnosis of amebiasis. The classic stool ova and parasite examination can be used, but it misses half of all Entameba histolytica colonic infection. However, the definitive diagnosis of amoebic colitis is made by the demonstration of hematophogous trophozoites of Entameba histolytica. [9] In our case, post-operative stool examination did not reveal any cysts or trophozoites. There was no associated diarrhea in the clinical presentation. Histologically, sections taken from the proximal part of the appendix were re-evaluated and were free of the trophozoites. Hence, the present case represents a rare form of amebic appendicitis that was confined to the appendix only.

The use of antimicrobials combined with appendectomy has produced a reduction in the incidence of septic complication. No deaths related to the acute appendicitis of amebic origin have been reported. This is because appendectomy removes the focus of infection and should therefore be considered the treatment of choice.

This report highlights acute appendicitis of amebic origin, which does not appear frequently. Appendicular amoebiasis can give the clinical features of acute appendicitis. Appendectomy, combined with antimicrobials, is the treatment of choice.

 
   References Top

1.Mogenson K, Pahle E, Kowalski K. Enterobius vermicularis and acute appendicitis. Acta Chir Scand 1985;151:705-7.   Back to cited text no. 1
    
2.Malik AK, Hanum N, Yip CH. Acute isolated amebic appendicitis. Histopathology 1994;24:87-8.  Back to cited text no. 2
[PUBMED]    
3.Zardawi IM, Kattampallil JS, Rode JW. Amebic appendicitis. Med J Aust 2003;178:523-4.   Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Zielke A. Appendicitis: Present-day diagnosis. Chirurg 2002;73:782-90.  Back to cited text no. 4
[PUBMED]    
5.Nadler S, Cappell MS, Bhatt B, Matano S, Kure K. Appendiceal infection by Entamoeba histolytica and Strongiloides stercoralis presenting as acute appendicitis. Dig Dis Sci 1990;35:603-8.  Back to cited text no. 5
[PUBMED]    
6.Gupta SC, Gupta AK, Keswani NK, Singh PA, Tripathy AK, Krishna V. Pathology of tropical appendicitis. J Clin Pathol 1989;42:1169-72.  Back to cited text no. 6
    
7.Guzman-Valdivia G. Acute amebic appendicitis. World J Surg 2006;30:1038-42.  Back to cited text no. 7
    
8.Ravdin J. Amebiasis. Clin Infect Dis 1995;20:1453-66.  Back to cited text no. 8
    
9.Reed SL. Amebiasis and infection with free-living amebas. In: Braunwald E, Fauci AS, Kasper DL, Hauser SL, Longo DL, Jameson JL, editors. Harrisons Principles of Internal Medicine. 15 th ed. Mc-Graw-Hill; 2001. p. 1197-203.  Back to cited text no. 9
    

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Correspondence Address:
Naorem Gopendro Singh
Department of Pathology, Al-Jahra Hospital, P.O. Box 62276, Jahra 02153
Kuwait
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.72080

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    Figures

  [Figure 1], [Figure 2]

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