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Year : 2019  |  Volume : 62  |  Issue : 1  |  Page : 169-170
Acute amoebic appendicitis: An unusual presentation of a usual infection


1 Department of Pathology, Chacha Nehru Bal Chikitsalaya, New Delhi, India
2 Department of Pediatric Surgery, Chacha Nehru Bal Chikitsalaya, New Delhi, India

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Date of Web Publication31-Jan-2019
 

How to cite this article:
Goyal A, Goyal S, Gupta CR. Acute amoebic appendicitis: An unusual presentation of a usual infection. Indian J Pathol Microbiol 2019;62:169-70

How to cite this URL:
Goyal A, Goyal S, Gupta CR. Acute amoebic appendicitis: An unusual presentation of a usual infection. Indian J Pathol Microbiol [serial online] 2019 [cited 2019 Jul 17];62:169-70. Available from: http://www.ijpmonline.org/text.asp?2019/62/1/169/251264




A 4-year-old girl presented to the emergency with right lower abdominal pain and fever since 4 days. Vitals of the child were stable. Abdominal examination revealed distension, rebound tenderness at Mc Burney's point and an ill-defined mass in the right iliac fossa. Laboratory investigations revealed neutrophilic leukocytosis with raised C-reactive protein levels. Abdominal ultrasound was suggestive of acute appendicitis with probe tenderness. The patient underwent laparoscopic appendicectomy. Grossly, the appendix was gray-white, pale, edematous, and friable [Figure 1]a. Histopathological examination showed mucosal ulceration along with extensive areas of transmural inflammation and focal enzymatic necrosis with nuclear debri [Figure 1]b, [Figure 1]c, [Figure 1]d. Numerous trophozoites of Entamoeba histolytica were seen within the lumen as well as invading the muscular layer of the appendix [Figure 2]a. Many of these showed erythrophagocytosis [Figure 2]b. At places, the trophozoites were seen infiltrating into the small vessels as well [Figure 2]c. Periodic acid–Schiff stain highlighted the trophozoites. The child was kept on follow-up and the stool examination done after a course of metronidazole was negative.
Figure 1: (a) Gross specimen showing a gray white, pale, edematous, and friable appendix. (b) Low-power view from appendix shows extensive areas of transmural liquefactive necrosis (H and E, ×40). (c) Higher magnification shows numerous round trophozoites surrounded by a clear zone (arrows), within an acute inflammatory exudate (H and E, ×100). (d) Photomicrograph showing partly ulcerated appendicular mucosa with amoebic trophozoite (arrow) in the necrotic debris within the lumen (H and E, ×100)

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Figure 2: (a) Section shows trophozoites of amoeba invading the smooth muscle fibers (black arrow) of muscular layer of appendix. The trophozoites were 10–60 μ in size with single, small nucleus, presence of karyosome, and bubbly cytoplasm (H and E, ×1000). (b): Section demonstrating erythrophagocytosis (black arrow) within the trophozoite (H and E, ×1000). (c) Microphotograph showing an amoebic trophozoite (black arrow) infiltrating the wall of a small blood vessel (H and E, ×400)

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Appendicular involvement is considered a particularly rare form of amoebiasis with a higher incidence in tropical countries. The reported incidence of trophozoites of E. histolytica in appendicectomy specimens varies from 0.5% (India) to 2.3% (Mexico).[1],[2] On literature review, reported mean age is 23.5 years with fewer than five cases in children (<12 years) till date.[3] The exact cause of inciting appendicitis in parasitic infestations is not clear because the vast majority of these cases (80%) are asymptomatic in endemic regions. Presumably, the luminal obstruction might be attributed to the presence of amoebae or intense mucosal edema caused by invading trophozoites. Invasion of E. histolytica into the wall of the appendix is required rather than the mere presence in the lumen, to diagnose true amoebic appendicitis.[3] However, in our case, the appendix showed mucosal ulcers along with areas of transmural necrosis. The trophozoites were seen invading the muscularis and blood vessels within the appendicular wall. Except histopathology, there are no reliable radiological or laboratory tests which can confirm the tissue invasive disease. The stool analysis is also not useful in endemic areas as it cannot differentiate between amoebic colitis and carriers.[3]

It is imperative to diagnose amoebic appendicitis. Complications such as perforation, liver abscess, abdominal sepsis, fulminant colitis, and colonic fistulae have been reported more commonly in amoebic appendicitis (25.4%–30.7%) as compared to nonamoebic appendicitis (1%–5%).[3] The postoperative treatment needs a prompt addition of metronidazole and follow-up for amoebiasis-related complications.[4] The index case also highlights the importance of routine histopathological examination in all appendicectomy cases as the clinical diagnosis is seldom suspected.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Gupta SC, Gupta AK, Keswani NK, Singh PA, Tripathi AK, Krishna V, et al. Pathology of tropical appendicitis. J Clin Pathol 1989;42:1169-72.  Back to cited text no. 1
    
2.
Hedya MS, Nasr MM, Ezzat H, Hamdy HM, Hassan AM, Hammam O, et al. Histopathological findings in appendectomy specimens: A retrospective clinicopathological analysis. J Egypt Soc Parasitol 2012;42:157-64.  Back to cited text no. 2
    
3.
Otan E, Akbulut S, Kayaalp C. Amebic acute appendicitis: Systematic review of 174 cases. World J Surg 2013;37:2061-73.  Back to cited text no. 3
    
4.
Pervez S, Raza AN. A child with acute appendicitis. Eur J Pediatr 2008;167:127-8.  Back to cited text no. 4
    

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Correspondence Address:
Surbhi Goyal
Department of Pathology, Chacha Nehru Bal Chikitsalaya, Geeta Colony, New Delhi - 110 031
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPM.IJPM_576_17

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