Cutaneous Amebiasis

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Cutaneous

Amebiasis

Mary Ellen Rimsza, MD, and Robert A. Berg. MD

From the Department of Pediatrics, University of Arizona College of Medicine, Tucson; and Department of Pediatrics, Maricopa County Hospital, Phoenix, Arizona

ABSTRACT. An infant with cutaneous amebiasis of the

vulva and amebic liver abscess is described. Epidemio-logic investigations and serologic studies were crucial in establishing the diagnosis. The vulvar amebic ulcers

re-sponded dramatically to metronidazole therapy.

Cuta-neous amebiasis is a rare complication of Entamoeba

histolytica infection which should be considered in the

differential diagnosis of perineovulvar or penile ulcers.

Cutaneous amebiasis may also occur on the abdominal

wall surrounding a draining hepatic abscess, colostomy site, or laparotomy incision. Pediatrics 1983;71:595-598;

amebiasis, genital ulcers, cutaneous amebiasis, metroni-dazole.

Severe Entamoeba histolytica infections with

ex-traintestinal involvement, although prevalent in

many parts of the world, are rare in the United

States. The most common extraintestinal infection

is a liver abscess. Rarely, cutaneous amebiasis of

the perineovulvar area or the abdominal wall

oc-curs. We describe an infant with amebic liver

ab-scess and vulvar ulcers.

CASE REPORT

A 12-month-old Hispanic girl was admitted to

Man-copa County General Hospital with a three-week history

ofanorexia, fever, irritability, and weight loss. On

admis-sion she was irritable and dehydrated; her temperature

was 39 C, her respiratory rate 40/mm and her pulse was

140 beats per minute. Weight (7.7 kg) and height (68.5

cm) were less than the third percentile for her age.

Examination of the external genitalia revealed two

well-circumscribed, ulcerative lesions on the inner aspect of

the labia majora. A whitish exudate was noted at the base

of each ulcer (Figure). The remainder of the physical

examination disclosed no abnormalities.

The hematocrit on admission was 28%. The WBC

count was 23,000/cu mm (48% neutrophils, 41%

lympho-cytes, and 8% monocytes). A Gram stain of the exudate

from the vulva lesions showed only numerous

neutro-phils. A dark-field examination of the exudate was

nega-tive. Intravenous fluid replacement and ampicilhin, 200

mg intravenously every six hours, were administered after

cultures were obtained. Several cultures of the blood,

stool, and genital lesions were negative for pathogens.

Viral cultures of the genital lesions were sterile. Three

examinations of the stool for ova and parasites were

negative.

On the third hospital day, the patient’s temperature

increased to 40.3 C and she began to have loose watery

stools. On the eighth hospital day, her abdomen became

distended and hepatomegaly was noted. An ultrasound

examination of the liver revealed an 8 cm x 7 cm cystic mass with an air fluid level. A countercurrent immunoe-lectrophoresis screen for amebiasis was positive.

Metro-nidazole therapy (50 mg/kg/day) was begun. Concurrent

epidemiologic evidence indicated a family cluster of

ame-biasis (Table 1).

The genital lesions, which had not improved with eight

days of meticulous local care, improved dramatically

dur-ing the first three days of metronidazole therapy, and

were totally resolved by the tenth day. Because fever,

abdominal distension, and diarrhea continued, the

he-patic lesion was aspirated percutaneously. It yielded 12

mmof thick odorless greenish-yellow fluid. Gram stain,

trichrome stain, and fungal stains of the aspirate were

negative, as were bacterial cultures. Serial sonography of

the liver showed a decrease in the size of the hepatic

abscess. An indirect hemagglutination test for amebiasis was positive at a titer of 1:1024. The patient’s condition continued to improve clinically, and she was discharged 25 days after admission.

EPIDEMIOLOGIC INVESTIGATIONS

Received for publication Dec 22, 1981; accepted Feb 26, 1982. Reprint requests to (M.E.R.) Department of Pediatrics, Man-copa County General Hospital, 2601 E Roosevelt, Phoenix, AZ 85008.

American Academy of Pediatrics.

Our index patient was the first child of a

19-year-old unmarried Hispanic woman living in Phoenix,

AZ. Nine people inhabited a crowded, filthy,

one-bedroom house with indoor toilet and bathroom

facilities. Stool and serologic data on family

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Figure. Ulcerative lesions on inner aspect of labia majora.

596 CUTANEOUS AMEBIASIS

TABLE 1. Epidemiologic Data8

Age

(yr) Sex

Stool

Serolo

CIE

gy

IHA

P.E. (patient) 1 F - + 1:1024

J.E. (mother) 19 F + + 1:4096

D.E. (grandmother) 34 F + + 1:4096

A.E. (grandfather) 34 M -

-D.I.E. (aunt) 14 F - + 1:128

J.L.E. (uncle) 16 M - - 1:128

S.E. (uncle) 5 M - + 1:4096

A.E. (uncle) 12 M + + 1:128

J.E. (uncle) 10 M +f + 1:4096

O.E. (uncle) 9 M +j + 1:2048

8 Abbreviations used are: CIE, countercurrent

immunoe-lectrophoresis; IHA, indirect hemagglutination. t Hymenolepis nana also noted.

family except AE. (grandfather) were treated with

metronidazole.

DISCUSSION

Cutaneous amebiasis is a rarely reported clinical

manifestation of E histolytica infection. In a review

of 5,097 patients with invasive amebiasis admitted

to a South African hospital, only two cases with

cutaneous involvement were noted.’ Nasse2 is

credited with the first report of cutaneous amebiasis

in 1891. The perineovulvar area is the most common

site of the cutaneous lesions, probably because of

prolonged and repeated skin contact with

dis-charges containing virulent trophozoites of E

his-tolytica.3

The characteristic amebic skin lesion is an

irreg-ularly shaped ulcer with a thickened well-defined

border surrounded by an erythematous halo.

Ini-tially the ulcer is superficial, but without

appropri-ate treatment deep tissue destruction occurs. The

base of the ulcer is filled with a hemopurulent

exudate composed of necrotic granulation tissue.

The lesions are painful and bleed easily.3’4

Amebic ulcers of the abdominal wall are usually

associated with skin contamination from a hepatic

abscess which is surgically drained5 or

sponta-neously ruptures.6 Skin lesions have also been

re-ported around colostomy stomata6 and laparotomy

incisions.5’6

The perineovulvar lesions usually result from

skin contact with contaminated fecal material.7 In

some cases, these lesions may have been

transmit-ted venereally.4 In adults, penile amebic ulcers and

amebic lesions of the vulva, clitoris, vaginal mucosa,

and cervix have been reported!’2

The first three cases of cutaneous amebiasis in

infancy were reported in 1960 by Biagi and

Martus-celli9 from Mexico City. The perineovulvar area is

the most common site of cutaneous amebiasis in

infancy (Table 2). Cutaneous amebiasis is more

invasive in children than in adults. Ifleft untreated,

cutaneous amebic ulcers can be extremely

destruc-tive. For example, a 14-month-old South African

girl with perineal amebic ulcers suffered destruction

of the anus, rectovaginal septum, and pelvic floor.’3

The diagnosis of cutaneous amebiasis can best be

made by microscopic examination of

trichrome-stained scrapings of the base of the ulcer or by a

biopsy from the edge of an ulcerative lesion.

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TABLE 2. Infantile Cutaneous Amebiasis

Case

No.

Author Site Age Sex

(moL

Country Treatment Outcome

1 Biagi and Inguinal 10 M Mexico Emetine Healed (10 days)

Martusceffi9 region

2 Biagi and Vulva 13 F Mexico Emetine Healed (10 days)

Martuscelli9

3 Biagi and Vulva 8 F Mexico Emetine Died

Martusceffi9

4 Wynne’3 Perineum 14 F South Africa Metronidazole Colostomy

required

5 Chacon’4 Vulva 4 F Mexico Dihydroemetine,

hydroxyquinoline

Healed (10 days)

6 Poltera27 Abdomen 9 M Uganda None Died

7 Present authors Vulva 12 F USA Metronidazole Healed (10 days)

turing the exudate for amebae may also be useful.’4

Superficial amebic ulcers respond quickly and

dra-matically to treatment with a tissue amebicide such

as metronidazole. Emetine, dihydroemetine, and

hydroxyquinoline have also been used successfully

(Table 2).

In 1978, 3,937 cases of endemic amebiasis were

reported to the Center for Disease Control.’5

Dys-entery was most common; liver abscess occurred as

an infrequent complication.16 McCarty et al’7

de-tected 290 pediatric cases of amebic liver abscesses

in the world literature; only seven occurred in the

United States. Eight additional cases in American

children have been reported since that review.’2’

Familial clusters of amebiasis have been frequent,

emphasizing the importance of epidemiologic

inves-tigations.

According to Barrett-Connor,22 stools contain

or-ganisms in less than 50% of patients with an amebic

liver abscess. Several studies support these

disap-pointing results.’6’23’24 Serology, however, is quite

useful. Indirect hemagglutination is positive in 88%

to 100% of cases, complement fixation in 84% to

100% of cases, and agar gel diffusion in 80% to

100%1,1625,26 Unfortunately, serologic tests rarely

become positive until several weeks after tissue

invasion has occurred.’8 Abscess cavities may be

demonstrated by radioisotopic liver scanning or

ultrasonography. Needle aspiration of the abscess

may reveal the classic thick anchovy-colored fluid,

and provide a source for identification of the

organ-ism. One third or less of the aspirates, however,

demonstrate amebae, and only 2/16 initial aspirates

in one study revealed the characteristic brown

color.’6

Amebiasis is endemic in the United States and

cutaneous amebiasis should be considered in the

differential diagnosis of perineovulvar or penile

ul-cers. Cutaneous amebiasis should also be

consid-ered in the evaluation of ulcerative lesions of the

abdominal wall, particulary those surrounding a

draining hepatic abscess, colostomy site, or

laparot-omy incision. Infants and small children stifi

wear-ing diapers will be particularly vulnerable to

pen-neovulvar lesions inasmuch as the infected stools

will have close contact with the skin. Preexistent

skin disease, malnutrition, and poor hygiene

prob-ably increase the risk of cutaneous amebiasis.

SUMMARY

An infant with Entamoeba histolytica infection

characterized by vulvar ulcers, hepatic abscess, and

colitis has been presented. To our knowledge this is

the first reported case of infantile cutaneous

ame-biasis in the United States, and the seventh case

recorded in the world literature. The clinical

pres-entation, diagnosis, and management of cutaneous

amebiasis has been discussed. Inasmuch as

ame-biasis is endemic in the United States, cutaneous

amebiasis should be considered in the evaluation of

perineovulvar and penile ulcers. Epidemiologic

in-vestigations and serologic studies may be crucial in

establishing the diagnosis of invasive amebiasis.

ACKNOWLEDGMENTS

The authors thank Vincent A. Fulginiti, MD, for

re-viewing this manuscript and Helen Daugherty and Diane

Gauthier for secretarial assistance.

REFERENCES

1. Adams FB, MacLeod, IN: Invasive amebiasis. Medicine

1977;56:315

2. Nasse D: Veber einen amoben befund bie leberascesst

dysenterie und nosocomialgangren. Arb Chir Klin 1891;5:95

3. Ruiz-Moreno F: Perianal skin amebiasis. Dir Colon Rectum

1967;1O:65

4. Biagi F: Cutaneous Amebiasis. Amsterdam, Excerpta

Med-ica 1969, p 205

5. Joseph L, Bhat HS: Amoebic ulceration of the abdominal

wall. Br J Surg 1967;54:187

6. Juniper K: Amebiasis in the United States. Bull NY Acad

Med 1971;47:448

7. Fujita WH, Barr RJ, Gottschalk HR: Cutaneous amebiasis.

Arch Dermatol 1981;117:309

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598 CUTANEOUS AMEBIASIS

1976;48:269

9. Biagi F, Martuscelli ,A: Cutaneous amebiasis in Mexico.

Dermatol Trop 1963;2:129

10. Poltera AA, Grech ES: Vulval amoebiasis: A case report.

East Afr Med J 1972;49:900

11. Majmuda B, Chaiken ML, Lee KU: Amebiasis ofthe clitoris

mimicking cacinoma. JAMA 1976;236:1145

12. Mungia H, Franco E, Valenzuela P: Diagnosis of genital

amebiasis in women by the standad Papanicolaou

tech-nique. Am J Obstet Gynecol 1966;94:181

13. Wynne, JM: Perineal amoebiasis. Arch Dir Child 1980;55:234 14. Chacon RA: Cutaneous amebiasis. Mod Probl Paediatr

1975;17:259

15. Annual summary 1978, Center for Disease Control.

Morbid-ity MortalMorbid-ity Weekly Rep September 1979

16. Babour GL, Juniper K: Aclinical comparison ofamebic and

pyogenic abscess of the liver in sixty-six patients. Am JMed

1972;53:323

17. McCarty E, Pathmanand C, Sunakorn P, et al: Amebic liver abscess in childhood. Am J Dir Child 1973;126:67

18. Dykes AC, Ruebush TK II, Gorelkin L, et al: Extraintestinal

amebiasis in infancy: Report of three patients and

epidemi-ologic investigations of their families. Pedkztrics 1980;65:799

19. Harrison HR, Crowe CP, Fulginiti VA: Amebic liver abscess

in children: Clinical and epidemiologic features. Pediatrics

1979;64:923

20. Jessee WF, Ryan JM, Fitzgerald JF, et al: Amebic liver

abscess in childhood. Clin Pediatr 1975;14:134

21. Wadlington WC, Faber R, O’Neill JA: Recent experience

with hepatic amebiasis. Clin Pediatr 1975;14:163

22. Barett-Connor E: Amebiasis today in the United States.

California Med 1971;114:1

23. Crane PS, Lee YT, Seel DJ: Experience in the treatment of

two hundred patients with amebic abscess of the liver in

Korea. Am J Surg 1972;123:332

24. Kotcher F, Muranda M, Gacia deSalagado V: Correlation

of clinical, paasitological, and serological data of individuals

infected with Entamoeba histolytica. Gastroenterology

1970;58:388

25. Milgram ED, Healy GR, Kagan IG: Studies on the use of

indirect hemagglutination test in the diagnosis of amebiasis.

Ga.stroenterology 1966;50:645

26. Krogstad DJ, Spencer HC, Healy GR: Amebiasis. N Engi J Med 1978;298:262

27. Poltera AA: Pseudomalignant cutaneous amebiasis in

Uganda. Trop GeogrMed 1973;25:139

ARTICLES

OF ATTACHMENT

Sixty-two percent of a sample of 199 first-year psychology students said that

they were attached to a special, soft object during childhood. The mothers of 80

of the students were asked the same questions and 45 of the students were

asked the same questions a year later. Nearly a quarter of the mothers’ answers

did not agree with their sons or daughters and nearly a fifth of the students

disagreed with themselves after 1 year. It is concluded that retrospective

evidence about attachment to objects is too unreliable for research or clinical

diagnosis.

Abstracted from P. Mahalski: The reliability of memories for attachment to special, soft objects

during childhood. (J Am Aced Child Psychiatry 1982;5:465).

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1983;71;595

Pediatrics

Mary Ellen Rimsza and Robert A. Berg