AMEBIASIS AND ITS CLINICAL COURSE TODAY Dr. Svistunov O.P. - Director of medical department ALSCON- RUSAL PLUNT in Nigeria, DTM&H( Wits,SA), Dip.inf.dis.( Moscow,Russia), P.h.D in Cardiology (Tver.Russia), Member of Royal Society of Tropical Medicine (London). Dr. Anya Kalu, Dr. Ime Umoh, Isiwu Ifeanyi BMLS,AIMLS,Ass.member HPC UK, Ndifreke Ekop B.S.C, Almls Med.Microbiology, parasitology . Hospital ALSCON-RUSAL PLUNT in Nigeria. While all parasitologists of the world are fighting for such global diseases as AIDs, tuberculosis, malaria and schistosomiasis, protozoal and fungous infections began their gradual attacks on the human population. At present Entamoeba histolytica is the cause of amebiasis and in humid and hot climate of the west Nigeria promotes to the development of more aggressive forms of Entamoeba histolytica and to more prolonged persistence of cysts in the environment. On the ground of our many years’ experience of work in hot countries we came to the conclusion that the clinical course of amoebic dysentery changes and differs from the forms earlier described by many Russian and foreign authors. The most aggressive form of Entamoeba histolytica is widely spread in hot and humid countries situated along the equator. The less aggressive form of amoeba was found among the workers arrived from Russia, Ukraine and other regions of The Union of Independent States (UIS). We have studied the clinical course of amebiasis in Nigerians working at the factory ALSCON (Nigeria) and the members of their families. The second stage of our investigation consisted of examination of all Russian employers who have been working in Nigeria for more than one month and those workers, who have just come from Russia. We found absolutely new clinical course of amebiasis, new symptoms of disease, its complications, and unfavorable prognosis for those workers who had not undergone the proper treatment. It was the main goal of our investigation. Life Cycle of Entamoeba histolytica Materials and methods During the period from March 2007 till February 2007 we examined 189 specialists from Russia and other countries of UIS as well as those specialists who worked and are working at the factory ALSCON in Nigeria. We also observed 1250 Nigerian workers and the members of their families. To diagnose the disease properly we used clinical data, methods of light microscopy, ultrasound diagnostics, colonoscopy and great experience of skilled Nigerian specialists: laboratorians, surgeons, gynecologists and therapeutists. Results Our thorough examinations showed that the high percentage of workers was suffering simultaneously from several diseases such as malaria, ascaridiasis, teniasis, strongyloidiasis, filariasis, AIDs, syphilis, tuberculosis, venereal and other parasitogenic diseases. Diagnostics of these illnesses is difficult. One patient may suffer from 3-4 diseases at the same time. For example: malaria, amebiasis, strongyloidiasis, and teniasis. Entamoeba histolytica was revealed in 80% cases during the first examination of Nigerian patients. Of 41 new coming specialists from St. Petersburg, Krasnoyarsk, Sayanogorsk (Russia) amebiasis was revealed in 18 patients, candidias of the bowels in -11, two of which had strogyloidiasis and teniasis. The rest of 148 patients survived amebiasis during their life in Nigeria. The high percentage of specialists suffered from amebiasis was treated for malaria, strongyloidiasis, teniasis and migratory larva simultaneously. On colonoscopy the lesion in the area of the cecum cupula looks like clusters of yellow granulations under the mucous membrane of the bowels and it has the form of a small sized band from 1 to 2cm in length. The investigation of the patient, who had amebic infection, which resulted in dynamic obstruction, was carried out in the central clinic №37 of Petergof. Ultrasound examination of the ileocecal area of this patient is shown on the Photo № 1. Ultrasound Examination of Ileocecal Region Surgeons often misdiagnose appendicitis, put a patient on the operating table erroneously suspecting appendicitis, and during operation they detect unchanged appendix but inflamed cecum cupula, in which maturation and discharge of the mobile form of amoeba (erythrophage) take place (From the experience of work in Nigeria, Cabo Verde, Mozambique). It is absolutely prohibited to operate such patients. The sutures will be disrupted and the patient will die from hemorrhage and developed peritonitis. The first symptoms of amoeba lesion are developing during several weeks. One of the typical symptoms of amebic lesion is a sharp pain on palpation in the region of cecum cupula and moderate tenderness in the sigmoid region. These symptoms are the result of inflammatory process caused by maturation of Entamoeba histolytica and a pain in the sigmoid is the result of intervention of erythrophage into the mucous membrane of sigmoid and rectum leading to spastic necrotizing ulcerative colitis. The surface of the skin in the abdomen is hyperemic and on pressing the hand usually leaves an impression on the abdomen. Photo №3. Hyperemia of Skin in Abdominal Region Hyperemia of the skin speaks about the onset of systemic vasculitis as a result of common intoxication, which is caused by the toxins of Entamoeba histolytica. The skin lesions caused by Entamoeba histolytica are often seen, especially in the places of close contact with the clothing. Skin Lesions Caused by Entamoeba Histolytica Diarrhea, as many authors report, is not present in most cases or lasts not more than one day and stops without any treatment. A patient complains of abdominal distention, pricking all over the abdomen and spasmodic pains in the right and the left iliac regions at nights. We revealed other more serious amebic complications in Nigeria. One of them is amebic involvement of the uterus. Photo №4. Multiple Uterine Amebomas Nurslings are also affected by amoeba; they are treated and infected again. When the period of girls’ maturation comes, sexual contacts with partners begin and as a result cysts and erythrophages of Entamoeba histolytica fall into the vagina and uterus. Besides erythrophages spread by hematogenic way. Erythrophages are invaded into the uterine mucosa and the formation of multiple fibromas and cysts of the uterus and the ovaries begins. We performed many operations on for multiple uterine ameboma. Photo 5. Multiple Uterine Cysts One of serious complications of Entamoeba histolytica lesions, which we found out, was damage of the eye fundus. The patient complained of deterioration of the eyesight and the appearance of a red spot in the field of eyesight. After treatment the red spot disappeared, the eyesight was restored, but insignificant dystrophic changes were marked on the fundus of the eye. We investigated new incoming specialists from Russia, Ukraine and revealed Entamoeba histolytica cysts in them. Conclusions Today we can not agree with the term “amebic carrier”. From the first day of penetration into the human body Entamoeba histolytica cyst causes changes in the zone of its reproduction, in ileocecal region of the bowels. If a patient feels himself clinically healthy, he does not go to the doctor for a long time. An attending medical doctor, who did not encounter with such pathology earlier, administers FGS, colonoscopy, ultrasound examination and many other tests. As a result the doctor in charge makes a diagnosis of gastritis, colitis, and bulbitis. As soon as such complications as ulcers of various localizations, abscesses of liver, brain and lungs caused by amoeba appear, the diagnosis becomes much more dangerous: Chron’s disease, meningitis, encephalitis, gastric carcinoma, skin cancer, dermal tuberculosis, damages of the retinal vessels, chronic prostatitis and others. We came to the conclusion that the most effective preparations for the treatment of amebic lesions are metronidazole and tinidazole. But the most effective way of treatment is taking both of them simultaneously in doses: Metronidazole 750 mg three times daily, during 5 days. Tinidazole 2 g in one dose, during 3 days. It is necessary to continue treatment till the complete disappearance of Entamoeba histolytica cysts. The repeated course of therapy with tinidazole only was carried out in 10% just after the first course of treatment, 2 g in one dose, 5 days. The technique of surgical treatment of abscesses of the liver, brain and lungs caused by Entamoeba histolytica lesions is written in the literature very well. Dynamic obstruction is treated conservatively if there are no intestinal abscesses and perforations. Intravenous injections of metronidazole and spasmolytics are administered. After the first defecation, usually on the third-fourth day after intestinal obstruction, the tablet form of preparations may be used. We recommend taking antiamebic preparations simultaneously with anticandidiasis drugs, during 10 days. The patient must be registered in a dispensary during a year and every quarter he must be examined on cysts and Entamoeba histolytica erythrophages. The possibility of taking one tablet of tinidazole a week for prophylaxis of amoeba is studied by the group of our experts in Nigeria. All medical workers and the workers of nutrition and water supply, the workers of pre-school and school institutions undergo regular (once a quarter) medical check-ups. All children of pre-school and school age must be examined every six months. All detected cases must be cured till the complete lack of cysts of Entamoeba histolytica. On the ground of performed work one can make the conclusion that today Entamoeba histolytica is really dangerous for the health and life of our patients. It may cause a number of serious hardly differentiated diseases, complications leading to misdiagnosis and accordingly to incorrect treatment, especially in such fields of medicine as gynaecology, urology, oncology, gastroenterology, neurology and many others. We would like to recommend to doctors of all medical institutions to attract attention to this type of pathology. On preventive medical check-ups the great attention must be paid to the state of gastro-intestinal tract of patients. It should be recommended to carry out health examination of women in the maternity homes and women’s consulting centers more thoroughly. Epidemiologists must work out a number of international programs of struggle with Entamoeba histolytica. It is necessary for military doctors to study epidemiology, clinic and pathogenesis of the disease thoroughly, because Entamoeba histolytica may be used as bacteriological weapon, leading to woman’s and probably to man’s sterility, and the great number of non-studied consequences of lesions caused by this type of protozoal infection. It is necessary to make careful study of the infection and to work out the methods of disinfection of water and treatment of food products. It is necessary to continue the elaboration of new medicinal preparations and disinfecting means, to organize mass propagandistic company of fighting against Entamoeba histolytica at a level of WHO.