ORIGINAL ARTICLE
Intestinal Amoebiasis in Children and its Effect on
Nutritional Status
Iqbal Ahmed Memon, Ammarah Jamal, Hamida Memon and Naila Parveen
ABSTRACT
Objective: To determine the frequency and clinical presentation of amoebic diarrhea in children and its effect on the
nutritional status of the affected children.
Study Design: Descriptive.
Place and Duration of Study: Department of Diarrhea Treatment Unit (DTU), Dow Medical College and Civil Hospital,
Karachi, from November 1998 to April 2001.
Methodology: Paediatric patients between the ages of > 1 month to 15 years were included, who visited the DTU of the
department with diarrhea. Stool samples of all these patients were checked under microscope for the vegetative forms of
Entamoeba Histolytica (E.H.). Patients who were positive for E.H. were evaluated for the symtomatology including the type
of diarrhea {acute watery diarrhea (AWD) or dysentery}, abdominal pain, tenesmus and nausea/vomiting. Examination
carried out was assessed for state of hydration, fever and anaemia and nutritional status of those less than 5 years of age.
The patients were divided into three age groups to assess the association of the age with severity and type of clinical
presentation. Chi- square test was applied to calculate the p-values. P-values of 0.05 or less were considered statistically
significant.
Results: The stool samples of 3870 patients with diarrhea were examined under microscope. Three hundred and twenty
eight (8.47%) of these samples were positive for E.H. The difference between the number of patients presenting with acute
watery diarrhea n=157, 47.86% and with dysentery n=171, 52.13% was found to be statistically non-significant (p=0.364).
Two hundred and seventy seven (84.45%) patients had tenesmus, while abdominal pain was present in 287 (87.5%).
Fever and malnutrition were present in 169 (51.52%) patients each. Malnutrition was significantly most frequent in 1-5
years of age groups (n=98, 57.98%, p=0.026). The nutritional evaluation of the 272 under-5 children with amoebic diarrhea
showed a significantly normal status in 123 (45.55%, p-value <0.001). All the signs and symptoms followed a similar trend
with
1-5 years age group being the most affected group. However, the frequency of blood in stools increased in direct
proportion to the increasing age.
Conclusion: Although dysentery was the more common presenting complaint, almost half of the patients presented with
watery diarrhea. Most of the patients with dysentery were under the age of 5 years. Fever was present in a high number
of patients. The age group most affected by amoebiasis and malnutrition was 1-5 years.
Key words:
Entamoeba histolytica. Diarrhea. Amoebiasis. Malnutrition.
INTRODUCTION
More than half of the people in the world are infested
with protozoa and helminthes. Most people are
asymptomatic but some intestinal parasites can cause
diarrhea and other associated problems.1 At least one
parasite, Entamoeba Histolytica (E.H), occurs as both
pathogenic and non-pathogenic strains. Although
amoebiasis is very common occurring worldwide and
infecting 10-12% of the world’s population, a vast
majority are entirely free of symptoms.1,2 About 10% of
those infected have clinical symptoms, which occur with
invasive amoebiasis thought to affect 48 million people
Department of Paediatrics Unit-II, Dow University of Health
Sciences, Civil Hospital, Karachi.
Correspondence: Dr. Iqbal Ahmed Memon, 18-G/I, 7th Gizri
Street, DHA, Phase-IV ,Karachi-75500.
E-mail: [email protected]
Received April 4, 2008; accepted March 4, 2009.
440
annually.1-2 Most (80-98%) of the symptomatic patients
present with amoebic colitis while the remaining
02-20% present with extra-intestinal disease, most
commonly as liver abscess.2 The incidence of invasive
amoebiasis varies greatly in different parts of the world.1
The prevalence of infection varies between 1% in
industrialized countries to between 50% and 80% in
tropical countries.1,2 Prevalence is increased so much
that the newborn are now being reported with
amoebiasis.4 No effective immunity develops even after
repeated infections. The mortality in untreated cases of
invasive amoebiasis is high. It is recognized as the third
most common cause of death from parasitic disease in
the world.5 The highest prevalence of infection is found
in adults.1,6 World Health Organization (WHO) has
estimated that 5-15% of all the childhood diarrheas in
the developing countries is protozoal in origin.7 E.H was
found to be responsible for 11% of the intestinal
parasites in acute diarrhea patients in India.8 It is not
clear that how much of this protozoal diarrhea and how
Journal of the College of Physicians and Surgeons Pakistan 2009, Vol. 19 (7): 440-443
Intestinal amoebiasis in children and its effect on nutritional status
much of the diarrhea in the tropics is contributed by E.H.
Loshak has reported an unexpectedly high prevalence
of amoebic colitis among acute diarrhea patients, E.H
infection was found in well over half of the patients with
acute diarrhea.9 Similar results were observed in Egypt,
where 57.1% of the general patients with acute
diarrheas were positive for E.H.10 On the contrary in
Saudi Arabia, E.H was found to be responsible for only
2.2% of acute diarrheas in under-5 children.11
The aim of this study was to assess the frequency of
amoebiasis in cases of acute diarrhea in paediatric
patients and the spectrum of clinical presentation of
amoebiasis in the local paediatric population.
METHODOLOGY
It was a descriptive study carried out at Diarrhea
Treatment Unit (DTU) of the Paediatric Department of
Dow University of Health Sciences (DUHS) and Civil
Hospital Karachi (CHK), over a period of two-and-a-half
years from November 1998 to April 2001.
The study included all paediatric patients under the age
of 15 years, who visited DTU of the department with
complaint of diarrhea of less than 14 days. Diarrhea was
defined as per WHO in the Control of Diarrhoeal
Diseases (CDD) program as “the passage of three or
more loose or watery stools in 24 hour period, a loose
stool being the one that would take the shape of a
container into which it is passed”.7 Fresh stool samples
of all these patients were microscopically examined for
the vegetative forms of Entamoeba Histolytica (E.H)
within 15 minutes in the ward laboratory by trained
technician. Patients whose stools were positive for E.
histolytica were evaluated for the symptomatology
including the type of diarrhea, whether Acute Watery
Diarrhea (AWD) or dysentery, abdominal pain,
tenesmus, fever and nausea/vomiting and the data was
recorded. AWD was defined as the acute onset of
frequent loose or watery stools without visible blood
lasting for less than 14 days, while dysentery was
defined as the presence of visible blood in the diarrhoeal
stools.7 Tenesmus was defined as the painful,
ineffective straining to empty the bowel.12 Patients were
taken to be febrile if their body temperature was found to
o
be 37.5 C or above.13 All were assessed for state of
hydration in accordance with the CDD programme.7
They were also examined for anemia and nutritional
status. Anemia was defined clinically as the presence of
palmer pallor.13 Abdominal pain and nausea were the
subjective complains in the older patients while the pain
was presumed to be present in infants if they cried
episodically with flexion of the thighs over the abdomen
especially just before defecation and getting relieved
after defecation. The nutritional status of those less than
5 years of age with amoebic diarrhea was classified as
per modified Gomez classification.14 Patients were
divided into three age groups (Group ‘A’ with
age = 0 ≤ 1 year, Group B with age = > 1 year - < 5
years; Group C with age > 5 years - < 15 years) to
assess the association of the age with the severity and
type of clinical presentation. The patients were treated
for diarrhea in accordance with the treatment plans as
per recommendations of control of diarrhoeal disease
program by WHO. Treatment was also given for the
associated problems, while the data was analyzed using
SPSS version 10 for windows. Chi-square test was
applied to calculate the p-values. P-values of 0.05 or
less were considered statistically significant.
RESULTS
A total of 3870 stool samples of all diarrhea patients
were analyzed under the microscope. Three hundred
and twenty eight (8.47%) of those samples proved to be
positive for the vegetative form of E.H. One hundred and
fifty seven (47.86%) patients had presented with AWD,
while 171 (52.13%) had dysentery at the time of
presentation. The difference between the number of
patients presenting with the two types of diarrheas was
not found to be statistically significance (Table I). Most of
the patients had tenesmus (84.5%) and abdominal pain
(87.5%, Table II). About half of the patients had fever
and malnutrition, while hydration status was normal in
85.37% patients (Table III). Malnutrition was significantly
most frequent in the 1-5 years age group (98, 57.98%,
p=0.026). The nutritional evaluation of 270 children less
than 5 years of age with amoebic diarrhea is shown in
Table IV. Nutritional status was significantly normal in
45.52% of patients with amoebic diarrhea (p < 0.001).
All the signs and symptoms followed a similar trend with
1-5 years age group being the most affected group. But
the results were not found to be statistically significant
except for overall malnutrition among all age groups
(p=0.026) and dehydration (p=0.034). Another
exception was the type of diarrhea where the frequency
of blood in stools increased in direct proportion to the
increasing age.
Table I: Types of diarrhea.
Age in years
Total
number
of patients
n
< 1 year
113
> 1-5 years
159
> 5-15 years
56
Total
328
Acute watery diarrhea
n
58
74
25
157
n percentage
n
51.32%
55
46.54%
85
44.64%
31
47.87%
171
Dysentery
p-value
n percentage
48.67%
53.45%
55.35%
52.13%
0.364
0.642
0.597
Table II: Symptoms of amoebiasis.
Symptoms
Total
< 1 year
number
of patients
n
n (n %)
Diarrhea
328 113 (34.45%)
Abdominal pain 287
96 (33.49%)
Tenesmus
277
94 (33.93%)
Nausea/vomiting
98
34 (34.69%)
Journal of the College of Physicians and Surgeons Pakistan 2009, Vol. 19 (7): 440-443
1-5 years
n (n %)
159 (48.47%)
140 (48.78%)
132 (47.65%)
48 (48.97%)
> 5-15 years p-value
n (n %)
56 (17.07%)
51 (17.77%)
51 (18.41%)
16 (16.32%)
0.748
0.793
0.668
0.739
441
Iqbal Ahmed Memon, Ammarah Jamal, Hamida Memon and Naila Parveen
Table III: Signs of amoebiasis.
Signs
Malnutrition
Fever
Anaemia
Dehydration
Total
number
of patients
n
169
169
79
50
< 1 year
47
61
27
23
n (n %)
(27.81%)
(36.09%)
(34.18%)
(46%)
1-5 years
n (n %)
98 (57.99%)
82 (48.52%)
38 (48.10%)
23 (46%)
> 5-15 years p-value
24
26
14
04
n (n %)
(14.20%)
(15.38%)
(17.72%)
(8%)
0.026*
0.315
0.346
0.034*
*P-values statistically significant.
Table IV:Nutritional status of < 5 years with amoebic diarrhea.
Age
Total
Normal
**PCMI
PCMII
PCMIII p-value
number
of patients
n
n (n %)
n (n %)
n (n %)
n (n%)
≤ 1 year
113
64 (56.64%) 31 (27.43%) 6 (5.31%) 12 (10.62%) <0.001*
> 1-5 years 159
59 (37.11%) 47 (29.56%) 28 (17.61%) 25 (15.72%) <0.001*
Total
272 123 (45.22%) 78 (28.68%) 34 (12.50%) 37 (13.60%)
* P-values statistically significant, ** PCM = Protein Calorie Malnutrition
DISCUSSION
Entamoeba histolytica is prevalent worldwide; endemic
foci are particularly common in the tropics and
especially in areas with low socio-economic and
sanitary standards. Humans are the major reservoir. It is
estimated that this disease, though usually
asymptomatic, is associated with an annual mortality of
40,000-110,000 deaths/year; amoebiasis is the third
leading parasitic cause of death on a global scale. It is
highly endemic in Africa, Latin America, India and
Southeast Asia. The infection acquired in India, Mexico
or Durban, South Africa, is apparently more virulent than
that from other locations.15
The presence of amoebiasis in 8.47% of the patients
with acute diarrhea is somewhat higher than expected if
we compare it with the prevalence of 5-15% of all
protozoal infections as a cause of acute diarrhea as
estimated by WHO. It is also higher than the reported
prevalence of 4.2-6.5% of E.H. infection in Bangladeshi
children with diarrhea but is similar to the result of a
Mexican study that found 8.4% of the samples to be
seropositive for E.H.16 In Jordan, 8% of the reported
acute gastroenteritis cases are because of E.H.17 A
similar study from Colombia reported E.H to be
responsible for 10% acute diarrhea in children.18
Contrary to these reports, an Australian study did not
find E.H in children with acute diarrhea.19 The most
common presenting symptoms of abdominal pain and
tenesmus being present in 87.5% and 84.5% of the
patients respectively are consistent with the reports in
the rest of literature.2 The next common symptom of
fever, which was present in a little over half of the
patients is contrary to the popular belief that fever is not
the usual feature of amoebiasis except in fulminant
amoebic colitis.1,3
The higher frequency of malnutrition in 51.5% of all the
patients and 54.5% of under-5 patients with amoebic
442
colitis in comparison to the 40% prevalence of
malnutrition among Pakistani children as reported by the
WHO in its annual “state of the world children” is
consistent with the already established fact that
diarrhoeal diseases reduce the growth rate of young
children thus making it an important cause of
malnutrition.20 Comparison of the number of diarrhoeal
episodes among Bangladeshi children with variable
nutrition revealed that better nourished children
experienced significantly fewer diarrhoeal episodes
compared with malnourished and/or stunted children.21
Most of the patients affected by amoebiasis belonged to
the age group of 1-5 years, which is contrary to the
reports from Bangladesh and Mexico, where the
amoebiasis was found to be most prevalent above the
age of 5 years.16 Similar trends were observed for the
rest of the clinical features with 1-5 years age group
being the most affected age group. The analysis of the
nutritional status of the under-5 children revealed
malnutrition to be more prevalent in the age group of
1-5 years with most of the patients falling in the category
of grade I malnutrition (p=0.001). The only exception
observed was in the type of diarrhea, where the
frequency of blood in stools increased in direct
proportion to the increasing age of the patient. Although
this pattern of increasing frequency of dysentery with
increasing age is consistent with the literature, most of
the patients (81%) were under the age of 5 years, which
is contrary to the reports of CDD/WHO. The latter states
that amoebic dysentery is rare under the age of 5 years
and therefore, treatment for amoebiasis should only be
given when bloody stools persist after consecutive
treatment with two antibiotics (each given for two days)
that are usually effective for Shigella or after
identification of trophozoits of EH containing red blood
cells in the stools.4,7 WHO also recommends that the
presence of AWD in under-5 children should always be
taken as viral in origin and hence the treatment
recommendations of CDD/IMCI, but this study, and
many more clearly show that amoebiasis may present
as AWD as was the case in almost 50% of various
populations. It is, thus, concluded that the prevalence of
amoebiasis among acute diarrheas is high, thus
mandating larger scale, multi-centre studies to confirm
the results so that we may recommend changes in the
treatment plans of CDD/WHO consistent with the local
scenario.
Higher prevalence of malnutrition and systemic
involvement in the form of fever associated with
amoebiasis and the involvement of children at younger
ages calls for an energetic approach and massive
planning to divert the attention of the concerned
personnel towards the provision of safe drinking water,
better sanitation and health education as these simple
maneuvers can go a long way to rid our child population
of this morbid and potentially fatal parasite.
Journal of the College of Physicians and Surgeons Pakistan 2009, Vol. 19 (7): 440-443
Intestinal amoebiasis in children and its effect on nutritional status
CONCLUSION
capture ELISA in patients presenting with acute diarrhea in
Cairo, Egypt. Trop Med Int Health 2002; 7:365-70.
Amoebic diarrhea was common in paediatric patients.
Dysentery was the more common presenting complaint,
almost half of the patients presented with watery
diarrhea. Most of the patients with dysentery were under
the age of 5 years. Fever was present in a high number
of patients. The age group affected significantly most by
amoebiasis and malnutrition was 1-5 years.
12. Roper N. Pocket medical dictionary. 14th edi. Edinburgh:
Churchill Livingstone, 1986.p.479.
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