The Interesting Case • Der intéressante Fall Un cas intéressant Dermatologica 151 : 253-256 (1975)
A Case of Cutaneous Amoebiasis I. SUNARWAN
Department of Dermatology (Head: Prof. M .K .P olano), University Hospital of Leiden, Leiden
Key Words. Amoebiasis, cutaneous • Metronidazol ■Entamoeba histolytica ■ Diloxanide furoate Abstract. The present report concerns a patient with ulceration around an artificial anus. The condition had been treated for some time as pyoderma gangrenosum but finally proved to be cutaneous amoebiasis; the presence of Entamoeba histolytica was demon strated. A cure was achieved with mctronidazol (Flagyl®) and diloxanide furoate (Furamide®) given orally.
History atul Physical Examination
Received: October 20, 1975; accepted: October 23, 1975.
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A 52-year-old man was admitted to our hospital because of extensive ulceration around an artificial anus (AA) on the upper right side of the abdomen. He had been treated for several years elsewhere for ulcerative colitis with periods of diarrhoea during which bloody stools were passed. In 1973, the patient developed an anal fistula and lost much weight. The fistula was treated surgically by total excision 2 weeks after an AA was applied to promote healing of the ulcerative process in the distal parts of the colon. Shortly after the operation, an indurative plaque appeared around the AA. This area slowly became larger as well as necrotic and ulcerated centrally. The ulcer continued to grow progressively and was extremely painful. Because neither antibiotic therapy nor the addition of prednisone to the medication gave any improvement, the patient was referred to the Leiden University Hospital. On admission, the diagnosis of pyoderma gangrenosum in ulcerative colitis was made, and
SUNARWAN
Fig. I. The skin condition at the time when the amoebic disease was diagnosed. Note the black necrotic mass covering a large part of the ulcer. Fig. 2. Appearance of the ulcer when the patient was discharged from hospital on December 23, 1974.
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254
A Case of Cutaneous Amoebiasis
255
the patient was treated accordingly, i.e. with a higher dose of prednisone orally and 1% tetracycline in a cream base locally. Some improvement seemed to be obtained initially, but it did not last long. The ulcer rapidly became larger and the patient’s general condition deteriorated. An immunosuppressive agent had no effect. The ulcer around the AA then measured 17 x 12 cm and was covered with a necrotic mass. The surrounding skin was red, infiltrated and very painful. A bloody mass flowed out of the proximal loop of the AA, which aroused the suspicion of the presence of an amoebic infection of the bowels and the skin. Microscopical examination cf scrapings from the floor of the ulcer and a sample taken from the bloody mass revealed many vegetative forms of Entamoeba histolytica with phagocytized red blood cells, thus confirming the diagnosis of amoebiasis cutis. The amoeba was cultured from the same materials, and the agar-gel diffusion test and immuno fluorescence investigation of the blood serum were positive too. Review of the histological slides prepared from tissue taken from margins of the ulcer did not show the presence of amoebae in the skin. When detailed history was taken, it was found that the patient had contracted amoebic dysentery in a Japanese prison camp in Indonesia during the second world war. He had not been completely free of symptoms since 1969, but a parasitological investigation per formed elsewhere had not shown amoebae as the cause.
Course The patient was treated with 750 mg metronidazol (Flagyl®), given orally 3 times daily for 10 days, followed by a 10-day course of 500 mg diloxanide furoate (Furamide®) 3 times daily. Improvement of the patient's general condition and of the skin condition was seen as early as the 2nd day of this treatment. The stools were no longer bloody, the ulcer was not painful, and the thick red wall surrounding the ulcer disappeared on the 3rd day. The histological and culture results showed no amoebae in the material from the ulcer nor from the faecal mass from the 2nd day on. The necrotic mass covering the ulcer sloughed off and cpithelization of the floor of the ulcer was observed. The further course was uneventful, and under topical medication alone the ulcer closed, leaving a scar. An operation to close the AA is scheduled.
Cutaneous amoebiasis is a very rare complication of amoebic dysentery [1, 2, 6, 8], The infective agent can reach the skin via an intestinal fistula, of a ruptura/drainage of a liver abscess. Direct implantation of the amoebae in skin lesions in the ano-genital region is effected by contaminated material from the bowels in cases of dysentery.
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Discussion
256
SUNARWAN
The infection manifests itself as a fast-growing, very painful ulcer accom panied by local necrosis; the surrounding skin is red and infiltrated. The diagnosis is based on the results of microscopical investigation and culture of material from the floor of the ulcer and the histological picture of the peripheral area of the ulcer. Immunofluorescence and agar-gel diffusion results obtained in blood serum may support the diagnosis [3-5], Treatment with metronidazol gave remarkable results [7], This case illustrates once again that awareness of the tropical diseases is also necessary in other climatic zones.
References 1 B iagi, F. : Cutaneous amocbiasis. Essays on tropical dermatology (Excerpta Medica, Amsterdam 1969). 2 G of.naw an : Eluidamoebiasis. Geneesk. Tijdschr. Ned.-Indie 81: 405 (1941). 3 Laarman, J.J. el a i: Evaluation of serological diagnosis of invasive amocbiasis in clinically suspected patients (in press, 1974). 4 Parelkar, S.N. et a!.: Indirect immunofluorescent staining of Entamoeba histolytica in tissues. Lancet /: 212 (1971). 5 Powell, S.J. et a i: Amoebic gel-diffusion precipitation test. Clinical evaluation in acute amoebic dysentery. Lancet i: 566 (1966). 6 Z uidema, P.J.: Enkele darmziekten bij gcrcpatriccrdcn uit Indonésie. Ned. Tijdschr. Geneesk. 103: 1812 (1959). 7 Z uidema, P.J.: Nieuwe amoebicide geneesmiddelen. Ned. Tijdschr. Geneesk. 114: 468 (1970). 8 W ilcocks and M anson-B ah r : Manson's tropical diseases; 17th cd., pp. 165-166 (Baillière, Tindall & Cox, London 1972).
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1. S unarwan, Department of Dermatology, Lcycnburg Hospital, Den Haag (The Nether
lands)
A Case of Cutaneous Amoebiasis I. SUNARWAN
Department of Dermatology (Head: Prof. M .K .P olano), University Hospital of Leiden, Leiden
Key Words. Amoebiasis, cutaneous • Metronidazol ■Entamoeba histolytica ■ Diloxanide furoate Abstract. The present report concerns a patient with ulceration around an artificial anus. The condition had been treated for some time as pyoderma gangrenosum but finally proved to be cutaneous amoebiasis; the presence of Entamoeba histolytica was demon strated. A cure was achieved with mctronidazol (Flagyl®) and diloxanide furoate (Furamide®) given orally.
History atul Physical Examination
Received: October 20, 1975; accepted: October 23, 1975.
Downloaded by: University of Chicago Library 205.208.116.24 - 2/3/2018 11:39:13 PM
A 52-year-old man was admitted to our hospital because of extensive ulceration around an artificial anus (AA) on the upper right side of the abdomen. He had been treated for several years elsewhere for ulcerative colitis with periods of diarrhoea during which bloody stools were passed. In 1973, the patient developed an anal fistula and lost much weight. The fistula was treated surgically by total excision 2 weeks after an AA was applied to promote healing of the ulcerative process in the distal parts of the colon. Shortly after the operation, an indurative plaque appeared around the AA. This area slowly became larger as well as necrotic and ulcerated centrally. The ulcer continued to grow progressively and was extremely painful. Because neither antibiotic therapy nor the addition of prednisone to the medication gave any improvement, the patient was referred to the Leiden University Hospital. On admission, the diagnosis of pyoderma gangrenosum in ulcerative colitis was made, and
SUNARWAN
Fig. I. The skin condition at the time when the amoebic disease was diagnosed. Note the black necrotic mass covering a large part of the ulcer. Fig. 2. Appearance of the ulcer when the patient was discharged from hospital on December 23, 1974.
Downloaded by: University of Chicago Library 205.208.116.24 - 2/3/2018 11:39:13 PM
254
A Case of Cutaneous Amoebiasis
255
the patient was treated accordingly, i.e. with a higher dose of prednisone orally and 1% tetracycline in a cream base locally. Some improvement seemed to be obtained initially, but it did not last long. The ulcer rapidly became larger and the patient’s general condition deteriorated. An immunosuppressive agent had no effect. The ulcer around the AA then measured 17 x 12 cm and was covered with a necrotic mass. The surrounding skin was red, infiltrated and very painful. A bloody mass flowed out of the proximal loop of the AA, which aroused the suspicion of the presence of an amoebic infection of the bowels and the skin. Microscopical examination cf scrapings from the floor of the ulcer and a sample taken from the bloody mass revealed many vegetative forms of Entamoeba histolytica with phagocytized red blood cells, thus confirming the diagnosis of amoebiasis cutis. The amoeba was cultured from the same materials, and the agar-gel diffusion test and immuno fluorescence investigation of the blood serum were positive too. Review of the histological slides prepared from tissue taken from margins of the ulcer did not show the presence of amoebae in the skin. When detailed history was taken, it was found that the patient had contracted amoebic dysentery in a Japanese prison camp in Indonesia during the second world war. He had not been completely free of symptoms since 1969, but a parasitological investigation per formed elsewhere had not shown amoebae as the cause.
Course The patient was treated with 750 mg metronidazol (Flagyl®), given orally 3 times daily for 10 days, followed by a 10-day course of 500 mg diloxanide furoate (Furamide®) 3 times daily. Improvement of the patient's general condition and of the skin condition was seen as early as the 2nd day of this treatment. The stools were no longer bloody, the ulcer was not painful, and the thick red wall surrounding the ulcer disappeared on the 3rd day. The histological and culture results showed no amoebae in the material from the ulcer nor from the faecal mass from the 2nd day on. The necrotic mass covering the ulcer sloughed off and cpithelization of the floor of the ulcer was observed. The further course was uneventful, and under topical medication alone the ulcer closed, leaving a scar. An operation to close the AA is scheduled.
Cutaneous amoebiasis is a very rare complication of amoebic dysentery [1, 2, 6, 8], The infective agent can reach the skin via an intestinal fistula, of a ruptura/drainage of a liver abscess. Direct implantation of the amoebae in skin lesions in the ano-genital region is effected by contaminated material from the bowels in cases of dysentery.
Downloaded by: University of Chicago Library 205.208.116.24 - 2/3/2018 11:39:13 PM
Discussion
256
SUNARWAN
The infection manifests itself as a fast-growing, very painful ulcer accom panied by local necrosis; the surrounding skin is red and infiltrated. The diagnosis is based on the results of microscopical investigation and culture of material from the floor of the ulcer and the histological picture of the peripheral area of the ulcer. Immunofluorescence and agar-gel diffusion results obtained in blood serum may support the diagnosis [3-5], Treatment with metronidazol gave remarkable results [7], This case illustrates once again that awareness of the tropical diseases is also necessary in other climatic zones.
References 1 B iagi, F. : Cutaneous amocbiasis. Essays on tropical dermatology (Excerpta Medica, Amsterdam 1969). 2 G of.naw an : Eluidamoebiasis. Geneesk. Tijdschr. Ned.-Indie 81: 405 (1941). 3 Laarman, J.J. el a i: Evaluation of serological diagnosis of invasive amocbiasis in clinically suspected patients (in press, 1974). 4 Parelkar, S.N. et a!.: Indirect immunofluorescent staining of Entamoeba histolytica in tissues. Lancet /: 212 (1971). 5 Powell, S.J. et a i: Amoebic gel-diffusion precipitation test. Clinical evaluation in acute amoebic dysentery. Lancet i: 566 (1966). 6 Z uidema, P.J.: Enkele darmziekten bij gcrcpatriccrdcn uit Indonésie. Ned. Tijdschr. Geneesk. 103: 1812 (1959). 7 Z uidema, P.J.: Nieuwe amoebicide geneesmiddelen. Ned. Tijdschr. Geneesk. 114: 468 (1970). 8 W ilcocks and M anson-B ah r : Manson's tropical diseases; 17th cd., pp. 165-166 (Baillière, Tindall & Cox, London 1972).
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1. S unarwan, Department of Dermatology, Lcycnburg Hospital, Den Haag (The Nether
lands)
