Gut, 1965, 6, 454

Incidence of intestinal amoebiasisF. P. ANTIA, H. G. DESAI, K. N. JEEJEEBHOY, AND A. V. BORKAR

From the Department of Gastroenterology, B. Y.L. Nair Charitable Hospital,Bombay, India

EDITORIAL SYNOPSIS This is an interesting study showing that the incidence of detecting infectionis highest when stool is taken for examination at sigmoidoscopy. The use of a saline purge isnot recommended.

The incidence of intestinal amoebiasis varies mark-edly in different countries and in the different partsof the same country. The incidence also varies withdifferent gastrointestinal symptoms (Shrivastav,1953; Antia, Chaphekar, Chhabra, Swami, andBorkar, 1961). Although there are a number ofreports on the incidence of Entamoeba histolytica

alone (Table I), only a few have dealt with theincidence of all types of amoebae (Table II). Thesereports, except that of Shrivastav, do not mentionthe incidence in dysentery, non-dysenteric diarrhoea,and asymptomatic patients. Also the patientsstudied were not drawn from different social strata.Consequently it is the object of this study to analyse

TABLE IINCIDENCE OF ENTAMOEBA HISTOLYTICA

Locality Symptoms No. of IncidencePatients ( %)

Cunningham and King (1916-17)Hardy and Spector (1935)Johnstone, David, and Reed (1933)Leitman and Vitlinskaya (1946)MacAdam (1919)Mayer (1940)Misra and Samant (1950)Patel (1945a)Patel (1945b)Shah et al. (1960)Sofia and Ciaravino (1944)Tribedi and De (1938)Vaidya (1942)

East Bengal (India)Chicago (U.S.A.)California (U.S.A.)Tashkent (U.S.S.R.)IndiaBikaner (India)Lucknow (India)Bombay (India)Bombay (India)Bombay (India)Asmara (Eritrea)Calcutta (India)Bombay (India)

DysenteryAsymptomaticVague abdominal symptomsAsymptomaticAsymptomaticAsymptomaticPatients admitted to a hospitalDiarrhoeaAsymptomaticVague abdominal symptoms

Vague abdominal symptomsAsymptomaticDysenteryDysentery

TABLE IIINCIDENCE OF DIFFERENT TYPES OF AMOEBAE

Incidence (0%)Locality No. of E. histolytica

PatientsE. coli

Antia et al. (1961)DysenteryNon-dysenteric diarrhoea

Blumenthal, Dutra, Paschal, and Kuhn1947)

DiarrhoeaNon-diarrhoea

Chaudhuri and Rai Chaudhuri (1946)Jhatakia and Mankad (1946)Shrivastav (1953)

Chronic abdominal symptomsAsymptomaticAcute dysentery

Bombay

Calcutta

CalcuttaBombayBombay

561 28-0 15 5239 1-2 1 3

219 31 5810 205

9,015 8-8856 130

1,010 35 6384 20-2104 49-0

454

8-29-85 1

25-5

41*649-22-9

Reference

15716133

9971,002351

1,083125125101

136700

1,370129

8-915-542-08-912-713-023-217-743-3580

63-929-810-2350

ReferenceE. nana L butschlii

1 44-4

5.51645.990

8-79.37

0-80-5

2-33-8090 3

1-11-3

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Incidence of intestinal amoebiasis

TABLE IIIINCIDENCE OF DIFFERENT TYPES OF AMOEBAE IN 4,160 PATIENTS

B. Y.L. Nair Charitable Hospital

Dysentery Non-dysenteric GastrointestinalDiarrhoea Symptoms

Other ThanDysentery orDiarrhoea

WithoutGastrointestinalSymptoms

No. of patients

Entamoeba histolyticaTrophozoitesTrophozoites and cystsCysts alone% incidence

Entamoeba coliTrophozoitesTrophozoites and cystsCysts alone% incidence

Endolimax nanaCysts% incidence

lodamoeba butschliiCysts% incidencePatients with one or more than onetype of amoebaeTotal no.% incidence

560' 360 2401

65197428-2

11195715 5

3071414-1

13132915-3

2

1I1*3

2

1I1*3

8 3 101 4 03 4-4

4 14 107 39 04

219 88 1639-0 24-4 6-6

1,500

115

786-2

714

19214-2

432-9

9060

27518 3

500

52

205.4

25

6013-4

193-8

173-4

9118 2

1,000 4,160

14I82-3

333-3

1111

909

64 7536-4 18 1

'Sample of stool was collected on sigmoidoscopy and examined immediately.

the incidence of amoebae in faeces using differentmethods of stool collection, in patients with orwithout gastrointestinal symptoms, and in patientsfrom different social strata of an urban population.

MATERIALS AND METHODS

The incidence of amoebae was studied during the last10 years in 4,160 patients (Table III) of both sexes,mostly between 15 and 50 years of age. Of these, 1,000patients had symptoms related to the gastrointestinaltract and were studied in private consultant practice.They were of the higher income group and lived in bettersanitary conditions. The rest (3,160) of the patients,studied at the B.Y.L. Nair Charitable Hospital, Bombay,were of a lower income group and lived in relativelyinsanitary surroundings. They were further dividedinto 920 patients with dysentery (frequent unformedstool with macroscopic and/or microscopic blood);240 patients with non-dysenteric diarrhoea (frequentunformed stools without blood); 1,500 patients withgastrointestinal symptoms other than dysentery ordiarrhoea; and 500 patients without gastrointestinalsymptoms who were admitted for complaints such ashydrocoele, abscess, or pyrexia.

COLLECTION OF FAECES In 560 patients with dysenteryand 240 patients with non-dysenteric diarrhoea thespecimen of stool obtained through a sigmoidoscopewas examined immediately. In other patients, the sample

of stool evacuated in the morning was examined. Of the500 patients without gastrointestinal symptoms seen in

TABLE IVINCIDENCE OF DIFFERENT TYPES OF

AMOEBAE IN FAECES OF 300 PATIENTS WITHOUTGASTROINTESTINAL SYMPTOMS ON NATURALEVACUATION AND AFTER A SATINE PURGE

Natural After a SalineEvacuation Purge

Entamoeba histolyticaTrophozoitesTrophozoites and cystsCysts alone% incidence

Entamoeba coliTrophozoitesTrophozoites and cystsCysts aloneY. incidence

lodamoeba butschliiCystsY. incidence

Endolimax nanaCysts% incidence

Patients with one or more than onetype of amoebaeTotal no.% incidence

83-0

22

259-6

62-0

62-0

72-6

6I

2410-3

51-6

72-3

455

TotalPrivatePractice

GastrointestinalSymptoms

39 3613-0 12-0

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F. P. Antia, H. G. Desai, K. N. Jeejeebhoy, and A. V. Borkarhospital, 300 were given a saline purge and the liquidsample was also examined (Table IV).ROUTINE EXAMINATION OF FAECES Thin films wereprepared by putting a drop of warm normal saline at oneend of a glass slide and a drop of Lugol's iodine at theother end, and in both a small amount of faeces wasmixed. Coverslips were put on these preparations andexamined under the microscope. Two such glass slideswere prepared. Thus four specimens, two of warmsaline and two of iodine, were examined in each patient.

FORMALINE-SALINE-ETHER CONCENTRATION METHOD Ineach patient the stool was also examined with thisconcentration method. About 2 g. of faeces was suspendedin 7 ml. of formaline-saline (5 ml. formaldehyde mixedwith 95 ml. saline). This suspension was allowed to standfor one minute, then filtered through a double layer ofgauze into a centrifuge tube. About 2 to 4 mi. of thefiltrate was mixed with an equal amount of ether andcentrifuged for three minutes at 2,500 r.p.m. The super-natant fluid was discarded and the sediment was examinedunder the microscope.

RESULTS

INCIDENCE OF ALL TYPES OF AMOEBAE In the differentgroups of patients the incidence showed markedvariation (Table III). In patients with dysentery,stool collected during sigmoidoscopy and examinedimmediately showed an incidence of 39 %, but whenthe stool collected during the morning evacuationwas examined the incidence was 24-4%; in patientswith non-dysenteric diarrhoea the incidence was66%; in patients with gastrointestinal symptomsother than dysentery or diarrhoea, the incidence was18-3 %; in patients without gastrointestinal symptomsthe incidence was 18-2 %; and in patients withgastrointestinal symptoms seen in private practicethe incidence was 6-4 %. The overall incidence of alltypes of amoebae in 4,160 patients was 18 1 %.

INCIDENCE OF ENTAMOEBA HISTOLYTICA The highestincidence of E. histolytica was 28-2% in patientswith dysentery whose sample of stool was collectedon sigmoidoscopic examination but the incidencewas 14-1 % in patients with dysentery whose naturalmorning evacuation was examined. In patients withgastrointestinal symptoms (other than dysentery ordiarrhoea) and also in those without gastrointestinalsymptoms the incidence was 6 2 and 54 Y% respect-ively. The incidence was 10-5% in all hospitalpatients and 2-3 % in patients studied in privatepractice.

ENTAMOEBA COLI The incidence of E. coli inhospital patients in various groups was between13-4 and 15-5%, except in patients with non-

dysenteric diarrhoea in whom it was only 1-3 %. Theincidence of E. coli in patients studied in privatepractice was 3 3 %.

ENDOLIMAX NANA The incidence of E. nana was2-6% in hospital patients and I1* % in patientsstudied in private practice.

IODAMOEBA BUTSCHLII The incidence of L butschliiwas 3 9% in hospital patients and 0-8% in patientsseen in private practice.

INCIDENCE AFTER A SALINE PURGE The incidence ofall types of amoebae in the natural evacuation of300 patients without gastrointestinal symptoms was13% (Table IV). In the same patients when theliquid sample after a saline purge was examined theincidence was 12 %.

DISCUSSION

The incidence of intestinal amoebiasis varies withthe method of stool collection, symptoms from thegastrointestinal tract, and sanitary conditions.

MET'HOD OF STOOL COLLECTION In dysentery, theincidence of E. histolytica is twice as great when thefaecal sample is collected during sigmoidoscopy aswhen the morning evacuation is examined (Table III).

In Bombay the incidence of E. histolytica inasymptomatic cases was reported as 43-3% (Patel,1945a) while in patients with vague abdominalsymptoms the incidence reported was 58% (Patel,1945b) and 63-9% (Shah, Mehta, Patel, andPhutane, 1960). This high incidence remains un-explained because in our study the maximumincidence of E. histolytica was 28-2% in patientswith dysentery whose sample of stool collected onsigmoidoscopy was examined immediately. Both theabove-mentioned authors reported the incidence ofE. histolytica only and made no mention of othertypes of amoebae. It is possible that their reportsincluded all types of amoebae.Warm stage For the detection of trophozoites a

warm stage is usually recommended. In a tropicalclimate a warm stage is unnecessary, as in the salinepreparation at room temperature amoebae showedmotility for six to eight hours and occasionally evenafter 24 hours.

Stool collection after saline purge For thedetection of vegetative forms of amoebae manyclinicians and pathologists advocate administrationof a saline purge and examination of a liquid sampleof stool. In our view, in patients with dysentery anddiarrhoea administration of a saline purge isundesirable but in patients without gastrointestinal

456

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Incidence of intestinal amoebiasis 457symptoms the stool examinations before and aftera saline purge does not show significant variation inthe incidence (Table IV).

SYMPTOMS OF THE PATIENTS The highest incidenceof amoebae (39 %) is in patients with dysentery whilein non-dysenteric diarrhoea the incidence is 6-6 %.The incidence of amoebae in patients with gastro-intestinal symptoms other than dysentery or diar-rhoea and in those without any gastrointestinalsymptoms is almost identical (about 18 %). Thesefindings suggest that amoebae may produce dysenterybut are probably an incidental finding in othergroups of patients.

SANITARY CONDITIONS The incidence of amoebae is207% in 3,160 hospital patients and 6-4% in 1,000patients seen in private practice (Table III). Theresults show a lower incidence of amoebae in patientsliving in improved sanitary conditions.

SUMMARY

The incidence of intestinal amoebiasis was studied in4,160 patients, and of amoebae in faeces varied withthe method of stool collection. In patients withdysentery, the incidence is higher when the stool iscollected directly from the colon through a sigmoido-scope than that collected from a natural morningevacuation (Table III). A saline purge for thedetection of amoebae in the stool is not desirable inpatients with dysentery or diarrhoea and in thosewithout gastrointestinal symptoms it does notincrease the incidence of amoebae in the stool.The incidence of amoebiasis also varied with

different gastrointestinal symptoms. Patients withdysentery (frequent unformed stools with blood)have the highest incidence.The incidence of amoebiasis is higher in patients

seen in hospital practice who live in insanitaryconditions as compared to those seen in private

practice who live in relatively better hygienicsurroundings.

REFERENCES

Antia, F. P., Chaphekar, P. M., Chhabra, R. H., Swami, G. A., andBorkar, A. V. (1961). The incidence of bacteria and parasitesin dysenteric and non-dysenteric diarrhoea. A study of 800cases. J. Ass. Phycns India, 9, 723-739.

Blumenthal, H. T., Dutra, F. N., Paschal, H., and Kuhn, L. R. (1947).The significance ofEndameba histolytica in stools of individualswith acute diarrhoea of moderate severity. Amer. J. trop. Med.,27, 711-721.

Chaudhuri, R. N., and Rai Chaudhuri, M. N. (1946). An analyticalstudy of intestinal protozoal infection with special reference toamoebiasis. Indian med. Gaz., 81, 230-234.

Cunningham, J., and King, H. H. (1917). Dysentery in the jails ofEastern Bengal. Indian J. med. Res., 4, 442-497.

Hardy, A. V., and Spector, B. K. (1935). The occurrence of infestationswith E. histolytica associated with water-borne epidemicdiseases. Publ. Hlth Rep. (Wash.), 50, 323-334.

Jhatakia, K. U., and Mankad, K. K. (1946). Incidence of intestinalprotozoa and parasites in routine stool examinations. J. Indiamed. Ass., 16, 44-47.

Johnstone, H. G., David, N. A., and Reed, A. C. (1933). A protozoalsurvey of one thousand prisoners, with clinical data on 92cases of amebiasis. J. Amer. med. Ass., 100, 728-731.

Leitman, M. Z., and Vitlinskaya, I. A. (1946). Treatment of carriers ofpathogenic protozoa. Trop. Dis. Bull., 43, 1143. (Abstr. ofpaper in Russian (1945). Med. Parazit. (Mosk.), 14 (6), 46.)

MacAdam, W. (1919). A report on the treatment of various types ofEntamoeba histolytica infection by the combined hypodermicand oral administration of emetine hydrochloride. Indian J.med. Res., 6, 363-379.

Mayer, M. (1940). Observations on amoebiasis and its treatment.Indian med. Gaz., 75, 262-266.

Misra, S. S., and Samant, P. N. (1950). Dysenteries and diarrhoeas:aetiological survey and management. Indian J. med. Sci., 4,539-549.

Patel, J. C. (1945a). Incidence of amoebic carriers in Bombay. IndianPhycn, 4, 244-249.

(1945b). Incidence of chronic amoebiasis in Bombay and non-dysenteric amoebic abdominal syndromes. Ibid., 4, 249-255.

Shah, J. R., Mehta, R. H., Patel, K. H., and Phutane, P. N. (1960).Studies on amebiasis. Part I. Amebiasis past and present.Indian J. med. Sci., 144, 84-91.

Shrivastav, J. B. (1953). A survey of the intestinal parasites in thehuman population in Bombay, with special reference toEndamoeba histolytica. Indian J. med. Res., 41, 397-414.

Sofia, F., and Ciaravino, E. (1944). Inchiesta coprologica sui natividell 'Eritrea. Boll. Soc. ital. Med. lg. trop., (Sez. Eritrea), 4,785-802. (Abstr. in Trop. Dis. Bull. (1946), 43, 37.)

Tribedi, B. P., and De, M. N. (1938). Observations on the dysentericconditions among Europeans of Calcutta. Brit. med. J., 1,1000-1003.

Vaidya, K. N. (1942). Observations on dysenteries. Med. Bull.(Bombay), 10, 331-336.

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Incidence of intestinal amoebiasis.

F P Antia, H G Desai, K N Jeejeebhoy and A V Borkar

doi: 10.1136/gut.6.5.4541965 6: 454-457 Gut

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