1. Case Report I2 陳信宏 94.7.25

2. introduction introduction A 25-year-old American homosexual man was seen in the emer ­ gency room for bloody diarrhea and crampy abdominal pain of several weeks' duration and was treated based on the results of laboratory studies. His symptoms resolved, and he appeared to make a full recovery. A 25-year-old American homosexual man was seen in the emer ­ gency room for bloody diarrhea and crampy abdominal pain of several weeks' duration and was treated based on the results of laboratory studies. His symptoms resolved, and he appeared to make a full recovery.

3. Present illness Present illness Six months later, he presented to his family physician suffering from weight loss, malaise, fever, fatigue, and abdominal pain in the right upper quadrant. Laboratory studies revealed leukocytosis, mild anemia, and elevated levels of liver enzymes, including alkaline phos-phatase and transaminases. Stool specimens for culture and examination for ova and parasites were negative for bacterial pathogens and par ­ asites. Six months later, he presented to his family physician suffering from weight loss, malaise, fever, fatigue, and abdominal pain in the right upper quadrant. Laboratory studies revealed leukocytosis, mild anemia, and elevated levels of liver enzymes, including alkaline phos-phatase and transaminases. Stool specimens for culture and examination for ova and parasites were negative for bacterial pathogens and par ­ asites.

4. Laboratory studies Laboratory studies A computed tomography (CT) scan of the liver A computed tomography (CT) scan of the liver was performed and revealed several hepatic lesions. Because of the CT scan abnor ­ malities, an ELISA for serum antibodies was ordered, which confirmed the diagno ­ sis of his illness. A cyst of the parasite causing his illness is shown in Fig. 4.1. was performed and revealed several hepatic lesions. Because of the CT scan abnor ­ malities, an ELISA for serum antibodies was ordered, which confirmed the diagno ­ sis of his illness. A cyst of the parasite causing his illness is shown in Fig. 4.1.

6. Questions?? Questions?? 1. What is this patient's diagnosis? Which protozoan parasite is shown in Fig. 4.1? 1. What is this patient's diagnosis? Which protozoan parasite is shown in Fig. 4.1? 2.How does the patient's illness correlate with his previous episode of bloody diarrhea? Why is the patient's stool specimen negative for parasites? 2.How does the patient's illness correlate with his previous episode of bloody diarrhea? Why is the patient's stool specimen negative for parasites? 3. Describe the life cycle of this parasite as it relates to this patient's infection. 3. Describe the life cycle of this parasite as it relates to this patient's infection. 4. Can abscesses caused by this parasite occur in organs other than the liver? 4. Can abscesses caused by this parasite occur in organs other than the liver? 5. Which laboratory tests were probably used to make a diagnosis at the time the patient was first seen in the emergency room? Which specimen might prove in making a diagnosis during the patient's latest visit? 5. Which laboratory tests were probably used to make a diagnosis at the time the patient was first seen in the emergency room? Which specimen might prove in making a diagnosis during the patient's latest visit? 6. What risk to the patient exists in performance of a surgical procedure to obtain 6. What risk to the patient exists in performance of a surgical procedure to obtain a liver abscess a liver abscess 7. How might the patient's homosexuality be related to his infection? 7. How might the patient's homosexuality be related to his infection? 8. How should this patient be treated? 8. How should this patient be treated? 9. Which serological tests were probably ordered to confirm the diagnosis? 9. Which serological tests were probably ordered to confirm the diagnosis? 10.Discuss methods of control and prevention of infection with this parasite. 10.Discuss methods of control and prevention of infection with this parasite.

7. Q1:What is this patient's diagnosis? Which protozoan parasite is shown in Fig. 4.1?

8. 1.amoebic dysentery 1.amoebic dysentery 2.Amoebic pus of liver 2.Amoebic pus of liver

9. Q2:How does the patient's illness correlate with his previous episode of bloody diarrhea? Why is the patient's stool specimen negative for parasites?

10. Clinical symptom of Amoebic dysentery : Clinical symptom of Amoebic dysentery : 1.bloody diarrhea with cramping pain 1.bloody diarrhea with cramping pain 2.mild fever,mild malasia 2.mild fever,mild malasia 3.S/R,S/C:half case of amoebic liver absess was 3.S/R,S/C:half case of amoebic liver absess was found. found. Half of the patient with amoebic dysentery with negative stool culture

11. Q3:Describe the life cycle of this parasite as it relates to this patient's infection.

13. Q4:Can abscesses caused by this parasite occur in organs other than the liver?

14. As the same before~~ As the same before~~

15. Q5:Which laboratory tests were probably used to make a diagnosis at the time the patient was first seen in the emergency room? Which specimen might prove useful in making a diagnosis during the patient's latest visit?

16. Ans1: Ans1: Haemoglobin Haemoglobin White cell count White cell count Erythrocyte sedimentation rate Erythrocyte sedimentation rate Stool examination Stool examination Sigmoidoscopy Liver function tests Sigmoidoscopy Liver function tests Serum proteins Serum proteins Serum bilirubin Serum bilirubin Serum enzymes Serum enzymes Other liver function tests Other liver function tests

17. Q5:Which laboratory tests were probably used to make a diagnosis at the time the patient was first seen in the emergency room? Which specimen might prove useful in making a diagnosis during the patient's latest visit? Ans2: Ans2: 1.Role of radiology 1.Role of radiology 2.Role of serology: 2.Role of serology: 3.Role of hepatic scintigraphy, ultrasonic imaging and CAT scan 3.Role of hepatic scintigraphy, ultrasonic imaging and CAT scan 4.Role of peritoneoscopy 4.Role of peritoneoscopy

18. Q6:What risk to the patient exists in performance of a surgical procedure to obtain a liver aspirate?

19. The complications more commonly encountered are secondary infection and haemorrhage. The complications more commonly encountered are secondary infection and haemorrhage.

20. Q7:How might the patient's homosexuality be related to his infection?

21. Immune disorder? Immune disorder? English report:homosexuality who has GI upset with amoebic dysentery(20%) English report:homosexuality who has GI upset with amoebic dysentery(20%)

22. Q8:How should this patient be treated?

23. Medical Management : Medical Management : Systemic amoebicidal drugs include emetine, dehydroemetine, chloroquine diphosphate, metronidazole and tinidazole. Systemic amoebicidal drugs include emetine, dehydroemetine, chloroquine diphosphate, metronidazole and tinidazole. Aspiration Aspiration Open drainage and other surgical procedures Open drainage and other surgical procedures

24. Q9:Which serological tests were probably ordered to confirm the diagnosis?

25. Gel diffusion precipitation test. Gel diffusion precipitation test. Indirect haemagglutintion test (I.H.A. test) Complement fixation test. Fluorescent antibody test. Latex agglutinaion test (L A test). Bentonite flocculation and bentonite phagocytosis test. Immunoelectrophoresis Skin test.

26. 10.Discuss methods of control and prevention of infection with this parasite