L7: Parasitic Infections of The Liver Flashcards
(100 cards)
1
Q
Parasitic infections of the liver can present a difficult and fascinating diagnostic puzzle.
A
…
2
Q
Diagnosis usually requires a careful history and physical examination
A
…
3
Q
Sometimes travel history, occupation, and recreational exposures provide clues.
- For example, a variceal bleed in an Egyptian patient with no stigmata of chronic liver disease may prompt consideration of schistosomiasis
A
…
4
Q
Parasites affecting the liver
A
5
Q
Protozoa affecting the liver
A
Amebic hepatitis and amebic liver abscess
Malaria
American trypanosomiasis (Chagas’ disease)
Leishmaniasis (Kala-azar)
6
Q
Helminthes affecting the liver
A
Hepatic schistosomiasis
Echinococcosis
Clonorchiasis and opisthorchiasis
Fascioliasis
Visceral larva migrans
7
Q
CA of Ameobic Liver Abscess
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Entamoeba histolytica.
8
Q
Transmission of Ameobic Liver Abscess
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Ingestion of contaminated food.
9
Q
Distribution of Ameobic Liver Abscess
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worldwide; more in tropics and areas with poor sanitation.
10
Q
age affected by Ameobic Liver Abscess
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usually between 20 and 40 years of age.
11
Q
E. histolytica usually causes …..
A
dysentery
12
Q
Sex affected by Ameobic Liver Abscess
A
More frequent in males
13
Q
Liver affection results when organisms traverse the bowel wall and reach the liver via the portal vein.
A
…
14
Q
Hepatic amebiasis may be …..
A
a) Diffuse (acute non-suppurative hepatitis).
b) Amebic liver abscess.
15
Q
Many patients were found to have severe immunosuppression, the most common causes being HIV and tuberculosis.
A
….
16
Q
CP of Ameobic Liver Abscess
A
17
Q
Symptoms of Ameobic Liver Abscess
A
Fever and abdominal pain: in 80-90% of patients.
Nausea, diarrhea, weight loss.
Cough: sometimes but not reliably present.
Amebic dysentery.
18
Q
Signs of Ameobic Liver Abscess
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19
Q
INVx of Ameobic Liver Abscess
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20
Q
Investigations for Ameobic Liver Abscess
- Amoebic Serology
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positive in 99% of patients.
21
Q
Investigations for Ameobic Liver Abscess
- Amoebic Cysts
A
may present in stools.
22
Q
Investigations for Ameobic Liver Abscess
- Imaging Of the Liver
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- A single cavitating area is seen, often with areas of solid liver tissue within it; occasionally, multiple abscesses are seen.
23
Q
Investigations for Ameobic Liver Abscess
- CBC
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Neutrophil leucocytosis is seen with mild anemia.
24
Q
Investigations for Ameobic Liver Abscess
- ARPs
A
- Low albumin, raised CRP, ESR and alkaline phosphatase, elevation of transaminases and
- Rarely, raised bilirubin are found.
25
Investigations for **Ameobic Liver Abscess**
- Blood Culture
Sterile
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Investigations for **Ameobic Liver Abscess**
- Aspiration
If the abscess is aspirated: anchovy sauce color, it does not have a foul smell (anaerobic bacteria).
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TTT of **Ameobic Liver Abscess**
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TTT of **Ameobic Liver Abscess**
- metronidazole
Metronidazole: 750 mg 3 times a day orally for 10 days
- Curative in 90% of patients.
- The drug also is available for IV administration.
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TTT of **Ameobic Liver Abscess**
- Tinidazole
Tinidazole, another nitroimidazole closely related to metronidazole, approved for the treatment of ALA and invasive amebiasis as effective as metronidazole.
30
TTT of **Ameobic Liver Abscess**
- Luminal Agents
- Administration of luminal agents (iodoquinol and paromomycin) should follow to eradicate E. histolytica residing in the colon.
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TTT of **Ameobic Liver Abscess**
- Percutaneous aspiration
If needed, percutaneous aspiration of amebic liver abscesses can be safely performed
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Possible Complications of **Ameobic Liver Abscess**
- The abscess may rupture into the abdominal cavity, the pleura, the lungs, or the pericardium.
- The infection can also spread to the brain.
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Another Name of **American Trypanosomiasis**
Chagas Disease
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CA of **American Trypanosomiasis**
Caused by a protozoa (T. cruzi)
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What transmits T.Cruzi?
Transmitted by the red winged bug (kissing bug).
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CP of **American Trypanosomiasis**
- Hepatosplenomegaly and mildly abnormal liver enzymes are common in the acute phase.
- With the development of cardiomyopathy, passive liver congestion is commonly seen with chronic disease.
- Other gastrointestinal manifestations include megacolon and megaesophagus.
37
Trypomastigote & Amastigotes in **American Trypanosomiasis**
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CA of **Leishmaniasis**
Caused by protozoan parasites transmitted by the sand fly in tropical regions.
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MOT of **Visceral Leishmaniasis**
Infection can be localized to the skin or spread throughout the reticuloendothelial system.
40
Kala-azar refers to ......
severe visceral leishmaniasis
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CP of **Visceral Leishmaniasis**
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Liver Histopathology in **Visceral Leishmaniasis**
Liver histopathology can show granulomas or severe fibrosis
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labs in **Visceral Leishmaniasis**
Modest increases in hepatic transaminases and alkaline phosphatase are common
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Dx of **Visceral Leishmaniasis**
Usually made by bone marrow biopsy, though splenic aspiration is a highly sensitive test (> 95%).
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TTT of **Visceral Leishmaniasis**
Pentavalent antimony compounds, pentamadine, or amphotericin B can be used for treatment
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CA of **Hepatic Shistosomaisis**
Schistosoma mansoni
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MOT of **Hepatic Shistosomaisis**
penetration of the skin by the infective cercaria of S. mansoni
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Normal Habitat of **Hepatic Shistosomaisis**
Colonic venous plexus.
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Main Pathology of **Hepatic Shistosomaisis**
in the colon is bilharzial dysentery.
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Sequalae of **Hepatic Shistosomaisis**
include colonic polyposis, hepatosplenic, and cardiopulmonary schistosomiasis.
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Pathogenesis of Liver Affection in **Hepatic Shistosomaisis**
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Stages of **Hepatic Shistosomaisis**
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Stage of shrunken liver and splenomegaly
Severe portal hypertension, collaterals may appear during this stage and hypersplenism may develop.
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Ascetic stage
Due to portal hypertension and hypoalbuminemia.
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Dx of **S.Mansoni**
Direct & Indirect Method
56
Direct Methods in Dx of **S.Mansoni**
A) Stool analysis: specific (100%) but of low sensitivity (40%)
B) Rectal snip biopsy: sensitive and specific.
C) Liver biopsy.
57
Indirect Methods in Dx of **S.Mansoni**
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TTT of **S.Mansoni**
59
What are Anti-Bilharzial Drugs?
- Praziquantel
- Oxamniquine
- Mirazid
- Endoscopic Polypectomy
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MOA of Praziquantel
The drug causes vacuolization of schistosoma tegument leading to disruption of the apical tegmental layer.
61
What is another name of **Echinococcus**?
Hydatid Disease
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CA of **Cystic echinococcosis**
E. granulosus
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CP of Cystic echinococcosis
It is typically a solitary slowly- growing hepatic cyst with potential for rupture and secondary complications.
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CA of **Alveolar echinococcosis**
E. multilocularis
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CP of **Alveolar echinococcosis**
An aggressive disease which often behaves like a malignancy.
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Geography of **E. granulosus**
occurs mainly in sheep-raising areas where canines eat the viscera of infected sheep.
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Geography of **E. multilocular**
occurs in only the northern hemisphere, often in arctic areas.
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Human is an ....... host (dead - end host).
intermediate
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CP of **E. granulosus**
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Infection by **E. granulosus**
- Although most E. granulosus infections are acquired in childhood
- The disease usually does not present until the fourth decade or later, as cystic lesions are usually slow-growing.
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Most of ...... are asymptomatic
E. granulosus infections
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CP of **E. granulosus**
About 80% of cases present as a solitary hepatic cyst, most commonly involving the right lobe.
Less frequently, multiple cysts can be seen within the liver or in extrahepatic sites.
As cysts grow larger than 5 to 10 cm, patients may begin to experience right upper quadrant abdominal discomfort and nausea.
73
When do patients infected with E. granulosus present with manifestations?
As cysts grow larger than 5 to 10 cm, patients may begin to experience right upper quadrant abdominal discomfort and nausea.
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Complications of **E. granulosus**
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Dx of **E. granulosus**
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Dx of **E. granulosus**
- Hx
Diagnosis can usually be made from the patient
history and medical imaging.
77
Dx of **E. granulosus**
- Serology
Serology can be helpful, but has variable sensitivity.
78
Dx of **E. granulosus**
- rads
Ultrasound or CT scan may reveal a smooth, round
cyst, internal septations and hydatid sand are often
visualized as well.
79
Cysts that appear heavily calcified are usually ......., and treatment may not be required.
non-viable
80
Protoscoleces of E.Granulosus
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TTT of ****E. granulosus****
82
First Line Therapy of **E. granulosus**
First line therapy for cystic echinococcosis remains surgery, usually without the infusion of a protoscolicidal agent.
83
PAIR Technique in TTT of **E. granulosus**
PAIR (Puncture, Aspiration, Injection and Reaspiration) is an ultrasound-guided percutaneous technique.
84
Albendazole in TTT of **E. granulosus**
Albendazole (10 - 15 mg / kg per day in 2 divided doses) is given several days before and 2- 3 months following treatment.
- May be given alone for 3-6 months.
85
What is F. Hepatica?
Fasciola hepatica is a liver fluke (trematode) that occurs in temperate sheep-raising areas throughout the world.
86
Transmission of F. Hepatica
87
CP of F. Hepatica
88
IP of **F. Hepatica**
- Typically fascioliasis presents one to 3 months after ingestion of metacercariae (acute fascioliasis) with fever, nausea, abdominal pain, hepatomegaly, and eosinophilia.
89
CP of F. Hepatica
- Occasionally hemobilia, subcapsular hematomas, or extrahepatic masses may occur.
- Even though chronic infection is generally asymptomatic, biliary obstruction can occur.
90
CP of Chronic **F. Hepatica**
- Even though chronic infection is generally asymptomatic, biliary obstruction can occur.
91
Dx of **F. Hepatica**
92
Dx of F. Hepatica in acute Cases
Whereas stool examination for ova and parasites is typically negative in acute infection, serologic tests (ELISA) are usually diagnostic.
93
Rads in Dx of **F. Hepatica**
- US may reveal an elongated, mobile and floating structure, 5-23 mm inside dilated CBD with no acoustic shadow.
- CT scanning may show characteristic tortuous tracks indicative of worm migration.
94
Dx of **F. Hepatica** in Chronic Cases
Unlike acute infection, chronic infection is associated with characteristic ova detectable by stool examination.
95
TTT of **F. Hepatica**
Triclabendazole is the only treatment for fascioliasis
96
What are **Clonorchis sinensis and opisthorchis**?
Clonorchis sinensis and opisthorchis species are parasitic flukes (trematodes).
97
geography of **Clonorchis sinensis and opisthorchis**
Infection is most common in the Far East, Southeast Asia, and parts of the former Soviet Union.
Cases have been reported in non-endemic areas due to the importation of fish products.
98
CP of Clonorchis sinensis and opisthorchis
Clinically like fascioliasis but carcinogenic.
99
TTT of **Clonorchis sinensis and opisthorchis**
Praziquantel (75 mg/kg in three divided doses for 1 day) is highly effective.
100
Done
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