S2916 When the Well Runs You Dry: A Case of Entamoeba histolytica Enteritis

Abstract

INTRODUCTION: Amoebiasis is the second leading cause of death from parasitic disease worldwide with approximately 40,000-100,000 yearly deaths. Entamoeba histolytica is a health risk when there is an insufficient barrier between human feces and water source. Most individuals are infected by ingestion of E. histolytica cysts in contaminated food or drinking water. In the United States, most cases arise in immigrants from endemic areas or those with lower socioeconomic status. We present a case of amoebic enteritis in a patient without history of travel but exposure to well water. CASE DESCRIPTION/METHODS: 44-year-old male with history of chronic pancreatitis attributed to familial hypertriglyceridemia, pancreatic pseudocyst status post CT-guided drainage and failure to thrive status post PEG-J placement presented with progressive intolerance of J-tube feeds. CT Scan of the abdomen and pelvis revealed no structural reason for the patient to be intolerant of his feedings but did reveal new mild thickening of the mid small bowel indicative of enteritis. A GI pathogen panel with PCR was sent to rule out infectious causes. His GJ tube was exchanged, and though he had ongoing pain, he was tolerating tube feeds and was subsequently discharged. The patient was readmitted 2 weeks later with worsening left lower quadrant abdominal pain and up to 10 episodes of watery bowel movements a day. GI Pathogen panel was noted to be positive for E. Histolytica. On detailed history, patient admitted to bathing, drinking, and flushing his GJ tube with well water. He was treated with Metronidazole 500mg every 8 hours for 10 days followed by paromomycin dosed 25-30mg/kg divided into 3 doses daily for 7 days. His diarrhea and left lower quadrant pain resolved. It was recommended that the patient have his well water tested for other infectious agents or parasites. DISCUSSION: Most Entamoeba infections are asymptomatic. Risk factors for severe disease and increased mortality include young age, pregnancy, immunosuppression, malignancy, and malnutrition. Our patient was at increased risk due to malnutrition and flushing of the J arm which allowed the parasitic trophozoites to bypass the gastric acid unharmed. Misdiagnosis for ulcerative colitis and subsequent treatment with steroids has been shown to precipitate severe and fulminant forms of amebic colitis. Careful history taking and testing of stool with PCR when feasible should be conducted before initiating immunosuppression for inflammatory bowel disease.Figure 1Figure 2