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Letters to the Editor

Indian Pediatrics 2004; 41:861-863

Role of Entamoeba histolytica in Acute Watery Diarrhea in Hospitalized Under-five Children


Acute diarrhea is a major cause of morbidity and mortality among children in developing countries and Rotavirus and Enterotoxigenic E. coli (ETEC) are the most frequent etiological agents(1,2). Although, E. histolytica is an uncommon cause of acute watery diarrhea in under-five children, anti-protozoal drugs (with or without antibiotics) continue to be used in this setting(3). This has been further compounded by the recent increase in the number of formulations containing antiparasitic agents with antibiotics. This case control, tertiary-care hospital based study was conducted to elucidate the role of E.histolytica in the causation of acute watery diarrhea in hospitalized under-five children in our setting.

The study was carried out over a three-month period (1 June-30 August, 2001) among the pediatric inpatients of Dr. R.M.L. hospital, New Delhi. All the patients satisfying the inclusion criteria were included in the study.

Inclusion criteria. Less than 5 year of age and acute watery diarrhea of less than 72-hour duration.

Exclusion criteria. Dysentery, mucoid diarrhea, and history of receiving any antiparasitic drug in the ten days prior to admission. Age and sex-matched controls were selected from among the hospital in-patients, provided they had not had diarrhea in the previous month and, had not received any antiparasitic drug in the last ten days. Information regarding age, sex, place of residence and source of water supply was obtained in a proforma. From each case and control, at least (approx.) 5 mL or 5 g of faeces was collected in a clean, sterile container, marked and dispatched by hand to the pathology laboratory. These samples were examined by one of the authors (RBY) within 30 minutes of collection. Both direct and concentration methods were used to examine the specimen for parasitic ova, blood cell, trophozoites and cysts. Definition of acute diarrhea and dysentery, indications for admission and the treatment protocols used were as per the standard guidelines(2). Mucoid diarrhea was defined as an episode with the presence of mucus in a loose stool (without any visible blood) throughout the entire duration of diarrhea, either reported by parents or noted on microscopic examination. Stool examination was not done on Sundays and public holidays, and after 3 p.m. on weekdays due to administrative constraints. An informed verbal consent was obtained from parents or caregivers of all cases and controls. Ninety-two of the control group parents and none of the cases refused consent. Significance of differences in proportions was assessed by c2 test using a 5% level of significance as cut-off.

A total of 156 patients and 156 controls were investigated. Age, sex, place of residence and source of water supply were not significantly different between the two groups. Only two children (1.3%) in the study group had evidence of acute infection with E.histolytica (one of these had 4-6 RBC/hpf on microscopy) whereas 12 (7.7%) had cysts of the same organism. In the control group, 14 (8.97%) of the children were cyst-passers whereas none had the presence of trophozoites of E. histolytica in stool. Ascaris ova were found in 5 (3.2%) and 2 (1.3%) children and G.lamblia cysts in 3 (1.9%) and 4 (2.6%) children respectively, in the study and control group. On statistical analysis, no significant difference was found between the two groups with respect to E. histolytica cyst passage or trophozoites in stool.

Previous studies of hospitalized outpatient children with acute diarrhea from developing countries have reported the prevalence of this organism to vary from nil to 4.9%(4-8). However, prevalence rates of 4-6% in control children have also been reported(4,9). None of the 402 under-3 children with diarrhea in Pakistan had evidence of E. histolytica infection as compared to 3.7% of the controls (4). Out of 265 under-5 inpatients with acute diarrhea in Jordan, only 4.9% had evidence of E.histolytica infection(5). 2.6% of 152 cases of acute childhood diarrhea in Calcutta were reported to have evidence of E.histolytica infection(6) as compared to only 0.5% and 0.6% of under 5 children with diarrhea in Nigeria and Dhaka, respectively(7,8). The report by Shetty et al has been one of the few reports implicating E.histolytica as a significant cause of diarrhea in children. In 361 pediatric in-patients with acute diarrhea, E.histolytica prevalence upto 20.3% (in 7-12 month age group) were reported(10).

However, on the basis of majority of the published studies, E.histolytica is an uncommon cause of acute diarrhea in under five children. Our findings also revalidate previous reports. Further, although stool microscopy was used for diagnosis in the study protocol, on retrospect stool microscopy results would not have contributed to change in therapeutics decision in 155 of the 156 children. We, therefore, wish to reiterate that stool microscopy and antiprotozoal agents do not have any role in the management of under-five children with acute watery diarrhea.

Devendra Mishra,
V.K. Gupta,
R.B. Yadav*,

Departments of Pediatrics and Pathology*
Dr. Ram Manohar Lohia Hospital,
New Delhi-110001,
India.
E-mail: [email protected]

 

References

 

1. World Health Organization. The treatment of diarrhea, Geneva. WHO/CDR/95.3, WHO, 1995.

2. Task Force on Diarrheal Disease. Guidelines for management of diarrhea in children. Indian Academy of Paediatrics, New Delhi, 2000.

3. Singh J, Bora D, Sachdeva V, Sharma RS, Verghese T. Prescribing pattern by doctors for acute diarrhea in children in Delhi, India. J Diarrheal Dis Res 1995; 13(4): 229-31.

4. Khan MMA, Baqai R, Iqbal J, Ghafoor A, Zuberi S, Burney MI. Causative agents of acute diarrhea in the first 3 years of life: Hospital - based study. J Gastroenterol Hepatol 1990; 5: 264-270.

5. Youssef M, Shurman A, Bougnoux M, Rawashdeh M, Bretagne S, Strockbine N. Bacterial, viral and parasitic enteric pathogens associated with acute diarrhea in hospitalized children from northern Jordan. FEMS Immunol Med Microbiol 2000; 28 : 257-263.

6. Chatterjee BD, Thawani G, Sanyal SN. Etiology of acute childhood diarrhea in Calcutta. Trop Gastroenterol 1989; 10: 158-166.

7. Albert MJ, Faruque ASG, Faruque SM, Sack RB, Mahalanabis D. Case control study of enteropathogens associated with childhood diarrhea in Dhaka, Bangladesh. J Clin Microbiol 1999; 37: 3458-3464.

8. Ogunsanya TI, Rotimi VO, Adenuga A. A study of the etiolotical agents of childhood diarrhea in Lagos, Nigeria. J Med Microbiol 1994; 40 : 10-14.

9. Soenarto Y, Sebodo T, Suryantoro P, Krisnomurti, Haksohusodo S, Ilyas, et al. Bacterial, parasitic agents and rotavirus associated with acute diarrhea in hospital in-patient Indonesian children. Trans R Soc Trop Med Hyg 1983; 77: 724-730

10. Shetty N, Narsimha M, Raghuveer TS, Elliott E, Farthing MJ, Macaden R. Intestinal amebiasis and giardiasis in southern Indian infants and children. Trans R Soc Trop Med Hyg 1999; 84: 382-384.

 

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