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WS/T 568-2017 English PDF

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WS/T 568-2017: Diagnosis of extraintestinal amoebic abscess
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GBZ 57 GB/T 31989 WS/T 565 WS/T 566 WS/T 564

Basic data

Standard ID	WS/T 568-2017 (WS/T568-2017)
Description (Translated English)	Diagnosis of extraintestinal amoebic abscess
Sector / Industry	Health Industry Standard (Recommended)
Classification of Chinese Standard	C61
Word Count Estimation	17,161
Date of Issue	2017-08-01
Date of Implementation	2018-02-01
Regulation (derived from)	State-Health-Communication (2017) 11
Issuing agency(ies)	National Health and Family Planning Commission of the People's Republic of China

WS/T 568-2017: Diagnosis of extraintestinal amoebic abscess

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Diagnosis of extraintestinal amoebic abscess ICS 11.020 C 61 WS People's Republic of China Health Industry Standard Diagnosis of amebiasis extraintestinal abscess 2017-08-01 released 2018-02-01 implementation Issued by the National Health and Family Planning Commission of the People's Republic of China

Foreword

This standard was drafted in accordance with the rules given in GB/T 1.1-2009. Drafting organizations of this standard. Fudan University, Institute of Parasitic Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Huashan, Fudan University Hospital, Sun Yat-sen University, Henan Provincial Center for Disease Control and Prevention The main drafters of this standard. Cheng Xunjia, Chen Jiaxu, Zhang Wenhong, Wu Zhongdao, Xu Bianli, Fu Yongfeng Diagnosis of amebiasis extraintestinal abscess

1 Scope

This standard specifies the diagnostic basis, principles, diagnosis and differential diagnosis of amoebiasis extraintestinal abscess. This standard is applicable to the diagnosis of amoebiasis extraintestinal abscess by medical institutions and disease prevention and control institutions at all levels.

2 Normative references

The following documents are indispensable for the application of this document. For dated reference documents, only the dated version applies to This document. For undated references, the latest version (including all amendments) applies to this document. WS 287 Diagnostic criteria for bacterial and amoebic dysentery

3 Terms and definitions

3.1 Entamoeba histolytica Entamoeba histolytica is a pathogenic protozoa of the genus Entamoeba, also known as dysentery amoeba, which is the pathogen of amebiasis Body (see Appendix A). 3.2 Carriers of Entamoeba histolytica cysts Only in the feces or intestines, the cysts of endoamoeba solubilized were detected without obvious clinical manifestations. 3.3 amoebiasis A disease caused by the invasion of the host's intestinal tissue or extra-intestinal tissue by the histolytic endoamoebic trophozoite. 3.4 Extraintestinal abscess of amebiasis Entamoebic trophozoites invaded the host’s intestinal mucosa and then invaded the small blood vessels in the intestinal wall, then invaded the portal venous system and spread with the bloodstream. Diseases caused by spreading to the liver or other extraintestinal tissues and organs, trophozoites dissolving host cells, etc. Amebiasis extraintestinal abscess mainly includes A Mibic liver abscess, amebic lung abscess, amebic brain abscess, etc.

4 Diagnosis basis

4.1 Epidemiological history A history of unclean eating or drinking; a history of an outbreak of amoebiasis; a history of diarrhea or irregular bowel movements before the onset; Patients with mebic dysentery; there are patients with amoebiasis in the co-living population (see Appendix B). 4.2 Clinical manifestations (see Appendix C) 4.2.1 Amoebic liver abscess Fever, loss of appetite, weight loss; right upper abdominal pain, hepatomegaly with tenderness and percussion pain. 4.2.2 Amoebic lung abscess Fever, loss of appetite, weight loss; the disease involves the corresponding symptoms of the lungs, chest and other organs. 4.2.3 Amoebic brain abscess Fever, loss of appetite, weight loss; headache, vomiting, dizziness, seizures, or neuropsychiatric symptoms. 4.3 Imaging examination (see Appendix D) 4.3.1 X-ray examination of the right thoracic diaphragm elevation, restricted breathing movement, misty shadows on the right lung bottom, thickening of the pleura or pleural effusion. 4.3.2 Ultrasound examination revealed liquid lesions in the liver. 4.3.3 CT and magnetic resonance examination revealed signs of liquid space-occupying lesions in the organs. 4.4 Laboratory inspection (see Appendix E) 4.4.1 Abscess puncture fluid is brown, like chocolate paste, sticky and smelly. 4.4.2 Abscess puncture fluid smear examination, detected amoebic trophozoites. 4.4.3 The test of amoebic nucleic acid in the tissue of the abscess puncture solution was positive. 4.4.4 Entamoeba histolytic antigen was detected in abscess puncture fluid or cerebrospinal fluid. 4.4.5 Anti-Entamoeba histolytic antibodies were detected in the serum. 4.5 Experimental treatment For suspected cases, anti-amebic drugs such as metronidazole are effective.

5 Principles of diagnosis

Diagnosis is based on epidemiological history, clinical manifestations, imaging examinations, laboratory examinations and experimental treatment results.

6 Diagnosis

6.1 Suspected cases Comply with any of 4.1 and 4.2. 6.2 Clinical diagnosis cases The following one can be diagnosed. a) Suspected cases, meeting any one of 4.3 and 4.4.1; b) Suspected cases, meeting any one of 4.3 and 4.4.3; c) Suspected cases, which meet any of 4.3 and 4.5 at the same time. 6.3 Confirmed cases Clinically diagnosed cases meet 4.4.2 or 4.4.3 or 4.4.4. 7 Differential diagnosis (see Appendix F) 7.1 Amoebic liver abscess should be differentiated from bacterial liver abscess, liver malignant tumor, fascioliasis, echinococcosis, etc. 7.2 Amoebic lung abscess should be differentiated from bacterial lung abscess, tuberculosis, and lung malignant tumors. 7.3 Amoebic brain abscess should be differentiated from bacterial brain abscess, brain malignant tumor, tuberculous encephalitis, hydatid disease, etc.

Appendix A

(Informative appendix) Etiology A.1 Pathogen Entamoeba histolytica has two periods. cyst and trophozoite, parasitizes in the terminal ileum or colon, and can invade extraintestinal tissues through the bloodstream. Corresponding symptoms such as liver, lung, and brain abscess. A.2 Form A.2.1 Trophozoite The trophozoites of Entamoeba histolytica are aggressive and can swallow red blood cells. The size of the trophozoites is between 10m～60m, not only It is related to the pleomorphism of the parasite and also depends on its parasitic location. Worms isolated from patient tissues often contain ingested red blood cells, White blood cells and bacteria can also be seen. The trophozoite moves by means of a single directional pseudopodia. It has a transparent ectoplasm and a granular endoplasm. A spherical vesicular nucleus. The edge of the thin nuclear membrane has a single layer of uniformly distributed and uniformly sized perinuclear stained plasmids. The nucleolus is small and centered with a slender colorless filamentous structure around it. A.2.2 Encapsulation The trophozoites form cysts in the intestinal cavity, and the process is called cyst formation. Trophozoites cannot form cysts in organs outside the intestinal cavity, Therefore, there is no cyst in the extraintestinal diseased tissue. There is a special nutrient storage structure in the cytoplasm, namely chromosome It is meaningful for the identification of insect species. There are glycogen vesicles in immature cysts; mature cysts have 4 nuclei, round, The diameter is 10m～16m. The nucleus is a vesicular nucleus, similar to a trophozoite. A.3 Life history Humans are a suitable host for Entamoeba histolytica. Entamoeba histolytica has a simple life history, including infectious cyst stage and proliferative Trophozoite stage. The infection period is a mature cyst containing four nuclei. Food and drinking water contaminated infectious cysts are ingested orally through the stomach and small intestine. In the neutral or alkaline environment of the terminal ileum or colon, the encapsulation is affected by the enzymes in the intestinal tract, and the worms are shed. Trophozoite in the upper part of the colon Feeding bacteria and two-division multiplication. The worms move down in the intestinal lumen, and form with the stimulation of intestinal contents such as dehydration or environmental changes In the early stage of a round cyst, a thick cyst wall is secreted and finally a quad-nuclear cyst is formed, which is excreted with feces to complete its life history. With one core Or dinuclear immature cysts can also be excreted. The cysts can remain infectious for several days to one month under suitable external conditions, but in the dry Easy to die in a dry environment. Trophozoites are the invasion form of worms and are also the disease-causing period. It can invade the intestinal mucosa, swallow red blood cells, destroy the intestinal wall, and cause the intestinal wall Ulcers; trophozoites can fall off into the intestinal cavity with necrotic tissue, and be excreted with feces through intestinal peristalsis; they can also spread to other organs along the bloodstream. Such as liver, lung, brain, etc. cause extraintestinal amoebic abscess.

Appendix B

(Informative appendix) Epidemiology B.1 Epidemic overview B.1.1 Global Amoebiasis is distributed worldwide. There are 50 million people in the world infected with Entamoeba histolytica, and 40,000 to 100,000 people die from amebiasis each year. The death rate of amebiasis is second only to malaria among parasitic protozoal diseases. Amoebiasis is most common in tropical and subtropical regions, such as India and India In regions such as Nicaea, the Sahara Desert and tropical Africa, Central and South America, this distribution is mainly characterized by climatic conditions, sanitary conditions, and nutritional conditions. Bad results. Other co-factors are high carbohydrate diet, alcoholism, heredity, intestinal bacterial infection, or local damage to the colonic mucosa Hurt etc. The prevalence of amebiasis is particularly serious in some special populations. From.1992 to.1994, Switzerland reported HIV infection in stool examination 3% of diarrhea patients suffer from amoebiasis. From.1990 to.1998, the United States reported that the incidence of amoebiasis among HIV/AIDS patients was 1.35%. In some tropical and subtropical areas, the peak age of amoebiasis infection is children under 14 years old and adults over 40 years old. B.1.2 China The national survey on the distribution of parasites in my country from 1988 to.1992 showed that the average infection rate of intestinal infections of endoamoeba histolytica 0.949%. It is estimated that the number of people infected in the country is 10.69 million, and there are 12 provinces with an infection rate of more than 1%. In.2007, some provinces and cities in my country The positive rate of anti-endomeba antibodies in the serum of HIV/AIDS patients was 7.9%, which was significantly higher than that of non-HIV infected patients..2012, A total of 1,312 sera were tested in 7 provinces, municipalities and autonomous regions across the country with the diagnostically significant target antigen of Entamoeba histolytica. The results showed that The positive rates of endoamoeba histolytic antibodies are Beijing. 1.06% (2/188), Shanghai. 3.85% (5/130), Sichuan. 7.04% (10/142), Guangxi. 3.17% (6/189), Guizhou. 14.39% (41/285), Qinghai. 0.53% (1/190), Xinjiang. 9.04% (17/188). B.2 Popular links B.2.1 Source of infection The source of infection of amoebiasis is chronic amoebiasis patients whose feces continue to discharge cysts or asymptomatic carriers of cysts. B.2.2 Ways of transmission The main way of human infection is oral infection, which is caused by eating food containing mature cysts, drinking water or using contaminated tableware. Foodborne outbreaks are caused by unsanitary eating habits or eating food prepared by carriers of cysts. Fly or cockroach Insects can spread the cysts mechanically, causing transmission. In addition, in homosexual people, cysts in feces can be directly invaded by mouth, so Ami Pakistani disease is listed as a sexually transmitted disease in countries such as Europe, America and Japan. B.2.3 Susceptible population The population is generally susceptible to Entamoeba histolytica. In some special populations, the infection of endoamoeba histolytica is more serious, such as suffering from Family members, male homosexuals, hospitalized mentally ill or mentally handicapped persons, prisoners and children in orphanages, etc. Entamoeba histolytic Susceptibility is related to age, living conditions, and other infection prevalence. B.3 Popular factors The cysts of the amoeba histolytica have strong resistance, can survive for several weeks under appropriate temperature and humidity, and maintain infectivity, and pass The digestive tract of flies or cockroaches is still infectious; the cysts are not resistant to dryness and high temperature. Due to poor living conditions and unclean drinking water Or food contamination and other factors have caused the spread of amoebiasis. Some gay men can cause tissue dissolution due to fecal-oral transmission The prevalence of endoameba has increased. In addition, mental disorders and abnormal cognitive ability of the mentally retarded are also susceptible factors. AC

Appendix C

(Informative appendix) Clinical manifestations C.1 Proactive performance Amoebic extraintestinal abscesses often have a history of intestinal amebiasis, with sudden or insidious onset, fulminant or persistent. Intestinal amoeba Diseases include asymptomatic, amoebic colitis, acute fulminant amoebic dysentery and its complications, intestinal perforation and secondary bacterial peritonitis, It may be a prodrome of extraintestinal amoebic abscess (see WS 287). C.2 Common manifestations C.2.1 Amoebic liver abscess The patient has fever, chills, night sweats, anorexia, and weight loss; there is pain in the upper right abdomen, radiating to the right shoulder, deep breathing and postural changes will increase Severe pain; full right upper abdomen, tenderness, muscle tension and percussion pain in the liver area. The liver is often diffusely enlarged, and the lesion is clearly Obviously localized tenderness and percussion pain. Some patients have limited fluctuations in the liver area. If the lungs are involved, patients may have cough, shortness of breath, etc.; A small number of patients can even develop jaundice. Peripheral white blood cell count is about 10% of patients have recent diarrhea And history of dysentery. 50% of patients can detect cysts and even trophozoites in the feces, and 58% of patients with liver abscess have colonoscopy. CT, Both ultrasound and magnetic resonance can show space-occupying lesions in the liver. A "chocolate sauce"-like pus can be seen in liver puncture, and amoebic trophozoites can be detected. C.2.2 Amoebic lung abscess The patient has fever, chills, night sweats, anorexia, and weight loss; chest pain, cough, and difficulty breathing. The main symptoms of the patient include Including serous effusion, abscess or consolidation formation, empyema and pulmonary bronchial fistula. Amoebic lung abscess will spontaneously form pleural serous Effusion. More than 10% of patients with liver abscess may have lung abscess or lung consolidation. Pulmonary bronchial fistula may cough up chocolate-colored content It may even detect active amoebic trophozoites. The abscess ruptures into the thoracic cavity, causing empyema, and sudden respiratory tract involvement. C.2.3 Amoebic brain abscess Patients often have a history of liver abscess or recent diarrhea and dysentery; and neuropsychiatric symptoms should be suspected of amoebic trophozoite invasion Attacked the central nervous system. The patient’s general symptoms include fever, night sweats, anorexia, and weight loss. Depending on the size and location of the abscess, the patient Headache, vomiting, dizziness, seizures, or neuropsychiatric symptoms; the patient can further develop meningoencephalitis. CT and Magnetic resonance imaging often reveals intracranial space-occupying lesions with unclear boundaries. Cerebrospinal fluid examination may find amoebic trophozoites or detect dissolution group Organomeba nucleic acid. C.3 Complications C.3.1 Abscess rupture The most common complication in patients with liver abscess is rupture of the abscess. Up to 35% of patients with liver abscess may have liver abscess rupture. Abscess ruptured Abdominal cavity, causing amoebic peritonitis in abdominal cavity; rupture of lung abscess into thoracic cavity can cause empyema, causing sudden dyspnea; left lobe amoebic The rupture of a liver abscess into the pericardium can cause pericardial amoebiasis. The patient has all the symptoms and signs of pericarditis, including pain in the precordial area and respiratory pain. Difficulty in breathing, cyanosis, pale complexion, progressive pericardial tamponade, and even shock. C.3.2 Secondary bacterial infection Another major complication of amoebic liver abscess is secondary bacterial infection. Because of the local infection at the puncture site of the abscess operation, Those who have local skin and mucosal ulcers that do not heal for a long time or have secondary infections of purulent bacteria; due to poor drainage of the intrahepatic bile ducts compressed by the abscess Cause bacterial infection. BD

Appendix D

(Normative appendix) Image inspection D.1 Imaging of amoebic liver abscess D.1.1 Ultrasound examination Abscesses are mostly located in the right lobe of the liver, mostly single, round or oval, often adjacent to the liver capsule, with a large diameter; the wall thickness of the abscess is about 1mm~ 3mm; the echo of the wall is also low, the inner wall can be clear and smooth; the internal echo of the abscess is mostly anechoic or hypoechoic, and can be uniform and dense The point-like echo distribution does not contain gas-like reflections. D.1.2 CT examination Plain scan lesions are low-density, and part of the liquefaction density is uneven; lesions are round or oval; rings of different density may appear around abscesses Shaped belt, single ring, double ring or three ring. The ring sign is a reliable sign for CT diagnosis of abscess. D.1.3 Magnetic resonance examination The morphological characteristics of abscesses were the same as those of CT. D.2 Imaging manifestations of lung abscess D.2.1 X-ray inspection The density of the center of the lesion is low, often a central cavity is formed, the inflammatory infiltration absorption around the cavity becomes clear, and the cavity wall is thicker. There may be a liquid level inside. D.2.2 CT examination Necrosis and liquefaction appear in the lesion area, showing a central low-density area, with thick fiber-walled cavities as the main manifestations, and the inner and outer walls of the cavity are clear Clarity. On enhanced scan, the abscess wall has obvious annular enhancement, while the central area is not enhanced. D.2.3 Magnetic resonance examination The morphological characteristics of abscesses were the same as those of CT. D.3 Imaging manifestations of brain abscess D.3.1 CT examination The abscess and necrotic tissue were low-density in plain scan, and the wall of iso-density abscess was seen around the low-density area. The abscess wall is mostly intact and circular, thick and thin Uniform, a small number of incomplete ring walls, abscess wall thickness of about 2mm ~ 3mm; enhanced scan, due to the capillary of the granulation tissue in the inner layer of the abscess wall Vascular permeability increases, and the abscess wall is mostly intact and ring-enhanced, with the characteristics of complete, smooth, uniform, and thin-walled. Incomplete, uneven thickness. D.3.2 Magnetic resonance examination The morphological characteristics of abscesses were the same as those of CT. CE

Appendix E

(Normative appendix) Laboratory examination E.1 Pathogen inspection E.1.1 Abscess puncture fluid smear Abscess puncture fluid or pink, with the extension of abscess time, the pus is "chocolate-colored", relatively viscous, can be directly smeared Check it under the microscope. The ingested red blood cells can be seen in the amoebic nourishment body, and the trophozoite is very sensitive to temperature changes or other liquid mixing It is recommended to complete the test within 30 minutes after puncture and pus extraction. It should be noted that most of the worms are located on the abscess wall, so attention should be paid during puncture and examination. Observed at high magnification, if it is an amoebic trophozoite, it can be seen that it stretches out pseudopods and makes directional movements. In addition, the trophozoite under the microscope needs to be The main differences in cell identification are as follows. ① histolytic amoebic trophozoite is larger than the host cell; ② the ratio of nucleus to cytoplasm is lower Host cell; ③The trophozoite has a vesicular nucleus, the nucleolus is centered, and the perinuclear staining plasmid is clear; ④The cytoplasm of the trophoblast may contain red blood cells and tissues Fragments. E.1.2 Abscess puncture fluid endoamoeba specific antigen detection Detection of the antigens of endoamoeba histolytic can be used for the diagnosis and differential diagnosis of amoebiasis. The most direct diagnosis method is to test the patient An antigen in pus or cerebrospinal fluid. Generally, ELISA method is used to detect the molecular weight of 170 kDa galactose/B in pus or cerebrospinal fluid of patients. The heavy chain subunit or molecular weight of galectin is 29/30 kDa cysteine-rich protein. This method is more effective in amoebic liver abscess Early detection of antibodies is more sensitive and specific, but this method of detecting antigens in serum is sensitive to patients with amoebic liver abscess after one week of treatment. Sensitivity decreased significantly. The monoclonal antibody with a molecular weight of 29/30kDa cysteine-rich protein can also detect liver abscess, lung abscess and skin Compared with the positive rate of PCR analysis, the detection rate of this antigen in skin abscess pus is almost 100%. E.1.3 Abscess puncture fluid endoamoeba nucleic acid examination The genetic characteristics of amebia histolytica can be used as a diagnostic or differential diagnosis marker for the diagnosis of amoebiasis extraintestinal abscess. in accordance with PCR method to diagnose or differentially diagnose patients’ pus puncture fluid cultures, skin ulcer secretions in worm DNA or paraffin sections DNA, these genes are often some repetitive sequences in ribosomal DNA outside the amoeba chromosome or SSU rRNA or rich silk Amino acid antigen DNA sequence. Use PCR amplification to detect the small rRNA gene or other histolytic endoamoeba-specific DNA sequence for diagnosis The most sensitive and effective method for extraintestinal abscess of amebiasis, even PCR detection of hepatic abscess puncture fluid DNA that is recovering can show 100% The positive reaction. E.2 Serological examination E.2.1 Serum anti-endomeba histolytic antibody detection Antibody diagnosis can effectively detect asymptomatic patients with cytolytic intraamoeba encapsulation, and serological methods can be used to distinguish intrahepatic amoeba Miba and Dispane Amoeba. Preparation of Entamoeba histolytica trophozoite natural antigen or recombinant Entamoeba histolytica marker target antibody Original as the detection antigen, including 170kDa galactose/acetylgalactosamine heavy chain unit, 150kDa galactose/acetylgalactosamine Glycolectin intermediate unit, a group of glycoproteins with a molecular weight of 37 kDa to 90 kDa, etc. E.2.1.1 ELISA method Preparation of natural antigen. first collect pure cultured (sterile) endoamoeba trophozoites, wash repeatedly with PBS and suspend in In a certain amount of PBS, ultrasonically pulverized and centrifuged at a high speed to take the supernatant to determine the protein content. Add 100μL to each well of 96-well microtiter plate Coating buffer (containing the above-mentioned natural protein 5μg), coated overnight at 4°C; after washing the plate with PBST, add blocking solution to each well and place in a humidified box at room temperature Block for 1 hour; discard the blocking solution, and add 100 μL 1.400 diluted serum of suspicious patients or healthy controls to each well. Incubate in the box for 1 hour; after washing the plate with PBST, add 100 μL of 1.1000 diluted HRP-labeled secondary antibody to each well, incubate for 1 hour in the wet box; wash the plate Then, add.200μL of color developing solution to each well, and react for 30min in the dark at room temperature; add 50μL of 2M H2SO4 to stop the reaction, microplate reader 490nm Measure the absorbance at the wavelength. In addition, to recombine, express, and purify the recombinant protein of the target antigen, add 100μL per well of 96-well microplate The buffer solution (containing 0.1 to 0.5μg of recombinant protein) is tested with the above-mentioned ELISA method. This kind of diagnostic kit in China is under development in. E.2.1.2 Immunofluorescence detection method Each hole of the histolytic endoamoebic trophozoi...

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