Dear Sir:
We read with great interest the article published by Gunther and others1 that describes the amebiasis-related mortality among United States residents from 1990 to 2007. Of 134 amebiasis deaths during the study period, human immunodeficiency virus (HIV) infection was a co-existing condition in 14 (10.4%), which was statistically significantly more common than in the control, non-amebiasis group with a matched odds ratio of 7.7 (95% confidence interval, 3.16–18.77). Although more studies are warranted to identify the causes of the higher association between HIV infection and amebiasis deaths in the United States, the findings of several previous studies between the 1980s and 2000s2–6 concluded infection with Entamoeba histolytica that is pathogenic was rare in men who have sex with men (MSM). Regardless of HIV serostatus, this may hinder health care providers from considering invasive amebiasis high in the list of differential diagnosis when HIV-infected patients present with symptoms of amebic colitis or abscesses that are difficult to be differentiated from other competing causes of colitis or liver abscess.7 Although the spectrum of amebiasis is similar between HIV-infected patients and the general population,8,9 the amebiasis-related mortality rate is low in developed countries where HIV-infected MSM have long been recognized as a high risk group for amebiasis.8,10,11 In the two largest case series of invasive amebiasis in HIV-infected men in Taiwan and Japan, Hung and others8 and Watanabe and others9 retrospectively reviewed 67 and 170 cases of invasive amebiasis, respectively, and the amebiasis-related mortality rate was 0% and 1.2%, respectively, despite a high percentage of amebic abscess and complications. Recent studies that report cases of invasive amebiasis in MSM and bisexuals in other developed countries12,13 and a higher frequency of amebiasis, detected by specific antigen assays for E. histolytica and serologies, in both developed and developing countries14–17 should raise concerns and warrant reevaluation of amebiasis in patients with HIV infection, especially in MSM.
- 1.↑
Gunther J, Shafir S, Bristow B, Sorvillo F, 2011. Short report: amebiasis-related mortality among United States residents, 1990–2007. Am J Trop Med Hyg 85: 1038–1040.
- 2.↑
Phillips SC, Mildvan D, William DC, Gelb AM, White MC, 1981. Sexual transmission of enteric protozoa and helminths in a venereal-disease-clinic population. N Engl J Med 305: 603–606.
- 3.
Quinn TC, Stamm WE, Goodell SE, Mkrtichian E, Benedetti J, Corey L, Schuffler MD, Holmes KK, 1983. The polymicrobial origin of intestinal infections in homosexual men. N Engl J Med 309: 576–582.
- 4.
Allason-Jones E, Mindel A, Sargeaunt P, Williams P, 1986. Entamoeba histolytica as a commensal intestinal parasite in homosexual men. N Engl J Med 315: 353–356.
- 5.
Sorvillo FJ, Strassburg MA, Seidel J, Visvesvara GS, Mori K, Todd A, Portigal L, Finn M, Agee BA, 1986. Amebic infections in asymptomatic homosexual men, lack of evidence of invasive disease. Am J Public Health 76: 1137–1139.
- 6.↑
Lowther SA, Dworkin MS, Hanson DL; Adult and Adolescent Spectrum of Human Immunodeficiency Virus Disease Project, 2000. Entamoeba histolytica/Entamoeba dispar in human immunodeficiency virus-infected patients in the United States. Clin Infect Dis 30: 955–959.
- 7.↑
Weber R, Ledergerber B, Zbinden R, Altwegg M, Pfyffer GE, Spycher MA, Briner J, Kaiser L, Opravil M, Meyenberger C, Flepp M, 1999. Enteric infections and diarrhea in human immunodeficiency virus-infected persons: prospective community-based cohort study. Swiss HIV Cohort Study. Arch Intern Med 159: 1473–1480.
- 8.↑
Hung CC, Ji DD, Sun HY, Lee YT, Hsu SY, Chang SY, Wu CH, Chan YH, Hsiao CF, Liu WC, Colebunders R, 2008. Increased risk for Entamoeba histolytica infection and invasive amebiasis in HIV seropositive men who have sex with men in Taiwan. PLoS Negl Trop Dis 2: e175.
- 9.↑
Watanabe K, Gatanaga H, Escueta-de Cadiz A, Tanuma J, Nozaki T, Oka S, 2011. Amebiasis in HIV-1-infected Japanese men: clinical features and response to therapy. PLoS Negl Trop Dis 5: e1318.
- 10.↑
Hung CC, Wu PY, Chang SY, Ji DD, Sun HY, Liu WC, Wu CH, Chang SC, 2011. Amebiasis among persons who sought voluntary counseling and testing for human immunodeficiency virus infection: a case-control study. Am J Trop Med Hyg 84: 65–69.
- 11.↑
Takeuchi T, Miyahira Y, Kobyash S, Nozaki T, Motta S, Matsuda L, 1990. High seropositivity for Entamoeba histolytica infection in Japanese homosexual men: further evidence for occurrence of pathogenic strains. Trans R Soc Trop Med Hyg 84: 250–251.
- 12.↑
Stark D, van Hal SJ, Matthews G, Harkness J, Marriott D, 2008. Invasive amebiasis in men who have sex with men, Australia. Emerg Infect Dis 14: 1141–1143.
- 13.↑
Salit IE, Khairnar K, Gough K, Pillai DR, 2009. A possible cluster of sexually transmitted Entamoeba histolytica: genetic analysis of a highly virulent strain. Clin Infect Dis 49: 346–353.
- 14.↑
Moran P, Ramos F, Ramiro M, Curiel O, González E, Valadez A, Gómez A, García G, Melendro EI, Ximénez C, 2005. Entamoeba histolytica and/or Entamoeba dispar : infection frequency in HIV+/AIDS patients in Mexico City. Exp Parasitol 110: 331–334.
- 15.
Chen Y, Zhang Y, Yang B, Qi T, Lu H, Cheng X, Tachibana H, 2007. Seroprevalence of Entamoeba histolytica infection in HIV-infected patients in China. Am J Trop Med Hyg 77: 825–828.
- 16.
Samie A, Barrett LJ, Bessong PO, Ramalivhana JN, Mavhandu LG, Njayou M, Guerrant RL, 2010. Seroprevalence of Entamoeba histolytica in the context of HIV and AIDS: the case of Vhembe district, in South Africa's Limpopo province. Ann Trop Med Parasitol 104: 55–63.
- 17.↑
James R, Barratt J, Marriott D, Harkness J, Stark D, 2010. Seroprevalence of Entamoeba histolytica infection among men who have sex with men in Sydney, Australia. Am J Trop Med Hyg 83: 914–916.