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specimens should be evaluated after concentration and staining Multiple serologic assays are available; these tests are fairly sensitive, although sensitivity is lower (~70% in colitis) early in illness, and they cannot distinguish recent and old disease, as they remain positive for years after infection A commercially available stool antigen test (TechLab) offers improved sensitivity (> 90% for colitis); it requires fresh or frozen (not preserved) stool specimens Colonoscopy of uncleansed bowel typically shows no specific findings in mild intestinal disease; in severe disease, ulcers may be found with intact intervening friable mucosa, resembling inflammatory bowel disease Examination of fresh ulcer exudate for motile trophozoites and for E histolytica antigen may yield a diagnosis 2 Hepatic abscess Abscesses can be identified by ultrasonography, CT, or MRI, with round or oval low-density nonhomogeneous lesions, with abrupt transition from normal liver to the lesion, and hypoechoic centers Abscesses are most commonly single, but more than one may be present The right lobe is usually involved Serologic tests for antiamebic antibodies are almost always positive, except very early in the infection Thus, a negative test in a suspicious case should be repeated in about a week The stool E histolytica antigen test is positive in ~40% of cases; a serum antigen test



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is under development Examination of stools for the organisms or antigen is frequently negative As imaging studies cannot distinguish amebic and pyogenic abscesses, when a diagnosis is not available from serologic studies, percutaneous aspiration may be indicated, ideally with an image-guided needle Aspiration typically yields brown or yellow fluid Detection of organisms in the aspirate is uncommon, but detection of E histolytica antigen is very sensitive and diagnostic The key risk of aspiration is peritoneal spillage leading to peritonitis from amebas or other (pyogenic or echinococcal) organisms





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Treatment of amebiasis generally entails the use of metronidazole or tinidazole to eradicate tissue trophozoites and a luminal amebicide to eradicate intestinal cysts (Table 35 6) Asymptomatic infection with E dispar does not require therapy This organism cannot be differentiated morphologically from E histolytica, but with negative serology E dispar colonization is likely, and treatment is not indicated Colonization with E histolytica is generally treated with a luminal agent Effective luminal agents are diloxanide furoate (500 mg three times daily with meals for 10 days), iodoquinol (diiodohy-

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Clinical Setting Asymptomatic intestinal infection Drugs of Choice and Adult Dosage Luminal agent: Diloxanide furoate, 500 mg orally three times daily for 10 days or Iodoquinol, 650 mg orally three times daily for 21 days or Paromomycin, 10 mg/kg orally three times daily for 7 days Mild to moderate intestinal infection Metronidazole, 750 mg orally three times daily (or 500 mg IV every 6 hours) for 10 days or Tinidazole, 2 g orally daily for 3 days plus Luminal agent (see above) Severe intestinal infection Metronidazole, 750 mg orally three times daily (or 500 mg IV every 6 hours) for 10 days or Tinidazole, 2 g orally daily for 3 days plus Luminal agent (see above) Hepatic abscess, ameboma, and other extraintestinal disease Metronidazole, 750 mg orally three times daily (or 500 mg IV every 6 hours) for 10 days or Tinidazole, 2 g orally daily for 3 days plus Luminal agent (see above)

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Specific information regarding common presentations of endocrine disorders appears on CMDT Online at http:// wwwaccessmedicinecom

Umesh Masharani, MB, BS, MRCP(UK)

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Diabetes mellitus is a syndrome with disordered metabolism and inappropriate hyperglycemia due to either a deficiency of insulin secretion or to a combination of insulin resistance and inadequate insulin secretion to compensate Type 1 diabetes is due to pancreatic islet B cell destruction predominantly by an autoimmune process, and these patients are prone to ketoacidosis Type 2 diabetes is the more prevalent form and results from insulin resistance with a defect in compensatory insulin secretion (Table 27 2)

Type 1 diabetes:

Polyuria, polydipsia, and weight loss associated with random plasma glucose 200 mg/dL Plasma glucose of 126 mg/dL or higher after an overnight fast, documented on more than one occasion Ketonemia, ketonuria, or both Islet autoantibodies are frequently present

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