Trichuris Trichiura (Whipworm, Roundworm)


Article Author:
Avinash Viswanath


Article Editor:
Mollie Williams


Editors In Chief:
Alexandra Caley
Sameh Boktor


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
4/1/2019 7:48:16 PM

Introduction

Trichuris trichiura, also known as the human whipworm, is a roundworm that causes trichuriasis in humans. It is referred to as the whipworm because it looks like a whip with wide handles at the posterior end. The whipworm has a narrow anterior esophagus and a thick posterior anus. The worms are usually pink and attach to the host via the slender anterior end. The size of these worms varies from 3 to 5 cm. The female usually larger than the male.[1]

The female worm can lay anywhere from 2000 to 10,000 eggs per day. The eggs are deposited in soil from human feces. After 14 to 21 days, the eggs mature and enter an infective stage. If humans ingest the embryonated eggs, the eggs start to hatch in the human small intestine and utilize the intestinal microflora and nutrients to multiply and grow. The majority of larvae move to the cecum, penetrate the mucosa and mature to adulthood. Infections involving a high-worm burden will typically involve distal parts of the large intestine.[1]

Trichuriasis is 1 of 3 well-documented soil-transmitted helminthiasis infections; the other 2 are ascariasis and hookworm infection. It is considered a neglected tropical disease by the World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC).

Etiology

The most common cause of trichuriasis is ingestion of infected eggs that are found in soil. This is often due to poor sanitary conditions, including open defecation and using human feces as fertilizer.

Some recent studies show that people with certain chromosome traits may be predisposed or have increased susceptibility to acquiring trichuriasis.[2]

Epidemiology

The egg of the whipworm is the infective stage, and favorable conditions for its maturation are warm and humid climate. This is why most of the disease burden is seen in tropical climates, specifically in Asia and less often, in Africa and South America. It is also found in rural parts of the southeast United States.

It is estimated that worldwide there are between 450 million to 1 billion active cases with most diagnosed in children. It is thought there is partial protective immunity that develops with age.[3][4]

Pathophysiology

A human host consumes infected eggs, typically while eating food. Once the embryonated eggs are ingested, the larvae hatch in the small intestine. From there they migrate to the large intestine, where the anterior ends lodge within the mucosa. This leads to cell destruction and activation of the host immune system, recruiting eosinophils, lymphocytes and plasma cells. This causes the typical symptoms of rectal bleeding and abdominal pain.

History and Physical

Patients will typically reside in or have visited areas that are endemic to the whipworm. The patient will usually complain of abdominal pain, painful passage of stools, abdominal discomfort, and mucus discharge. Rectal prolapse is known to occur in a heavy infestation. Children may develop anemia, growth retardation, and even impaired cognitive development. The latter 2 are thought to be due to iron deficiency and poor nutrition secondary to worm burden and are not a direct cause of the infestation.[5][4]

Evaluation

The diagnosis is made by using the Kato-Katz method for counting eggs per unit weight of feces. One caveat is that from the time the eggs are ingested to development of the mature worm, there is a time lag of about three months. During this period, there may be no signs of an infestation and the stools may not show evidence of any eggs or shedding.

There have been case reports of patients reporting symptoms in areas that are resource-rich where the diagnosis has been made with colonoscopy. The classic finding is the “coconut cake rectum.” There have recently been studies which show a whipworm dance on ultrasound, and this is a modality that can easily be used in resource-poor settings.[6]

PCR assays are currently being developed and used. This has improved the specificity and sensitivity of detecting the whipworm.[7]

Treatment / Management

The treatment is with mebendazole or albendazole. The suggested dose of mebendazole 100 mg twice a day for 3 days or albendazole is 200 to 400 mg twice a day for 3 days. Mebendazole has been shown to be more effective and is considered the first-line treatment.

Ivermectin (200 mcg/kg daily) can be used; however, it is not as effective as the first 2.

It is important to keep in mind that there are often co-infections with other helminths so treatments with multiple medications may be required.

Differential Diagnosis

Given that a whipworm infection can cause abdominal pain, there includes a large differential of abdominal processes. These include but are not limited to appendicitis, colitis, cholecystitis, perforated intestine. Bloody diarrhea can be caused by inflammatory bowel disease (IBD), bacterial pathogens or other soil-transmitted helminths. The constellation of cognitive disruption, constipation, and abdominal pain can also be seen with lead toxicity and is an important consideration for children.

The differential should include:

  • Chronic anemia
  • Giardiasis
  • Other parasitic helminth infections

Prognosis

The whipworm tends to be more resistant to treatment than other helminths, with some studies listing cure rates as low as 28% to 36%. Whipworms can still be present after treatment however it is thought that a low worm count leads to no significant disease burden.

Complications

Trichuris dysentery syndrome can be found in children (with no adult cases noted) and is seen when there is a very high worm burden. This often leads to diarrhea, tenesmus, iron deficiency anemia and growth retardation. The growth retardation is typically secondary to poor nutrition and consequently causes the cognitive delay.

Postoperative and Rehabilitation Care

Adults and children should be treated appropriately for the anemia they experience. Many global organizations stress the importance of increased education for children who have been treated for whipworm infection. Not doing so keeps them behind in school when compared to peers of their same age group who were not infected.

Deterrence and Patient Education

The best way to prevent trichuriasis is to improve personal hygiene, wash all fruit and vegetables, and teach everyone about the importance of hand washing. Global initiatives have been started which focus on improved sanitation, poverty reduction, and periodic chemotherapy.

Pearls and Other Issues

Ongoing studies are being performed with regards to the hygiene hypothesis which have shown improved symptoms of diseases such as Crohn’s or ulcerative colitis with the use of the Trichuris suis (pig whipworm) ova.[8][9][10]

Enhancing Healthcare Team Outcomes

The diagnosis of whipworm is not easy because the infection is not often encountered in the US. The disorder is best managed by a multidisciplinary team that includes an infectious disease expert, internist, gastroenterologist, and the primary care physician. Following treatment, education of the patient is vital to prevent recurrence. 

 

The infectious disease nurse should emphasize the need to improve personal hygiene, wash all fruit and vegetables, and teach everyone about the importance of hand washing. Global initiatives have been started which focus on improved sanitation, poverty reduction, and periodic chemotherapy.[11]


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Trichuris Trichiura (Whipworm, Roundworm) - Questions

Take a quiz of the questions on this article.

Take Quiz
What is the best way to prevent Trichuriasis when traveling in the tropics?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A female patient presents with a roundworm infection. She has three children who are aged 5, 8, and 10. Mebendazole is prescribed for treatment. What counseling point should be shared with the mother?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is the best method to identify Trichuris trichiura?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
How is Trichuris trichiura transmitted?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 7-year-old male is brought to your clinic by his mom who says for the past year he has been different than usual. She says he initially was a very bright child; however, recently he seems to be falling behind in school. His vital signs and physical exam are normal. The growth charts reveal the patient has started to decline, going from the 50th percentile in height to the 25th percentile. The travel history includes a visit to Kenya about a year ago. You treat the patient for possible whipworm infection. What can be expected for the course of this disease?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Trichuris Trichiura (Whipworm, Roundworm) - References

References

What impact will the achievement of the current World Health Organisation targets for anthelmintic treatment coverage in children have on the intensity of soil transmitted helminth infections?, Truscott JE,Turner HC,Anderson RM,, Parasites & vectors, 2015 Oct 22     [PubMed]
Interrupting transmission of soil-transmitted helminths: a study protocol for cluster randomised trials evaluating alternative treatment strategies and delivery systems in Kenya., Brooker SJ,Mwandawiro CS,Halliday KE,Njenga SM,Mcharo C,Gichuki PM,Wasunna B,Kihara JH,Njomo D,Alusala D,Chiguzo A,Turner HC,Teti C,Gwayi-Chore C,Nikolay B,Truscott JE,Hollingsworth TD,Balabanova D,Griffiths UK,Freeman MC,Allen E,Pullan RL,Anderson RM,, BMJ open, 2015 Oct 19     [PubMed]
Prevalence and risk factors associated with the presence of Soil-Transmitted Helminths in children studying in Municipal Corporation of Delhi Schools of Delhi, India., Ranjan S,Passi SJ,Singh SN,, Journal of parasitic diseases : official organ of the Indian Society for Parasitology, 2015 Sep     [PubMed]
Two quantitative trait loci influence whipworm (Trichuris trichiura) infection in a Nepalese population., Williams-Blangero S,Vandeberg JL,Subedi J,Jha B,Dyer TD,Blangero J,, The Journal of infectious diseases, 2008 Apr 15     [PubMed]
Trichuriasis., Bansal R,Huang T,Chun S,, The American journal of the medical sciences, 2018 Feb     [PubMed]
Vaccination Against Whipworm: Identification of Potential Immunogenic Proteins in Trichuris muris Excretory/Secretory Material., Shears RK,Bancroft AJ,Sharpe C,Grencis RK,Thornton DJ,, Scientific reports, 2018 Mar 14     [PubMed]
A Randomised, Double-blind, Placebo-controlled Trial of Trichuris suis ova in Active Crohn's Disease., Schölmerich J,Fellermann K,Seibold FW,Rogler G,Langhorst J,Howaldt S,Novacek G,Petersen AM,Bachmann O,Matthes H,Hesselbarth N,Teich N,Wehkamp J,Klaus J,Ott C,Dilger K,Greinwald R,Mueller R,, Journal of Crohn's & colitis, 2017 Apr 1     [PubMed]
Helminth therapy (worms) for induction of remission in inflammatory bowel disease., Garg SK,Croft AM,Bager P,, The Cochrane database of systematic reviews, 2014 Jan 20     [PubMed]
Sonographic whipworm dance in trichuriasis., Vijayaraghavan SB,, Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine, 2009 Apr     [PubMed]
Improved PCR-Based Detection of Soil Transmitted Helminth Infections Using a Next-Generation Sequencing Approach to Assay Design., Pilotte N,Papaiakovou M,Grant JR,Bierwert LA,Llewellyn S,McCarthy JS,Williams SA,, PLoS neglected tropical diseases, 2016 Mar     [PubMed]
Maldonade IR,Ginani VC,Riquette RFR,Gurgel-Gonçalves R,Mendes VS,Machado ER, Good manufacturing practices of minimally processed vegetables reduce contamination with pathogenic microorganisms. Revista do Instituto de Medicina Tropical de Sao Paulo. 2019 Feb 14;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of CNS-Public Community Health. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for CNS-Public Community Health, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in CNS-Public Community Health, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of CNS-Public Community Health. When it is time for the CNS-Public Community Health board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study CNS-Public Community Health.