Trichuris Trichiura (Whipworm) Infection (Trichuriasis)
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Trichuriasis, which is infection with the parasite Trichuris trichiura, or whipworm, is a very common intestinal helminthic infection worldwide. About one quarter of the world’s population is thought to carry the parasite. Principally a problem in tropical Asia and, to a lesser degree, in Africa and South America, a lack of a tissue migration phase and a relative lack of symptoms characterize whipworm infection. Trichuris is also notable for its small size compared with Ascaris lumbricoides. Only individuals with heavy parasite burden become symptomatic. Vitamin A deficiency has been seen in patients with trichuriasis.
Poor hygiene is associated with T trichiura transmission, and children are especially vulnerable because of their high exposure risk. This is especially true in developing countries, where poor sanitary conditions correlate with heavy disease burden and infections. One study in Nigeria was undertaken to determine helminth infection status and hygienic conditions in primary schools. Prevalence of helminth infection was higher in the schools where hygiene conditions (ie, tapwater, handwashing soap) were lacking. The study results recommended that the school health programs include deworming, health education, and improvement of hygiene conditions. [1]
The whipworm derives its name from its characteristic whiplike shape; the adult (male, 30-45 mm; female, 35-50 mm) buries its thin, threadlike anterior half into the intestinal mucosa and feeds on tissue secretions, not blood. This relative tissue invasion causes occasional peripheral eosinophilia. The cecum and colon are the most commonly infected sites, although in heavily infected individuals, infection can be present in more distal segments of the GI tract, such as the descending colon and rectum. See the image below.
Note that T trichiura is usually found in association with other helminths that flourish under similar conditions, a common pathogen being A lumbricoides.
Trichuris, as with Ascaris lumbricoides, is spread via fecal-oral transmission. Eggs are deposited in soil through human feces. After 10-14 days in soil, eggs become infective. In contrast to other parasites, such as A lumbricoides, no tissue migratory phase occurs with Trichuris organisms, confining infection to the GI tract. Larvae hatch in the small intestine, where they grow and molt, finally taking up residence in the cecum and ascending colon. In people with a heavy burden of infection, the entire colon and rectum may be infested with worms. The time from ingestion of eggs to development of mature worms is approximately 3 months. During this time, there may be no shedding of eggs and only limited evidence of infection in stool samples. Worms may live from 1-5 years, and adult female worms lay eggs for up to 5 years, shedding up to 20,000 eggs per day.
See the image below.
Immunologically, cytokines such as interleukin 25 (IL-25) mediate type 2 immunity and are required for the regulation of inflammation in the gastrointestinal tract.
Recent linkage analyses of a genome-wide scan revealed that two quantitative trait loci on chromosomes 9 and 18 may be responsible for the susceptibility to trichuriasis in some genetically predisposed individuals. [2]
United States
Whipworm infection is rare overall but is more common in the rural Southeast, where 2.2 million people are thought to be infected.
International
Whipworm infection is more common in less-developed countries. T trichiura is carried by nearly one quarter of the world population.
Whipworm infection is rarely fatal and is usually asymptomatic, but symptoms may be present in heavily infected individuals. Loose stools may be present with minimal blood with the development of chronic anemia if bleeding is chronic. Nocturnal stooling is quite common. In individuals with a heavy burden of worms, dysentery and colitis may be seen. Finger nail clubbing may also be present. In children, vitamin deficiencies (vitamin A) may contribute to developmental delay and growth retardation. Rectal prolapse may occur in heavily infected hosts.
Trichuriasis has no racial predilection.
Boys are more likely to be infected with T trichiura because they are thought to eat more dirt than girls.
Children are more commonly infected than adults due to poor hygiene and increased consumption of soil. Children are also more heavily infected. Furthermore, it is widely believed that partial protective immunity develops with age and children are not protected initially.
The prognosis of trichuriasis is excellent with proper treatment; however, without education and changes in behavior/waste management, re-infection is very common.
Good personal hygiene is highly recommended. Where relevant, community waste management systems should be developed to reduce exposure to potentially infected waste.
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Kwame Donkor, MD Staff Physician, Department of Emergency Medicine, Olive View Internal Medicine, University of California Los Angeles Medical Center
Kwame Donkor, MD is a member of the following medical societies: American College of Emergency Physicians
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Scott Lundberg, MD Assistant Clinical Professor of Medicine, UCLA School of Medicine; Consulting Staff, Departments of Medicine and Emergency Medicine, Olive View Medical Center
Scott Lundberg, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Physicians, Society of General Internal Medicine, Association of Program Directors in Internal Medicine
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Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Mark L Plaster, MD, JD Executive Editor, Emergency Physicians Monthly
Mark L Plaster, MD, JD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians
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Jeter (Jay) Pritchard Taylor, III, MD Assistant Professor, Department of Surgery, University of South Carolina School of Medicine; Attending Physician, Clinical Instructor, Compliance Officer, Department of Emergency Medicine, Palmetto Richland Hospital
Jeter (Jay) Pritchard Taylor, III, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Columbia Medical Society, Society for Academic Emergency Medicine, South Carolina College of Emergency Physicians, South Carolina Medical Association
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Mark Louden, MD Assistant Professor of Clinical Medicine, Division of Emergency Medicine, Department of Medicine, University of Miami, Leonard M Miller School of Medicine
Mark Louden, MD is a member of the following medical societies: American College of Emergency Physicians
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The authors and editors of Medscape Reference gratefully acknowledge the medical review of this article by Joseph U Becker, MD.
The authors and editors of Medscape Reference also gratefully acknowledge the contributions of previous author, Eric L Weiss, MD, to the development and writing of this article.
Trichuris Trichiura (Whipworm) Infection (Trichuriasis)
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