Trichuris trichiura
( WHIP WORM )
IAN LOON GENALDO,MD
LECTURER
Trichuris trichiura:
is
a soil transmitted helminths
Holomyarian – based on the arrangement of
somatic muscle in a cross section. ( the cells are
small, numerous and closely packed in a narrow
zone ).
Parasite Biology: (Male Worms)
measurement: 30 to 45 mm ( long )
posterior end: coiled posterior with a single spicule and
a retractile sheath ( capable of drawn back or in ).
Male Worm:
Spicules:
Spicule protruding from
the spicular sheath at the
posterior end of a male (
worm )
Parasite Biology: (Female Worms)
measurement: 35 to 50 mm
BLUNT posterior end
Parasite Biology: Trichuris trichiura
has attenuated anterior three – fifths.
- traverse by a narrow esophagus ( resembling a
string of beads ).
Parasite Biology: Trichuris trichiura
posterior two – fifths:
- contains: 1. intestine
2. single set of
reproductive
organs
Eggs:
measurements: 50 um to 54 um by 23 um
shape: lemon foot ball shape with plug – like translucent
polar prominences.
outer: yellowish
inner shell: transparent
Egg:
Fertilized egg – unsegmented at oviposition
Embryonic development – takes place outside the host
when eggs are deposited in clayish soil.
Ascaris eggs VS Trichuris eggs in soil:
( comparison on dessication )
Ascaris eggs – are resistant
Trichuris eggs – are susceptible.
Life cycle: Trichuris trichiura
important to note:
- Ascaris – HAS heart – lung migration
- Trichuris – NO heart – lung migration
Life cycle: Trichuris trichiura
Embryonated eggs – INGESTED.
Small Intestine – larva hatch and
penetrate the intestinal villi.
( they remain for 3 to 10 days ).
Life cycle: Trichuris trichiura
INHABIT – the Cecum and Colon – ( as ADULT
WORMS )
( worms secret a pore forming protein
called TT47 – allows them to imbed
their entire whip like portion into
the intestinal wall ).
Life cycle: Trichuris trichiura
undergo Copulation.
after copulation – female worms lay eggs.
passed out with the feces and deposited
in the soil.
SOIL – under favorable condition
> eggs develop.
> become embryonated
( with in 2 to 3 weeks )
Pathogenesis and Clinical manifestions:
Petechial hemorrhages – caused by the anterior portion
of the worm – embedded in the mucosa ( hyperemic and
edematous ).
Enterorrhagia or intestinal
bleeding – common.
> predispose to Amoebic
dysentery.
- because the ulcers
provide suitable site
for tissue invasion by
Entamoeba histolytica.
Pathogenesis and Clinical manifestions:
Appendicitis or Granuloma formation:
- the appendix ( lumen ) is filled with worms – result to
irritation ------- Inflammation.
Pathogenesis and Clinical manifestions:
Trichuris Dysentery Syndrome – manifested by chronic
dysentery and a rectal prolapse.
- seen in patient with heavy intensity
infection.
( the worms maybe found throughout the
colon
and rectum ).
Rectal Prolapse:
Intensity of Infection:
Important in understanding the clinical picture.
- e.g. infection with over 5,000 Trichuris trichiura
eggs per gram of feces – SYMPTOMATIC.
Intensity of Infection:
Heavy Chronic Trichuriasis:
- frequent blood streaked diarrheal stool.
- abdominal pain
- nausea and vomiting
- weight loss
Intensity of Infection:
ANEMIA – strongly correlated to heavy intensity
Trichuriasis.
- blood loss ( from such infection )
- ( 0.8 to 8.6 ml/day )
children:
- > 800 worms ------- ANEMIA
Intensity of Infection:
Light infection:
- moderately associated with anemia.
- usually ASYMPTOMATIC.
- presence of parasite maybe discovered only in
routine stool examinations.
Other Signs and Symptoms:
poor appetite
wasting (low weight-for-height )
stunting (low height-for-age )
reduced intellectual and cognitive development in
children
Other Signs and Symptoms:
Other Signs and Symptoms:
Prognosis:
very good
Diagnosis:
Clinical diagnosis – possible in very heavy chronic
trichuris infection.
signs and symptoms:
1. frequent blood streaked diarrhea.
2. abdominal pains
3. rectal prolapse – adult worms attached to the rectal
mucosa.
Diagnosis:
Light infections:
symptoms – are absent
Laboratory diagnosis - essential
Laboratory Diagnosis:
Direct Fecal Smear (DFS) – with a drop of saline solution.
Kato Thick Smear Method – alternative diagnostic
technique.
- uses 20 to 60 mg of stool
sample.
- highly recommended in the
diagnosis
of Trichuriasis.
Diagnosis: (Kato – Katz Technique)
is a quantitative method.
employs egg counting – to determine the intensity of
helminth infections.
used to assess the efficacy of antihelminthic drugs in
terms of cure rates and egg reduction rate.
used in epidemiological surveys to monitor helminth
control programs.
single examination: for Trichuris detection - ( sensitivity:
91.4%; specificity: 94.4%)
Kato Thick and Kato – Katz Techniques:
both are simple and low cost.
has high sensitivity and specificity for the detection of
Trichuris egg as well as Eggs of other soil transmitted
helminths ( STH ).
Acid Ether Formalin – Ether/ Ethyl Acetate
Concentration Techniques:
Used for the diagnosis of Trichuriasis.
FLOTAC Technique:
Shown to be more sensitive in the
diagnosis of trichuriasis compared to
kato katz and ether/ethyl acetate
concentration technique.
Treatment:
Mebendazole – Drug of choice
- 100mg BID x 3 days.
- preparations: 500mg/tablet
oral suspension – 20mg/ml x 30 ml
- 50mg/ml x 10 ml
How to give?
1 dose treatment: 500mg to be taken as single dose
3 day treatment: 5ml bid x 3 consecutive days
20mg/ml suspension: 5ml bid x 3 consecutive days.
50mg/ml suspension: 10ml in a single dose
Mebendazole: ( Antiox )
Albendazole:
alternative drug.
Mebendazole VS Albendazole: (Cure rates)
mebendazole 500mg/tablet once daily for 3 days shown
to have a highest cure rate ( 71% ) COMPARED to
Albendazole 400mg/tablet given once a day for 3 days
( 56% ).
Preventive Chemotherapy:
Through mass drug administration:
- Mebendazole: given as a 500mg single dose
- Albendazole: is given as a 400 mg single dose.
Recent Local studies:
It has been shown that:
- Albendazole in combination with Ivermectin ( a
drug used to treat filariasis ) exhibited better cure and
egg reduction rates than Albendazole alone.
Contraindications for Mebendazole and
Albendazoles:
hypersensitivity
early pregnancy ( with the first trimester )
Adverse effects:
mild and transient:
- headache
- nausea and vomiting
- gastrointestinal discomfort
- itchiness
Deworming: ( children )
improved and language development
reduced malnutrition
nutritional status and intellectual development have been
shown to improve after deworming
Epidemiology:
Trichuriasis – occurs in both temperate and tropical
countries.
more widely distributed in warm, moist areas of the
world.
globally – approximately 604 to 795 million are
infected.
most prevalent in east asia and pacific island regions
least prevalent – middle east and north african region
Epidemiology: ( different age group )
Children 5 to 15 years of age – are most frequently infected
and have highest intensity of infection.
recent sentinel survey ( philippines ):
- PREVALENCE of Trichuris: ranged from 4.5 to 55.1 % in
preschool children.
- school aged children: 8.1 to 57.9%
> distribution of trichuris is similar to A. lumbricoides.
> Prevalence of coinfections with the two helminths is 19.1%.
( recent sentinel survey )
Prevention and Control:
strategies for prevention and control of Trichuris infection are
similar to those for Ascaris infection.
WHO recommendations:
- mebendazole 500 mg OR Albendazole 400 mg among
school aged children in communities where the prevalence of
STH infections is greater than 50%.
- Treatment of other High risk group:
- preschool children
- women of childbearing age
- pregnant women in the 2nd and 3rd
trimester.
- lactating women
- high risk occupation
Prevention and Control:
communities with Soil Transmitted Helminths prevalence
of <50%.
- ONCE A YEAR treatment is recommended.
Prevention and Control: ( other strategies )
(Important in STH control)
Provision of safe water.
Environmental sanitation
Hygiene education
Referrences:
Medical Parasitology in the Philippines, 3rd edition
2015 by Vicente Belizario Jr.
WHO
Center for Disease and Prevention -
https://www.cdc.gov/dpdx/trichuriasis/index.html
