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Trichuris trichiura
(Whip worm)
 2
Synonyms

Trichocephalus trichiurus and Trichocephalus dispar

Geographical distribution
The human whipworm is cosmopolitan in distribution but is more
common in the warm moist regions of the world, where both the
incidence and the intensity of the infection may be high.
While whip- worm infection is more or less coextensive with
ascariasis the former is more prevalent in areas of high rainfall, high
humidity, and dense shade.
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Morphology, Biology and Life Cycle
The whip worms are attenuated in the anterior three-fifths
of the body and fleshy in the posterior portion.

The male measures 30 to 45 mm in length and has its

caudal extremity coiled through 360° or more. A single
lanceolate spicule protrudes through a retractile sheath
The female measures 35 to 50 mm in length and is bluntly
rounded at the posterior end.
The adult worms are rarely recovered from the stool, since
they are attached to the wall of the large intestine.
Esophagus is of the stichosome type and it occupies the
anterior thin part of the body.
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The eggs
• Barrel-shaped
• Have a triple shell, the outermost layer of which is
brown (bile stained)
• bipolar, unstained mucoid plugs.
• The eggs measure 50 to 54 μm by 22 to 23 μm.
• They are passed in the feces in the unsegmented
stage and require at least 10 to 14 days for
embryonation in the soil

These eggs were differentiated from those

of T. vulpis, the dog whipworm as T. vulpis
eggs are 70 to 80 x 30 to 42 um and have
prominent, but relatively small, polar plugs.
 People become infected on
swallowing the fully embryonated
eggs.
 The larva hatches in the small
intestine and enters the crypts of the
lower intestine and colon, eventually
entering the epithelium of the cecum
and other parts of the large intestine.
Once it is firmly established in the
epithelium at one site, the developing
worm probably is unable to move to a
different site.

5
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Epidemiology

• Conditions favorable for development of the eggs of T. trichiura consist of

warm shaded moist soil . The eggs are much less resistant to desiccation
and heat than are those of Ascaris, will not usually develop to the infective
stage on hard clay, ashes, or cinders, and will not survive direct sun's rays,
intense cold, a putrefying medium, or action of many chemical agents.

• The greatest prevalence of trichuriasis typically occurs in children of

primary school age who contaminate door-yard soil with their feces
and later pick up the infective eggs and in various ways transfer them
to their mouths.
 Pathogenesis and Pathology 7

The immature Trichuris trichiura - Little tissue reaction and slight damage
threads its entire body in the -No bleeding into or around the tunnel.
epithelium of the colon and -Some infiltration of plasma cells,
creates, by a lytic action, a lymphocytes , and sometimes eosinophils is
syncytium of the epithelial cells seen between the crypts.
as its head advances
-The mucosa is edematous and friable.
In whipworm dysentery -Anal sphincter tone is lost.
-The rectum tends to prolapse.

-The exact mechanism by which Trichuris trichiura affects the

human host is by two processes mechanical and allergic.
 Clinical presentation 8

 Asymptomatic
With no abnormalities in laboratory findings except for the presence of eggs
in the stools.
 Symptomatic (chronic dysentery -like syndrome)
 chronic diarrhea dt diffuse colitis
 chronic dysentery with abdominal cramps and severe rectal tenesmus
 Interference with nutrition, the child loses weight or fails to gain weight.
 Hypochromic anemia -which is seen in cases with prolonged massive infection- is due to
the general malnutrition and blood loss from the friable colon and prolapsed
rectum, not directly to the extraction of blood from the host by the parasite. Anemia
does not occur in light infections, nor even in symptomatic infections, when there is
adequate intake of iron and protein.
 Rectal prolapse, and finger clubbing
 Diagnosis 9
 Clinically
By the dysentery with marked tenesmus.
 Lab diagnosis
o Demonstration of the characteristic eggs in the patient's feces, but quantitation is
essential to relate the infection to clinical signs and symptoms by:
-The direct smear technique, infections are classified as light (less than 10 eggs
per smear), heavy (over 50 per smear), or massive (too numerous to count)
-concentration by centrifugal flotation or sedimentation to detect very light
infections.
o Charcot-Leyden crystals are abundant among the exudates and may become
abundant in the diarrheal or dysenteric stools.
o Hypochromic anemia and peripheral eosinophilia <15%
 Proctoscopy
For examination of the rectal mucosa or during prolapse.
 Treatment 10

 Several available drugs are very effective, including :

• Mebendazole: 100mg twice / day / 3 days between meals is 90% effective in the first dose.
Works by selectively and irreversibly blocking glucose uptake and other nutrients in the intestine where
helminths live.
• Albendazole. works by decreasing whipworm ATP production, causing energy depletion, immobilization,
and finally death.
Albendazole and mebendazole, are the drugs of choice for treatment.
- Alternatives
• Nitazoxanide
• Tribendimidine
These medication gets rid of any whipworms and whipworm eggs in the body. It is usually needs to be taken
for one to three days. Side effects are minimal.
 Iron supplements may also be prescribed if the infected person suffers from anemia.
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Prevention

-Sanitary disposal of feces should reduce both the prevalence and

intensity of the infection
- Children can be trained not to defecate promiscuously on the
ground
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Case scenario:
A 46-year-old man complained of two episodes of bright red rectal bleeding
during the past month. He also had diarrhea intermittently for the past two
months associated with visible mucus in the stool. There was no significant
previous medical illness, and physical examination was also unremarkable.
Proctoscopic examination showed two internal hemorrhoids which were banded.
Due to the history of prolonged diarrhea, colonoscopy was arranged for him. This
revealed a swollen ileocecal valve associated with superficial ulceration
(Figure 1). Biopsies were taken to rule out possible malignancy. The current
diagnosis was internal haemorrhoids with possibility of colonic malignancy. A
simple stool for microscopic examination was not ordered for him since the
clinical diagnosis pointed towards malignancy.
Figure 1 13
A swollen ileocecal valve with superficial ulceration. A few thread-like nematodes embedding
the intestinal mucosa were seen (arrow).
Differential diagnosis of Bloody diarrhea
14
Non infectious :
 inflammatory bowel disease (IBD)
 Adenocarcinoma
 Arteriovenous malformation
 Diverticulitis
Bacterial :
 bacterial pathogens : Salmonellosis (Salmonella spp) ,(Shigella spp), (Campylobacter
pylori),( enteroinvasive and enterohemorrhagic E. coli, (Yersinia enterocolitica)
Parasitic :
 Trichuris trichura
 Amoebic dysentery (less chronic , no malnutrition , no rectal prolapse )
 Histopathological examination of the biopsied tissue from the
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ileocecal valve showed moderate lymphocytic cell infiltrates in the
mucosa together with cross sections of an adult female nematode
with multiple ova were observed within the body, and these ova
appeared to have terminal plugs.

400x H&E Multiple ova with terminal plugs observed within the body (arrow).
These findings were consistent with an adult female Trichuris trichiura. He was treated with
oral albendazole 200 mg daily for three days and remained asymptomatic on followup several
months later.
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Capillaria philippinensis
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Geographical distribution

Widely distributed in the Northern Luzon area of the Philippines.

The disease has become widespread in Thailand and cases have been
reported in Japan, Taiwan, Iran, and Egypt.

Morphology and Life Cycle

The worms live burrowed into the mucosa of the small

bowel, mainly the jejunum. The adult worms are small.
 18
Males are 2.3 to 3.17 mm long and
have ventrolateral caudal expansions
and a very long, smooth spicular
sheath.
Female worms are 2.5 to 4.3 mm long
and have two almost equal parts, with
the anterior containing the esophagus
and stichosome (esophageal glands)
and the posterior containing the
intestine and reproductive system.
 Females produce eggs with thin shells and free larvae, as well as the
19
typical thick-shelled eggs that pass in the stool.
All stages of development are seen in the human host, and internal
autoinfection is a normal part of the life cycle.

Eggs
 Peanut shaped
 Flattened bipolar plugs and striated shells
 Measuring 36 to 45 μm long by 20 μm wide
and somewhat resembling T. trichiura eggs
 Require 10 to 14 days in the soil to
embryonate and 3 weeks to develop into the
infective form in fish
Human infection is initiated by the ingestion of raw fish; the infective 20
larvae are located in the mucosa of the fish intestine.
 21
Pathogenesis

The worms live burrowed into the

mucosa of the small bowel, mainly the
jejunum.

Most of the abnormality is found in the

small intestine, where the wall is
thickened and indurated and contains many
larval and adult worms.
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Clinical presentation

Symptoms are related to the worm burden; with large numbers of worms, there
may be intestinal malabsorption and fluid loss along with electrolyte and plasma
protein imbalance leading to:
 Watery stools are passed (up to eight per day), with fluid loss of several
liters.
 Rapid weight loss and muscle wasting
 Abdominal distention, and edema
 Death from pneumonia, heart failure, hypokalemia, or cerebral edema may
occur within several weeks to a few months
 In some cases, patients reported chronic abdominal pain and diarrhea over a
period of many months prior to diagnosis.
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Diagnosis

• Stool examination
Diagnosis is based on recovery and identification of the eggs in the
stool, which might also contain larvae or adult worms.
Knowledge of the geographic range would also provide specific clues
to a possible infection.

• Duodenal aspiration
It might reveal adult worms
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Treatment

 Replacement therapy

(IV fluids and replacement of protein and albumin deficiency)

 Albendazole

400mg daily for 20 days.

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Prevention

-Since infection is acquired by eating raw fish, in endemic

areas fish should be thoroughly cooked before being eaten.

-Adequate disposal of feaces

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Case scenario :
A 33-year-old woman came from the outskirts of Danzhou city, Hainan
province, China. In April 2010, she reported an 11-month history of
recurrent diarrhea associated with colicky pain. The watery diarrhea
had persisted since May 2009, occurring about three to four times daily.
She also experienced weight loss of 12.5 kg. She was admitted to an
outpatient clinic and one hospital in Danzhou. Since May 2009 to
March 2010, the patient was given a treatment of checking diarrhea.
The detailed diagnosis, treatment and lab investigation of her diarrhea
were not clear. In April 2010, because her symptoms could not be
relieved, she was admitted to People’s Hospital of Hainan province in
Haikou, China.
 Clinical examination showed moderate dehydration; pallor; 27
a soft, nontender, nondistended abdomen; and marked
pitting edema of the lower limbs. The liver and spleen were
not enlarged.
Serum total protein and albumin levels were low (47 and 14 g/L,
respectively), and proteinuria was not detected (Table 1). A chest
radiograph and abdominal ultrasound did not disclose any
specific abnormalities. Gastroscopy showed hyperemia, edema,
and superficial erosions in the gastric antrum.
The patient reported eating sashimi of two raw Misgurnus
anguillicaudatus loaches every day from March to April in 2009 to
treat a 7-year history of constipation. One month later, the diarrhea
associated with colicky pain emerged and persisted.
In May 2010, Stool examinations were carefully performed 9 28
times through direct smear method and brine flotation by the
Department of Parasitology of Hainan Medical College.
Eggs (0–1 eggs/10 ×40 microscopic fields) that were
elongated and peanut-shaped with flattened bipolar plugs and
striated shells (43.7 × 14.6 μm) were observed as shown in
Figure1.
Differntial Diagnosis 29

 Diphylibothrium latum (Intestinal and mainly presented by severe

nutritional deficiency especially Vit B12)

 Capillaria philippenensis( Intestinal and mainly presented by severe

diarrhea with rapid loss of weight & muscle “ protein losing
enteropathy “ )

 Anaiskis (Gastric & intestinal and mainly presented by Gastric

complains (ulcer like symptoms)

 Clonorchis sinensis (Hepatic and mainly presented by abdominal

pain , fever & jaundice)
 Buccal cavity Esophagous Male female vulva Special
feature

Ascaris lumbricoides lips with 3 Cylindrical Post. End Paired genital Pre Whitish
, papillae curved tubules equatorial streak along
Finely No entire body
dendiculated gubernaculum
Triangular buccal
cavity

Trichuris Delicate Post. End Post. End At anterior Attentuated

capillary tube coiled , single blunt round , extremity in ant part ,
with stylet spicule single genital of the fleshy at
organs worm posterior end

Entrobius vermicularis No buccal Double bubled Post. End Post. End Pre
capsule , 3 lips , curved , slender equatorial
cervical alae caudal alae pointed ,
paired genital
organs
 Buccal cavity Esophagous Male Female vulva Special feature

Capillaria philipenesis stichosome Ventrolateral Divided into Post equatorial Smaller than
caudal expansion , 2 equal parts trichuris trichura
long smooth anterior &
spiculated sheath posterior

Trichostrongylus No buccal Copulatory bursa , Paired genital Pre equatorial Resembles hook
cavity sculptured organs worm adult
spicules
Ascaris Lumbricoides Trichuris Entrobius vermicularis Capillaria philipenesis Trichostrongylus

Thick shell   barrel shaped Oval compressed  peanut shaped   oval

Brown   clear mucoid- laterally flattened with flattened   longer
The wall is  appearing polar on one side (D bipolar plugs  the ends are
Formed of 3 plugs . shape) striated shell  more pointed
layers have thick shell  than in
hookworm eggs.
 Ascaris lumbricoides Trichuris trichura Entrobius Capillaria philipenensis Trichostrongylus
vermicularis

MOI  Ingestion of  Swallowing of  – Anus to mouth  Ingestion of raw fish  Penetration of 

embryonated egg egg directly or Airborne  contain embryonated skin by L3
airborne  indirectly Autoinfection  egg ingestion of L3 
Mechanical  No  Autoinfection 
Autoinfection

C/P Lung (loffler’s Mechanical Female migration + Severe enteropathy with Truamatic damage
Syndrome ) allergic effect . Nervous S + malabsorption + M. to SI + Hge
Intestinal with Usually light Intestinal wasting
malabsorption . symptoms inflammtion

Dx  X-ray in lung  Egg in stool  Hx  Egg in stool  Egg in stool 

phase Charcot layden  Anal swab  Larva or adult in stool  Larva in culture 
Stool or barium in  crystal
intestinal

TreatRR Mebendazole Mebendazole Albendazole Albendazole Alcopar

men AlbRendazole Albendazole mebendazole Replacement therapy Ivermectin
Replacement therapy 1%white ppt
ointment