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Trichuris trichiura infection (trichuriasis) – Whipworm

Trichuris trichiura is a parasite known as whipworm that causes trichuriasis, a disease in which the patient suffers from bloody diarrheas. 

In this article, we will first have a short explanation of how is the gastrointestinal system composed and what parasites are for a better understanding of the subject. Further on, there will be a description of the parasite Trichuris trichiura, its life cycle, the symptoms it causes, and how it gets transmitted.

Finally, diagnostic methods and various treatments will be discussed. For this and much more information on the subject, directly from a doctor, continue reading.

How is the gastrointestinal system composed?

The human body has several systems that contribute to its normal functioning while staying in balance with others. The gastrointestinal system (GIS) is in charge of ingesting and processing food, absorbing nutrients, and dismissing residues. This series of actions is what we know as digestion.

Digestive system
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It starts in the mouth with chewing and salivating, down to the anus where there is the residues’ excretion as feces. All these processes take place due to physical and chemical activities. The first one consists of the entire system’s mechanical movements that help with the passing and processing of food. The latter entails various enzymes and juices that make possible the absorption of nutrients like proteins, carbohydrates, fats, minerals, and vitamins. This is an ongoing process that happens throughout the organs in the gastrointestinal system in different ways.

The GIS has organs like the esophagus, stomach, intestines, and liver, but we will be focusing on the intestines. They can be divided into the small intestine and large intestine. The small intestines’ main function is to absorb nutrients while the large intestine compacts food waste and absorbs the remaining water.

The large intestine is the last section of the GIS and consists of the cecum, colon, and rectum. Their walls (as most of the GIS’s) are made by a mucous, a sub-mucous, a muscle, and a serous layer. In these, there are cells, glands, blood vessels, and nerves. The intestines’ walls also have a bacteria flora, which can help in processing some molecules. It also protects us from other bacteria that can cause us harm.

Layers of the Gastrointestinal Tract
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What is a parasite?

A parasite is a microorganism that depends on other living beings to reproduce and to get nutrients from. They have all kinds of shapes of sizes and different life cycles, depending on the parasite.

Two main kinds of parasites infect humans; helminth and protozoa parasites. The first are multicellular organisms, meaning their body is composed of two or more cells. Importantly, most of these are easily visible to the naked eye. On the other hand, unicellular organisms (protozoa) consist of only one cell and all their functions relay within that cell. This type needs to be seen with a microscope or other mechanisms due to its small size.

Both helminthic and protozoa parasites can live freely in the environment, the place varying with the parasite. They cannot reproduce or feed in that period but surely can wait to infect their particular host.

Helminthic parasites can live in the gastrointestinal system, blood, under the skin, and in the lymphatic system. They might also go through other organs like the lungs in their life cycle or erratically go to organs they shouldn’t.

An erratic trip to other organs the parasite is not supposed to go to could have severe consequences. Protozoa can live in the gastrointestinal system and the bloodstream as well. Both types of parasites can have a definitive host in which they live and an intermediate host. The latter plays a part in the parasite’s life cycle but are not the main living being they live in.

What does trichuriasis mean?

Trichuriasis is the name of the disease caused by the parasite Trichuris trichiura. This parasite is a helminth, more specifically a nematode or roundworm, because of its body’s round shape.

Scientists classify it as well as an intestinal helminth since its place of living in humans’ large intestines. Trichuris can also infect other animals, but it is another type of Trichuris like Trichuris suis, which infects pigs.

Other animals like rodents, baboons, dogs, and ruminants can also suffer from trichuriasis, but other Trichuris species as well. It is still under study if these animals could spread trichuriasis to humans, as to this day, it’s still a human to human infection.

Human whipworm is an intestinal parasite that affects mostly the large intestine. This causes problems in the gastrointestinal system.

The severity of the disease will depend on the severity of the infection itself. The latter is determined by the number of parasites a person has. If the person has a mild infection, the disease could pass under the table as the parasites don’t do much damage. On the other hand, if the person has a large number of whipworms, it can cause a lot of symptoms and complications even.

Luckily, in most cases, there are a small number of parasites, which makes it a rather non-complicated disease. 

The world health organization (WHO) and medical professionals also catalog it as a soil-transmitted helminth infection. The parasites need to get to the soil to continue developing and be ready to infect further. There will be a more profound explanation on this topic moreover.

What is the life cycle of Trichuris trichiura? What is the infective stage of Trichuris trichiura?

As we already know, parasites have life cycles they need to follow to reproduce, grow, and infect hosts. For a Trichuris trichiura infection to happen, the parasite needs to complete its life cycle like every other parasite.

Trichuris lifecycle
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It first starts with the excretion of the Trichuris trichiura eggs with the human feces. These whipworm eggs recently excreted are not infectious (cannot infect other humans even if ingested) as they still need to develop. In the soil, the unembryonated eggs (non-infectious) first pass through two different stages before becoming embryonated eggs (capable of infecting a human). They need the humidity and warmth of the soil for their maturation to happen.

File:Egg of Trichuris trichiura.jpg
Egg of Trichuris trichiura
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If they fall into any other place like water, sand, or a non-natural floor like cement, they do not live. Embryonated eggs are the infective stage of the human whipworm; they pass the infection to people that ingest them. It takes approximately 15 to 30 days for the eggs to become infective. This means it’s unlikely a person can suffer from a reinfection due to their own feces unless there’s bad hygiene.

Afterward, the person ingests the embryonated eggs through different ways that will be explained further on. The eggs hatch and release a stage of the parasite scientists know as larvae on the small intestine. These are a young form of the parasite that cannot reproduce and doesn’t suppose a threat to the host. Later on, they grow into their adult form.

The adult worm travels to the large intestine, commonly to the cecum and the first portion of the colon. In these, they establish themselves into the mucosa and copulate. The female worm can produce up to twenty thousand Trichuris eggs daily seventy days after the infection. The eggs go out with the human feces and begin their life cycle once again. Adult worms can live up to a year, in which they create millions of eggs.

How do you get trichuris trichiura?

As we already explained, Trichuris comes from the ingestion of their eggs, specifically embryonated eggs, which are the infective stage. Now, there are different ways a person can get in contact with them and get the disease. 

The Trichuris eggs come out with human feces, and in some places, there isn’t correct disposal of them. This means that the feces with the eggs can stay around in the same area where they excreted them. In other cases, rain and nearby small rivers can transport the soil with the eggs to other surroundings.

When people get in touch with the soil with their bare hands, they can get the eggs stuck in them. Later on, the patients put their hands on their mouths and ingest the eggs without realizing since they’re microscopic.

Another way of getting trichuriasis is by eating food contaminated with the infective eggs. This can happen when people use feces as fertilizer for crops and vegetables. The eggs can stay in the food which people later sell and then consume, propagating the disease. If a person has dirty hands and cooks with them, it can pass the eggs directly to the food. This situation takes place, particularly with raw foods, vegetables, and fruits, because the heat of cooking usually kills the parasite. 

Eating soil is an additional way a person can contract the disease. Many children eat soil when they are little, and it can cause them a parasitic infection. It isn’t just because of whipworm but due to many other intestinal helminths that their infective stage is found on the ground.

What do whipworms look like? What color is a whipworm?

The whipworm derives its name because of its characteristic whip-like shape. The worm has an anterior part of its body, which is the side where its head is. It also has a posterior side in which its tail is.

The anterior side is thin, and the parasite uses it to bury itself in the mucous (colon’s lining), feeding itself with it. It’s important to emphasize that the worm doesn’t feed on the blood but the intestinal walls’ nutrients. The posterior side of the parasite gets increasingly bigger, thicker, and rounder. This makes the parasite look like a whip, being the posterior the handle and the anterior the whip. 

File:Trichuris-adult.jpg
Trichuris-adult
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There’s a female worm and a male worm, and even though they’re the same species, they look a bit different. The female worm is larger, measuring 35-50mm, and has her tail unrolled. The male worm is shorter, measuring 30-45mm, and has his tail coiled in a spiral shape.

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Male Trichuris trichiura
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Most helminths follow this pattern in which the female is larger than the male. The particular whip-like shape and specific size of the parasite help identify it in its adult form. The worm’s color is white-ish, although it can look pink because of mucus and blood in the intestines. 

What are the symptoms of trichuriasis?

The symptoms of this parasitic intestinal infection can go under the radar since, most often than not, they are not even there. The majority of these patients don’t present symptoms at all unless there is a heavy infection.

Since trichuriasis is an intestinal infection, most of its symptoms will reflect on the gastrointestinal sphere. One of the characteristic symptoms this parasite cause is bloody diarrhea (dysentery). It contains a combination of watery stools, mucus, and blood, which can also be painful when the patient goes to the bathroom. It can become quite frequent and happens mostly at nighttime, although this varies in each patient.

There might also be a vague abdominal pain associated with diarrhea. A heavy infection takes place when there’s a minimum of 200 worms in the patients’ intestines at the same time.

A classical sign found in children is growth retardation. This might go unseen as it happens slowly and chronically over time. When the patient’s mother brings the child to the doctor, they might find the child is under the expected size for its age.

The growth retardation can result from a combination of chronic diarrhea and poor absorption of nutrients in the intestines. In both cases, the child does not get the nutrients it needs to grow in its key years for development. These patients also suffer from impaired mental growth, which can translate to not being efficient at school as before.

The patient can also appear to be pale and feeling tired. This can happen because of anemia, a condition where there is a reduction of functioning red blood cells. These special cells carry and distribute oxygen from the lungs to the body and then bring CO2 back to the lungs. Anemia can also contribute to the growth retardation previously mentioned as it alters normal biological processes in the body.

What are the risk factors for a whipworm infection or trichuriasis?

The primary risk factor is to have poor hygiene or to live somewhere lacking necessary sanitation prevention measures. It is not only a deficit of feces disposal but a lack of clean water services too. If the person doesn’t properly clean their foods and wash their hands before eating, they are more at risk of infection. Being a kid is a risk factor since some eat soil and don’t have proper hygiene care. They are also more at risk of suffering complications.

This disease occurs more commonly in tropical countries. Scientists believe there are around 1 billion people with the parasite, making it one of the commonest. In the United States, it is common in the southern states, such as Tennessee, Georgia, Louisiana, etc.

Is trichuriasis serious? Why does Trichuris trichiura cause anemia? 

In most cases, whipworm infection is not as dangerous as it needs a very heavy infection (or parasite load) even to cause any symptoms. It mostly represents a severe concern in young children with a large parasite number and poor conditions.

The most common complication is anemia. It happens because the parasite attaches itself to the mucous (colon’s lining), causing a very small wound on the site. This wound can bleed, but it isn’t usually a great amount of blood. When the amount of parasites increases, the amount of blood loss increases and leads to anemia.

Another complication is growth retardation, as the infection habitually occurs in the most important years for a child to grow. If a doctor doesn’t treat the disease, it can have permanent consequences for the child’s life.

An uncommon but serious complication of trichuriasis is rectal prolapse. This is when the rectum comes outside of the body through the anal canal. For this to happen, there has to be a heavy infection for the parasites to reach the rectum.

File:Prolapse of the rectum Wellcome L0061308.jpg
Prolapse of the rectum
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In this body part, the parasite can damage the nerves in contact with the organ’s muscular layer. It causes the rectum to be weaker and to prolapse outside of the body through the anus.

How do you know if you have whipworms or trichuriasis? 

In the diagnosis of Whipworm, doctors consider clinical, epidemiological, and laboratory aspects. It is unlikely to make a clinical diagnosis in mild and moderate infections due to patients lacking symptoms that usually guide doctors towards a trichuriasis diagnosis. This latter situation results in underestimating the real number of cases of this disease, as there may be people with the infection but no symptoms. Therefore, patients lacking symptoms don’t seek medical care.

When there’re symptoms of the disease and doctors suspect from it or they want to screen for this infection. They order a stool test (stool examination); the patient will need to take a stool sample to the lab for analysis. This makes it possible to determine the presence of parasites or eggs in the stool, either if someone has symptoms or not. Whipworm eggs have a distinctive lemon shape with transparent caps on both ends.

The doctor could also ask for a complete blood count. A blood analysis consists of the extraction of a small amount of blood from the patient. This test will check the blood for infection signs, immune system issues, bleeding problems, and anemia (low iron).

Iron deficiency anemia occurs due to chronic blood loss, which some patients with trichuriasis suffer from. Whipworm patients often have eosinophilia. This is the elevation of eosinophils, a type of white blood cells. These cells are responsible for the immune defense against some types of parasites.

Are whipworms visible in stool? 

Whipworms are very small; the adult’s length coincides with that of a matchstick. Some people may see these worms in their stool when they go to the toilet, but it is not common. They may look like tiny pieces of white thread.

Now, although you do not see worms in your stool, it does not mean that you don’t have the disease. Generally, these worms live in the intestine and expel their eggs through the feces. But worm eggs are too small, and professionals can only see them using a microscope.

Other intestinal parasites such as Ascaris lumbricoides do tend to be easier to visualize in the stool due to their size. Adult male worms are 15 to 25 cm in length, and adult females are 25 to 35 cm. As worms grow, they can grow to a pencil’s thickness and live for one to two years. Seeing worms in stool can mean that the parasite load is high and treatment is pending as complications might happen.

Other parasites like Enterobius vermicularis can sometimes be seen in the margins of the anus. However, for them to appear in a stool sample or for the person to identify them is very unlikely. They are 5mm, white roundworm that causes anal itching, especially in the night time.

How is Trichuris trichiura infection (trichuriasis) treated?

The primary treatment against Trichuris trichiura is mebendazole, an anti-helminthic. The mebendazole acts by blocking the parasite’s glucose ingestion, causing its death as they cannot get nutrients. The treatment consists of a pill (100 mg) taken orally for three days, two times per day. This is the most effective treatment against whipworm to date.

Another treatment option is albendazole. This one acts by reducing the parasite’s energy until it dies by decreasing ATP production in its body. ATP is a molecule that provides energy for almost all biological metabolic processes. The treatment consists of two pills of 200 mg taken together (400 mg totally) a day for three days taken orally. Doctors recommend taking this medication along with food for better results.

Other treatments available are oxantel pamoate and ivermectin, although the most effective are the ones previously mentioned. Combination therapy with ivermectin and albendazole is quite popular amongst doctors since it is more effective than monotherapy (using one alone). There can be an oxantel pamoate and albendazole combination therapy as well. 

Treatments are more effective if the patient repeats them after two weeks. That way, medication can kill the remaining parasites. A stool sample and examination can aid confirm if the parasites disappeared from the person or are still present. In case trichuriasis persists, doctors must repeat the treatment to the patient.

Patients can also take iron supplementation if they have anemia to increase red blood cells in the body. The priority is to kill the parasite; if not, the anemia will persist even if it receives treatment.

How do you prevent Whipworm?

There are some precautions you can take to reduce the risk of catching a whipworm infection. Humans most commonly contract the whipworm after eating soil contaminated with human feces. For this reason, the highest on the to-do list is the proper disposal of human feces, away from homes, crops, and water sources.

Simple and effective proper hygiene, such as hand washing, is one of the best ways to prevent whipworm spread. After going to the bathroom and before eating or handling food are the most important moments to wash the hands. The doctor’s advice is that you wash your hands for at least 20 seconds with soap and warm water while rubbing.

In some parts of the world, people use human feces as fertilizer on crops. For this reason, before consuming all raw vegetables and fruits, it is necessary to wash, peel, or cook them.

Doctors also recommend boiling or purifying drinking water. Do not hesitate to visit your doctor or pediatrician if you notice symptoms of whipworm infection. They could order tests and give proper treatment to stop the spread and prevent more infections.

It is also necessary to prevent contact with animal feces to minimize the transmission of other parasitic diseases. The recommendation is to keep farm animals, such as pigs, in pens and to wash these areas regularly.

Which type of helminth infection can be diagnosed using tape?

The Graham test, or rape test, is a test that doctors use to detect intestinal parasites in the body of people and even animals. Its focus is to determine the existence of Enterobius vermicularis’ eggs. This is a small parasitic nematode that causes an intestinal disease known as oxyuriasis or enterobiasis. These parasites live in the large intestine and rectum and generate discomfort and itching in the anal area at night.

This test has been in use since the 1930s and has proven to be an effective method ever since. There should be a collection of samples from the person’s anus first thing in the morning with transparent adhesive tape to perform the test. This is due to the adult females migrating at night through the anal canal to the area near the anus to deposit them.

The tape is subsequently spread on a slide, and then specialists analyze the samples under the microscope. If eggs appear, it indicates the body’s infestation, and it is necessary to start treatment. In general, scientists suggest collecting the samples on three different days to ensure the test’s accuracy.

It is important to know that the test will not be valid if the person washes the area or defecates. This is because these actions can remove the eggs from the margins of the anus. Doctors cannot diagnose other soil-transmitted helminths like Ascaris or Trichuris with this method as they do not appear near the anus.

What other diseases seem like trichuriasis?

Since whipworm infection can cause abdominal pain, there is a wide spectrum of abdominal disorders to consider. The differential diagnosis should include in both adults and children infection with other soil-transmitted helminths (hookworm, ascariasis, strongyloidiasis) or overall bloody diarrhea causes. Also, doctors should consider other causes of chronic anemia or giardiasis.

For example, for an older adult (with forty years or more) having bloody diarrhea, trichuriasis would not be the first disease a doctor would look for. Instead, the doctor would screen for colon cancer or another serious disease, like inflammatory bowel disease.

The most distinctive feature of hookworm from other soil-borne helminths is the form of infection. The worm penetrates while humans walk barefoot on infected soil. There is pruritic dermatitis (itchy skin rash) and migration from the site of skin penetration. There may be peripheral eosinophilia (again, high eosinophil levels in the blood).

Finally, the hookworms bind to the intestinal lining (intestinal mucosa) and, through the mucosa, suck human blood. Chronic blood loss leads to anemia, iron deficiency, and protein-energy malnutrition. This can make it similar to Trichuris, but the anemia in this parasite is more severe while the diarrhea is not.

Ascaris lumbricoides can cause diarrhea, although it is not similar to Trichuris’ bloody diarrhea. This parasite could be in relation to periods of constipation with ¨common¨ watery diarrhea without mucus or blood. In severe cases, it can lead to malnutrition and a growth decrease because of reducing nutrients the body absorbs.

Do you think you have a Trichuris trichiura infection (trichuriasis)?

This tool is a Whipworm Symptoms Checker. It gathers the most important signs, symptoms, and risk factors of infection due to Trichuris trichiura. Therefore, the tool will tell anybody who uses it the likelihood of their symptoms because of trichuriasis (whipworm or Trichuris trichiura infection). Using the tool is free and would only take a few minutes.

What do you think?

Written by Dr. Esteban Kosak

Doctor of Medicine - MD Recently Graduated from Medical School and inspired to aid the global population during this situation. I think that we shall no longer be waiting to see a doctor when we feel sick. Several times we feel disease searches in Google drive us to a rabbit hole and come out thinking that we may die of cancer or something very serious, given that symptoms may seem to fit a wide variety of illnesses. Since I recently graduated from medical school. I have all the medical information fresh in my mind. My thorough experience as an expert researcher allows me to very-well known the different diseases and conditions that affect human bodies. Empowered by the United Nations 17 Sustainable Development Goals (SGDs). I think that we all can provide a grain of sand to help humanity. That's why we created Symptoms.Care a place where you can come and screen your symptoms and find what different illnesses can be related to them. Armed with the right information you can instantly, discretely, secure and from the comfort of your home talk with a Doctor that can Evaluate your Symptoms and help you seek the right treatment.

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