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Whipworm dysentery
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Whipworm dysentery Thomas D. McCaffery Jr, MD Department of Medicine Louisiana State University School of Medicine and Charity Hospital New Orleans, Louisiana
Nonspecific inflammatory bowel disease, such as ulcerative colitis or granulomatous (Crohn's colitis, is usually heralded by a syndrome of diarrhea, episodic rectal bleeding, weight loss, and abdominal cramps. Consideration of a parasitic etiology of such a clinical syndrome, e.g., amoebiasis, is often investigated and perfunctory stool examinations performed. The presence of the whipworm, Trichuris trichiuria, in such stool examinations is met with interesting queries but generally is considered an innocuous commensal parasite hardly responsible for any clinical symptoms. However, severe infections of whipworms have been reported to cause bloody diarrhea, severe anemia, weight loss, and abdominal cramps, similar to the syndrome of nonspecific inflammatory bowel disease.' I have had an opportunity to evaluate a young patient in whom the whipworm was responsible for the dysenteric syndrome. The case is reported here because of its rarity. CASE REPORT A 16 year old black female (L60-355486) resident of Southeast Louisiana State Mental Hospital in Mandeville, Louisiana, was admitted to Charity Hospital, New Orleans, for evaluation of vomiting and diarrhea of 6 weeks' duration. She had been confined for the past 2 years because of an adjustment reaction of adolescence associated with depression and hysterical features. Diarrhea and cramps worsened, despite symptomatic measures; and weight loss (20 Ibs) ensued. Stool examinations revealed Trichuris trichiuria. Physical examination revealed evidence of dehydration. The abdomen was flat and nontender with no palpable organs or masses. Rectal examination revealed stool positive for occult blood. The hematocrit was 39% and the WBC was 14,400; the total eosinophil count was 294/mm.' The serum sodium was 118 mEq, potassium 2.2 mEq, and creatinine 0.5 mg. The SMA-12 chemical analysis was normal. Stool examinations were positive for occult blood and revealed numerous T. trichiuria eggs (450/direct smear) and trophozoites of Endamoeba histolytica. Radiographs of the chest and abdomen and a barium enema were normal. She was given intravenous fluids with potassium supplementation on admission. Proctoscopy revealed massive numbers of Trichuris trichiuria worms attached to a friable mucosa. Colonoscopy was performed in an attempt to delineate the extent of involvement. Examination to 40 cm revealed minimal disruption of the colon mucosa proximal to that of the friable rectal mucosa. Massive numbers of actively motile Trichuris trichiuria worms were seen throughout the colon examined (Figure 1). No definitive ulcerations or disruptions of the mucosa were identified. Hexyresorcinol (0.2%) retention enemas and tetracycline, 1 g daily for 10 days, were administered. During treatment the whipworm egg count was gradually reduced (to 79/direct smear). E. histolytica infection was no longer evident on multiple follow-up stool examinations. Her dysentery cleared, and she was discharged to outpatient follow-up.
Figure 1. Colonoscopic view of the normal colonic mucosa with multiple whipworms attached.
DISCUSSION The whipworm, Trichuris trichiuria, is a cosmopolitan parasite and probably one of the commonest human nematode infections in the southern United States. The adult worm possesses a characteristic whip-like shape, in which the anterior portion is long and threadlike, the posterior and major portion being broader. Gravid female worms release their eggs into the bowel lumen. These eggs are lemonshaped, bile stained, and double-shelled with a characteristic clear knob at either end. The eggs are passed with the stool and embryonate in the soil to become infective within a few weeks. After ingestion by the human host, the infective eggs hatch in the upper duodenum, undergo maturation attached to adjacent intestinal villi, and then migrate to their final habitat in the large bowel. The anterior portion of the whipworm attaches usually to the intestinal mucosa of the cecum and appendix and ordinarily produces no overt tissue reaction, even though bleeding may occur. In heavy infections the nematode may be found throughout the colon and rectum.' The clinical picture of whipworm infections varies with the total number of worms present in the bowel lumen as calculated from the stool examination and is reported as the "worm burden.'" Light infections (4 to 12 eggs/direct smear) are usually asymptomatic or give rise to mild symptoms, such as right lower quadrant pain, eructation, pruritus, and indigestion. Nevertheless, the relationship of these symptoms to the actual infection is doubtful, and the patient's complaints in this setting are often considered coincidental to the presence of the nematode.'" Heavy whipworm infections (> 100 eggs/ direct smear) manifest a characteristic dysenteric syndrome, as seen in outpatients, consisting of profuse diarrhea of long duration, dysentery, often bloody, abdominal pain and tenderness, dehydration, tenesmus, weight loss, and hypochromic anemia.'" Previously, iron deficiency anemia was considered not a component of whipworm infection irrespective of the degree of worm burden. However, it has been demonstrated that this nematode may produce a profound anemia similar to GASTROINTESTINAL ENDOSCOPY
173
that generally attributed to hookworm infection. This is due to the ability of the whipworm to suck blood from its host during attachment.' In parasitic infections of the gastrointestinal tract, the presence of multiple concomitant parasites is not uncommon. Trichuriasis and amoebiasis are often concomitant infections. There is a greater likelihood of simultaneous Endamoeba histolytica infection with increasingly heavier whipworm infections."] In a study of the New Orleans area, 60% of the children with greater than 3,000 worms (300 eggs/direct smear) had concurrent amoebiasis compared to 2.5% in controls. Our patient conformed to this observation. s The simultaneous presence of trichuriasis and amoebiasis in the patient with heavy whipworm infections and the dysenteric syndrome have often prompted clinicians to incriminate the amoeba as the cause of the dysentery. However, it has been shown that the clinical symptoms are due to the presence of the whipworm because the syndrome persists in patients from whom amebas have been eradicated. The pathogenesis of concurrent amoebiasis in whipworm infections is unknown but is considered related to the colonic mucosal damage by the whipworm which in some fashion predisposes it to amoebic infection.] The treatment of whipworm infections is essentially an attempt to reduce the worm burden to a low, asymptomatic level. Complete eradication is an almost impossible task.'·]·s Mebendazole (Vermox), 200 mg daily for 3 days, is considered the drug of choice. 6 In multiple infections, e.g., with ascaris, ancylostoma, strongyloides, and enterobius, it is equally effective as combination therapy and should be utilized. However, it is a new drug that has been released only recently and is not generally available. Thiabendazole (Mintezol), 25 mg per day for 2 days, is considered an acceptable alternative. It also is effective in multiple infections that include the previously mentioned parasites. The use of the time-honored 0.2% aqueous suspension of hexyresorcinol retention enemas 3 or 4 times dai ly is considered the treatment of choice in whipworm dysentery.] Due to the irritant nature of this compound on the skin, the patient's buttocks must be coated with a petroleum jelly base to protect the skin.
ACKNOWLEDGLEMENTS The author wishes to express his gratitude to Mrs. Alice Brown, Ruth Jones, and Ardys Heurtin for technical assistance and to Mrs. Heurtin for secretarial skills in preparing this manuscript.
REFERENCES 1. GETZ l: Massive' infection with Trichuris trichiuria in children. Arner Dis Child 70:19,1945 2. HUNTER GW, FRYE WW, SWARTZWELDER ]C: A manual of tropical medicine, Ed. 3, Philadelphia: W. B. Saunders Co. 1960, pp 401-404 3. JUNG RC, JELUFFE DB: The clinical picture and treatment of whipworm infection. W Afr Med J 1: 11 1952 4. lAYRISSE M APARCEDO l, MARTINEZ.TORRESC, ROCHE M: Blood loss due to infection with Trichuris trichiura. Amer J Trop Med 16:613, 1967 5. JUNG RC, BEAVER PC: Clinical observations of Trichocephalus trichiurus (whipworm) infestation in children. Pediatrics 8:548, 1951 6. AARON H, ed: Drugs for parasitic infections. Med Lett 16:5, 1974 I
VOLUME 21, NO.4, 1975
Counsel to Authors GASTROINTESTINAL ENDOSCOPY seeks to publish original papers describing investigations and significant observations relating to the various endoscopic technics employed in the study of digestive diseases. Descriptions of new instruments or methods, innovative applications of endoscopy, analyses of experience, and extraordinary case reports are welcome subjects. Readers who are piqued or prodded by published articles are encouraged to submit brief comments that the Editor may include in the "Reflex" section. Announcements of postgraduate courses, new facilities, cooperative studies and other items of interest to endoscopists are invited. Address typescripts and editorial correspondence to the editor. Typescripts should be submitted in duplicate on white paper of standard (8 1/2 x 11 inches) size. All copy, including footnotes, references, and captions, should be double spaced with generous margins. The title page should include the author's names, the institution where the work was performed, and the name and address to which requests for reprints should be sent. Illustrations, including photographs and charts, should be submitted as glossy prints not less than 5 x 7 inches, preferably of uniform size. These must be unmounted and clearly labeled on the back, lightly in pencil, to indicate first author's name, figure number, and top of illustration. Radiographs and endoscopic photographs must be of high contrast for proper reproduction. A reasonable number of pertinent illustrations in black and white can be allowed without charge. Color reproduction can be arranged at cost to the author. References should be indicated by consecutive numbers in the text and enumerated at the end of the paper in the same order. Each reference should conform to the following example: Scope GE, Optic F: What we saw. Gastroenterology 50: 1001, 1962. All authors should be listed (not "et al. "). Abbreviations of journal names are to be used as in Index Medicus. Helpful information pertaining to the preparation of scientific articles will be found in Style Manual for Biological Journals, Ed. 2, published by American Institute of Biological Sciences, 3900 Wisconsin Ave., N.W., Washington, D.C. 20016. Galley proofs will be sent to the author for necessary corrections with the understanding that they are to be promptly returned. Reprints should be ordered when galley proof is returned. A purchase form will be furnished. Authors are reminded to retain in their own files a copy of the typescript and illustrations submitted.
Whipworm dysentery Thomas D. McCaffery Jr, MD Department of Medicine Louisiana State University School of Medicine and Charity Hospital New Orleans, Louisiana
Nonspecific inflammatory bowel disease, such as ulcerative colitis or granulomatous (Crohn's colitis, is usually heralded by a syndrome of diarrhea, episodic rectal bleeding, weight loss, and abdominal cramps. Consideration of a parasitic etiology of such a clinical syndrome, e.g., amoebiasis, is often investigated and perfunctory stool examinations performed. The presence of the whipworm, Trichuris trichiuria, in such stool examinations is met with interesting queries but generally is considered an innocuous commensal parasite hardly responsible for any clinical symptoms. However, severe infections of whipworms have been reported to cause bloody diarrhea, severe anemia, weight loss, and abdominal cramps, similar to the syndrome of nonspecific inflammatory bowel disease.' I have had an opportunity to evaluate a young patient in whom the whipworm was responsible for the dysenteric syndrome. The case is reported here because of its rarity. CASE REPORT A 16 year old black female (L60-355486) resident of Southeast Louisiana State Mental Hospital in Mandeville, Louisiana, was admitted to Charity Hospital, New Orleans, for evaluation of vomiting and diarrhea of 6 weeks' duration. She had been confined for the past 2 years because of an adjustment reaction of adolescence associated with depression and hysterical features. Diarrhea and cramps worsened, despite symptomatic measures; and weight loss (20 Ibs) ensued. Stool examinations revealed Trichuris trichiuria. Physical examination revealed evidence of dehydration. The abdomen was flat and nontender with no palpable organs or masses. Rectal examination revealed stool positive for occult blood. The hematocrit was 39% and the WBC was 14,400; the total eosinophil count was 294/mm.' The serum sodium was 118 mEq, potassium 2.2 mEq, and creatinine 0.5 mg. The SMA-12 chemical analysis was normal. Stool examinations were positive for occult blood and revealed numerous T. trichiuria eggs (450/direct smear) and trophozoites of Endamoeba histolytica. Radiographs of the chest and abdomen and a barium enema were normal. She was given intravenous fluids with potassium supplementation on admission. Proctoscopy revealed massive numbers of Trichuris trichiuria worms attached to a friable mucosa. Colonoscopy was performed in an attempt to delineate the extent of involvement. Examination to 40 cm revealed minimal disruption of the colon mucosa proximal to that of the friable rectal mucosa. Massive numbers of actively motile Trichuris trichiuria worms were seen throughout the colon examined (Figure 1). No definitive ulcerations or disruptions of the mucosa were identified. Hexyresorcinol (0.2%) retention enemas and tetracycline, 1 g daily for 10 days, were administered. During treatment the whipworm egg count was gradually reduced (to 79/direct smear). E. histolytica infection was no longer evident on multiple follow-up stool examinations. Her dysentery cleared, and she was discharged to outpatient follow-up.
Figure 1. Colonoscopic view of the normal colonic mucosa with multiple whipworms attached.
DISCUSSION The whipworm, Trichuris trichiuria, is a cosmopolitan parasite and probably one of the commonest human nematode infections in the southern United States. The adult worm possesses a characteristic whip-like shape, in which the anterior portion is long and threadlike, the posterior and major portion being broader. Gravid female worms release their eggs into the bowel lumen. These eggs are lemonshaped, bile stained, and double-shelled with a characteristic clear knob at either end. The eggs are passed with the stool and embryonate in the soil to become infective within a few weeks. After ingestion by the human host, the infective eggs hatch in the upper duodenum, undergo maturation attached to adjacent intestinal villi, and then migrate to their final habitat in the large bowel. The anterior portion of the whipworm attaches usually to the intestinal mucosa of the cecum and appendix and ordinarily produces no overt tissue reaction, even though bleeding may occur. In heavy infections the nematode may be found throughout the colon and rectum.' The clinical picture of whipworm infections varies with the total number of worms present in the bowel lumen as calculated from the stool examination and is reported as the "worm burden.'" Light infections (4 to 12 eggs/direct smear) are usually asymptomatic or give rise to mild symptoms, such as right lower quadrant pain, eructation, pruritus, and indigestion. Nevertheless, the relationship of these symptoms to the actual infection is doubtful, and the patient's complaints in this setting are often considered coincidental to the presence of the nematode.'" Heavy whipworm infections (> 100 eggs/ direct smear) manifest a characteristic dysenteric syndrome, as seen in outpatients, consisting of profuse diarrhea of long duration, dysentery, often bloody, abdominal pain and tenderness, dehydration, tenesmus, weight loss, and hypochromic anemia.'" Previously, iron deficiency anemia was considered not a component of whipworm infection irrespective of the degree of worm burden. However, it has been demonstrated that this nematode may produce a profound anemia similar to GASTROINTESTINAL ENDOSCOPY
173
that generally attributed to hookworm infection. This is due to the ability of the whipworm to suck blood from its host during attachment.' In parasitic infections of the gastrointestinal tract, the presence of multiple concomitant parasites is not uncommon. Trichuriasis and amoebiasis are often concomitant infections. There is a greater likelihood of simultaneous Endamoeba histolytica infection with increasingly heavier whipworm infections."] In a study of the New Orleans area, 60% of the children with greater than 3,000 worms (300 eggs/direct smear) had concurrent amoebiasis compared to 2.5% in controls. Our patient conformed to this observation. s The simultaneous presence of trichuriasis and amoebiasis in the patient with heavy whipworm infections and the dysenteric syndrome have often prompted clinicians to incriminate the amoeba as the cause of the dysentery. However, it has been shown that the clinical symptoms are due to the presence of the whipworm because the syndrome persists in patients from whom amebas have been eradicated. The pathogenesis of concurrent amoebiasis in whipworm infections is unknown but is considered related to the colonic mucosal damage by the whipworm which in some fashion predisposes it to amoebic infection.] The treatment of whipworm infections is essentially an attempt to reduce the worm burden to a low, asymptomatic level. Complete eradication is an almost impossible task.'·]·s Mebendazole (Vermox), 200 mg daily for 3 days, is considered the drug of choice. 6 In multiple infections, e.g., with ascaris, ancylostoma, strongyloides, and enterobius, it is equally effective as combination therapy and should be utilized. However, it is a new drug that has been released only recently and is not generally available. Thiabendazole (Mintezol), 25 mg per day for 2 days, is considered an acceptable alternative. It also is effective in multiple infections that include the previously mentioned parasites. The use of the time-honored 0.2% aqueous suspension of hexyresorcinol retention enemas 3 or 4 times dai ly is considered the treatment of choice in whipworm dysentery.] Due to the irritant nature of this compound on the skin, the patient's buttocks must be coated with a petroleum jelly base to protect the skin.
ACKNOWLEDGLEMENTS The author wishes to express his gratitude to Mrs. Alice Brown, Ruth Jones, and Ardys Heurtin for technical assistance and to Mrs. Heurtin for secretarial skills in preparing this manuscript.
REFERENCES 1. GETZ l: Massive' infection with Trichuris trichiuria in children. Arner Dis Child 70:19,1945 2. HUNTER GW, FRYE WW, SWARTZWELDER ]C: A manual of tropical medicine, Ed. 3, Philadelphia: W. B. Saunders Co. 1960, pp 401-404 3. JUNG RC, JELUFFE DB: The clinical picture and treatment of whipworm infection. W Afr Med J 1: 11 1952 4. lAYRISSE M APARCEDO l, MARTINEZ.TORRESC, ROCHE M: Blood loss due to infection with Trichuris trichiura. Amer J Trop Med 16:613, 1967 5. JUNG RC, BEAVER PC: Clinical observations of Trichocephalus trichiurus (whipworm) infestation in children. Pediatrics 8:548, 1951 6. AARON H, ed: Drugs for parasitic infections. Med Lett 16:5, 1974 I
VOLUME 21, NO.4, 1975
Counsel to Authors GASTROINTESTINAL ENDOSCOPY seeks to publish original papers describing investigations and significant observations relating to the various endoscopic technics employed in the study of digestive diseases. Descriptions of new instruments or methods, innovative applications of endoscopy, analyses of experience, and extraordinary case reports are welcome subjects. Readers who are piqued or prodded by published articles are encouraged to submit brief comments that the Editor may include in the "Reflex" section. Announcements of postgraduate courses, new facilities, cooperative studies and other items of interest to endoscopists are invited. Address typescripts and editorial correspondence to the editor. Typescripts should be submitted in duplicate on white paper of standard (8 1/2 x 11 inches) size. All copy, including footnotes, references, and captions, should be double spaced with generous margins. The title page should include the author's names, the institution where the work was performed, and the name and address to which requests for reprints should be sent. Illustrations, including photographs and charts, should be submitted as glossy prints not less than 5 x 7 inches, preferably of uniform size. These must be unmounted and clearly labeled on the back, lightly in pencil, to indicate first author's name, figure number, and top of illustration. Radiographs and endoscopic photographs must be of high contrast for proper reproduction. A reasonable number of pertinent illustrations in black and white can be allowed without charge. Color reproduction can be arranged at cost to the author. References should be indicated by consecutive numbers in the text and enumerated at the end of the paper in the same order. Each reference should conform to the following example: Scope GE, Optic F: What we saw. Gastroenterology 50: 1001, 1962. All authors should be listed (not "et al. "). Abbreviations of journal names are to be used as in Index Medicus. Helpful information pertaining to the preparation of scientific articles will be found in Style Manual for Biological Journals, Ed. 2, published by American Institute of Biological Sciences, 3900 Wisconsin Ave., N.W., Washington, D.C. 20016. Galley proofs will be sent to the author for necessary corrections with the understanding that they are to be promptly returned. Reprints should be ordered when galley proof is returned. A purchase form will be furnished. Authors are reminded to retain in their own files a copy of the typescript and illustrations submitted.