Trichuris dysentery syndrome

Sir,

Trichuris trichiura is a common intestinal nematode known as “whipworm”, because of its whip like appearance. Most infections’ with the whipworm are asymptomatic; however, severe infections may present with anemia and chronic diarrhea, and in long-standing cases cause growth retardation.

We have reported such a case of a 9 year old boy, who was apparently normal till around a year back. Initially, he developed watery diarrhoea; however, later he noticed blood and mucus in the stool. Symptoms such as abdominal pain, vomiting, or melena were absent. There were no signs of abdominal distension or pedal oedema. The patient was treated with antibiotics and antihelminthics, however did not have any relief in the symptoms. He went on to develop anaemia and stunting of growth, and was referred to us for evaluation. On physical examination, he showed emaciation, short stature, pallor and skin changes typical of malabsorption. Hematologic investigations revealed iron deficiency anaemia, raised erythrocyte sedimentation rate, low serum albumin and low serum calcium. Ultrasound examination of abdomen, chest X-ray and serum immunoglobulin levels’ test showed normal results. Mantoux test and human immunodeficiency virus Enzyme-linked immunosorbent assay (HIV ELISA) were negative. Stool routine showed eggs of Hook worms and Trichuris trichiura. We made a clinical diagnosis of malabsorption syndrome with differential diagnosis of celiac disease, tropical sprue, intestinal tuberculosis and inflammatory bowel disease. Esophagogastroscopy and colonoscopy with ileoscopy was done. Esophagoscopy and duodenal biopsy were normal. Colonoscopy showed [Figure 1]a and b heavy infestation with Trichuris trichiura. Ileal biopsy was normal. Colonic biopsies showed mild infiltration of colonic mucosa with lymphocytes and occasional eosinophils. A diagnosis of trichuris dysentery syndrome was made and the patient was started on albendazole 400 mg once a day for seven days. Repeat colonoscopy after 2 weeks showed complete worm clearance. Follow-up of patient one year later revealed resolution of anaemia and improvement in the skin and growth velocity.

Trichuriasis is an intestinal infection in humans caused by ingesting embryonated eggs of Trichuris trichiura from the environment. Colonized eggs hatch and enter the crypts of the small intestine as larvae. After 1 to 3 months of maturation, the parasites migrate to the cecum where they mate and lay eggs. ^[1] Adult worms are 3-4 cm in length and have thin, tapered anterior regions, giving them a whip-like structure, and hence the name. The eggs are barrel shaped, measure 50 × 23 micrometer, and have a plug like prominence at either ends. Under ideal sconditions, eggs survive for as long as one year in the soil. ^[1] Eggs are not infective unless embryonated, and thus the worms do not multiply in the host and are not directly transmitted to other persons.

An estimated 800 million persons harbor Trichuris trichiura worldwide, of which 114 million are preschool-age children and 233 million are school-age children. ^[1],[2] Heavy infestation with Trichuris trichiura seen in children presents with mucoid diarrhea, rectal bleeding, rectal prolapse, iron deficiency anemia, finger clubbing, growth retardation and cognitive impairment. This syndrome has traditionally been named as trichuris dysentery syndrome (TDS). ^[1],[2] Severe stunting and clubbing of fingers in TDS have been attributed to increased tumor necrosis factor alpha and other cytokines in the lamina propria of the colonic mucosa and peripheral blood, decreased plasma insulin like growth factor I, and decreased collagen synthesis. ^[3] TDS mimics other chronic diarrheas’ like inflammatory bowel disease, intestinal tuberculosis, polyposis syndrome or sprue. In an endemic area, the diagnosis of TDS is by the typical clinical findings and by identifying eggs in stool (Heavy Infestation >10,000 eggs per gram of faeces). ^[2] Colonoscopy and intestinal biopsy helps in detecting heavy infestation and in ruling out other causes of chronic diarrhea. Treatment of Trichuris trichiura infection is with mebendazole 100 mg three times a day for 3 days, or albendazole 400 mg once a day for 3 days. ^[4] Trichuris dysentery syndrome requires treatment with albendazole 400 mg once daily for five to seven days. ^[5] Most patients’ improve with treatment and do not have recurrence. In endemic areas, helminthic infestation should be considered in the differential diagnosis of malabsorption.

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1755-6783.85777

[Figure 1]