Two unrelated Bangladeshi women, a 61-year-old with chronic diarrhea, lower abdominal pain, poor appetite, and weight loss for two years with normal physical exam and unremarkable laboratory tests; and a 58-year-old with epigastric pain, bloating, poor appetite, weight loss for three months, and iron-deficiency anemia, presented for colonoscopy. Colonoscopy revealed two white-colored worms in the cecum (Figs. 1, 2). The worms had a narrow anterior part embedded in the mucosa and a wide posterior part shaped like a whip protruding in the lumen. The worms were removed with biopsy forceps. Pathology/microbiology revealed Trichuris trichiura. Edematous colonic mucosa with focally increased eosinophils was reported in the latter case. Stool studies revealed few Trichuris trichiura ova. Both patients were treated with albendazole with subsequent symptom resolution.
Figure 1 Endoscopic view of Trichuris trichiura in the cecum (next to appendiceal orifice)
Figure 2 Trichuris trichiura in the cecum
Trichuris trichiura infection is endemic in tropical and subtropical countries [1]. When the infestation is limited, the carriers are usually asymptomatic. However, when the whipworm burden is high, anemia, abdominal pain, weight loss, appendicitis, obstruction, rectal prolapse, perforation, or bloody diarrhea may ensue [2]. Diagnosis is usually made by identification of barrel-shaped ova in stool. The parasite anchors to the mucosa at its anterior end, which makes it difficult to treat with anthelminthic agents.
Colonoscopy is an excellent diagnostic and therapeutic modality in infected persons living in non-endemic areas. The worm can be retrieved with the use of biopsy forceps. After endoscopic removal of the attached whipworms, anthelminthic therapy should be initiated. Anisakis, another parasitic worm with similar morphologic features, may confound the diagnosis [3].