Trichomoniasis

Disease Type: Parasitic Disease

Common Name: : Trichomoniasis
Causative Agent: Trichomonas vaginalis
Disease Discription: Trichomoniasis, sometimes referred to as "trich", is a common
sexually transmitted disease (STD). It is caused by the single-celled protozoan (the
smallest, single-celled members of the animal kingdom) parasite Trichomonas vaginalis.
Trichomoniasis is primarily an infection of the genitourinary tract; the most common site
of infection is the urethra and the vagina in women. if the normal acidity of the vagina is
shifted from a healthy, semi-acidic pH (3.8 - 4.2) to a much more basic one (5 - 6) that is
conducive to T. vaginalis growth. Some of the symptoms of T. vaginalis include: preterm
delivery, low birth weight, and increased mortality as well as predisposing to HIV
infection, AIDS, and cervical cancer.[5] T. vaginalis has also been reported in the urinary
tract, fallopian tubes, and pelvis and can cause pneumonia, bronchitis .This disease is
most common in women and uncircumcised men. For uncircumcised men, the most
common site for the infection is the tip of the penis.
According to the World Health Organization's annual estimates, there are an estimated
7.4 million trichomoniasis cases each year in the United States, with over 180 million
cases reported worldwide.

Fig. Trichomoniasis infection in human female Vagina and Bird

Causes of Disease:

• Physiologic
–Many women will have a consistent, slightly clear, non-odor-producing
 discharge, either midcycle or premenstrually, particularly if they are on oral
contraceptives
–A change in odor, consistency, or color of discharge may signify that evaluation
is necessary
–Increased discharge is associated with pregnancy
• Sexually transmitted disease
–Trichomonas vaginalis: “Strawberry cervix” with punctate erythema,
flagellated oval organisms on wet mount
–Gonorrhea/Chlamydia may be associated with pelvic pain/dysmenorrhea and
dyspareunia
• Bacterial vaginosis
–Various organisms and changes in normal flora with a characteristic fishy odor
–Not considered an STD
–Increases the risk of preterm delivery in pregnant women

• Alteration of normal vaginal flora and/or inflammatory response

–Candida albicans overgrowth is more common with recent antibiotic use,
poorly controlled diabetes, and/or pregnancy; presents with intensely pruritic,
inflamed, and erythematous introitus
–Doderlein's cytolysis (caused by an overgrowth of lactobacilli)

• Atrophic vaginitis
–Common in postmenopausal women, especially those not on HRT
–Poor coital lubrication, dyspareunia
–Dysuria due to atrophic urethral tissue
• Foreign body vaginitis (e.g., retained tampon)
• Noninfectious irritant/allergic contact vaginitis (e.g., soaps, feminine pads,
perfumes)
• Cervicitis (usually due to gonorrhea or Chlamydia)
• Cervical dysplasia, cancer, or polyps
• Vaginal or vulvar trauma or cancer

Physiologic leukorrhea
–In newborns for 2–3 weeks, due to maternal estrogen effect, and in pubertal girls
–Discharge typically clear to white, sticky, and nonirritating
–Newborns may have withdrawal bleeding

• Infections
–Bacterial vaginosis: Previously known as nonspecific vaginitis; polymicrobial
in etiology (coliforms, streptococci, Gardnerella); discharge may be gray and
malodorous (fishy smell) but generally nonirritating
–Candida: Discharge may be cheesy and white with erythematous, pruritic,
irritated vulva; typical discharge is rarely seen in prepubertal children; discharge
typically has no odor
–Trichomonas: Discharge may be frothy, malodorous, creamy, green, bloody, or
pruritic (or asymptomatic)
 –Chlamydia: Commonly asymptomatic or a nonspecific discharge
–Gonorrhea: Infection is commonly asymptomatic or has a gray-white, thick,
purulent discharge
–Group A β-hemolytic streptococci: Discharge may be bloody
–Shigella: Discharge may be bloody

• Irritation/hygiene
–Due to bubble baths and other chemical irritants, tight clothing, obesity,
poor wiping
• Foreign body
–Commonly includes toilet paper, forgotten tampon
–Discharge is often bloody and malodorous
• Anatomic
–Ectopic urethra
–Rectovaginal fistula
–Urethral prolapse
• Urinary tract infection
• Masturbation
• Sarcoma botyroides
• Oral contraceptives (estrogen effect) [7]

Risk Factors: The list of risk factors mentioned for Trichomoniasis in various sources
includes:

• Unsafe sex
• Multiple sexual partners
• Towels
• Toilet water

Causative Agent:
Pathogen Name: Trichomonas vaginalis,
Pathogen Description: Trichomonas vaginalis, an anaerobic, parasitic flagellated
protozoan, is the causative agent of trichomoniasis, and is the most common pathogenic
protozoan infection of humans in industrialized countries. [1] The WHO has estimated that
180 million infections are acquired annually worldwide. The estimates for North America
alone are between 5 and 8 million new infections each year, with an estimated rate of
asymptomatic cases as high as 50%.[2]
Taxonoimic Classification:

Domain: Eukaryota
(unranked) Excavata
Phylum: Metamonada
Class: Parabasalia
Order: Trichomonadida
Genus: Trichomonas
Species: T. vaginalis
Ultrastructure of the T. vaginalis

Other pathgenic species : T. tenax and Pentatrichomonas hominis

Morphology and toxin production:

The T. vaginalis trophozoite is oval as well as

flagellated. Five flagella arise near the cytosome;
four of these immediately extend outside the cell
together, while the fifth flagellum wraps backwards
along the surface of the organism. The functionality
of the fifth flagellum is not known. In addition, a
conspicuous barb-like axostyle projects opposite the
four-flagella bundle; the axostyle may be used for
attachment to surfaces and may also cause the tissue
damage noted in trichomoniasis infections.[4]

Fig. Two T. vaginalis trophozoites obtained from in vitro culture

While T. vaginalis does not have a cyst form, organisms can survive for up to 24 hours in
urine, semen, or even water samples. Combined with an ability to persist on fomites with
a moist surface for 1 to 2 hours, T. vaginalis is among the most durable protozoan
trophozites.Trichomonads multiply via binary fission. The Trichomonas species exist
only as trophozoites and do not take on a cyst
form,2 but recent research has suggested that
under unfavorable conditions they may assume
a pseudocyst form.T. vaginalis is a primitive
eukaryotic organism that is in most respects
similar to other eukaroyotes, but its energy
metabolism bears a stronger resemblance to that
of anaerobic bacteria.
Protein function:

T. vaginalis also has many enzymes that catalyze a number of reactions making the
organism relevant to the study of protein function. T. vaginalis lacks mitochondria and
other necessary enzymes and cytochromes to conduct oxidative phosphorylation. T.
vaginalis obtains nutrients by transport through the cell membrane and by phagocytosis.
The organism is able to maintain energy requirements by the use of a small amount of
enzymes to provide energy via glycolysis of glucose to glycerol and succinate in the
cytoplasm, followed by further conversion of pyruvate and malate to hydrogen and
acetate in an organelle called the hydrogenosome.[3]

Genetic sequence:

A draft sequence of the Trichomoniasis genome was published on January 12, 2007 in
the journal Science confirming that the genome has at least 26,000 genes, a similar
number to the human genome.[6]

Epidemiology:
Trichomoniasis is one of the most common sexually transmitted infections found in the
United States. The CDC estimates that 5 million new cases occur annually. It is found in
3-5% of females in North America. .

Trichomonas vaginalis has a high prevalence among African-Americans in urban centers.

T. vaginalis is a significant corellate with other sexually-transmitted infections.
According to the CDC, it is an important cofactor in HIV transmission and may increase
HIV shedding (risk of contraction from an infected individual).

Infection is often overlooked in studies due its mild clinical presentation, lack of adverse
effects on fertility, and lack of evidence of poor birth outcomes. Underdiagnosis is
estimated at 50% or more. However, T. vaginalis may persist in a host for 2+ years if
untreated.

Disease Host: Human(most probably Female) ,animals and birds

Disease Transmission:
The vagina is the most common site of infection in women, and the urethra (urine canal)
is the most common site of infection in men.
The parasite is sexually transmitted through penis-to-vagina intercourse or vulva-to-vulva
(the genital area outside the vagina) contact with an infected partner. Women can acquire
the disease from infected men or women, but men usually contract it only from infected
women.
Fig.Life cycle of disease.
Signs and symptoms of disease:

In women, the symptoms of trichomoniasis include an unpleasant vaginal odor, and a

heavy, frothy, yellow discharge from the vagina. The genital area (vulva) is often very
itchy, and there is frequently pain with urination or with sexual intercourse. The labia
(lips) of the vagina, the vagina itself, and the cervix (the narrowed, lowest segment of the
uterus that extends into the upper part of the vagina) will be bright red and irritated.
Women may also experience lower abdominal discomfort.

In men, there may be no symptoms at all. Some men notice a small amount of yellowish
discharge from the penis, usually first thing in the morning. There may be some mild
discomfort while urinating, testicular pain or tenderness, or lower abdominal pain. Some
men infected with trichomoniasis experience persistent urethritis.

The use of antibiotics is a contributing factor to recurrent trichomoniasis in some women

because antibiotics affect the balance of bacteria in the vagina, allowing such organisms
as T. vaginalis to multiply more rapidly.
Typically, only women experience symptoms associated with Trichomonas infection.

Symptoms include:

• Vaginitis - itching, burning, and inflammation of the vagina

• Cervicitis - inflammation of the cervix
• Urethritis - inflammation of the urethra
• Green/Yellow, frothy vaginal discharge

Most men with trichomoniasis do not have signs or symptoms; however, some men may
temporarily have an irritation inside the penis, mild discharge, or slight burning after
urination or ejaculation.

Some women have signs or symptoms of infection which include a frothy, yellow-green
vaginal discharge with a strong odor. The infection also may cause discomfort during
intercourse and urination, as well as irritation and itching of the female genital area. In
rare cases, lower abdominal pain can occur. Symptoms usually appear in women within 5
to 28 days of exposure.

Diagnosis:
Trichomoniasis is diagnosed by visually observing the trichomonads via a microscope. In
women, the doctor collects the specimen during a pelvic examination by inserting a
speculum into the vagina and then using a cotton-tipped applicator to collect the sample.
The sample is then placed onto a microscopic slide and sent to a laboratory to be
analyzed. An examination in the presence of trichomoniasis may also reveal small red
ulcerations on the vaginal wall or cervix

Trichomoniasis tends to be underdiagnosed in men because of the relative mildness of

symptoms in men and insufficiently sensitive diagnostic tests. The recent introduction of
DNA amplification, however, indicates that the incidence of trichomoniasis in men is
much higher than was previously thought.
The presence of T. vaginalis, as stated by the liquid-based Pap smear pathology report, is
highly specific and warrants treatment without further testing, eliminating an office visit
to perform a confirmatory test. In asymptomatic patients, the Pap smear detected T.
vaginalis in 9.6% more women who otherwise would not have had a test performed.[9]

Treatment:

Cure of trichomoniasis may be difficult to achieve with alternative treatments. Some

practitioners suggest eliminating sweets and carbohydrates from the diet and supplement
with antioxidants, including vitamins A, C, and E, and zinc. Naturopaths may
recommend treatment with two douches (a wash used inside the vagina), alternating one
in the morning and one at bedtime. One douche contains the herbs calendula (Calendula
officinalis), goldenseal (Hydrastis canadensis), and echinacea (Echinacea spp.); the other
douche contains plain yogurt with live acidophilus cultures. The herbal douche helps to
kill the protozoa while the yogurt reestablishes healthy flora in the vagina. Tea tree oil is
another alternative remedy for trichomoniasis. Acidifying the vagina by douching with
boric acid or vinegar may also be useful. Although not a cure, The Gynecological
Sourcebook suggests inserting a garlic (Allium sativum) suppository (a peeled whole
clove wrapped in gauze) every 12 hours for symptomatic relief.

Other remedies include vaginal suppositories that include the ingredient acidophilus once
a day for three days. An alternative medicine practitioner can recommend the correct
mixture. A vaginal douche consisting of grapefruit seed extract may also help relieve
symptoms.

Allopathic Treatment:

The usual treatment is a single large dose of metronidazole (Flagyl) or split doses over
the course of a week. Some sources suggest clotrimazole (Gyne-lotrimin, Mycelex) as an
alternative treatment showing a lower cure rate. Application of Betadine, a concentrated
antiseptic solution, is another recommendation, although Betadine is messy, stains, and
should not be used by pregnant women. However, the Centers for Disease Control (CDC)
states that there are no effective alternatives to therapy with metronidazole available.
Topical treatment with metronidazole is not advised. Individual evaluations are
recommended for those who are allergic to metronidazole or who experience treatment-
resistant trichomoniasis. Sexual partners of an infected individual must all be treated, to
prevent the infection from being passed back and forth. Sexual intercourse should be
avoided until all partners are cured.

As of late 2003, the number of cases of metronidazole-resistant trichomoniasis appears to

be increasing rapidly. Some success has been reported with the broad-spectrum anti-
parasitic drug nitazoxanide, but further research needs to be done. A group of researchers
in Thailand is currently investigating the effectiveness of a group of drugs known as
bisquaternary quinolinium salt compounds in treating trichomoniasis.
Women who are taking antibiotics for other illnesses should speak to their health care
provider about the possibile effects of the medication(s) on the balance of organisms in
their vagina.

Prevention of disease:

Because trichomoniasis is a sexually transmitted disease, abstinence is the preferred

method to avoid contraction of this disease. Safe sex and hygiene practices may also help
prevent trichomonas infection.

• Wear condoms.

• Wash before and after intercourse.

• Don't share swimsuits or towels. (Trichomonads survive for up to 45 minutes

outside the body.)

• Shower immediately after swimming in a public pool. [8]

Geographical Distribution:
Trichomoniasis occurs worldwide. There is a higher prevalence among people with
multiple sexual partners and/or other venereal diseases. An estimated 120 million cases
of trichomoniasis occur worldwide each year.

Disease Statistics:
The American Social Health Association estimates trichomoniasis affects 7.4 million
previously unaffected Americans each year and is the most frequently presenting new
infection of the common sexually transmitted diseases.
Worldwide prevalence of Trichomoniasis:

Globally, an estimated 170 million people acquired Trichomonas vaginalis, a sexually

transmitted parasite, in 1997. (Source: excerpt from Sexually Transmitted Diseases
Statistics, NIAID Fact Sheet: NIAID)
The following table attempts to extrapolate the above incidence rate for Trichomoniasis
to the populations of various countries and regions. As discussed above, these incidence
extrapolations for Trichomoniasis are only estimates and may have very limited
relevance to the actual incidence of Trichomoniasis in any region:

Country/Region Extrapolated Incidence Population Estimated Used

Trichomoniasis in North America (Extrapolated Statistics)
USA 5,398,077 293,655,4051
Canada 597,571 32,507,8742
Mexico 1,929,404 104,959,5942
Trichomoniasis in Central America (Extrapolated Statistics)
Belize 5,017 272,9452
Guatemala 262,510 14,280,5962
Nicaragua 98,524 5,359,7592
Trichomoniasis in Caribbean (Extrapolated Statistics)
Puerto Rico 71,653 3,897,9602
Trichomoniasis in South America (Extrapolated Statistics)
Brazil 3,384,211 184,101,1092
Chile 290,881 15,823,9572
Colombia 777,771 42,310,7752
Paraguay 113,811 6,191,3682
Peru 506,329 27,544,3052
Venezuela 459,878 25,017,3872
Trichomoniasis in Northern Europe (Extrapolated Statistics)
Denmark 99,510 5,413,3922
 Finland 95,854 5,214,5122
Iceland 5,403 293,9662
Sweden 165,191 8,986,4002
Trichomoniasis in Western Europe (Extrapolated Statistics)
Britain (United Kingdom) 1,107,917 60,270,708 for UK2
Belgium 190,225 10,348,2762
France 1,110,739 60,424,2132
Ireland 72,969 3,969,5582
Luxembourg 8,505 462,6902
Monaco 593 32,2702
Netherlands (Holland) 299,966 16,318,1992
United Kingdom 1,107,917 60,270,7082
Wales 53,639 2,918,0002
Trichomoniasis in Central Europe (Extrapolated Statistics)
Austria 150,271 8,174,7622
Czech Republic 22,907 1,0246,1782
Germany 1,515,158 82,424,6092
Hungary 184,418 10,032,3752
Liechtenstein 614 33,4362
Poland 710,043 38,626,3492
Slovakia 99,697 5,423,5672
Slovenia 36,975 2,011,473 2
Switzerland 136,964 7,450,8672
Trichomoniasis in Eastern Europe (Extrapolated Statistics)
Belarus 189,531 10,310,5202
Estonia 24,662 1,341,6642
Latvia 42,395 2,306,3062
Lithuania 66,321 3,607,8992
Russia 2,646,581 143,974,0592
Ukraine 877,427 47,732,0792
Trichomoniasis in the Southwestern Europe (Extrapolated Statistics)
Azerbaijan 144,639 7,868,3852
Portugal 193,458 10,524,1452
Spain 740,455 40,280,7802
Georgia 86,284 4,693,8922
Trichomoniasis in the Southern Europe (Extrapolated Statistics)
 Italy 1,067,233 58,057,4772
Greece 195,726 10,647,5292
Trichomoniasis in the Southeastern Europe (Extrapolated Statistics)
Albania 65,161 3,544,8082
Bosnia and Herzegovina 7,492 407,6082
Bulgaria 138,198 7,517,9732
Croatia 82,663 4,496,8692
Macedonia 37,501 2,040,0852
Romania 410,947 22,355,5512
Serbia and Montenegro 199,005 10,825,9002
Trichomoniasis in Northern Asia (Extrapolated Statistics)
Mongolia 50,575 2,751,3142
Trichomoniasis in Central Asia (Extrapolated Statistics)
Kazakhstan 278,376 15,143,7042
Tajikistan 128,888 7,011,556 2
Uzbekistan 485,485 26,410,4162
Trichomoniasis in Eastern Asia (Extrapolated Statistics)
China 23,875,874 1,298,847,6242
Hong Kong s.a.r. 126,013 6,855,1252
Japan 2,340,680 127,333,0022
Macau s.a.r. 8,185 445,2862
North Korea 417,234 22,697,5532
South Korea 886,649 48,233,7602
Taiwan 418,195 22,749,8382
Trichomoniasis in Southwestern Asia (Extrapolated Statistics)
Turkey 1,266,432 68,893,9182
Trichomoniasis in Southern Asia (Extrapolated Statistics)
Afghanistan 524,148 28,513,6772
Bangladesh 2,598,170 141,340,4762
Bhutan 40,175 2,185,5692
India 19,578,503 1,065,070,6072
Pakistan 2,926,403 159,196,3362
Sri Lanka 365,903 19,905,1652
Trichomoniasis in Southeastern Asia (Extrapolated Statistics)
East Timor 18,736 1,019,2522
Indonesia 4,383,326 238,452,9522
 Laos 111,546 6,068,1172
Malaysia 432,398 23,522,4822
Philippines 1,585,325 86,241,6972
Singapore 80,034 4,353,8932
Thailand 1,192,380 64,865,5232
Vietnam 1,519,536 82,662,8002
Trichomoniasis in the Middle East (Extrapolated Statistics)
Gaza strip 24,356 1,324,9912
Iran 1,240,867 67,503,2052
Iraq 466,446 25,374,6912
Israel 113,952 6,199,0082
Jordan 103,147 5,611,2022
Kuwait 41,499 2,257,5492
Lebanon 69,434 3,777,2182
Saudi Arabia 474,190 25,795,9382
Syria 331,192 18,016,8742
United Arab Emirates 46,395 2,523,9152
West Bank 42,485 2,311,2042
Yemen 368,104 20,024,8672
Trichomoniasis in Northern Africa (Extrapolated Statistics)
Egypt 1,399,217 76,117,4212
Libya 103,521 5,631,5852
Sudan 719,635 39,148,1622
Trichomoniasis in Western Africa (Extrapolated Statistics)
Congo Brazzaville 55,111 2,998,0402
Ghana 381,563 20,757,0322
Liberia 62,327 3,390,6352
Niger 208,833 11,360,5382
Nigeria 326,293 12,5750,3562
Senegal 199,487 10,852,1472
Sierra leone 108,159 5,883,8892
Trichomoniasis in Central Africa (Extrapolated Statistics)
Central African Republic 68,795 3,742,4822
Chad 175,340 9,538,5442
Congo kinshasa 1,072,004 58,317,0302
Rwanda 151,446 8,238,6732
 Trichomoniasis in Eastern Africa (Extrapolated Statistics)
Ethiopia 1,311,334 71,336,5712
Kenya 606,288 32,982,1092
Somalia 152,658 8,304,6012
Tanzania 663,066 36,070,7992
Uganda 485,115 26,390,2582
Trichomoniasis in Southern Africa (Extrapolated Statistics)
Angola 201,811 10,978,5522
Botswana 30,132 1,639,2312
South Africa 817,067 44,448,4702
Swaziland 21,493 1,169,2412
Zambia 202,678 11,025,6902
Zimbabwe 67,497 1,2671,8602
Trichomoniasis in Oceania (Extrapolated Statistics)
Australia 366,050 19,913,1442
New Zealand 73,415 3,993,8172
Papua New Guinea 99,637 5,420,2802

Refrence:
1. Scientists crack the genome of the parasite causing trichomoniasis. Physorg.com. Jan. 12,
2007.
2. Associated Press, Abstinence students still having sex, MSNBC, April 16, 2007.
Retrieved March 12, 2008.
3. Vaginitis/Trichomoniasis :Reduce your risk, American Social Health Association.
Retrieved March 12, 2008.
4. Vaginitis/Trichomoniasis :Treatment for trichomoniasis, American Social Health
Association. Retrieved March 12, 2008.
5. Schwebke J, Burgess D (2004). "Trichomoniasis". Clin Microbiol Rev 17 (4): 794–803,
table of contents. doi:10.1128/CMR.17.4.794-803.2004. PMID 15489349
6. Soper D (2004). "Trichomoniasis: under control or undercontrolled?". Am J Obstet
Gynecol 190 (1): 281–90. doi:10.1016/j.ajog.2003.08.023. PMID 14749674.
7. www.wrongdiagnosis.com
8. www.e-medicin.com
9. www.who.int/std_diagnostics