OfficialreprintfromUpToDate

www.uptodate.com2017UpToDate

Enterobiasis(pinworm)andtrichuriasis(whipworm)

Authors: KarinLeder,MBBS,FRACP,PhD,MPH,DTMH,PeterFWeller,MD,MACP
SectionEditor: EdwardTRyan,MD,DTMH
DeputyEditor: ElinorLBaron,MD,DTMH

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Apr2017.|Thistopiclastupdated:Feb09,2017.

INTRODUCTIONEnterobiusvermicularis(pinworm)andTrichuristrichiura(whipworm)aretwoofthemost
commonnematodeinfectionsworldwide[1].

ENTEROBIASIS(PINWORM)Enterobiasisoccursinbothtemperateandtropicalclimatesitisthemost
commonhelminthicinfectionintheUnitedStatesandWesternEurope[2].Prevalenceestimatessuggest
thereare40millioninfectedpersonsintheUnitedStates[3].

Humansaretheonlynaturalhost.Infectionoccursinallsocioeconomicgroupstransmissionismostefficient
whenpeoplearelivinginclosed,crowdedconditionsandiscommonwithinfamilies.Enterobiasisisobserved
mostfrequentlyamongschoolchildrenaged5to10yearsitisrelativelyuncommoninchildren<2yearsold.

LifecycleandtransmissionE.vermicularishasasimplelifecycle(figure1).Thecyclebeginswithegg
depositionbygravidadultfemalewormsontheperianalfolds.Autoinfectionoccursbyscratchingtheperianal
areaandtransferringinfectiveeggstothemouthwithcontaminatedhands.Persontopersontransmission
canoccurbyeatingfoodtouchedbycontaminatedhandsorbyhandlingcontaminatedclothesorbedlinens.
Infectionmayalsobeacquiredviacontactwithenvironmentalsurfaces(curtains,carpeting)thatare
contaminatedwitheggs.Inaddition,eggsmaybecomeairborne,inhaled,andswallowed.

Followingingestion,eggshatchandreleaselarvaeinthesmallintestine.Theadultwormsestablish
themselvesinthegastrointestinaltract,mainlyinthececumandappendix.Thetimeintervalfromingestionof
infectiveeggstoovipositionbytheadultfemalesisaboutonemonth.Eachfemalewormcanproduce10,000
ormoreeggs.Thelifespanoftheadultsistwotothreemonths.Mostinfectedindividualshaveafewto
severalhundredadultworms.Thewormburdenisnotdistributedevenlyamongindividualstheonequarter
ofthepopulationthatismostheavilyinfectedhasmorethan90percentofthetotalwormburden[4].

Gravidfemalesmigratethroughtherectumontotheperianalskintodepositeggsthisusuallyoccursatnight.
Thelarvaeinsidetheeggsgenerallymaturewithinfourtosixhours,resultingininfectiveeggs.Theeggs
begintoloseinfectivityafteronetotwodaysunderwarmanddryconditionsbutmaysurvivemorethantwo
weeksincooler,morehumidenvironments.

ClinicalmanifestationsMostEnterobiusinfectionsareasymptomatic.Themostcommonsymptomof
enterobiasisisperianalitching,alsoknownaspruritusani.Thisiscausedbyaninflammatoryreactiontothe
presenceofadultwormsandeggsontheperianalskinandoccurspredominantlyatnight.Scratchingleadsto
lodgingofeggsbeneaththefingernails,facilitatingsubsequentautoinfectionand/orpersontoperson
transmission.Secondarybacterialinfectionscanresultiftheexcoriationissevere.Nocturnalprurituscanalso
leadtodifficultysleeping[5].

Occasionally,thewormburdenissohighthatabdominalpain,nausea,andvomitingdevelop.Adultpinworms
maybefoundinnormalandinflamedappendicesfollowingsurgicalremoval,butwhetherornottheycause
appendicitisisstilldebated[610].Eosinophilicenterocolitiscanoccur,thoughperipheraleosinophiliais
generallynotobserved[11,12].
Inaddition,adultwormscanmigratetoextraintestinalsites.Vulvovaginitishasbeendescribed,whichcan
increasesusceptibilitytourinarytractinfections[13,14].Involvementofothergenitourinarysiteshasbeen
describedincludingsalpingitis,oophoritis,cervicalgranuloma,andperitonealinflammation.Enterobius
infestationofthenasalmucosahasalsobeenobserved[15].

DiagnosisEnterobiasiscanbediagnosedviaapinwormpaddletest.Thisisaclearplasticpaddlecoated
withanadhesivesurfaceononesidethatispressedagainstseveralareasoftheperianalregion.Thepaddle
isthenplacedontoaglassslideandeggscanbevisualizedunderamicroscope.Thediagnosticyieldis
greatestifthetestisperformedatnightorfirstthinginthemorning,priortobathing.

Eggsare50by25micronandareasymmetricallyflattenedononeside,givingthemacharacteristic"bean
shaped"appearance(picture1).Repeattestingmaybenecessarytoincreasethesensitivity.

Femaleadultwormsmayalsobedetectedintheperianalarea.Theyarewhite,pinshaped,and8to13mm
long.

Theutilityofstoolexaminationislimitedsincewormsandeggsarenotgenerallypassedinstool.

TreatmentTreatmentofenterobiasisconsistsofthefollowinganthelminthicoptions:

Albendazole(400mgorallyoncerepeatintwoweeks)ormebendazole(100mgorallyoncerepeatin
twoweeks)[1619].Asingledoseresultsinrelativelyhighcurerates,althoughaseconddoserepeated
attwoweeksachievesacureratecloseto100percentandhelpspreventrecurrenceduetoreinfection
[8,20].(See'Lifecycleandtransmission'above.)

Pyrantelpamoate(11mg/kgmaximum1g).ItisthemostfrequentlyusedmedicationintheUnited
Statesasitischeapandavailableoverthecounterandalsohasanefficacyofcloseto100percentiftwo
dosesaregiventwoweeksapart[19].Adverseeffectscanincludeanorexia,nausea,vomiting,abdominal
cramps,diarrhea,neurotoxiceffects,andtransientincreasesinhepaticenzymes.

Reinfectioniscommon,despiteeffectivetherapy.Therefore,simultaneoustreatmentoftheentirehousehold
iswarrantedgivenhightransmissionratesamongfamilies.Inaddition,allbeddingandclothesshouldbe
washed.Hygienicmeasures,suchasclippingoffingernails,frequenthandwashing,andbaths,arealsohelpful
forreducingreinfectionandspreadofinfection.

IvermectinhasefficacyagainstE.vermicularisbutisnotgenerallyusedforthisindication[21,22].Inone
study,twodosesofivermectin200mcg/kggivenatanintervalof10daysresultedinacureof100percentfor
enterobiasis[23].

Piperazineisnolongerusedbecauseoflowerefficacyandincreasedtoxicitycomparedwiththe
benzimidazoles.

PregnancyTreatmentofenterobiasisinpregnantwomenshouldbereservedforpatientswith
significantsymptoms.Pyrantelpamoateisfavoredovermebendazoleoralbendazolefortreatmentof
symptomaticenterobiasisinpregnantwomen[24,25].

Inonestudyof192pregnantwomenexposedtomebendazoleduringpregnancy(72percentduringthefirst
trimester),noincreaseinmajormalformationswasobservedcomparedwithmatchedcontrols,althoughthere
weremoreelectiveterminationsinthegroupreceivingmebendazole[26].

TRICHURIASIS(WHIPWORM)Trichuriasisoccursmostcommonlyintropicalclimates.Itisestimatedthat
approximatelyonequarteroftheworldpopulationcarriesthisparasite[27].Incommunitieswheretrichuriasis
isendemic,infectionmaybepresentinmorethan90percentofindividuals,butthemajorityofthetotalworm
burdenisgenerallycarriedbyfewerthan10percent[28].T.trichiuraisfrequentlyobservedinassociationwith
othergeohelminthssuchasAscarislumbricoides,sincethesepathogensthriveundersimilarconditions.
Transmissionoftrichuriasisisassociatedwithpoorhygiene.Individualsofallagescanbecomeinfected.
Childrenareparticularlyvulnerabletoinfectionbecauseoftheirhighexposureriskandbecausepartial
protectiveimmunityisthoughttodevelopwithage.

LifecycleandtransmissionThelifecyclefortrichuriasisbeginswithpassageofunembryonatedeggsin
thestool(figure2).Inthesoil,theeggsembryonateandbecomeinfectivein15to30days.Afteringestionvia
foodorhandscontaminatedwithsoil,theeggshatchinthesmallintestineandreleaselarvaethatmatureinto
adultworms,whichbecomeestablishedinthececumandascendingcolonaftertwotothreemonths.Inheavy
infections,wormsmayalsobefoundinthedistalcolonandrectum[27].

Theadultsmeasureapproximately4cminlength.Thethinendisembeddedinthebowelmucosaandthe
thickendisvisiblewithinthebowellumen.Thefemalesbegintoproduceeggs60to70daysafterinfection
andshed3000to20,000eggsperday.Thelifespanoftheadultsisonetothreeyears.

Reinfectioniscommonfollowingtherapyinendemicareas.Adequatedisposalofhumanfecesandgood
sanitaryconditionscaninterrupttransmission.Goodpersonalhygieneandcarefulwashingofvegetablesand
fruitsgrownincontaminatedareasisalsoimportant.

ClinicalmanifestationsMostinfectionswithT.trichiuraareasymptomatic.Clinicalsymptomsaremore
frequentwithmoderatetoheavyinfections.Stoolscanbelooseandoftencontainmucusand/orblood.
Nocturnalstoolingiscommon.Colitisanddysenteryoccurmostfrequentlyamongindividualswith>200
worms,andsecondaryanemiamaybeobserved.Infectedindividualsmayhaveaperipheraleosinophiliaof
upto15percent.

Rectalprolapsecanoccurinthesettingofheavyinfection,andembeddedwormsmaybevisualizeddirectlyin
themucosaoftheinflamedrectum(picture2).Picaandfingerclubbingareotherpotentialcluestothe
diagnosis.

Childrenwhoareheavilyinfectedmayhaveimpairedgrowthand/orcognition[29,30].However,itcanbe
difficulttoquantifytheroleoftrichuriasisinisolationfromcomorbiditiesandothersocialfactors.

DiagnosisThediagnosisoftrichuriasisismadebystoolexaminationforeggs(picture3).Theeggsare50
by20micronsandhaveacharacteristicbarrelshapewithsmooththickwallandahyalineplugateachend.
TheKatoKatztechniquecanbeusedtoquantifyeggnumbers,whichtendstocorrelatewiththeadultworm
burden[31,32].

Proctoscopyorcolonoscopycanbeperformedandfrequentlydemonstratesadultwormsprotrudingfromthe
bowelmucosa(picture4).Theadultwormisshapedlikeawhip.Theposteriorpartofthewormiswiderand
lookslikethewhiphandle,andtheanteriorpartislongandthin.

PCRusingnextgenerationsequencingtechniquesareincreasinglybecomingavailableandareabletodetect
soiltransmittedhelminthsincludingT.trichiura.Theutilizationofsuchmethodologieshastheabilityto
improvespeciesspecificityandlimitsofparasitedetection[33].Sensitivityandspecificityvaryaccordingthe
specifictestused:onestudyshowedthat,comparedwithmicroscopicexaminationoffecalsamples,sensitivity
andspecificityofamultiplexPCRwas87and83percent,respectively[34].

Treatment

OverviewTreatmentoftrichuriasisconsistsofanthelminthictherapywithmebendazole(100mgorally
twicedailyforthreedays70to>90percentcure)[8,35]oralbendazole(400mgorallyoncedailyforthree
days80percentcure)[36].Albendazoleshouldbeconsideredsecondlinetreatmentasitsefficacyislower
[37,38],althoughalbendazolemaybeusedifcoinfectionwithhookwormhasnotbeenexcluded.Astudy
showedcurerateswithasingle400mgdoseofalbendazoleof2.6percentwitheggreductionratesof45
percent,comparedwith11.8and75percent,respectively,forasingle500mgdoseofmebendazole[37].For
patientswithheavyinfection(atleast1000Trichuriseggs/gfeces),treatmentregimensoffivetosevendays
maybewarranted[39].
Oxantelpamoatehasbeenevaluatedfortreatmentoftrichuriasisdataarelimited.Onestudyamongchildren
inTanzanianotedreasonableefficacyandtolerabilitywithoptimumtherapeuticdoserangeof15to30mg/kg
(15mg/kg:49percentcureand97percenteggreductionrate30mg/kg:59percentcurerateand99percent
eggreductionrate)[40].

Albendazoleplusoxantelpamoate(inregionswhereavailable)maybemoreefficaciousthanmebendazoleor
albendazolealone[37,41].Onestudyincluding450childrenwithtrichuriasisnotedthattreatmentwithoxantel
pamoate(20mg/kgsingledose)andalbendazole(400mgsingledose)resultedinhighercureandegg
reductionratesat3weeksand18weeksaftertreatmentthanalbendazoleormebendazolealone[37,42].

Ivermectinhassomeactivityagainsttrichuriasis,thoughitisnotaseffectiveasmebendazoleoralbendazole
forindividualtherapy[21,22,43].Therearelimiteddataonnitazoxanidefortreatmentoftrichuriasis[44].

Issuesrelatedtopopulationbasedtreatmentarediscussedseparately.(See"Massdrugadministrationfor
controlofparasiticinfections".)

PregnancyMebendazoleandalbendazoleshouldbeavoidedduringpregnancy,particularlyduringthe
firsttrimester.Therisksofadministeringtreatmenttopregnantwomenwithtrichuriasismustbeweighed
againsttherisksofdelayingtreatment.Therapyforpatientswithtrichuriasisintheabsenceofsignificant
symptomscanbedeferreduntilafterdelivery.

INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,TheBasics
andBeyondtheBasics.TheBasicspatienteducationpiecesarewritteninplainlanguage,atthe5thto6th
gradereadinglevel,andtheyanswerthefourorfivekeyquestionsapatientmighthaveaboutagiven
condition.Thesearticlesarebestforpatientswhowantageneraloverviewandwhoprefershort,easyto
readmaterials.BeyondtheBasicspatienteducationpiecesarelonger,moresophisticated,andmore
detailed.Thesearticlesarewrittenatthe10thto12thgradereadinglevelandarebestforpatientswhowant
indepthinformationandarecomfortablewithsomemedicaljargon.

Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremail
thesetopicstoyourpatients.(Youcanalsolocatepatienteducationarticlesonavarietyofsubjectsby
searchingonpatientinfoandthekeyword(s)ofinterest.)

Basicstopics(see"Patienteducation:Pinworms(TheBasics)")

SUMMARYANDRECOMMENDATIONS

Enterobiusvermicularis(pinworm)andTrichuristrichiura(whipworm)aretwoofthemostcommon
nematodeinfectionsworldwide.Enterobiasisoccursinbothtemperateandtropicalclimatesitisthemost
commonhelminthicinfectionintheUnitedStatesandWesternEurope.Trichuriasisoccursmost
commonlyintropicalclimates.(See'Introduction'above.)

Enterobiasis

ThelifecycleofEnterobiusbeginswitheggdepositionbygravidadultfemalewormsontheperianalfolds
(figure1).Autoinfectionoccursbyscratchingtheperianalareaandtransferringinfectiveeggstothe
mouthwithcontaminatedhands.Persontopersontransmissioncanoccurbyeatingfoodtouchedby
contaminatedhandsorbyhandlingcontaminatedclothesorbedlinens.(See'Lifecycleandtransmission'
above.)

MostEnterobiusinfectionsareasymptomatic.Themostcommonsymptomofenterobiasisisperianal
itching,whichoccurspredominantlyatnight.Occasionally,thewormburdenissohighthatabdominal
pain,nausea,andvomitingdevelop.Enterobiasiscanbediagnosedviaexaminationofcellophanetape
foreggsafterpressingtotheperianalskin(picture1).Theutilityofstoolexaminationislimitedsince
wormsandeggsarenotgenerallypassedinstool.(See'Clinicalmanifestations'aboveand'Diagnosis'
above.)
 Wesuggesttreatmentofenterobiasiswithalbendazole,mebendazole,orpyrantelpamoate(Grade2C)
dosingisoutlinedabove.Simultaneoustreatmentoftheentirehouseholdiswarranted,givenhigh
transmissionratesamongfamilies.(See'Treatment'above.)

Trichuriasis

Thelifecyclefortrichuriasisbeginswithpassageofunembryonatedeggsinthestool,whichbecome
infectivein15to30days(figure2).Afteringestionviafoodorhandscontaminatedwithsoil,theeggs
hatchandreleaselarvaethatmatureintoadultswormsthatbecomeestablishedinthecolonaftertwoto
threemonths.(See'Lifecycleandtransmission'above.)

MostinfectionswithT.trichiuraareasymptomatic.Rectalprolapsecanoccur,primarilyinthesettingof
heavyinfection.Stoolscanbelooseandoftencontainmucusand/orblood.Nocturnalstoolingis
common.Thediagnosisoftrichuriasisismadebystoolexaminationforeggs(picture3).(See'Clinical
manifestations'above.)

Treatmentoftrichuriasisusuallyconsistsofmebendazole(threedays)oralbendazole(threedays)
alternateregimensanddosingareoutlinedabove.(See'Treatment'above.)

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Topic5692Version23.0
GRAPHICS

Enterobiasislifecycle

Eggsaredepositedonperianalfolds(1).Selfinfectionoccursbytransferring
infectiveeggstothemouthwithhandsthathavescratchedtheperianalarea(2).
Persontopersontransmissioncanalsooccurthroughhandlingofcontaminated
clothesorbedlinens.Enterobiasismayalsobeacquiredthroughsurfacesinthe
environmentthatarecontaminatedwithpinwormeggs(eg,curtains,carpeting).
Somesmallnumberofeggsmaybecomeairborneandinhaled.Thesewouldbe
swallowedandfollowthesamedevelopmentasingestedeggs.Followingingestion
ofinfectiveeggs,thelarvaehatchinthesmallintestine(3)andtheadults
establishthemselvesinthecolon(4).Thetimeintervalfromingestionofinfective
eggstoovipositionbytheadultfemalesisaboutonemonth.Thelifespanofthe
adultsisabouttwomonths.Gravidfemalesmigratenocturnallyoutsidetheanus
andovipositwhilecrawlingontheskinoftheperianalarea(5).Thelarvae
containedinsidetheeggsdevelop(theeggsbecomeinfective)infourtosixhours
underoptimalconditions(1).Retroinfection,orthemigrationofnewlyhatched
larvaefromtheanalskinbackintotherectum,mayoccurbutthefrequencywith
whichthishappensisunknown.

Reproducedfrom:CentersforDiseaseControlandPrevention.DPDx:Enterobiasis.
Availableat:http://www.cdc.gov/dpdx/enterobiasis/index.html.

Graphic57681Version3.0
Enterobiuseggs

(A)EggsofE.vermicularisinacellulosetapepreparation.
(B)EggsofE.vermicularisinawetmount.
(C)EggofE.vermicularisinaniodinestainedwetmountfromaformalinconcentrate.
(D)EggsofE.vermicularisviewedunderUVmicroscopy.

Reproducedfrom:CentersforDiseaseControlandPrevention.DPDx:Enterobiasis.Availableat:
http://www.cdc.gov/dpdx/enterobiasis/index.html.

Graphic65366Version5.0
Trichuriasislifecycle

Theunembryonatedeggsarepassedwiththestool(1).Inthesoil,theeggsdevelop
intoatwocellstage(2),anadvancedcleavagestage(3),andthentheyembryonate
(4)eggsbecomeinfectivein15to30days.Afteringestion(soilcontaminatedhandsor
food),theeggshatchinthesmallintestine,andreleaselarvae(5)thatmatureand
establishthemselvesasadultsinthecolon(6).Theadultworms(approximately4cmin
length)liveinthececumandascendingcolon.Theadultwormsarefixedinthat
location,withtheanteriorportionsthreadedintothemucosa.Thefemalesbeginto
oviposit60to70daysafterinfection.Femalewormsinthececumshedbetween3000
and20,000eggsperday.Thelifespanoftheadultsisaboutoneyear.

Reproducedfrom:CentersforDiseaseControlandPrevention.DPDx:Trichuriasis.Available
at:http://www.cdc.gov/dpdx/trichuriasis/index.html.

Graphic75177Version3.0
Trichuriasisrectalprolapse

Rectalprolapseduetotrichuriasis.Whiteadultwormscanbeseenonthe
surfaceofthemucosa.

FromthecollectionofHermanZaiman,"APresentationofPictorialParasites."
Reproducedwithpermissionfrom:theAmericanSocietyofTropicalMedicineand
Hygiene.

Graphic87128Version1.0
Trichuriasiseggs

(A)EggofT.trichiurainaniodinestainedwetmount.
(B)EggofT.trichiurainanunstainedwetmount.
(C)EggofT.trichiurainanunstainedwetmount.
(D)TwoeggsofT.trichiura,showingthevariabilityinsizeofthespecies.

Reproducedfrom:CentersforDiseaseControlandPrevention.DPDx:Trichuriasis.Availableat:
http://www.cdc.gov/dpdx/trichuriasis/index.html.

Graphic54175Version5.0
Trichuriasisscope

ImageshowingtheposteriorendofanadultT.trichiura,takenduringa
colonoscopy.

Reproducedfrom:CentersforDiseaseControlandPrevention.ParasitesandHealth:
Trichuriasis.Availableat:http://www.cdc.gov/parasites/whipworm/.

Graphic68026Version4.0
ContributorDisclosures
KarinLeder,MBBS,FRACP,PhD,MPH,DTMH Grant/Research/ClinicalTrialSupport:Sanofi
[Splenectomy(Appdevelopment)]. PeterFWeller,MD,MACP Grant/Research/ClinicalTrialSupport:
GlaxoSmithKline[AntiIL5mAbforEGPA(Mepolizumab)]. EdwardTRyan,MD,DTMH Consultant/Advisory
Boards:BectonDickinson[Feverdiagnostic]. ElinorLBaron,MD,DTMH Nothingtodisclose

Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseare
addressedbyvettingthroughamultilevelreviewprocess,andthroughrequirementsforreferencestobe
providedtosupportthecontent.Appropriatelyreferencedcontentisrequiredofallauthorsandmustconform
toUpToDatestandardsofevidence.

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