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Enterobiasis (pinworm) and trichuriasis (whipworm)

Authors: Karin Leder, MBBS, FRACP, PhD, MPH, DTMH, Peter F Weller, MD, MACP
Section Editors: Edward T Ryan, MD, DTMH, Morven S Edwards, MD
Deputy Editor: Elinor L Baron, MD, DTMH

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Nov 2022. | This topic last updated: Oct 25, 2022.

INTRODUCTION

Enterobius vermicularis (pinworm) and Trichuris trichiura (whipworm) are two of the most
common nematode infections worldwide [1].

Enterobiasis occurs in both temperate and tropical climates; it is the most common helminthic
infection in the United States and Western Europe. Trichuriasis occurs most commonly in
tropical climates.

ENTEROBIASIS (PINWORM)

Enterobiasis occurs in both temperate and tropical climates; it is the most common helminthic
infection in the United States and Western Europe [2]. Prevalence estimates suggest there are
40 million infected persons in the United States [3].

Humans are the only natural host. Infection occurs in all socioeconomic groups; transmission is
most efficient when people are living in closed, crowded conditions and is common within
households. Enterobiasis is observed most frequently among school children aged 5 to 10
years; it is relatively uncommon in children <2 years old.

Life cycle and transmission — E. vermicularis has a simple life cycle ( figure 1). The cycle
begins with egg deposition by gravid adult female worms on the perianal folds. Autoinfection
occurs by scratching the perianal area and transferring infective eggs to the mouth with
contaminated hands. Person-to-person transmission can occur by eating food touched by
contaminated hands or by handling contaminated clothes or bed linens. Infection may also be
acquired via contact with environmental surfaces (curtains, carpeting) that are contaminated
with eggs. In addition, eggs may become airborne, inhaled, and swallowed.

Following ingestion, eggs hatch and release larvae in the small intestine. The adult worms
establish themselves in the gastrointestinal tract, mainly in the cecum and appendix. The time
interval from ingestion of infective eggs to oviposition by the adult females is about one month.
Each female worm can produce 10,000 or more eggs. The life span of the adults is two to three
months. Most infected individuals have a few to several hundred adult worms. The worm
burden is not distributed evenly among individuals; the one-quarter of the population that is
most heavily infected has more than 90 percent of the total worm burden [4].

Gravid females migrate through the rectum onto the perianal skin to deposit eggs; this usually
occurs at night. The larvae inside the eggs generally mature within four to six hours, resulting
in infective eggs. The eggs begin to lose infectivity after one to two days under warm and dry
conditions but may survive more than two weeks in cooler, more humid environments.

Clinical manifestations — Most Enterobius infections are asymptomatic. The most common

symptom of enterobiasis is perianal itching, also known as pruritus ani. This is caused by an
inflammatory reaction to the presence of adult worms and eggs on the perianal skin and occurs
predominantly at night. Scratching leads to lodging of eggs beneath the fingernails, facilitating
subsequent autoinfection and/or person-to-person transmission. Secondary bacterial infections
can result if the excoriation is severe. Nocturnal pruritus can also lead to difficulty sleeping [5].

Occasionally, the worm burden is so high that abdominal pain, nausea, and vomiting develop.
Adult pinworms may be found in normal and inflamed appendices following surgical removal,
but whether or not they cause appendicitis is still debated [6-12]. Eosinophilic enterocolitis can
occur, though peripheral eosinophilia is generally not observed [13,14]. (See "Eosinophilic
gastrointestinal diseases".)

In addition, adult worms can migrate to extraintestinal sites. Vaginal enterobiasis can occur
with a wide range of clinical presentations; many patients are asymptomatic, but vulvovaginitis
has been described, which can increase susceptibility to urinary tract infections [15-17].
Involvement of other genitourinary sites has been described including salpingitis, oophoritis,
cervical granuloma, and peritoneal inflammation. Enterobius infestation of the nasal mucosa
has also been observed [18].

Diagnosis — Enterobiasis should be suspected in patients with anal pruritus, particularly

school-aged children.
The diagnosis can be established in one of the following ways:

● Visual inspection of the anal verge and undergarments, where mobile worms are
sometimes visible. The white, pin-shaped female pinworm (8 to 13 mm long) may look like
bits of cotton thread and can be confirmed by laboratory identification ( picture 1).

● Paddle test – The paddle test is performed by pressing a plastic paddle (coated with an
adhesive surface) or piece of cellophane tape against the perianal region and then placing
onto a glass slide, which is then examined under a microscope for pinworm eggs. The
diagnostic yield is greatest if the test is performed at night or first thing in the morning
prior to bathing. Repeat testing over three days may be necessary to increase the
sensitivity.

● Samples collected from under fingernails may be analyzed for pinworm eggs.

Eggs are 50 by 25 micron and are asymmetrically flattened on one side, giving a characteristic
"bean-shaped" appearance ( picture 2).

Stool examination is not useful since worms and eggs are generally not passed in stool.

Differential diagnosis — The differential diagnosis includes of enterobiasis includes infectious,

dermatologic, and other causes. (See "Approach to the patient with anal pruritus".)

Treatment — The approach to treatment of enterobiasis is discussed below. In the absence of

definitive diagnosis, empiric treatment is reasonable for patients with relevant clinical
manifestations of anal pruritus. In cases of confirmed enterobiasis, simultaneous treatment of
the entire household is warranted regardless of symptoms in other household members given
high transmission rates within households.

Nonpregnant adults and children — Options for treatment of enterobiasis include [19-22]:

● Albendazole (adults and children: 400 mg orally once on empty stomach, repeat in two
weeks)
● Mebendazole (adults and children: 100 mg orally once, repeat in two weeks)
● Pyrantel pamoate (adults and children: 11 mg/kg, maximum 1 g; repeat in two weeks;
available over the counter in the United States)

The above regimens have been associated with cure rates of 90 to 100 percent in a number of
studies [8,22,23].
Ivermectin has efficacy against E. vermicularis but is not generally used for this indication [24-
26]. Piperazine is not used because of lower efficacy and higher toxicity compared with the
benzimidazoles.

Pregnant women — Treatment of enterobiasis in pregnant women should be reserved for

patients with significant symptoms. Pyrantel pamoate is favored over mebendazole or
albendazole for treatment of symptomatic enterobiasis in pregnant women [27,28]. The dosing
is the same as for nonpregnant adults. (See 'Nonpregnant adults and children' above.)

In one study of 192 pregnant women exposed to mebendazole during pregnancy (72 percent
during the first trimester), no increase in major malformations was observed compared with
matched controls, although there were more elective terminations in the group receiving
mebendazole [29].

Preventing transmission — In addition to treatment, all bedding and clothes should be

washed. Hygienic measures, such as clipping of fingernails and frequent handwashing are also
helpful for reducing reinfection and spread of infection. Showering is preferred over taking a
bath, because showering avoids potential contamination of bath water with pinworm eggs [30].

TRICHURIASIS (WHIPWORM)

Trichuriasis occurs most commonly in tropical climates. It is estimated that approximately one-
quarter of the world population carries this parasite [31]. In communities where trichuriasis is
endemic, infection may be present in more than 90 percent of individuals, but the majority of
the total worm burden is generally carried by fewer than 10 percent [32]. T. trichiura is
frequently observed in association with other geohelminths such as Ascaris lumbricoides, since
these pathogens thrive under similar conditions. (See "Ascariasis".)

Transmission of trichuriasis is associated with poor hygiene. Individuals of all ages can become
infected. Children are particularly vulnerable to infection because of their high exposure risk
and because partial protective immunity is thought to develop with age.

Life cycle and transmission — The life cycle for trichuriasis begins with passage of
unembryonated eggs in the stool ( figure 2). In the soil, the eggs embryonate and become
infective in 15 to 30 days. After ingestion via food or hands contaminated with soil, the eggs
hatch in the small intestine and release larvae that mature into adult worms, which become
established in the cecum and ascending colon after two to three months. In heavy infections,
worms may also be found in the distal colon and rectum [31].
The adults measure approximately 4 cm in length. The thin end is embedded in the bowel
mucosa and the thick end is visible within the bowel lumen. The females begin to produce eggs
60 to 70 days after infection and shed 3000 to 20,000 eggs per day. The life span of the adults is
one to three years.

Reinfection is common following therapy in endemic areas. Adequate disposal of human feces
and good sanitary conditions can interrupt transmission. Good personal hygiene and careful
washing of vegetables and fruits grown in contaminated areas is also important.

Clinical manifestations — Most infections with T. trichiura are asymptomatic. Clinical

symptoms are more frequent with moderate to heavy infections. Stools can be loose and often
contain mucus and/or blood. Nocturnal stooling is common. Colitis and dysentery occur most
frequently among individuals with >200 worms, and secondary anemia may be observed.
Infected individuals may have a peripheral eosinophilia of up to 15 percent.

Rectal prolapse can occur in the setting of heavy infection, and embedded worms may be
visualized directly in the mucosa of the inflamed rectum ( picture 3). Pica and finger clubbing
are other potential clues to the diagnosis.

Children who are heavily infected may have impaired growth and/or cognition [33,34]. However,
it can be difficult to quantify the role of trichuriasis in isolation from comorbidities and other
social factors.

Diagnosis — The diagnosis of trichuriasis is established via stool examination for eggs

( picture 4). The eggs are 50 by 20 microns and have a characteristic barrel shape with
smooth thick wall and a hyaline plug at each end. The Kato-Katz technique can be used to
quantify egg numbers, which tends to correlate with the adult worm burden [35,36].
Particularly in light infections, examination of more than one sample improves sensitivity, and
three samples should optimally be examined before excluding infection.

Polymerase chain reaction (PCR) using next-generation sequencing techniques are increasingly
becoming available and are able to detect soil-transmitted helminths including T. trichiura. The
utilization of such methodologies has the ability to improve species specificity and limits of
parasite detection [37]. Sensitivity and specificity vary according the specific test used. In one
study evaluating a multiplex PCR, the sensitivity and specificity were 87 and 83 percent,
respectively , compared with stool microscopy [38]. In another study (using the combined
results of triplicate Kato-Katz thick smears and PCR as the gold standard), the sensitivity of
quantitative PCR for detecting T. trichiura was 72 percent [39]. PCR tests may therefore become
an increasingly more standard method for diagnosing or ruling out infection.
If proctoscopy or colonoscopy are performed, adult worms protruding from the bowel mucosa
may be observed ( picture 5). The adult worm is shaped like a whip; the posterior part of the
worm is relatively wide and looks like a whip handle, and the anterior part is long and thin.

Treatment

Nonpregnant adults and children — For patients with trichuriasis, we treat asymptomatic

and symptomatic cases.

● Treatment regimens – Treatment regimen options include [19,40,41]:

• Monotherapy with either albendazole (adults and children: 400 mg orally once daily for
three days) or mebendazole (adults and children: 100 mg orally twice daily for three
days)

• Combination therapy with albendazole (400 mg orally once daily for three days) plus
ivermectin (600 mcg/kg once daily for three days)

We prefer initial treatment with either albendazole or mebendazole (three-day regimen).

Combination therapy (ivermectin plus albendazole) is a reasonable alternative treatment
and appeared to have superior efficacy in one trial; a three-day course of albendazole and
ivermectin had a slightly higher egg reduction rate (100 versus 98 percent) and cure rate
(100 versus 89 percent) than a single-day course of combination therapy [41]. Single-dose
albendazole or mebendazole has insufficient efficacy and should not be used.

● Alternative regimens – Proposed alternative regimens include combination therapy with

oxantel pamoate and albendazole (for two days) or combination therapy with oxantel
pamoate and ivermectin (either alone or in combination with other anthelminthic agents)
[42]; further study of these regimens is needed, and these regimens are therefore not
recommended as first-line therapy.

● Follow-up – We perform follow-up stool examination a few weeks after treatment to

detect those with persistent infection; this is especially important for patients with heavy
infections (at least 1000 Trichuris eggs/g stool). In patients with heavy infection, treatment
with albendazole for a longer duration (five to seven days) may be warranted [19,43-45].

● Efficacy

• Combination therapy – Use of combination therapy is supported by the following

trials:
 - In a 2019 meta-analysis including 114 studies, one-day combination therapy with
albendazole-ivermectin was more efficacious than one-day albendazole
monotherapy for curing T. trichiura infection (relative risk 3.22, 95% CI 1.84-5.63)
[46].

- In a 2021 randomized trial including 176 children with trichuriasis in Honduras,

three-day combination therapy (albendazole 400 mg and ivermectin 200 mcg/kg)
was associated with a slightly higher egg reduction rate (100 versus 98 percent)
and cure rate (100 versus 89 percent) than one-day combination therapy [41].

- In a 2022 randomized trial including more than 1600 patients age 6 to 60 years
with trichuriasis among three study sites, higher cure rates were observed among
those treated with one-day combination therapy (albendazole 400 mg and
ivermectin 200 mcg/kg) than among those treated with one-day monotherapy
(albendazole 400 mg) in Laos (66 versus 8 percent) and Pemba Island (49 versus 6
percent), but not in Côte d’Ivoire (14 versus 10 percent) [47].

• Monotherapy – In general, the efficacy of monotherapy for treatment of trichuriasis is

relatively low, especially when administered as a single dose. In one trial including 240
children in Tanzania with trichuriasis randomly assigned to treatment with
mebendazole (500 mg single dose) or albendazole (400 mg single dose), cure rates and
egg reduction rates 21 days later were higher among those treated with mebendazole
(11.8 versus 2.6 percent and 75 versus 45 percent, respectively) [42]. In a subsequent
meta-analysis including 38 trials and more than 8800 patients with trichuriasis, cure
rates for mebendazole and albendazole were 42 and 31 percent, respectively [40].

Data on use of ivermectin monotherapy for treatment of trichuriasis are limited

[24,25,48]. In one study including 126 preschool-aged children in Côte d'Ivoire with
trichuriasis, ivermectin (200 mcg/kg orally once) was no more effective than placebo;
among 166 school-aged children, the cure rate of ivermectin (up to 600 mcg/kg) was
only 12 percent [49].

Data on use of oxantel pamoate (monotherapy) for treatment of trichuriasis are

limited, and drug availability is limited [42,50]. In one study including 350 children in
Tanzania with trichuriasis randomly assigned to treatment with oxantel pamoate or
placebo, the optimum therapeutic dose range was 15 to 30 mg/kg (15 mg/kg: 49
percent cure and 97 percent egg reduction rate; 30 mg/kg: 59 percent cure rate and 99
percent egg reduction rate) [41,50].
 ● Mass treatment – In regions where mass chemotherapy is given without follow-up of
individuals for detection of cure, use of oxantel pamoate in combination with albendazole
may be more efficacious than mebendazole or albendazole alone [42,51]. In the above
trial of children with trichuriasis in Tanzania, 119 were randomly assigned to treatment
with this regimen (oxantel pamoate 20 mg/kg, plus 400 mg of albendazole, administered
on consecutive days); three weeks later, the cure rate was 31 percent and the egg
reduction rate was 96 percent [42].

Issues related to population-based treatment are discussed separately. (See "Mass drug
administration for control of parasitic infections".)

Pregnant women — Mebendazole and albendazole should be avoided during pregnancy,

particularly during the first trimester. The risks of administering treatment to pregnant women
with trichuriasis must be weighed against the risks of delaying treatment. Therapy for patients
with trichuriasis in the absence of significant symptoms can be deferred until after delivery.

Differential diagnosis — The differential diagnosis includes of trichuriasis depends on the

presentation.

● For patients with symptomatic intestinal infection, other relevant nematodes

(roundworms) include Ascaris, hookworm (Ancylostoma duodenale and Necator
americanus), and Strongyloides. Loose stools or colitis may be caused by a range of
infectious agents that can be identified via stool examination including bacteria
(Salmonella, Campylobacter, Shigella, enterotoxigenic Escherichia coli, Yersinia, and
others), viruses (norovirus, rotavirus, adenoviruses, astrovirus, and others), protozoa
(Cryptosporidium, Giardia, Cyclospora, Entamoeba, and others), or by noninfectious
etiologies including inflammatory bowel disease. (See "Diagnostic approach to diarrhea in
children in resource-rich countries" and "Approach to the adult with acute diarrhea in
resource-rich settings".)

● Eosinophilia has a range of infectious (especially other helminths) and noninfectious

causes. (See "Approach to the patient with unexplained eosinophilia".)

● Rectal prolapse may be caused by A. lumbricoides or other infections, conditions that

increase intra-abdominal pressure, cystic fibrosis, pelvic floor weakness, and other
conditions. (See "Overview of rectal procidentia (rectal prolapse)" and "Rectal prolapse in
children".)

MEDICATION COST
The cost of albendazole and mebendazole in the United States can be prohibitive for patients
without adequate prescription drug coverage. According to a website that compares retail drug
prices without insurance (GoodRx), generic albendazole costs $200 to 300 USD per course;
mebendazole (brand Emverm) $1000 to 1500 USD per course [52]. Pyrantel pamoate treatment
is available without a prescription at about $20 USD per course. Resources for patients needing
help with prescription costs are available. (See 'Information for patients' below.)

INFORMATION FOR PATIENTS

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Here are the patient education articles that are relevant to this topic. We encourage you to print
or email these topics to your patients. (You can also locate patient education articles on a
variety of subjects by searching on "patient info" and the keyword(s) of interest.)

● Basics topics (see "Patient education: Pinworms (The Basics)" and "Patient education:
Coping with high drug prices (The Basics)")
● Beyond the Basics topic (see "Patient education: Coping with high prescription drug prices
in the United States (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

● Epidemiology − Enterobius vermicularis (pinworm) and Trichuris trichiura (whipworm) are

two of the most common nematode infections worldwide. Enterobiasis occurs in both
temperate and tropical climates; it is the most common helminthic infection in the United
States and Western Europe. Trichuriasis occurs most commonly in tropical climates. (See
'Introduction' above.)

● Enterobiasis (pinworm)
 • Life cycle − The life cycle of Enterobius begins with egg deposition by gravid adult
female worms on the perianal folds ( figure 1). Autoinfection occurs by scratching
the perianal area and transferring infective eggs to the mouth with contaminated
hands. Person-to-person transmission can occur by eating food touched by
contaminated hands or by handling contaminated clothes or bed linens. (See 'Life cycle
and transmission' above.)

• Clinical manifestations and diagnosis − Most Enterobius infections are asymptomatic.

The most common symptom of enterobiasis is perianal itching, which occurs
predominantly at night. Occasionally, the worm burden is so high that abdominal pain,
nausea, and vomiting develop. Enterobiasis can be diagnosed via egg examination of
cellophane tape or plastic paddle (coated with an adhesive surface) after pressing to
the perianal skin ( picture 2). The utility of stool examination is limited since worms
and eggs are not generally passed in stool. (See 'Clinical manifestations' above and
'Diagnosis' above.)

• Treatment − For patients with enterobiasis, we suggest treatment with albendazole,

mebendazole, or pyrantel pamoate (Grade 2C); dosing is outlined above. Simultaneous
treatment of the entire household is warranted, given high transmission rates within
households. (See 'Treatment' above.)

● Trichuriasis (whipworm)

• Life cycle − The life cycle for trichuriasis begins with passage of unembryonated eggs
in the stool, which become infective in 15 to 30 days ( figure 2). After ingestion via
food or hands contaminated with soil, the eggs hatch and release larvae that mature
into adults worms that become established in the colon after two to three months. (See
'Life cycle and transmission' above.)

• Clinical manifestations and diagnosis − Most trichuriasis infections are

asymptomatic. Rectal prolapse can occur, primarily in the setting of heavy infection.
Stools can be loose and often contain mucus and/or blood. Nocturnal stooling is
common. The diagnosis of trichuriasis is made by stool examination for eggs
( picture 4). (See 'Clinical manifestations' above and 'Diagnosis' above.)

• Treatment − For patients with trichuriasis, we suggest initial treatment with either
albendazole or mebendazole (three-day regimen) (Grade 2C). Combination therapy
(ivermectin plus albendazole) is a reasonable alternative. Single-dose albendazole or
mebendazole has insufficient efficacy and should not be used. Dosing is summarized
above. (See 'Treatment' above.)
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REFERENCES

1. Jourdan PM, Lamberton PHL, Fenwick A, Addiss DG. Soil-transmitted helminth infections.
Lancet 2018; 391:252.
2. Moore TA, McCarthy JS. Enterobiasis. In: Tropical Infectious Diseases: Principles, Pathogens
and Practice, 3rd ed, Guerrant R, Walker DH, Weller PF (Eds), Saunders Elsevier, Philadelphi
a 2011. p.788.
3. Centers for Disease Control and Prevention. Enterobiasis (Enteroblus vermicularis) https://
www.cdc.gov/dpdx/enterobiasis/index.html (Accessed on January 10, 2020).

4. Maizels RM, Bundy DA, Selkirk ME, et al. Immunological modulation and evasion by
helminth parasites in human populations. Nature 1993; 365:797.
5. Jones JE. Pinworms. Am Fam Physician 1988; 38:159.
6. Stĕrba J, Vlcek M. Appendiceal enterobiasis--its incidence and relationships to appendicitis.
Folia Parasitol (Praha) 1984; 31:311.
7. Wiebe BM. Appendicitis and Enterobius vermicularis. Scand J Gastroenterol 1991; 26:336.

8. Grencis RK, Cooper ES. Enterobius, trichuris, capillaria, and hookworm including
ancylostoma caninum. Gastroenterol Clin North Am 1996; 25:579.
9. Arca MJ, Gates RL, Groner JI, et al. Clinical manifestations of appendiceal pinworms in
children: an institutional experience and a review of the literature. Pediatr Surg Int 2004;
20:372.
10. da Silva DF, da Silva RJ, da Silva MG, et al. Parasitic infection of the appendix as a cause of
acute appendicitis. Parasitol Res 2007; 102:99.
11. Efared B, Atsame-Ebang G, Soumana BM, et al. Acute suppurative appendicitis associated
with Enterobius vermicularis: an incidental finding or a causative agent? A case report.
BMC Res Notes 2017; 10:494.
12. Sousa J, Hawkins R, Shenoy A, et al. Enterobius vermicularis-associated appendicitis: A 22-
year case series and comprehensive review of the literature. J Pediatr Surg 2022; 57:1494.
13. Liu LX, Chi J, Upton MP, Ash LR. Eosinophilic colitis associated with larvae of the pinworm
Enterobius vermicularis. Lancet 1995; 346:410.

14. Cacopardo B, Onorante A, Nigro L, et al. Eosinophilic ileocolitis by Enterobius vermicularis:

a description of two rare cases. Ital J Gastroenterol Hepatol 1997; 29:51.
15. Burkhart CN, Burkhart CG. Assessment of frequency, transmission, and genitourinary
complications of enterobiasis (pinworms). Int J Dermatol 2005; 44:837.
16. Patel B, Sharma T, Bhatt GC, Dhingra Bhan B. Enterobius vermicularis: an unusual cause of
recurrent urinary tract infestation in a 7-year-old girl: case report and review of the
literature. Trop Doct 2015; 45:132.

17. Tsai CY, Junod R, Jacot-Guillarmod M, et al. Vaginal Enterobius vermicularis diagnosed on
liquid-based cytology during Papanicolaou test cervical cancer screening: A report of two
cases and a review of the literature. Diagn Cytopathol 2018; 46:179.
18. Vasudevan B, Rao BB, Das KN, Anitha . Infestation of Enterobius vermicularis in the nasal
mucosa of a 12 yr old boy--a case report. J Commun Dis 2003; 35:138.
19. Drugs for Parasitic Infections, 3rd ed, The Medical Letter, New Rochelle, NY 2013.
20. Wang BR, Wang HC, Li LW, et al. Comparative efficacy of thienpydin, pyrantel pamoate,
mebendazole and albendazole in treating ascariasis and enterobiasis. Chin Med J (Engl)
1987; 100:928.
21. Horton J. Albendazole: a review of anthelmintic efficacy and safety in humans. Parasitology
2000; 121 Suppl:S113.
22. St Georgiev V. Chemotherapy of enterobiasis (oxyuriasis). Expert Opin Pharmacother 2001;
2:267.
23. Wendt S, Trawinski H, Schubert S, et al. The Diagnosis and Treatment of Pinworm Infection.
Dtsch Arztebl Int 2019; 116:213.

24. Naquira C, Jimenez G, Guerra JG, et al. Ivermectin for human strongyloidiasis and other
intestinal helminths. Am J Trop Med Hyg 1989; 40:304.
25. Ottesen EA, Campbell WC. Ivermectin in human medicine. J Antimicrob Chemother 1994;
34:195.
26. Heukelbach J, Wilcke T, Winter B, et al. Efficacy of ivermectin in a patient population
concomitantly infected with intestinal helminths and ectoparasites. Arzneimittelforschung
2004; 54:416.
27. Tietze PE, Jones JE. Parasites during pregnancy. Prim Care 1991; 18:75.
28. Van Riper G. Pyrantel pamoate for pinworm infestation. Am Pharm 1993; NS33:43.
29. Diav-Citrin O, Shechtman S, Arnon J, et al. Pregnancy outcome after gestational exposure to
mebendazole: a prospective controlled cohort study. Am J Obstet Gynecol 2003; 188:282.
30. Centers for Disease Control and Prevention. Parasites - Enterobiasis (also known as Pinwor
m Infection): Prevention and Control. https://www.cdc.gov/parasites/pinworm/prevent.htm
 l (Accessed on March 03, 2021).
31. Cooper E. Trichuriasis. In: Tropical Infectious Diseases: Principles, Pathogens and Practice,
3rd ed, Guerrant R, Walker DH, Weller PF (Eds), Saunders Elsevier, Philadelphia 2011. p.791.
32. Bundy DA. Epidemiological aspects of Trichuris and trichuriasis in Caribbean communities.
Trans R Soc Trop Med Hyg 1986; 80:706.
33. Nokes C, Grantham-McGregor SM, Sawyer AW, et al. Moderate to heavy infections of
Trichuris trichiura affect cognitive function in Jamaican school children. Parasitology 1992;
104 ( Pt 3):539.
34. Forrester JE, Bailar JC 3rd, Esrey SA, et al. Randomised trial of albendazole and pyrantel in
symptomless trichuriasis in children. Lancet 1998; 352:1103.
35. Tarafder MR, Carabin H, Joseph L, et al. Estimating the sensitivity and specificity of Kato-
Katz stool examination technique for detection of hookworms, Ascaris lumbricoides and
Trichuris trichiura infections in humans in the absence of a 'gold standard'. Int J Parasitol
2010; 40:399.
36. Knopp S, Speich B, Hattendorf J, et al. Diagnostic accuracy of Kato-Katz and FLOTAC for
assessing anthelmintic drug efficacy. PLoS Negl Trop Dis 2011; 5:e1036.
37. Pilotte N, Papaiakovou M, Grant JR, et al. Improved PCR-Based Detection of Soil
Transmitted Helminth Infections Using a Next-Generation Sequencing Approach to Assay
Design. PLoS Negl Trop Dis 2016; 10:e0004578.
38. Phuphisut O, Yoonuan T, Sanguankiat S, et al. Triplex polymerase chain reaction assay for
detection of major soil-transmitted helminths, Ascaris lumbricoides, Trichuris trichiura,
Necator americanus, in fecal samples. Southeast Asian J Trop Med Public Health 2014;
45:267.

39. Mationg MLS, Gordon CA, Tallo VL, et al. Status of soil-transmitted helminth infections in
schoolchildren in Laguna Province, the Philippines: Determined by parasitological and
molecular diagnostic techniques. PLoS Negl Trop Dis 2017; 11:e0006022.
40. Moser W, Schindler C, Keiser J. Efficacy of recommended drugs against soil transmitted
helminths: systematic review and network meta-analysis. BMJ 2017; 358:j4307.
41. Matamoros G, Sánchez A, Gabrie JA, et al. Efficacy and Safety of Albendazole and High-Dose
Ivermectin Coadministration in School-Aged Children Infected With Trichuris trichiura in
Honduras: A Randomized Controlled Trial. Clin Infect Dis 2021; 73:1203.
42. Speich B, Ame SM, Ali SM, et al. Oxantel pamoate-albendazole for Trichuris trichiura
infection. N Engl J Med 2014; 370:610.
 43. Sirivichayakul C, Pojjaroen-Anant C, Wisetsing P, et al. The effectiveness of 3, 5 or 7 days of
albendazole for the treatment of Trichuris trichiura infection. Ann Trop Med Parasitol 2003;
97:847.
44. Hall A, Nahar Q. Albendazole and infections with Ascaris lumbricoides and Trichuris
trichiura in children in Bangladesh. Trans R Soc Trop Med Hyg 1994; 88:110.
45. Steinmann P, Utzinger J, Du ZW, et al. Efficacy of single-dose and triple-dose albendazole
and mebendazole against soil-transmitted helminths and Taenia spp.: a randomized
controlled trial. PLoS One 2011; 6:e25003.
46. Clarke NE, Doi SAR, Wangdi K, et al. Efficacy of Anthelminthic Drugs and Drug
Combinations Against Soil-transmitted Helminths: A Systematic Review and Network Meta-
analysis. Clin Infect Dis 2019; 68:96.
47. Hürlimann E, Keller L, Patel C, et al. Efficacy and safety of co-administered ivermectin and
albendazole in school-aged children and adults infected with Trichuris trichiura in Côte
d'Ivoire, Laos, and Pemba Island, Tanzania: a double-blind, parallel-group, phase 3,
randomised controlled trial. Lancet Infect Dis 2022; 22:123.
48. Marti H, Haji HJ, Savioli L, et al. A comparative trial of a single-dose ivermectin versus three
days of albendazole for treatment of Strongyloides stercoralis and other soil-transmitted
helminth infections in children. Am J Trop Med Hyg 1996; 55:477.

49. Wimmersberger D, Coulibaly JT, Schulz JD, et al. Efficacy and Safety of Ivermectin Against
Trichuris trichiura in Preschool-aged and School-aged Children: A Randomized Controlled
Dose-finding Trial. Clin Infect Dis 2018; 67:1247.
50. Moser W, Ali SM, Ame SM, et al. Efficacy and safety of oxantel pamoate in school-aged
children infected with Trichuris trichiura on Pemba Island, Tanzania: a parallel, randomised,
controlled, dose-ranging study. Lancet Infect Dis 2016; 16:53.
51. Speich B, Ali SM, Ame SM, et al. Efficacy and safety of albendazole plus ivermectin,
albendazole plus mebendazole, albendazole plus oxantel pamoate, and mebendazole
alone against Trichuris trichiura and concomitant soil-transmitted helminth infections: a
four-arm, randomised controlled trial. Lancet Infect Dis 2015; 15:277.
52. GoodRx. Emverm. https://www.goodrx.com/emverm (Accessed on December 02, 2020).
Topic 5692 Version 39.0
GRAPHICS

Enterobiasis life cycle

Eggs are deposited on perianal folds (1). Self-infection occurs by

transferring infective eggs to the mouth with hands that have
scratched the perianal area (2). Person-to-person transmission can
also occur through handling of contaminated clothes or bed linens.
Enterobiasis may also be acquired through surfaces in the
environment that are contaminated with pinworm eggs (eg, curtains,
carpeting). Some small number of eggs may become airborne and
inhaled. These would be swallowed and follow the same development
as ingested eggs. Following ingestion of infective eggs, the larvae
hatch in the small intestine (3) and the adults establish themselves in
the colon (4). The time interval from ingestion of infective eggs to
oviposition by the adult females is about one month. The life span of
the adults is about two months. Gravid females migrate nocturnally
outside the anus and oviposit while crawling on the skin of the perianal
area (5). The larvae contained inside the eggs develop (the eggs
become infective) in four to six hours under optimal conditions (1).
Retroinfection, or the migration of newly hatched larvae from the anal
skin back into the rectum, may occur but the frequency with which this
happens is unknown.

Reproduced from: Centers for Disease Control and Prevention. DPDx: Enterobiasis.
Available at: http://www.cdc.gov/dpdx/enterobiasis/index.html.

Graphic 57681 Version 3.0

Enterobius worm

Male and female Enterobius vermicularis, mounted specimens.

Reproduced from: Centers for Disease Control and Prevention. Enterobiasis: Image
Gallery. Available at: https://www.cdc.gov/dpdx/enterobiasis/index.html (Accessed on
May 14, 2021).

Graphic 131524 Version 1.0

Enterobius eggs

(A) Eggs of E. vermicularis in a cellulose-tape preparation.

(B) Eggs of E. vermicularis in a wet mount.

(C) Egg of E. vermicularis in an iodine-stained wet mount from a formalin

concentrate.

(D) Eggs of E. vermicularis viewed under UV microscopy.

Reproduced from: Centers for Disease Control and Prevention. DPDx: Enterobiasis. Available at:
http://www.cdc.gov/dpdx/enterobiasis/index.html.

Graphic 65366 Version 5.0

Trichuriasis life cycle

The unembryonated eggs are passed with the stool (1). In the soil, the
eggs develop into a two-cell stage (2), an advanced cleavage stage (3), and
then they embryonate (4); eggs become infective in 15 to 30 days. After
ingestion (soil-contaminated hands or food), the eggs hatch in the small
intestine, and release larvae (5) that mature and establish themselves as
adults in the colon (6). The adult worms (approximately 4 cm in length) live
in the cecum and ascending colon. The adult worms are fixed in that
location, with the anterior portions threaded into the mucosa. The females
begin to oviposit 60 to 70 days after infection. Female worms in the cecum
shed between 3000 and 20,000 eggs per day. The life span of the adults is
about one year.

Reproduced from: Centers for Disease Control and Prevention. DPDx: Trichuriasis. Available
at: http://www.cdc.gov/dpdx/trichuriasis/index.html.

Graphic 75177 Version 3.0

Trichuriasis rectal prolapse

Rectal prolapse due to trichuriasis. White adult worms can be seen

on the surface of the mucosa.

From the collection of Herman Zaiman, "A Presentation of Pictorial Parasites."

Reproduced with permission from: the American Society of Tropical Medicine and
Hygiene.

Graphic 87128 Version 1.0

Trichuriasis eggs

(A) Egg of T. trichiura in an iodine-stained wet mount.

(B) Egg of T. trichiura in an unstained wet mount.

(C) Egg of T. trichiura in an unstained wet mount.

(D) Two eggs of T. trichiura, showing the variability in size of the species.

Reproduced from: Centers for Disease Control and Prevention. DPDx: Trichuriasis. Available at:
http://www.cdc.gov/dpdx/trichuriasis/index.html.

Graphic 54175 Version 5.0

Trichuriasis scope

Image showing the posterior end of an adult T. trichiura, taken

during a colonoscopy.

Reproduced from: Centers for Disease Control and Prevention. Parasites and Health:
Trichuriasis. Available at: http://www.cdc.gov/parasites/whipworm/.

Graphic 68026 Version 4.0

Contributor Disclosures
Karin Leder, MBBS, FRACP, PhD, MPH, DTMH No relevant financial relationship(s) with ineligible
companies to disclose. Peter F Weller, MD, MACP Consultant/Advisory Boards: GlaxoSmithKline
[Eosinophilic diseases]. Other Financial Interest: AstraZeneca [Hypereosinophilic syndrome]. All of the
relevant financial relationships listed have been mitigated. Edward T Ryan, MD,
DTMH Grant/Research/Clinical Trial Support: Sanofi [Yellow fever]. All of the relevant financial relationships
listed have been mitigated. Morven S Edwards, MD Grant/Research/Clinical Trial Support: Pfizer [Group B
Streptococcus]. Other Financial Interest: Texas State University personal services agreement [Chagas
disease]. All of the relevant financial relationships listed have been mitigated. Elinor L Baron, MD,
DTMH No relevant financial relationship(s) with ineligible companies to disclose.

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.

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