Manuscript titleInfection with male and femaleTrichuris trichiuradiagnosed in a non-epidemic areaAuthors: Masaki Inoue1, Marin Ishikawa2, Sho Tanaka1, Xinhan Zhang1, Hiromi Okada3, Takuto Miyagishima11 Department of Gastroenterology, Kushiro Rosai Hospital, Kushiro, Japan.2 Genomics Unit, Keio Cancer Center, Keio University School of Medicine, Tokyo, Japan.3 Department of Surgical Pathology, Kushiro Rosai Hospital, Kushiro, Japan.Corresponding author: Masaki Inoue, MD, PhD, Department of Gastroenterology, Kushiro Rosai Hospital, 13-23, Nakazonocho, Kushiro, Hokkaido 085-8533, Japan.Tel: +81-154-22-7191E-mail: [email protected] statement: Written informed consent was obtained from the patient to publish this report in accordance with the journal’s patient consent policy.Key words: endoscopy, Trichuris trichiura , parasite, whipwormConflict-of-interest statement: We have no financial relationships to disclose.Funding and Acknowledgement details: NoneExplanationA Burmese man in his 20s underwent colonoscopy at our hospital in Japan because of abdominal discomfort. He had come to Japan from Myanmar two years ago and had worked on a pig farm. He had had diarrhea for five months and was taking a drug for controlling intestinal function but had persistent abdominal discomfort. Blood samples showed elevated fractions of eosinophils (white blood cells 7900/μL, eosinophils 15.6%). Colonoscopy (PCF-H290ZI; Olympus, Tokyo, Japan) showed that there were four whipworms including one brown whipworm and three white whipworms in the cecum and ascending colon. The white whipworm was attached to the cecum mucosa ([Fig. 1], [Fig. 2]). The brown one was detected at the ascending colon. Magnified endoscopy and narrow band imaging showed that it had a stripe pattern and that its cranium was burrowing under the colonic mucosa ([Fig. 3]). The whipworms coiled themselves up and wound slowly in response to a stimulus. We removed all of them by using biopsy forceps. Histopathological examination revealed that the brown one was a female whipworm (Trichuris trichiura ) and the three white worms were male ([Fig. 4], [Fig. 5]). The female had a uterus with worm eggs. The egg inspection was negative. After oral administration of Mebendazole, his abdominal discomfort disappeared.T. trichiura 　infection is prevalent in tropical regions and non-epidemic in Japan. T. trichiura is thought to live for one to eight years as an adult [1]. Therefore, the worms that the patient was infected with in Myanmar could have lived for two years in Japan.T. trichiura parasitizes only humans through fecal-oral transmission. In non-epidemic areas, the frequency of endoscopic identification has been increasing due to the increasing number of immigrants from epidemic countries [2]. To prevent infection, it is important to pay attention to sanitary conditions such as soil and water sources [3].References[1] D.E. ElliotIntestinal wormsM. Feldman, L.S. Friedman, L.J. Brandt (Eds.), Sleisenger and Fordtran’s gastrointestinal and liver disease: pathophysiology/diagnosis/management (8th ed), Elsevier, Philadelphia (2006), pp. 2435-2457[2] Lorenzetti R, Campo SM, Stella F, Hassan C, Zullo A, Morini S. An unusual endoscopic finding: Trichuris trichiura . Case report and review of the literature. Dig Liver Dis. 2003 Nov;35(11):811-3. doi: 10.1016/s1590-8658(03)00455-9. PMID: 14674673.[3] Kattula D, Sarkar R, Rao Ajjampur SS, Minz S, Levecke B, Muliyil J, Kang G. Prevalence & risk factors for soil transmitted helminth infection among school children in south India. Indian J Med Res. 2014 Jan;139(1):76-82. PMID: 24604041; PMCID: PMC3994744.Figure 1A white whipworm in the cecum. Histopathological examination revealed that it was a male worm. The other two white whipworms were in the ascending colon.Figure 2A brown whipworm in the ascending colon. Histopathological examination revealed that it was a female worm.Figure 3A picture of the female worm obtained by using narrow band imaging showed that its cranium was burrowing under the colonic mucosa.Figure 4Histopathological image of a male whipworm.Figure 5Histopathological image of the female whipworm.