Multiple infections with helminths--whipworm, hookworm, and roundworm.

An 84-year-old woman presented with dyspnea due to an exacerbation of chronic heart failure caused by severe anemia (hemoglobin 4.4g/dL). Colonoscopy revealed a cloud of white worms moving among tarry stool in the cecum and ascending colon. The posterior portions of the worms were located in the colon lumen, while the anterior portions were firmly embedded in colon mucosa (●" Fig.1). One of the parasites was removed with biopsy forceps and identified as a whipworm (Trichuris trichiura). Esophagogastroduodenoscopy (EGD) showed significant infection with threadlike worms, which were clinging to the duodenalmucosaand suckingblood, causing mild erosion (●" Fig.2,●" Video1). The intestinal and reproductive organs of the parasite were observed on magnified endoscopy (●" Fig.3). While observing these worms, a largerwormwith a creamywhite color was seen moving freely through the lumen (●" Video1). Both of these worms were retrieved using biopsy forceps; the smaller organism was found to be a hookworm (Necator americanus) and the larger one was a roundworm (Ascaris lumbricoides). Capsule endoscopy (Pillcam SB capsule; Given Imaging, Yoqneam, Israel) revealed both hookworm and roundworm infection in the small intestine. The hookworms were observed withdrawing blood from intestinal mucosa (●" Fig.4, ●" Video2). Whipworms, hookworms, and roundworms are soil-transmitted helminths that present a major disease burden globally, but particularly in regions of poor sanitation. In this case, the entire gastrointestinal tract was examined, revealing that hookworms and roundworms infested the upper part of the small intestine, whereas whipworms lived in the large intestine. The patient was treated with a 3-day course of mebendazole. The eradication of parasites was confirmed on EGD and colonoscopy 2 weeks after completing pharmacotherapy.Noeggswere found in a subFig.1 Endoscopic image of a whipworm (Trichuris trichiura) in the colon. The anterior portion was embedded in the colon mucosa, while the posterior portion, with coiled tail, was present in the colon lumen. The intestinal organ of the worm was seen as a gray line. The anterior portion elongated in a rubberlike manner when removal was attempted. Fig.2 Endoscopic images of hookworms (Necator americanus) and a roundworm (Ascaris lumbricoides). Several hookworms were seen clinging to the duodenal mucosa, while a roundworm moved freely through the lumen. Examples of both worms were retrieved using biopsy forceps.