Trichinosis Clinical Presentation

  • Author: Clinton Murray, MD; Chief Editor: Burke A Cunha, MD   more...
 
Updated: Jan 4, 2010
 

History

The European Center for Disease Control has proposed definitions and algorithms for diagnosis of acute trichinellosis in humans.[1] They focus on clinical, laboratory, and epidemiological criteria, along with a series of symptoms. The criteria can also be used to differentiate very unlikely, suspected, probable, highly probable, and confirmed cases (see Staging). Knowledge of the incubation period can help pinpoint the source of the infection, both in individual cases and in outbreaks.

Trichinellosis may progress from an enteric (ie, intestinal) phase to a parenteral (ie, invasive) phase to a period of convalescence.

  • The intestinal phase usually causes symptoms in the first week of illness.
    • Diarrhea is the most common symptom.
    • Constipation, anorexia, and diffuse weakness may occur.
    • Occasionally, severe enteritis due to a massive inoculum of Trichinella species occurs.
    • Symptoms typically last 2-7 days but may persist for weeks.
    • With certain Trichinella species and in certain population groups and geographic regions, the disease may not progress beyond the intestinal stage.
    • Nausea is reported in 15% of patients, vomiting in 3%, and diarrhea in 16%.
    • Dyspnea may occur with exertion.
    • Abdominal discomfort and cramps may occur.
  • The invasive phase corresponds to the migration of the larvae from the intestine to the circulatory system and eventually to the striated muscles. This phase is associated with a higher rate of symptoms than the intestinal stage.
    • The duration varies from weeks to months.
    • Severe myalgia develops in 89% of patients.
    • The central nervous system (CNS) is involved in 10%-24% of patients, with a mortality rate of 50%. Approximately 52% of patients present with headaches. Other symptoms include deafness, ocular disturbances, weakness, and monoparesis.
    • Cardiac system involvement occurs during the third week of infection, with a mortality rate of 0.1%, often during the fourth to eighth week of infection. Death may result from congestive heart failure and/or arrhythmias.
    • Pulmonary system involvement occurs in 33% of patients, with symptoms lasting up to 5 days. Patients present with dyspnea, a cough, and hoarseness.
  • The convalescent phase, which corresponds to encystment and repair, may be present for months to years after infection.
    • The encystment of larvae can lead to cachexia, edema, and extreme dehydration.
    • Symptoms usually decrease around the second month, except in the case of T pseudospiralis infection , which may cause symptoms for several months.
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Physical

  • Intestinal phase
    • Abdominal distention may be present.
    • Macular or petechial rashes affect 20% of patients.
    • Diarrhea may occur.
  • Invasive phase
    • After 2 weeks, 91% of patients have a fever that peaks around the fourth week. This degree of fever is unique among helminthic infections. Temperatures can reach 104°F (40°C).
    • Weakness and/or myositis occur in 82% of patients. Muscles become stiff, hard, and edematous. Muscles with increased blood flow (eg, extraocular muscles, masseters, larynx, tongue, neck muscles, diaphragm, intercostals, limb flexors, lumbar muscles) are most frequently involved. Involvement of the diaphragm may result in dyspnea.
    • Periorbital edema is reported in 77% of patients.
    • Rash (macular or petechial) is reported in 15%-65% of patients.
    • Ocular findings include subconjunctival hemorrhages in 9% of patients, conjunctivitis in 55%, and incidences of chemosis and retinal hemorrhage.
    • The CNS is involved in 10%-24% of patients. Of these, 53%-96% exhibit meningoencephalitis, 40%-73% exhibit focal paralysis and/or paresis, 39%-71% exhibit delirium, 20% exhibit decreased or absent deep-tendon reflexes, 17% exhibit meningitis, and 2% exhibit evidence of psychosis.
    • Signs of cardiac system involvement include hypertension, increased venous pressure, and, in 18% of patients, peripheral edema.
    • Subungual splinter hemorrhages occur in 8% of patients.
  • Convalescent phase
    • Edema is present in 18% of patients.
    • Patients are easily fatigued.
    • Weakness may occur.
    • Weight loss may occur.
    • Myalgia may occur.
    • Ocular signs with chronic headaches may be present.
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Causes

  • Trichinella species develop in a single host and are spread from that host to the next without an arthropod intermediate. The intensity and frequency of exposure to infected meat determine the severity of the disease.
  • Infections are related to cultural differences in food cooking and storing methods, specifically the inadequate cooking or freezing of meat.
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Contributor Information and Disclosures
Author

Clinton Murray, MD  Program Director, Infectious Disease Fellowship, San Antonio Uniformed Services Health Education Consortium

Clinton Murray, MD is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Association of Military Surgeons of the US, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Specialty Editor Board

Pranatharthi Haran Chandrasekar, MBBS, MD  Professor, Department of Internal Medicine, Director of Infectious Disease Fellowship, Harper Hospital, Wayne State University School of Medicine

Pranatharthi Haran Chandrasekar, MBBS, MD is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

John L Brusch, MD, FACP  Assistant Professor of Medicine, Harvard Medical School; Consulting Staff, Department of Medicine and Infectious Disease Service, Cambridge Health Alliance

John L Brusch, MD, FACP is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Eleftherios Mylonakis, MD  Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital

Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD  Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

References

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Trichinosis. Life cycle of Trichinella species parasite. (Image courtesy of the CDC)
Table. Important Characteristics of Trichinella Species
Species Distribution Major Host Reservoir Infectivity Resistance to Freezing
T spiralis (T1)CosmopolitanSwine, wild boar, bear, horse, foxHighNone
Trichinella nativa (T2)ArcticBear, horseHighHigh
Trichinella britovi (T3)TemperateWild boar, horseModerateNone
Trichinella pseudospiralis (T4)CosmopolitanBirds, omnivorous mammalsModerateNone
Trichinella murrelli (T5)Temperate, near arcticBearLowLow
Trichinella nelsoni (T7)TropicalWarthogHighNone
Trichinella papuae (T10)Papua New GuineaWarthogModerateNone
Trichinella zimbabwensis (T11)Central AfricaCrocodilesUnknownNone
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