British Medical Journal
To the Editor
September 5th 1991
GUT TRICHOMONIASIS AS A CAUSE OF APPENDICOPATHY
Sir, - I would like to give some remarks as to the article of Dr. Seuri
about higher incidence of appendectomy in persons having frequent
contact with pigs (1).
I have recently had a female patient, 29 years of age, wife of a
swineherd, having genital trichomoniasis since delivery 6 years ago.
She had clinical exacerbations 3-4 times a year and persistently
positive findings in cervical smears. In the initial phase of
exacerbations, parasites and trophozoites have been found, while in
remissions they have been found in cervical mucus in aflagellary
Five months ago, she was sent by a practitioner to gynaecologist
because of pains in the lower stomach. Quite normal finding of inner
genital organs was established, but surprisingly, microscopic finding
of trichomonads in cervical mucus was negative. The patient was sent to
a surgeon and the appendectomy was made the same day.
Having been intrigued by spontaneous clearing of cervical mucus, I
examined microscopically stained wet films of the squeezed excaudate
from amputated inflamed appendix and aflagellary form of trichomonads
was detected. As the culture was negative, it was not possible to
determine the parasite species. At the gynaecological examination, 3
months after the appendectomy, cervical smear became positive again.
As the main cause of appendicitis has not been recognised since now,
various bacteria have been given more or less importance. However, Dr.
Seuri’s finding is in positive correlation also with the very frequent
Trichomonas suis infection of the whole digestive tract of pigs, mostly
in cecum. On the other hand, Trichomonas Hominis (Intestinalis)
infection of the human guts is not rare, mostly in cecum and appendix.
Trichomonads are obligatory immunogenic agents, even if they are
localised intraluminally, and all 3 human species have crossed
immunity. Longstanding and polystrain sensitization of man by
Trichomonas suis antigens can exhaust immune apparatus, well known
event in parasitoses. In such cases, pre-existing appendix
trichomoniasis of man, especially associated with (micro) trauma of
mucosa, can widen epithelia lesion, or at least prevent
re-epithelisation, thus enabling deeper invasion of the bacteria. To my
knowledge, the only study about trichomonas infection of inflamed
appendix, using direct microscopic examination of cuted appendix,
reports an 8% incidence (2).
Rare incidence of appendectomy in woman, in Dr. Seuri’s report, could
be attributed to frequent trichomoniasis of genital tract in women,
which elicits protective immunity against extragenital trichomonas
infection. Frequent challenges with pig trichomonas antigen can weaken
immune resistance to pre-existing subclinical Trichomonas hominis
infection of appendix by man. The well known beneficial effect of
preoperative metronidazole use by appendectomy can be at least partly
ascribed to neglected gut trichomoniasis. So, Dr. Seuri’s finding of
the positive correlation between appendectomy and frequent contacts
with pigs, casts a new light on possible involvement of the Trichomonas
species in pathogenesis of Appendicitis.
Public Health Centre Stari Grad
University and Medical Centre
71000 Sarajevo, Yugoslavia
1. Seuri M. Risk of appendectomy in occupations
entailing contacts with pigs. BMJ 1991, 303:345-6.
2. Jašović M. The role of parasites in ethiology of
appendicopathy. Acta Chir Iugosl 1961, 8(9):