African trypanosomiasis

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Pathogen

• Trypanosoma brucei
  • Trypanosoma brucei gambiense
  • Trypanosoma brucei rhodesiense

Morphology

1. amastigote
2. promastigote
3. epimastigote
4. trypomastigote

nucleus, kintoplast, undulating membrane, flagellum

Life cycle

• T. brucei group don't infect human cells
• T. cruzi needs to infect human cells to multiply

Vector

• tsetse fly
  • genus Glossina
  • adult 6-15 mm long

Epidemiology

• >70% of cases in recent 10 years are reported from DRC
• 10-100 new cases in a year in Angola, Central African Republic, Chad, Congo Republic, Gabon, Guinea, Malawi and South Sudan

African trypanosomiasis

• Sleeping sickness

	Trypanosoma brucei gambiense	Trypanosoma burcei rhodesiense	Trypanosoma brucei brucei
Distribution	West Africa Broader area to the west of Great Rift Valley In 24 countries	East Africa Limited to the east of Great Rift Valley In 13 countries	Trypanosomiasis of stock and wild animals Called as "Nagana"
Vector	Glossina palpalis In humid environment rivers and waterholes Anthroponotic; human-to-human	Glossina morsitans In dryer environment Savannah Mainly bite animals
Infectivity	Mainly infect to human Adapted to human, leading to relatively slow and mild disease progression	Mainly infect to animals Adapted to animals, leading to relatively rapid progress of disease
Human infection	98% of total cases Chronic infection Incubation months to years	2% of total cases Acute infection Incubation weeks to months	No human case

Pathogenesis

1. trypanosomal chancre after tsetse fly bite
2. acute hemolymphatic stage
   1. fever, headache, myalgia, arthralgia, lymphadenopathy, splenomegaly
3. chronic meningoencephalitic stage
   1. headache, alteration of mental status, coma

• more acute by T. brucei rhodesiense, slower by T. brucei gambiense

Diagnosis

• serology
  • card agglutination test for trypanosomiasis (CATT)
  • mass population screening
  • low sensitivity/specificity
• molecular
  • PCR, LAMP
• microscopy
  • chancre fluid, blood, lymph node aspirate, CSF
    • centrifugation and examination of buffy coat
  • wet praparation for motile trypanosoma
  • Giemsa stain (with fixed)

Define the clinical stage of rhodesiense

• lumbar puncture
  • CSF WBC > 5 cell/mm³ stage 2

Treatment

• should commence in earlier stage
  • difficult to treat in CNS involvement
• acute stage
  • suramin > pentamidine
  • suramin side effects
    • 90% urticaria
    • 50% adrenal cortical damage
    • peripheral neuropathy - axonal or demyelinating
    • renal dysfunction
• chronic stage
  • melarsoprol (Mel B)
    • only for T. b. rhodesiense
  • eflornithine (DL-a-difluoromethilornithine; DFMO)
    • only for T. b. gambiense
  • nifurtimox-eflornithine; NECT
    • only for T. b. gambiense
• both stage
  • fexinidazole
    • only for T. b. gambiense
    • should be administered within 30 min. after solid meal