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African Trypanosomiasis

(African Sleeping Sickness; Human African Trypanosomiasis; HAT)

By

Chelsea Marie

, PhD, University of Virginia;


William A. Petri, Jr

, MD, PhD, University of Virginia School of Medicine

Last review/revision Dec 2022
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Human African trypanosomiasis is infection with protozoa of the species Trypanosoma brucei, transmitted by the bite of a tsetse fly. Symptoms include characteristic skin lesions, intermittent fever, headache, rigors, transient edema, generalized lymphadenopathy, and often fatal meningoencephalitis. Diagnosis is by identification of the organism in blood, lymph node aspirate, or cerebrospinal fluid or sometimes by serologic tests. Treatment is with fexinidazole, suramin, pentamidine, melarsoprol, or eflornithine, depending on the infecting subspecies, clinical stage, and drug availability.

Human African trypanosomiasis is caused by Trypanosoma brucei gambiense in West and Central Africa and by T. brucei rhodesiense in East Africa; both species are endemic in Uganda. Trypanosoma brucei gambiense accounts for 98% of all cases of African trypanosomiasis, and T. brucei rhodesiense accounts for 2%. African trypanosomiasis has been targeted for eradication by the World Health Organization (WHO) and, as a result of control efforts, there has been a dramatic decrease (> 95%) in the number of reported cases worldwide. In 2021, approximately 800 combined cases were reported to the WHO, with over 90% caused by T. b. gambiense (see WHO: Human African trypanosomiasis). On average, 1 case is diagnosed in the US each year, always in travelers returning to the US from endemic regions.

The organisms are transmitted by tsetse flies and can be transmitted prenatally from mother to fetus. Rarely, the infection is transmitted through blood transfusions; theoretically, it could be transmitted through organ transplantation.

Pathophysiology of African Trypanosomiasis

Metacyclic trypomastigotes inoculated by tsetse flies transform into bloodstream trypomastigotes, which multiply by binary fission and spread through the lymphatics and bloodstream after inoculation. Bloodstream trypomastigotes multiply until specific antibodies produced by the host sharply reduce parasite levels. However, a subset of parasites escape immune destruction by a change in their variant surface glycoprotein and start a new multiplication cycle. The cycle of multiplication and lysis repeats.

Late in the course of African trypanosomiasis, trypanosomes appear in the interstitial fluid of many organs, including the myocardium and eventually the central nervous system. The cycle is continued when a tsetse fly bites an infected human or animal.

Humans are the main reservoir of T. b. gambiense, but this species may also reside in animals. Wild game animals are the main reservoir of T. b. rhodesiense.

Symptoms and Signs of African Trypanosomiasis

African trypanosomiasis has 3 stages:

  • Cutaneous

  • Hemolymphatic

  • Central nervous system

Cutaneous

A papule may develop at the site of the tsetse fly bite within a few days to 2 weeks. It evolves into a red, painful, indurated nodule that may ulcerate (trypanosomal chancre).

Hemolymphatic

Over several months in T. b. gambiense infection but a period of weeks with T. b. rhodesiense, intermittent fever, headaches, rigors, muscle and joint pain, and transient facial swelling develop. An evanescent, circinate erythematous rash may develop. It is most readily visible in light-skinned patients. Generalized lymphadenopathy often occurs.

Winterbottom sign (enlarged lymph nodes in the posterior cervical triangle) is characteristic with T. b. gambiense sleeping sickness.

Central nervous system (CNS)

In the Gambian form, CNS involvement occurs months to several years after onset of acute disease. In the Rhodesian form, disease is more fulminant, and CNS invasion often occurs within a few weeks.

CNS involvement can result in persistent headache, inability to concentrate, personality changes (eg, progressive lassitude and indifference), daytime somnolence, tremor, ataxia, and terminal coma.

Without treatment, death occurs within months of disease onset with T. b. rhodesiense and during the 2nd or 3rd year with T. b. gambiense. Untreated patients die in coma of undernutrition or secondary infections.

Diagnosis of African Trypanosomiasis

  • Light microscopy of blood (thin or thick smears) or other fluid sample

Diagnosis of African trypanosomiasis is made by identifying trypanosomes in fluid from a chancre, lymph node aspirate, blood, bone marrow aspirate, or, during the late stage of infection, cerebrospinal fluid (CSF). Preferred sources are blood smears for T. b. rhodesiense and fluid aspirated from an enlarged lymph node for T. b. gambiense. Wet preparations should be examined for motile trypanosomes, and smears should be fixed, stained with Giemsa (or Field) stain, and examined. The concentration of trypanosomes in blood is often low, and concentration techniques (eg, centrifugation, miniature anion-exchange centrifugation, quantitative buffy coat technique) enhance sensitivity.

Antibody detection assays are not very useful clinically because seroconversion occurs after the onset of symptoms. However, a card agglutination test for T. b. gambiense is useful in mass screening programs to identify candidates for microscopic examination.

A lumbar puncture Lumbar Puncture (Spinal Tap) Lumbar puncture is used to do the following: Evaluate intracranial pressure and cerebrospinal fluid (CSF) composition (see table Cerebrospinal Fluid Abnormalities in Various Disorders) Therapeutically... read more should be done in all patients with African trypanosomiasis. When CSF is involved, opening pressure may be increased, and CSF has elevated levels of lymphocytes ( 6 cells/mcL), total protein, and nonspecific IgM. In addition to trypanosomes, characteristic Mott cells (plasma cells with cytoplasmic vacuoles that contain immunoglobulin [Russell bodies]) may be present.

Other, nonspecific laboratory findings include anemia, monocytosis, and markedly elevated serum levels of polyclonal IgM.

Treatment of African Trypanosomiasis

Treatment of African trypanosomiasis is guided by species and stage of disease.

  • Without CNS involvement, fexinidazole or, alternatively, pentamidine for T. b. gambiense; suramin for T. b. rhodesiense

  • With CNS involvement, fexinidazole for nonsevere T. b. gambiense; eflornithine (if available) alone or in combination with nifurtimox, or melarsoprol (if eflornithine is not available), for severe T. b. gambiense; melarsoprol for T. b. rhodesiense

Fexinidazole is the first-choice treatment for nonsevere T. b. gambiense, with or without CNS involvement. (See the World Health Organization.) Fexinidazole is taken orally once a day for 10 days at the following doses:

  • For patients ≥ 35 kg: 1800 mg/day in the loading phase (4 days), followed by 1200 mg/day in the maintenance phase (6 days)

  • For patients 20 to 34 kg: 1200 mg/day in the loading phase (4 days), followed by 600 mg/day in the maintenance phase (6 days)

Criteria for outpatient treatment with fexinidazole include reliable adherence to dosing, absence of psychiatric disorders, and body weight ≥ 35 kg.

Criteria for inpatient treatment includes any of the following characteristics:

  • Body weight < 35 kg

  • At risk for poor compliance

  • History of psychiatric disorders (to monitor for neuropsychiatric reactions)

Patients with signs and symptoms of severe disease should be evaluated by lumbar puncture and cerebrospinal fluid (CSF) examination. Patients with severe disease (white blood cell count ≥ 100 cells/microL in CSF), where lumbar puncture is not feasible, or who cannot be treated with fexinidazole should be treated as outlined below.

Without central nervous system (CNS) involvement

Fexinidazole is the first-choice treatment for nonsevere T. b. gambiense without CNS involvement.

Pentamidine and suramin are effective against bloodstream stages of both T. brucei subspecies but do not cross the blood-brain barrier and are not useful for CNS infection.

Pentamidine is used for T. b. gambiense in patients not treated with fexinidazole.

Suramin is the only drug effective for the hemolymphatic stage of T. b. rhodesiense. Suramin is not used to treat T. b. gambiense, because although potentially effective, it has been associated with adverse effects, including nausea, vomiting, photophobia, hyperesthesias, peripheral neuropathy, nephrotoxicity, urticaria, and pruritus. Also, serious hypersensitivity reactions can occur in patients co-infected with Onchocerca volvulus, which is endemic in many areas of West Africa where T. b. gambiense occurs.

The dosage of pentamidine is 4 mg/kg IM or IV once a day for 7 to 10 days.

An initial test dose of suramin (available from the Centers for Disease Control and Prevention [CDC]) 100 mg IV (to exclude hypersensitivity) is followed by 20 mg/kg (up to 1 g) IV on days 1, 3, 7, 14, and 21.

With central nervous system (CNS) involvement

Fexinidazole is the first-choice treatment for nonsevere disease with CNS involvement due to T. b. gambiense.

When available, eflornithine 100 mg/kg IV every 6 hours for 14 days is used for severe disease with CNS involvement due to T. b. gambiense (eflornithine is ineffective for T. b. rhodesiense). WHO recommends eflornithine 200 mg/kg IV every 12 hours for 7 days in combination with nifurtimox 5 mg/kg orally 3 times a day for 10 days (1 Treatment reference Human African trypanosomiasis is infection with protozoa of the species Trypanosoma brucei, transmitted by the bite of a tsetse fly. Symptoms include characteristic skin lesions, intermittent... read more Treatment reference ). Eflornithine (100 mg/kg IV every 6 hours for 14 days) monotherapy may be given when nifurtimox is unavailable or contraindicated and when fexinidazole cannot be given. Adverse effects of eflornithine include gastrointestinal symptoms, bone marrow suppression, and seizures. Common adverse effects of nifurtimox are anorexia, nausea, vomiting, weight loss, polyneuropathy, headache, dizziness, and vertigo.

Melarsoprol, an organic arsenical, is often used in African countries because of the limited availability of eflornithine, even though adverse effects can be severe and life threatening. Melarsoprol dosage is as follows:

  • For T. b. gambiense: 2.2 mg/kg (maximum dose 180 mg) IV once a day for 10 days

  • For T. b. rhodesiense: 2 to 3.6 mg/kg IV once a day for 3 days; after 7 days, 3.6 mg/kg once a day for 3 days, followed 7 days later by another 3-day course at this dose

In the US, eflornithine, nifurtimox, and melarsoprol can be obtained from the CDC.

Alternative regimens have been proposed for debilitated patients with severe CNS involvement. Serial follow-up examinations, including cerebrospinal fluid analysis, are recommended every 6 months (sooner if symptoms return) for 2 years.

Serious adverse effects of melarsoprol include encephalopathic reactions, exfoliative dermatitis, cardiovascular toxicity (hypertension, arrhythmia, heart failure), and the gastrointestinal and renal toxicity of arsenicals.

Corticosteroids have been used to decrease the risk of encephalopathic reactions.

There is no test of cure. After treatment, patients should be monitored for relapse for 24 months. Recurrence of symptoms necessitates re-examination of CSF for parasites.

Treatment reference

Prevention of African Trypanosomiasis

Prevention of African trypanosomiasis includes avoiding endemic areas and protecting against tsetse flies.

Visitors to game parks should wear substantial wrist- and ankle-length clothing (tsetse flies bite through thin clothes) in neutral colors that blend with the background and should use insect repellents, although efficacy of repellents against tsetse flies may be limited.

Pentamidine can help prevent T. b. gambiense infection, but it may damage pancreatic beta cells, resulting in insulin release and hypoglycemia followed later by diabetes; thus, it is no longer used for prophylaxis.

Key Points

  • African trypanosomiasis is caused by Trypanosoma brucei gambiense in West and Central Africa and by T. b. rhodesiense in East Africa; tsetse flies are the main vector.

  • There are 3 stages of disease: cutaneous, hemolymphatic, and CNS (sleeping sickness).

  • Diagnose using light microscopy of blood (thin or thick smears) or another fluid sample.

  • Treatment of African trypanosomiasis varies by species and stage of disease.

  • Without CNS involvement, use fexinidazole or, alternatively, pentamidine for T. b. gambiense and suramin for T. b. rhodesiense.

  • With CNS involvement, use fexinidazole for nonsevere T. b. gambiense; eflornithine (if available) alone or in combination with nifurtimox, or melarsoprol (if eflornithine is not available) for severe T. b. gambiense; and melarsoprol for T. b. rhodesiense.

More Information

The following English-language resource may be useful. Please note that The Manual is not responsible for the content of this resource.

Drugs Mentioned In This Article

Drug Name Select Trade
NebuPent, Pentam
Vaniqa
Lampit
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