Case presentation in Case presentation in infectious diseaseinfectious disease報告人報告人 : I : I 22 陳師儀陳師儀地點地點 ::檢驗科會議室檢驗科會議室時間時間 : 94/12/26 10:00 AM : 94/12/26 10:00 AM Supervisor : Supervisor : 盧章智主任盧章智主任

Chief complain Chief complain

headache, anorexia, diarrhea, vomiting, chiheadache, anorexia, diarrhea, vomiting, chills, fever, night sweats, and increasing sleells, fever, night sweats, and increasing sleepiness for weeks piness for weeks

Present illnessPresent illness

A 25-year-old woman recently returned to A 25-year-old woman recently returned to USA from a 2-week safari vacation in USA from a 2-week safari vacation in Tanzania (East Africa)Tanzania (East Africa)

Visit several game parks during stay in Visit several game parks during stay in AfricaAfrica

ask help to ER complaining of as ask help to ER complaining of as mentioned for weeks mentioned for weeks

experience of many bug bites during her experience of many bug bites during her to game parksto game parks

Past and personal Hx Past and personal Hx

No mentioned in the caseNo mentioned in the case

Physical examPhysical exam

a pale, emaciated woman with a painless, a pale, emaciated woman with a painless, erythemtous lesion located on shouldererythemtous lesion located on shoulder

No adenopathy was notedNo adenopathy was noted

Lab dataLab data

B/R : systemic inflammatory responseB/R : systemic inflammatory response Platelet :75000 (15*10 Platelet :75000 (15*10 33 -40*10 -40*1033 ) ) CRP: 210 mg/l (<0.3)CRP: 210 mg/l (<0.3) Hgb: 8.5 g/dl (anemic ,which type ?)Hgb: 8.5 g/dl (anemic ,which type ?)

Blood smearBlood smear

A arge number of pleomorphic hemo-fkgellates, some being slender and some being stumpy, were visible

Slender type

Stumpy

type

Differential diagnosisDifferential diagnosis

Hemoflagellates

Leishmania Trypnosoma

Morphology of hemoflagellate of hMorphology of hemoflagellate of humanuman

Single promastigote form

pleomorphism

Differential diagnosisDifferential diagnosis

Hemoflagellates

Leishmania Trypnosoma

Differential diagnosisDifferential diagnosis

African trypanosomiasis (sleeping sicknesAfrican trypanosomiasis (sleeping sickness) , which type?s) , which type?

Difference between Difference between T .brucei rhodesienT .brucei rhodesiense and gambiencese and gambience

T. brucei gamT. brucei gambiencebience

T. BruceiT. Brucei

rhodesiencerhodesienceToxicity Toxicity Lower to human and Lower to human and

livestocklivestockHigher to human and Higher to human and livestocklivestock

Host Host reservoirreservoir

Human ,mostHuman ,most Animal ,mostAnimal ,most

vectorvector G .palpalis(G .palpalis( 帕舌蠅帕舌蠅 ))

((tsetse flytsetse fly))

G.Morsitans(G.Morsitans( 毛舌毛舌蠅蠅 ))

((tsetse flytsetse fly))

geographgeographic ic locationlocation

West Africa West Africa East AfricaEast Africa

habitathabitat River River Grassland and parkGrassland and park

Clinical Clinical featurefeature

ChancreChancre

Winterbottom”signWinterbottom”sign

ChancreChancre

Rapid progressionRapid progression of symptoms (within of symptoms (within several weeks)several weeks)

Geographic distributionGeographic distribution

G

R

Winterbottom ‘ signWinterbottom ‘ sign

Posterior neck Ln enlargement

Final diagnosisFinal diagnosis

Trypanosoma .brucei rhodesienceTrypanosoma .brucei rhodesience

TreatmentTreatment

Suramin (germanin)-early stageSuramin (germanin)-early stage Melarsoprol (Mel B -arsenical) –CNS toxicitMelarsoprol (Mel B -arsenical) –CNS toxicit

y y

Diagnosis criteriaDiagnosis criteria

Detection parasite in bloodstreamDetection parasite in bloodstream Enlarged lymph node aspirateEnlarged lymph node aspirate CSF fluid study –protein and cell contentCSF fluid study –protein and cell content Complement fixation test Complement fixation test Fluorescence antibody testFluorescence antibody test Elevated IgM count conc in blood and CSFElevated IgM count conc in blood and CSF

Thanks for your attention!Thanks for your attention!