Ten Years of Tryps and Tsetses

Lucille Blumberg & John Frean

National Institute for Communicable Diseases

Source: Simarro et al. PLoS Negl Trop Dis 2011; 5: e1007

Country of acquisition

Number of cases and sites, 2004-2014

Malawi 6 (Kasungu 5, Nkhotakota 1)

Zambia 6 (Luangwa Valley 3, Kasanka 2, Kafue 1)

Tanzania 3 (Serengeti)

Zimbabwe 3 (Kariba 1, Mana Pools 2)

Uganda 2 (Queen Elizabeth National Park, ?Murcheson Falls)

TOTAL 20

No. of cases (%)

Foreign tourist 9

Expatriate or resident 4

Conservationist 2

Game farmer 2

Foreign soldier, field exercise

1

Pilot: tourist transport 1

Church-related travel 1

TOTAL 20

Common management errors

• Poor history taking

• Narrow clinical vision

• Missing key clinical signs

• Delaying transfer to better care, including definitive treatment

• Incorrect application of diagnostic tests

• Inexperienced lab personnel

MISSED AND MIS-DIAGNOSIS

Trypanosomal

chancres

“23 - 27th October - my 27-yr-old cousin walked in the Luangwa Valley, eastern Zambia, ++ insect bites 1st November- severe joint and muscle ache, a splitting headache and fevers. 2nd Nov- “strange purple lesion” on her left ankle, which subsequently developed surrounding swelling3rd Nov - GP - Coartem and Amoxil, then 'Ciprovid'. She felt terrible and so was driven through to Lusaka.5th Nov - hospital 39.7 C, stable. Neg. tests . ………malaria, trypanosomal serology Another doctor saw her today and suspected tick bite fever, doxycycline RxInsurance company disallowed t/f to SA as her 'risk score' is 13, only transfer if < 4 So, all plans to fly her out have been abandoned…………..”

7th Nov- ‘Plts now 18, being given platelet transfusion and transfer tomorrow morning to JHB’.

Tick bite eschar

Patient’s lesion

Laboratory diagnostic aspects

• Blood– Thick and thin films, as for malaria

– May be very scanty: buffy coat, wet prep

HiPlease adviseInformed by Uthungulu district* that they have a patient with sleeping sicknessDetails very sketchy, confirmed by lab –awaiting results to be faxedUnable to get info from the ward- sister is off

*Richards Bay area, KwaZulu-Natal Province, South Africa

I went to see the patient …. 76 yrs, no travel history and she only stays with a 12 year old boy who is going to school.

Currently the patient is on the following treatment:diabetichypertensioniron supplement

Patient presented with anaemia, thrombocytopenia & leucocytosis. Clinically no symptoms of trypanosomiasis.

Peripheral blood smear done – indicated trypanosomaparasites in blood. They have not started any treatment pending results from IALCH as the recommended treatment of pentamidine – a bit cautious re side effects.

Lab diagnosis (cont’d)

CSF

• Timing and technique

• Microscopy

– May be very, very scanty

– Fragile: minimise delay in reaching lab

– Experienced technologist/medical scientist

– Double-spin method: caveats

Image: Marc Mendelson

Image: Marc Mendelson

Assessing CNS involvement

• Decreased level of consciousness is not necessarily a sign of CNS invasion

– Renal, hepatic, respiratory dysfunction/failure

• Lab findings - textbook:

>5 leucocytes/mm3 and/or protein >0.6 g/L

= CNS invasion,

BUT not in isolation………assess clinical context

67-yr-old hunter, ex Tanzania……rapid progression and deterioration -marked jaundice and liver dysfunction, profound thrombocytopenia -oozing from catheter sites, renal dysfunction, progressive deterioration in central nervous function with confusion and agitation. ARDS, no myocarditis.

Suramin therapy was commenced for the haemolymphatic stage of East African trypanosomiasis

CSF: cerebospinal fluid revealed the presence of 15 neutrophils, protein of 0.7 g/l but no trypanosomes.

Suramin: adverse reactions• Cardiovascular

collapse• Skin reaction• Nephrotoxicity• Longest 1/2 life

34-year-old game ranger, ex Mana Pools, Zimbabwe

• Admitted to UTH, Lusaka, Zambia

• Hb 5, WCC 2.3, platelets 15, tryps++ on smear

• Progressive deterioration in CNS

• CSF o/a: RBCs+++, tryps ++

• Renal failure: creat 850 µmol/l

CNS: tryps or not?

• Tourist, ex-Malawi

• Clinically well

• CSF: 126 cells, protein 0.6 gm/l

• No trypanosomes

• Hunter, ex-Tanzania

• Depressed, LOC and agitation

• CSF: 15 neutrophils, protein 0.7 gm/l

• No trypanosomes

Patients must earn their melarsoprol!

• CNS involvement confirmed

• Melarsoprol commenced – initial improvement then deterioration-convulsions…..died

• Melarsoprol encephalopathy: 10% incidence, 50% mortality

• Reduced by prednisolone priming

Middle-aged tourist, ex-Serengeti

Outcomes: 2004-2014

• 2 deaths: overall mortality 10%

– Kariba game rancher: myocarditis

– Serengeti tourist: CNS involvement, ?melarsoproltoxicity

• Treatment readily available in Johannesburg via NICD