A disease caused by trypanosomes (a protozoa) and transmitted to humans by several species of tsetse fly
Cause
- Trypanosoma rhodesiense (mostly in the Central and Eastern regions of Uganda)
- Trypanosoma gambiense (mostly in West Nile region)
Clinical features
- May be history of tsetse fly bite and swelling at site of bite after 7-14 days (more often in rhodesiense, rarely in T. Gambiense)
T.Rhodesiense
- Incubation is 2-3 weeks
- Early stage (haemolymphatic stage): headache not responding to common analgesics, fever, generalised lymphadenopathy, joint pains
- Late stage (meningoencephalitis stage): after some weeks, neurological and psychiatric symptoms like apathy, day sleepiness, paralysis, seizures
- If not treated: cachexia, lethargy, coma and death within 3-6 months
T.gambiense
- Similar to the rhodesiense but less acute and with slower progression
- Incubation can last several years
Differential diagnosis
- Malaria, meningitis
- TB, HIV/AIDS
Investigations
- Blood: Slides for trypanosomes
- CSF: For trypanosomes, lymphocyte count
- Aspirate from chancre/lymph node: for trypanosomes
Management
This is based on the findings of the CSF analysis, determining the stage of disease. To determine the medicine of choice, the disease is divided into two stages: early and late stage
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STAGE
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FEATURES
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Early (first) stage
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- CSF is normal
- Lymphocytes <5 cells/mm3
- Total protein <37 mg/dl (by dye-binding protein assay) or < 25 mg/dl (by Double Standard & Centrifuge Method)
- Absence of trypanosomes (by Double Standard and Centrifuge Method)
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Late (second) stage
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- Lymphocytes > 5 cell/ mm3 And/or
- Presence of trypanosomes
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Patient with suspected or diagnosed sleeping sickness should be managed at referral facilities.
Treatment
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Early (first) stage
T. rhodesiense sleeping sickness
For both children and adults
Suramin IV
A test dose of 5 mg/kg of body weight should first be administered to test for anaphylactic reaction
Followed by five injections of 20 mg/kg every 5 days interval
Day 0: 5 mg/kg body weight
Day 3: 20 mg/kg body weight
Day 8: 20 mg/kg body weight
Day 13: 20 mg/kg body weight
Day 18: 20 mg/kg body weight
Day 23: 20 mg/kg body weight If anaphylaxis: do not administer
T. gambiense sleeping sickness
For both children and adults
Pentamidine IM 4 mg/kg daily for 7 days
Give food 1 hour before to prevent hypoglycaemia
The patient should be in a supine position during administration and 1 hour after to prevent hypertension
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RR |
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Late (second) stage
T. rhodesiense sleeping sickness
For both children and adults
- IV Melarsoprol 2.2 mg/kg body weight daily for 10 days
T.gambiense sleeping sickness Children ≤ 12 years and <35 kg
- Eflornithine IV 150 mg/kg 6 hourly for 14 days (total dose of 600 mg/kg/day.) Dilute 150 mg/kg dose of eflornithine into the 100 ml of distilled water. Administer the infusion over at least 2 hours
Children >12 years up to 15 years
- Eflornithine IV 100 mg/kg 6 hourly for 14 days (total dose of 400 mg/kg per day). Dilute the eflornithine dose of 100 mg/kg into the 100 ml of distilled water. Administer the infusion over at least 2 hours (rate 20 drops/minute)
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RR |
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Adults >15 years
- Nifurtimox/Elfornithine combination therapy (NECT)
- Nifurtimox: 5 mg/kg every 8 hours orally for 10 days (15 mg/kg/day)
- Plus Eflornithine 200 mg/kg 12 hourly for 7 days (400 mg/kg/day). Dilute Eflornithine dose of 200 mg/kg into 250 ml of distilled water and administer the infusion over at least 2 hours (50 drops/minute)
- Infusions are given slowly to prevent convulsions
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Relapses
- IV melarsoprol 2.2 mg/kg once daily for 10 days
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| Note:
Corticosteroids: Should be given to patients with late trypanosomiasis on melarsoprol who may have hypoadrenalism - the steroids may also reduce any drug reactions
Do not give hydrocortisone after day 24, even though the melarsoprol treatment is not yet complete
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If prednisolone is used instead of hydrocortisone, the anti-inflammatory action is similar but the correction of the hypoadrenalism will be much less marked
Suramin: Do not use this medicine for early or late stage T. gambiense treatment in onchocerciasis-endemic areas as it may cause blindness in any onchocerciasis-infected patients by killing the filariae in the eye
Prevention
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- Trapping of tsetse flies
- Clearing of bushes around homes and paths
- Early detection and treatment of cases
