Second stage African Trypanosomiasis presented as Non Convulsive Status Epilepticus

Human African Trypanosomiasis also known as sleeping sickness is a common disease in South Sudan. There are two recognized sstage, The early hemolymphatic stage and The late encephalitic stage when the CNS is involved specially with Gambians infection, broad neurologic spectrum has been reported such as psychiatric, motor, sensory. Our case highlights that late neurologic complications such as epilepsy should be considered in patients with long standing history of African Trypanosomiasis specially if they developed progressive mental and behavioral changes.


Introduction
Human African trypanosomiasis (HAT), also known as sleeping sickness, is caused by protozoan parasites. There are two forms of the disease: an acute form which occurs mainly in East Africa and caused by Trypanosoma brucei rhodesiense, and a more chronic form which mainly occurs in West and Central Africa, caused by Trypanosoma brucei gambiense.
Human African trypanosomiasis (HAT) is characterized by an early stage, known as the hemolymphatic stage, during which trypanosomes circulate in the blood or lymphatics, and a late stage, in which there is involvement of the central nervous system (CNS). Trypanosoma brucei gambiense causes a slowly progressive infection, and an oligo symptomatic phase can last for months or years.
Early infection (stage I) -Early symptoms of HAT infection include intermittent headache, fevers, malaise, and arthralgia. These symptoms may correspond with successive waves of parasitemia and antibody production. Hepatomegaly and particularly splenomegaly may be observed, and generalized lymphadenopathy may also be present. Other nonspeci c symptoms may be present including pruritus, rash, weight loss, and facial swelling. Neuroendocrine disturbances leading to amenorrhea in women or impotence in men may also occur. The duration of this phase is approximately three years in T. b. gambiense infection. In contrast, T. b. rhodesiense presents as an acute illness with poor demarcation between stages and leading to death within months.
Late infection (stage II) -Late infection refers to involvement of the central nervous system (CNS). The death rate is 100% in the absence of treatment. Stage II is de ned by an increase in the number of white blood cells (> 5 cells / microL) in the cerebrospinal uid. Activated plasma cells with eosinophilic inclusions containing IgM, called Mott morule cells, can be seen in cerebrospinal uid (CSF), Following early T. b. gambiense infection, progressive diffuse meningoencephalitis and parenchymal edema of the brain develop, with perivascular and meningeal in ammatory in ltrates, cerebral micro hemorrhages, and widespread multifocal white matter demyelination (Stage II). Symptoms include headache, di culty concentrating, di culty performing complex tasks (2 or 3 step activities), personality changes, psychosis, sensory disturbances, tremors, and ataxia. Meningismus and focal neurologic signs may occur, but are unusual. Disturbed circadian sleep / wakefulness frequently develops a cycle leading to daytime sleepiness. Seizures can occur, especially in children. The deterioration progresses gradually until the patient is in a stupor or coma.
Case description 16 year old boy from South Sudan referred to Sudan National Centre for Neurological Sciences with mental deterioration and behavioral changes for the last 9 months, to degree that he became unable to communicate with his family and inattentive to his surroundings, he had poor school performance ended by leaving school. There were no motor or sensory symptoms, and no symptoms related to other systems.
His past medical history is only signi cant to African Trypanosomiasis 3 years back which had been treated by combination therapy.
He has no family history of similar condition or neurological diseases.
Physical Exam: The patient was conscious disorientated to time ,place and persons . The patient showed remarkable improvement in his cognitive function and started to communicate with his family.
He had been referred back to his country as the combination therapy Nifurtimox-E ornithine for African Trypanosomiasis treatment is not available in Sudan after separation.

Discussion
In our case we suspected late second stage African Trypanosomiasis with neurological complications such as non convulsive state as the patient presented with progressive decline of his cognitive function and our suspicious was con rmed by EEG, and supported more by remarkable cognitive improvement with Anti Convulsant thearpy.

Conclusion
Our case highlights that late second stage African Trypanosomiasis with neurological complications such as non convulsive status epilepticus should be suspected in any patient who developed progressive cognitive decline and behavioral changes following long standing history of African Trypanosomiasis and routine Electro-encephalogram EEG is the best tool to diagnose non convulsive status epilepticus.
Medical health professionals should suspect second stage African Trypanosomiasis with neurological complications such as non convulsive status epilepticus in any patient who have history of African Early referral of the patients with second stage African Trypanosomiasis with progressive cognitive decline to Neurology Centers with Elector-encephalogram EEG facility might help to diagnose non convulsive status epilepticus in conjunction with early clinical suspicion of the condition will enhance the improvement of the prognosis.Further reporting of such cases is recommended.

Declarations
Ethics approval: Not applicable Consent to participate: Verbal and written consents were obtained from the patient before writing the case or using investigations.
A Consent for participation in the study and publishing the manuscript was taken from the Patient's Parents.

Consent for publication:
The patient gave writtenWritten consent to publish this information was obtained from the patient. consent for his personal clinical details along with his MRI images to be published in this study. This patient has not been reported in any other submission by the authors or anyone else.
Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

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