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 nonspecific 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 defined by an increase in the number of white blood cells (> 5 cells / microL) in the cerebrospinal fluid. Activated plasma cells with eosinophilic inclusions containing IgM, called Mott morule cells, can be seen in cerebrospinal fluid (CSF), Following early T. b. gambiense infection, progressive diffuse meningoencephalitis and parenchymal edema of the brain develop, with perivascular and meningeal inflammatory infiltrates, cerebral micro hemorrhages, and widespread multifocal white matter demyelination (Stage II). Symptoms include headache, difficulty concentrating, difficulty 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.
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 significant to African Trypanosomiasis 3 years back which had been treated by combination therapy.
He has no family history of similar condition or neurological diseases.
The patient was conscious disorientated to time ,place and persons .
Abbreviated mini mental score was zero. There was no signs of meningeal irritation, intact cranial nerves, normal fundal examination. Normal upper and lower limbs motor examinations. Sensations were intact. Stable vital signs Other systems examinations were unremarkable.
Routine laboratory investigations:
Complete haemogram was normal apart from low Hb% 8.9g\dl M.C.V 65.5fl
Renal and liver function tests were normal
Blood for trypanosomiasis:
Buffy coat preparation: no trypanosome seen
Wet preparation: no trypanosoma seen
Thin blood film: no trypanosoma seen
CSF Fluid Analysis:
Cells : less than 5 cells/ml,Glucose : 8.7 mg/dl,LDH : 27 u/l
Protein : 29.3 mg/dl
Card Agglutination Trypanosomiasis Test was positive
MRI Brain was normal
US abdomen: was normal apart from slightly enlarged spleen with normal texture
Was suggestive of on-going generalized seizure activity
-Intravenous Phenytoin loading and maintenance, Oral Carbamazepine 400mg twice/day and tonics
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-Eflornithine for African Trypanosomiasis treatment is not available in Sudan after separation.