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African Trypanosomiasis Treatment & Management

  • Author: Randy O Odero, MB, ChB; Chief Editor: Pranatharthi Haran Chandrasekar, MBBS, MD  more...
 
Updated: Apr 11, 2016
 

Approach Considerations

Prehospital care of African trypanosomiasis (sleeping sickness) centers on management of the acute symptoms of fever and malaise in conjunction with close monitoring of the patient’s neurologic status. In the emergency department, if central nervous system (CNS) symptoms are severe, airway management to prevent aspiration becomes important, along with an immediate blood smear, complete blood count (CBC), and lumbar puncture for trypanosome detection.

If late stage disease is present or CNS disease complications and coma occur, intensive care unit (ICU) staff are needed while treatment is administered (ie, melarsoprol for East African trypanosomiasis or eflornithine for West African trypanosomiasis). Potential adverse effects from such drugs, including hematologic, renal, and hepatic function must be monitored.

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Pharmacologic Therapy

The type of drug treatment used depends on the type and stage of African trypanosomiasis (sleeping sickness). Management recommendations were published in The Medical Letter on Drugs and Therapeutics in March 2000 (see the Table below).[10]

Table. Medications Recommended for Treatment of African Trypanosomiasis (Open Table in a new window)

Type of Trypanosomiasis Medications
Stage 1 (Early or Hemolymphatic Stage) Stage 2 (Late or Neurologic Stage)
East African trypanosomiasis (caused by Trypanosoma brucei rhodesiense) Suramin 100-200 mg IV test dose, then 1 g IV on days 1, 3, 7, 14, 21 Melarsoprol 2-3.6 mg/kg/day IV for 3 days; after 1 week, 3.6 mg/kg/day for 3 days; after 10-21 days, repeat cycle
West African trypanosomiasis (caused by Trypanosoma brucei gambiense) Pentamidine isethionate 4 mg/kg/day IM for 10 days



or



Suramin 100-200 mg IV test dose, then 1 g IV on days 1, 3, 7, 14, 21



Nifurtimox-eflornithine combination therapy (NECT): Nifurtimox 5 mg/kg PO q8h for 10 days and eflornithine 200 mg/kg IV q12h for 7 days



or



Eflornithine 400 mg/kg/day IV in 2 divided doses for 14 days



or



Melarsoprol IV for 10 days



For the treatment of late-stage T brucei gambiense trypanosomiasis, combination therapy may be more effective than monotherapy. In an open randomized trial comparing melarsoprol monotherapy (2 different regimens), nifurtimox monotherapy, and melarsoprol-nifurtimox combination therapy in 278 patients, the 48 relapses recorded were limited to the 3 monotherapy groups.[11] The authors concluded that a consecutive 10-day low-dose melarsoprol-nifurtimox regimen was more effective than the standard melarsoprol regimen.

A trial comparing eflornithine monotherapy with nifurtimox-eflornithine combination therapy in patients with late-stage T brucei gambiense infection found that whereas cure rates were comparable, adverse effects were more common in patients who received eflornithine monotherapy (25.5% vs 9.6%).[12] Nifurtimox-eflornithine combination therapy (NECT) was confirmed as a promising regimen for use in late-stage T brucei gambiense trypanosomiasis in a study from the Congo.[13] It demonstrated fewer major adverse events. Further studies confirmed the efficacy of NECT.[14, 15, 16]

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Prevention

No vaccine is available for African trypanosomiasis. Chemoprophylaxis is unavailable.

Avoidance of travel to areas heavily infested with tsetse flies is recommended. Tsetse flies are attracted to moving vehicles and dark contrasting colors. They are not affected by insect repellants and can bite through lightweight clothing. At-risk travelers are advised to wear wrist- and ankle- length clothing that is made of medium-weight fabric in neutral colors.

Treatment of asymptomatic carriers is possible, and infection can be detected by means of the card agglutination test for trypanosomiasis (CATT) or lymph node aspiration and confirmed with smears.

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Consultations

An infectious disease specialist should be consulted for evaluation of both early- and late-stage African trypanosomiasis in a symptomatic patient with recent travel or suspicious parasitic exposure.

Because African trypanosomiasis is so rarely encountered in the United States, it may be advisable to contact the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, for assistance in the diagnosis and treatment of this disease (Division of Parasitic Diseases, 770-488-7760; Drug Service, 404-639-3670).

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Long-Term Monitoring

In both early- and late-stage trypanosomiasis, symptoms usually resolve after treatment, and the parasitemia clears on repeat blood smears.

Patients who have recovered from late-stage East African trypanosomiasis should undergo lumbar punctures every 3 months for the first year. Patients who have recovered from West African trypanosomiasis should undergo lumbar punctures every 6 months for 2 years.

If symptoms return, the CSF WBC count is higher than 20/µL, CSF pleocytosis occurs, or trypanosomes are still present in blood or CSF, a relapse is suggested. However, a persistently elevated CSF WBC count may also be observed in recovering patients; thus, the change (increase or decrease) in the WBC count is more diagnostically helpful than the count by itself. If a relapse is noted, repeat treatment with melarsoprol or eflornithine may be considered.

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Contributor Information and Disclosures
Author

Randy O Odero, MB, ChB Infectious Disease Specialist

Randy O Odero, MB, ChB is a member of the following medical societies: American College of Physicians, Infectious Diseases Society of America, Society for Healthcare Epidemiology of America

Disclosure: Nothing to disclose.

Coauthor(s)

Kerry O Cleveland, MD Professor of Medicine, University of Tennessee College of Medicine; Consulting Staff, Department of Internal Medicine, Division of Infectious Diseases, Methodist Healthcare of Memphis

Kerry O Cleveland, MD is a member of the following medical societies: American College of Physicians, Society for Healthcare Epidemiology of America, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Pranatharthi Haran Chandrasekar, MBBS, MD Professor, Chief of Infectious Disease, Program Director of Infectious Disease Fellowship, Department of Internal Medicine, Wayne State University School of Medicine

Pranatharthi Haran Chandrasekar, MBBS, MD is a member of the following medical societies: American College of Physicians, American Society for Microbiology, International Immunocompromised Host Society, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Additional Contributors

Daniel R Lucey, MD, MPH, MD, MPH 

Daniel R Lucey, MD, MPH, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians

Disclosure: Nothing to disclose.

Kitonga P Kiminyo, MD Consulting Staff, ID Consultants, Inc

Kitonga P Kiminyo, MD is a member of the following medical societies: Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Acknowledgements

Gary L Gorby, MD Associate Professor, Departments of Internal Medicine and Medical Microbiology and Immunology, Division of Infectious Diseases, Creighton University School of Medicine; Associate Professor of Medicine, University of Nebraska Medical Center; Associate Chair, Omaha Veterans Affairs Medical Center

Gary L Gorby, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, American Society for Microbiology, Infectious Diseases Society of America, and New York Academy of Sciences

Disclosure: Nothing to disclose.

Joseph F John Jr, MD, FACP, FIDSA, FSHEA Clinical Professor of Medicine, Molecular Genetics and Microbiology, Medical University of South Carolina College of Medicine; Associate Chief of Staff for Education, Ralph H Johnson Veterans Affairs Medical Center

Disclosure: Nothing to disclose.

Daniel R Lucey, MD, MPH Chief, Fellowship Program Director, Department of Internal Medicine, Division of Infectious Diseases, Washington Hospital Center; Professor, Department of Internal Medicine, Uniformed Services University of the Health Sciences

Daniel R Lucey, MD, MPH is a member of the following medical societies: Alpha Omega Alpha and American College of Physicians

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

References
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  2. Truc P, Lando A, Penchenier L, Vatunga G, Josenando T. Human African trypanosomiasis in Angola: clinical observations, treatment, and use of PCR for stage determination of early stage of the disease. Trans R Soc Trop Med Hyg. 2012 Jan. 106(1):10-4. [Medline].

  3. Simarro PP, Cecchi G, Franco JR, Paone M, Fèvre EM, Diarra A, et al. Risk for human african trypanosomiasis, central Africa, 2000-2009. Emerg Infect Dis. 2011 Dec. 17(12):2322-4. [Medline].

  4. Rock KS, Torr SJ, Lumbala C, Keeling MJ. Quantitative evaluation of the strategy to eliminate human African trypanosomiasis in the Democratic Republic of Congo. Parasit Vectors. 2015 Oct 22. 8 (1):532. [Medline].

  5. Pandey A, Atkins KE, Bucheton B, Camara M, Aksoy S, Galvani AP, et al. Evaluating long-term effectiveness of sleeping sickness control measures in Guinea. Parasit Vectors. 2015 Oct 22. 8 (1):550. [Medline].

  6. Kohagne TL, M'eyi MP, Kamkuimo RG, Kaba D, Louis JF, Mimpfoundi R. Transmission of human African trypanosomiasis in the Komo-Mondah focus, Gabon. Pan Afr Med J. 2011. 8:36. [Medline]. [Full Text].

  7. Bonnet J, Boudot C, Courtioux B. Overview of the Diagnostic Methods Used in the Field for Human African Trypanosomiasis: What Could Change in the Next Years?. Biomed Res Int. 2015. 2015:583262. [Medline].

  8. Nzou SM, Fujii Y, Miura M, Mwau M, Mwangi AW, Itoh M, et al. Development of multiplex serological assay for the detection of human African trypanosomiasis. Parasitol Int. 2015 Nov 10. 65 (2):121-127. [Medline].

  9. Büscher P, Mertens P, Leclipteux T. Sensitivity and specificity of HAT Sero-K-SeT, a rapid diagnostic test for serodiagnosis of sleeping sickness caused by Trypanosoma brucei gambiense: a case-control study. Lancet Glob Health. June 2014. 2 (6):e359–e363. [Medline]. [Full Text].

  10. Abramowicz M. Drugs For Parasitic Infections. Abramowicz M, ed. The Medical Letter on Drugs and Therapeutics. New Rochelle, NY: The Medical Letter, Inc; 2000. 1-12.

  11. Bisser S, N'Siesi FX, Lejon V, Preux PM, Van Nieuwenhove S, Miaka Mia Bilenge C, et al. Equivalence trial of melarsoprol and nifurtimox monotherapy and combination therapy for the treatment of second-stage Trypanosoma brucei gambiense sleeping sickness. J Infect Dis. 2007 Feb 1. 195(3):322-9. [Medline].

  12. Priotto G, Kasparian S, Ngouama D, Ghorashian S, Arnold U, Ghabri S, et al. Nifurtimox-eflornithine combination therapy for second-stage Trypanosoma brucei gambiense sleeping sickness: a randomized clinical trial in Congo. Clin Infect Dis. 2007 Dec 1. 45(11):1435-42. [Medline].

  13. Gilles Eperon, Manica Balasegaram, Julien Potet, Charles Mowbray, Olaf Valverde and François Chappuis. Treatment options for second-stage gambiense human African trypanosomiasis. Expert Rev Anti Infect Ther. 2014 Nov 1. 12(11):1407–1417. [Medline]. [Full Text].

  14. Franco JR, Simarro P, Diarra A. Monitoring the use of nifurtimox-eflornithine combination therapy (NECT) in the treatment of second stage gambiense human African trypanosomiasis. Res Rep Trop Med. 2012. 3:1 - 9.

  15. Schmid C, Kuemmerle A, Blum J. In-hospital safety in field conditions of nifurtimox eflornithine combination therapy (NECT) for T. b. gambiense sleeping sickness. PLoS Negl Trop Dis. 2012. 6(11):e1920. [Medline]. [Full Text].

  16. Alirol E, Schrumpf D, Amici Heradi J. Nifurtimox-eflornithine combination therapy for second-stage gambiense human African trypanosomiasis: medecins Sans Frontieres experience in the Democratic Republic of the Congo. Clin Infect Dis. 2013. 56(2):195–203. [Medline]. [Full Text].

 
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African trypanosomiasis (sleeping sickness). Human trypanosomes blood smear.
Table. Medications Recommended for Treatment of African Trypanosomiasis
Type of Trypanosomiasis Medications
Stage 1 (Early or Hemolymphatic Stage) Stage 2 (Late or Neurologic Stage)
East African trypanosomiasis (caused by Trypanosoma brucei rhodesiense) Suramin 100-200 mg IV test dose, then 1 g IV on days 1, 3, 7, 14, 21 Melarsoprol 2-3.6 mg/kg/day IV for 3 days; after 1 week, 3.6 mg/kg/day for 3 days; after 10-21 days, repeat cycle
West African trypanosomiasis (caused by Trypanosoma brucei gambiense) Pentamidine isethionate 4 mg/kg/day IM for 10 days



or



Suramin 100-200 mg IV test dose, then 1 g IV on days 1, 3, 7, 14, 21



Nifurtimox-eflornithine combination therapy (NECT): Nifurtimox 5 mg/kg PO q8h for 10 days and eflornithine 200 mg/kg IV q12h for 7 days



or



Eflornithine 400 mg/kg/day IV in 2 divided doses for 14 days



or



Melarsoprol IV for 10 days



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