History
Symptoms of stage 1 (early or hemolymphatic stage) African trypanosomiasis (sleeping sickness) include the following:
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Painful skin chancre that appears about 5-15 days after the bite, resolving spontaneously after several weeks (less commonly seen in T brucei gambiense infection)
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Intermittent fever (refractory to antimalarials), general malaise, myalgia, arthralgias, and headache; usually 3 weeks after the bite
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Generalized or regional lymphadenopathy - Posterior cervical lymphadenopathy (Winterbottom sign) is characteristic of T brucei gambiense African trypanosomiasis
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Facial edema (minority of patients)
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Transient urticarial, erythematous, or macular rashes 6-8 weeks after onset
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Trypanids (ill-defined, centrally pale, evanescent, annular, or blotchy edematous erythematous macules on the trunk)
Symptoms of stage 2 (late or neurologic stage) African trypanosomiasis include the following:
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Persistent headaches (refractory to analgesics)
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Daytime somnolence followed by nighttime insomnia
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Behavioral changes, mood swings, and, in some patients, depression
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Loss of appetite, wasting syndrome, and weight loss
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Seizures in children (rarely in adults)
Physical Examination
Physical findings in stage 1 (early or hemolymphatic stage) African trypanosomiasis include the following:
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Indurated chancre at bite site
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Skin lesions (trypanids) in light-skinned patients
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Lymphadenopathy - Axillary and inguinal lymphadenopathy are more common in East African trypanosomiasis, and cervical lymphadenopathy is more common in the West African form; the classic Winterbottom sign (ie, enlarged, nontender, mobile posterior cervical lymph node) is clearly visible
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Fevers, tachycardia, irregular rash, edema, and weight loss
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Organomegaly, particularly splenomegaly (T brucei gambiense African trypanosomiasis)
Physical findings in stage 2 (late or neurologic stage) African trypanosomiasis include the following:
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CNS manifestations - Onset is slower in West African trypanosomiasis (months to a year), and manifestations may include irritability, tremors, increased muscle rigidity and tonicity, occasional ataxia, and hemiparesis, with overt meningeal signs being rare; East African trypanosomiasis usually has a faster onset (weeks to a month) and does not exhibit a clear distinction between the 2 stages
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Kerandel sign (delayed pain on compression of soft tissue)
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Behavioral changes consistent with mania or psychosis, speech disorders, and seizures
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Stupor and coma (giving rise to the name sleeping sickness)
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Psychosis
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Sensory disorders
Complications
Complications of African trypanosomiasis may include the following:
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Anemia and fatigue
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Wasting syndrome
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Meningoencephalitis and seizures
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Stupor or coma (sleeping sickness)
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Death
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Perinatal death or abortion (after congenital infection)
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African trypanosomiasis (sleeping sickness). Human trypanosomes blood smear.
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Trypanosoma life cycle. Courtesy of the CDC Division of Parasitic Diseases and Malaria (DPDx at https://www.cdc.gov/dpdx/trypanosomiasisafrican/index.html).
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Trypanosoma brucei in a thin blood smear stained with Giemsa. Courtesy of the CDC Division of Parasitic Diseases and Malaria (DPDx at https://www.cdc.gov/dpdx/trypanosomiasisafrican/index.html).
Tables
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 4-5 mg/kg IV test dose, then 20 mg/kg (maximum 1 g/dose) IV on days 1, 3, 7, 14, 21 |
Melarsoprol 2.2 mg/kg/day (maximum 180-200 mg) IV for 10 days |
West African trypanosomiasis (caused by Trypanosoma brucei gambiense) |
Pentamidine isethionate 4 mg/kg/day IM for 10 days or Suramin 4-5 mg/kg IV test dose, then 20 mg/kg (maximum 1 g/dose) IV on days 1, 3, 7, 14, 21 or Fexinidazole 20 to < 35 kg: 1200 mg PO qd on Days 1-4, then 600 mg qd on Days 5-10 Fexinidazole 35 kg or greater: 1800 mg PO qd on Days 1-4, then 1200 mg qd on Days 5-10 |
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 or Fexinidazole PO for 10 days |
