African Trypanosomiasis Treatment & Management

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

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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