On September 9, 1981, a 72-year-old male from Edinburg, Texas,
developed fever and weakness 16 days after being bitten by tsetse
flies during a hunting trip in northwest Tanzania. Several days
after
onset of fever, he noticed a raised, tender, erythematous nodule
(6-8
cm in diameter) on the posterior aspect of his right arm. He was
hospitalized in Africa and treated for 5 days with a cephalosporin
for
presumed cellulitis. After little improvement, he returned to
Texas
on September 20.
On arrival, the patient had a temperature of 38.9 C (102 F), a
morbilliform rash of the trunk, and right-sided, anterior cervical
lymphadenopathy. Laboratory tests revealed a hemoglobin of 10.7
g/100
ml, a white-cell count of 2,400/mm((3)), and a platelet count of
75,000/mm((3)); peripheral blood smears showed trypanosomes.
Cerebrospinal fluid (CSF) contained 12 red cells and 18 mononuclear
cells/mm((3)), with a normal protein (32 mg/dL); no trypanosomes or
morula cells of Mott (thought to be degenerated plasma cells) were
observed. Serum obtained on September 21 and tested at CDC reacted
to
trypanosome antigen by indirect immunofluorescence at a dilution of
1:4096.
Treatment with suramin (1 g intravenously on days 1, 3, 7, 14,
and
21) was initiated on September 22, and within 48 hours of the first
dose, neck swelling decreased noticeably, and rash and fever
disappeared. The thrombocytopenia, anemia, and leukopenia resolved
over a 2-week period. A second lumbar puncture on October 1, 10
days
after therapy was begun, showed five lymphocytes/mm((3)), a protein
of
27 mg/dL, and no IgM. Several follow-up examinations during the
past
year showed no clinical evidence of recurrent illness, but the
patient
declined additional lumbar punctures.
Reported by R Reves, H Dupont, W Sievert, University of Texas
Health
Sciences Center, Houston; Protozoal Diseases Br, Div of Parasitic
Diseases, Center for Infectious Diseases, CDC.
Editorial Note
Editorial Note: This is the sixth published report since 1967 of
imported African trypanosomiasis (African sleeping sickness) in
Americans (1). All six patients have shared several
characteristics:
exposure to infected tsetse flies while visiting game parks in
eastern
or southern Africa, development of acute, febrile illness
consistent
with Trypanosoma brucei rhodesiense infection 1-21 days after
visiting
Editorial Note: This is the sixth published report since 1967 of
imported African trypanosomiasis (African sleeping sickness) in
Americans (1). All six patients have shared several
characteristics:
exposure to infected tsetse flies while visiting game parks in
eastern
or southern Africa, development of acute, febrile illness
consistent
with Trypanosoma brucei rhodesiense infection 1-21 days after
visiting
the game parks, detectable typanosomes on peripheral blood smears,
and
recovery after appropriate therapy. Only two of the five earlier
cases showed clear evidence of central nervous system (CNS)
involvement; both patients had elevated CSF protein, increased CSF
cell count, and trypanosomes in the CSF.
Suramin is recommended for treating the hemolymphatic stage of
African trypanosomiasis, but because it does not cross the
blood-brain
barrier, it is ineffective against trypanosomes in the CNS.
Melarsoprol, a relatively toxic drug, is used either alone or in
combination with suramin when infection has progressed to involve
the
CNS (2).
The patient described here illustrates the difficulty a
physician
may encounter in determining whether CNS invasion has occurred.
Little diagnostic difficulty occurs when trypanosomes are observed
in
the CSF, and similarly, the presence of morula cells of Mott or an
elevated CSF IgM is thought to strongly suggest CNS involvement
(4).
An elevated CSF cell count usually accompanies these other
findings,
but the significance of a mildly elevated cell count alone is
difficult to assess. Physicians caring for the patient reported
here
elected to use suramin alone, and the decreased CSF cell count
after
10 days of treatment was reassuring. Another patient, with an
elevated CSF cell count (10/mm((3))) and normal IgM, presented a
similar diagnostic dilemma in 1980; he was also treated
successfully
with suramin alone, and has shown no signs of CNS involvement
during
the past 2 years (3).
Any individual with African trypanosomiasis should be monitored
for evidence of CNS involvement during treatment and at regular
intervals for 1-2 years thereafter (4).
References
Spencer HC Jr, Gibson JJ Jr, Brodsky RE, Schultz MG. Imported
African trypanosomiasis in the United States. Ann Intern Med
1975;82:633-8.
Drugs for parasitic infections. The Medical Letter
1982;24:5-12.
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