Ten Years of Tryps and Tsetses. Lucille Blumberg & John Frean National Institute for Communicable Diseases

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1 Ten Years of Tryps and Tsetses Lucille Blumberg & John Frean National Institute for Communicable Diseases

3 Source: Simarro et al. PLoS Negl Trop Dis 2011; 5: e1007

4 Country of acquisition Number of cases and sites, Malawi 6 (Kasungu 5, Nkhotakota 1) Zambia 6 (Luangwa Valley 3, Kasanka 2, Kafue 1) Tanzania 3 (Serengeti) Zimbabwe 3 (Kariba 1, Mana Pools 2) Uganda TOTAL 20 2 (Queen Elizabeth National Park,?Murcheson Falls)

6 No. of cases (%) Foreign tourist 9 Expatriate or resident 4 Conservationist 2 Game farmer 2 Foreign soldier, field exercise Pilot: tourist transport 1 Church-related travel 1 TOTAL 20 1

7 Common management errors Poor history taking Narrow clinical vision Missing key clinical signs Delaying transfer to better care, including definitive treatment Incorrect application of diagnostic tests Inexperienced lab personnel

8 MISSED AND MIS-DIAGNOSIS Trypanosomal chancres

23-27th October - my 27-yr-old cousin walked in the Luangwa Valley, eastern Zambia, ++ insect bites 1st November- severe joint and

2nd Nov- strange purple lesion on her left ankle, which subsequently developed surrounding swelling 3 rd Nov - GP - Coartem and

malaria, trypanosomal serology Another doctor saw her today and suspected tick bite fever, doxycycline Rx Insurance company

10 23-27th October - my 27-yr-old cousin walked in the Luangwa Valley, eastern Zambia, ++ insect bites 1st November- severe joint and muscle ache, a splitting headache and fevers. 2nd Nov- strange purple lesion on her left ankle, which subsequently developed surrounding swelling 3 rd Nov - GP - Coartem and Amoxil, then 'Ciprovid'. She felt terrible and so was driven through to Lusaka. 5 th Nov - hospital 39.7 C, stable. Neg. tests. malaria, trypanosomal serology Another doctor saw her today and suspected tick bite fever, doxycycline Rx Insurance company disallowed t/f to SA as her 'risk score' is 13, only transfer if < 4 So, all plans to fly her out have been abandoned.. 7 th Nov- Plts now 18, being given platelet transfusion and transfer tomorrow morning to JHB. Patient s lesion Tick bite eschar

11 Laboratory diagnostic aspects Blood Thick and thin films, as for malaria May be very scanty: buffy coat, wet prep

14 Hi Please advise Informed by Uthungulu district* that they have a patient with sleeping sickness Details very sketchy, confirmed by lab awaiting results to be faxed Unable to get info from the ward- sister is off *Richards Bay area, KwaZulu-Natal Province, South Africa

15 I went to see the patient. 76 yrs, no travel history and she only stays with a 12 year old boy who is going to school. Currently the patient is on the following treatment: diabetic hypertension iron supplement Patient presented with anaemia, thrombocytopenia & leucocytosis. Clinically no symptoms of trypanosomiasis. Peripheral blood smear done indicated trypanosoma parasites in blood. They have not started any treatment pending results from IALCH as the recommended treatment of pentamidine a bit cautious re side effects.

20 Lab diagnosis (cont d) CSF Timing and technique Microscopy May be very, very scanty Fragile: minimise delay in reaching lab Experienced technologist/medical scientist Double-spin method: caveats

21 Image: Marc Mendelson

22 Image: Marc Mendelson

23 Assessing CNS involvement Decreased level of consciousness is not necessarily a sign of CNS invasion Renal, hepatic, respiratory dysfunction/failure Lab findings - textbook: >5 leucocytes/mm 3 and/or protein >0.6 g/l = CNS invasion, BUT not in isolation assess clinical context

67-yr-old hunter, ex Tanzania rapid progression and deterioration - marked jaundice and liver dysfunction, profound thrombocytopenia - oozing from catheter sites, renal dysfunction, progressive

24 67-yr-old hunter, ex Tanzania rapid progression and deterioration - marked jaundice and liver dysfunction, profound thrombocytopenia - oozing from catheter sites, renal dysfunction, progressive deterioration in central nervous function with confusion and agitation. ARDS, no myocarditis. Suramin therapy was commenced for the haemolymphatic stage of East African trypanosomiasis CSF: cerebospinal fluid revealed the presence of 15 neutrophils, protein of 0.7 g/l but no trypanosomes.

25 Suramin: adverse reactions Cardiovascular collapse Skin reaction Nephrotoxicity Longest 1/2 life

26 34-year-old game ranger, ex Mana Pools, Zimbabwe Admitted to UTH, Lusaka, Zambia Hb 5, WCC 2.3, platelets 15, tryps++ on smear Progressive deterioration in CNS CSF o/a: RBCs+++, tryps ++ Renal failure: creat 850 µmol/l

27 CNS: tryps or not? Hunter, ex-tanzania Depressed, LOC and agitation CSF: 15 neutrophils, protein 0.7 gm/l No trypanosomes Tourist, ex-malawi Clinically well CSF: 126 cells, protein 0.6 gm/l No trypanosomes Patients must earn their melarsoprol!

28 Middle-aged tourist, ex-serengeti CNS involvement confirmed Melarsoprol commenced initial improvement then deteriorationconvulsions..died Melarsoprol encephalopathy: 10% incidence, 50% mortality Reduced by prednisolone priming

29 Outcomes: deaths: overall mortality 10% Kariba game rancher: myocarditis Serengeti tourist: CNS involvement,?melarsoprol toxicity Treatment readily available in Johannesburg via NICD

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