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African trypanosomiasis, also known as sleeping sickness, is a protozoan parasitic disease caused by the genus Trypanosoma.
African trypanosomiasis is caused by Trypanosoma brucei gambiense and Trypanosoma brucei rhodesiense, transmitted to humans by the bite of an infected tsetse fly (Glossina species). The pathophysiology of the disease involves two stages. The first stage (hemolymphatic stage) is characterized by the multiplication of the parasites in the bloodstream and lymphatic system. The second stage (meningoencephalitic stage) occurs when the parasites cross the blood-brain barrier and invade the CNS, leading to neurological symptoms.
According to the WHO, 2,184 new cases of human African trypanosomiasis were estimated in 2016.
Clinically, the disease presents with non-specific symptoms such as fever, headache, and lymphadenopathy in the early stage. As the disease progresses to the second stage, neurological manifestations such as sleep disturbances, cognitive changes, and motor abnormalities become apparent. If left untreated, the disease is usually fatal, with progression to severe neurological disease and death.
Prognosis and risk of recurrence
The prognosis of the disease has improved with the availability of effective treatments. However, late-stage disease can still be associated with significant morbidity and mortality.
The following summarized guidelines for the evaluation and management of african trypanosomiasis are prepared by our editorial team based on guidelines from the World Health Organization (WHO 2019) and the Infectious Diseases Society of America (IDSA 2008).
Perform a lumbar puncture for stratification in patients not meeting the following criteria:
low index of suspicion of severe disease based on clinical judgment, and
high confidence that the patient will have an appropriate follow-up to detect relapse early
Consider performing a lumbar puncture in patients rejecting or not tolerating fexinidazole, to decide between pentamidine and nifurtimox-eflornithine combination therapy.
Setting of care
Consider deciding on outpatient administration of fexinidazole (under daily supervision) in consultation with the patient, family members, and clinicians, taking into account the following factors:
convenience to the patient and the family (such as distance and costs)
development of side effects interfering with treatment compliance
capacity of the healthcare system for supervised administration as an outpatient
Hospitalize patients in the following cases:
concomitant psychiatric disorders
pediatric patients with body weight < 35 kg
≥ 100 WBCs in CSF after treatment (exceptionally) with fexinidazole
risk of poor compliance with treatment
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Nifurtimox-eflornithine combination therapy
Administer pentamidine in pediatric patients aged < 6 years or weighing < 20 kg with first-stage disease. Administer nifurtimox-eflornithine combination therapy in patients with second-stage disease.
Administer fexinidazole in pediatric patients aged ≥ 6 years or weighing ≥ 20 kg with first- or second-stage disease with WBCs in CSF < 100/µL.
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Patients with encephalitis