Trypanosomiasis (sleeping Sickness)

Clinical Description

Suspect in any patient presenting with fever from areas near:

• Wildlife Reserves: Vwaza, Nkhotakota, Majete, Mwabvi
• National Parks: Kasungu, Liwonde, Lengwe
• Phirilongwe (Mangochi), Machinga, Mwanza
• Lower Shire borders with Mozambique or from any other areas where Tsetse fly is found.

Signs and Symptoms

• Suspect in children from these areas who remain sick after presumptive malaria

Treatment

• Increased suspicion in any sick patient from these areas with a history of:
• Headache, Vomiting, Weakness, Changes in mood, Convulsions, Drowsiness, Mental slowness

Investigations

• Travel history is very important
• Suspect also in any patient from these areas where the cause of illness is not otherwise apparent.
• Trypanosomiasis can be acute in children (resembling malaria) and can be more chronic in adults
• Early stage trypanosomiasis may cause myocarditis
• Examination may reveal anaemia, lymph gland enlargement and spleen enlargement
• Nearly all cases have a hard and painful subcutaneous nodule (chancre) which is evidence of an infected bite

Non-pharmacological

• Procedure at Health Centres
• Refer the patient immediately to the nearest hospital
• Request close family members of the patient to undergo examination at the hospital as they may also be infected

Pharmacological

Hospital management

• Request for a thick blood smear
• If negative more tests will be needed to confirm this diagnosis
• If diagnosis is confirmed by blood smear or other bloodtest:
• Start Suramin
• as follows: Day 1: 5mg/kg
• Day 2: 20mg/kg
• Day 3: Do a lumbar puncture
• If LP is normal (stage 1 trypanosomiasis):give
• Suramin 20mg/kg on day 3, 10, 17, 24, 31
• If LP is abnormal (stage 2 or CNS trypanosomiasis): stop suramin, start

Melarsprolol (Mel-B) as follows:

• Day 3:1.2mg/kg
• Day 4:2.4mg/kg
• Day 5:3.6mg/kg
• Day 6:3.6mg/kg
• Repeat this 4-day Melarsprolol cycle after one
• and two weeks

NOTES ON TREATMENT REGIMEN

• If any medicine reaction occurs (e.g. skin rash, exfoliative dermatitis, reactive encephalitis) stop treatment and inform the clinical officer or medical officer immediately
• Do a lumbar puncture (LP) on day 3. Subsequent treatment depends on whether this is found to be normal or abnormal
• Freshly reconstitute the Suramin (Sur) 1 g vial of powder with 10 mL water for injection to make a 10% solution (100 mg/mL)
• Add the required dose of 20 mg/kg (0.2 mL of injection/kg) up to a maximum of 1 g (the whole vial) in adults of 50 kg or over to 200 mL of dextrose 5% and infuse over 2 hours. Alternatively give the dose as a slow IV injection.
• Melarsoprol (Mel B) dose is 3.6 mg/kg (=0.1ml/kg). Give this as a slow IV push. Take great care to avoid extravasation as the medicine is highly irritant. In adults of 50 kg or over the dose is the maximum permissible 180 mg (i.e. one 5 mL ampoule)
• Prednisolone may be added to Melarsprolol with a dose of 40mg once daily. The dose in children is 1 mg/kg once daily
• Control any seizures with Diazepam 5-10 mg slow IV with or without the addition of Phenytoin 150-300 mg as a single daily dose taken with water
• Anti-trypanosomal treatment may cause abortion in pregnancy, but this must be regarded as an unavoidable risk
• Follow-up: review the patient for repeat blood film and LP at 3, 6, 12 and 24 months post- treatment