Pitfalls in the Diagnosis of Trypanosomiasis in Low Endemic Countries: A Case Report

Abstract

A 28-year-old man presented to a referral hospital in Harare, Zimbabwe, with a 6 month history of intermittent fevers and headaches. He worked as a game ranger in the Zambezi Valley. At the onset of his illness, he was treated for malaria with intravenous quinine at a district hospital despite a negative rapid diagnostic test. The symptoms worsened in the 2 months preceding presentation with onset of drenching night sweats and significant weight loss. He had been extensively investigated over this period at a private hospital in Harare, where investigations for HIV infection, diabetes mellitus, and cryptococcal and tuberculous meningitis were negative. A lymph node biopsy had shown reactive changes only. Nevertheless, he was commenced on treatment for tuberculosis. However, he continued to deteriorate, developing progressive generalised rigidity and episodes of confusion. On examination he was very ill, delirious, and febrile with a temperature of 39uC but had no cutaneous lesions and no lymphadenopathy. He had generalised increased tone and the kernig sign was negative. He had brisk reflexes generally and the plantar reflexes were upgoing. However, there were no focal neurological signs and examination of the other systems was unremarkable. Human African trypanosomiasis was suspected and confirmed on a thin blood smear (Figure 1). The cerebrospinal fluid (CSF) showed a protein of 4.6 g/L (0.15– 0.45 g/L), glucose 4.3 mmol/L (2.8– 4.2 mmol/L) and 6 mononuclear cells/ mm. No specific search for trypanosomes was performed on the CSF, which was analysed before the diagnosis was made. The blood glucose was 6.1 mmol/L and the full blood count was as follows: white cell count 6.28610/mL, haemoglobin 7.5 g/dL, and platelets 145610/mL. The urea and electrolytes were normal. The final diagnosis was stage 2 rhodesiense trypanosomiasis. The specific drugs for this stage (suramin and melarsoprol) were available from the World Health Organization (WHO) emergency country stock. Despite melarsoprol being availed urgently, the patient died, before the initial dose was administered. Consent: Informed written consent for publication of the case was obtained from the patient’s relatives.