Sleeping sickness in travelers - do they really sleep?

Karin Urech,Andreas Neumayr,Johannes Blum,Elodie Ghedin

doi:10.1371/journal.pntd.0001358

Abstract

The number of imported Human African Trypanosomiasis (HAT) cases in non-endemic countries has increased over the last years. The objective of this analysis is to describe the clinical presentation of HAT in Caucasian travelers. Literature was screened (MEDLINE, Pubmed) using the terms “Human African Trypanosomiasis”, “travelers” and “expatriates”; all European languages except Slavic ones were included. Publications without clinical description of patients were only included in the epidemiological analysis. Forty-five reports on Caucasians with T.b. rhodesiense and 15 with T.b. gambiense infections were included in the analysis of the clinical parameters. Both species have presented with fever (T.b. rhodesiense 97.8% and T.b. gambiense 93.3%), headache (50% each) and a trypanosomal chancre (T.b. rhodesiense 84.4%, T.b. gambiense 46.7%). While sleeping disorders dominate the clinical presentation of HAT in endemic regions, there have been only rare reports in travelers: insomnia (T.b. rhodesiense 7.1%, T.b. gambiense 21.4%), diurnal somnolence (T.b. rhodesiense 4.8%, T.b. gambiense none). Surprisingly, jaundice has been seen in 24.2% of the Caucasian T.b. rhodesiense patients, but has never been described in HAT patients in endemic regions. These results contrast to the clinical presentation of T.b. gambiense and T.b. rhodesiense HAT in Africans in endemic regions, where the presentation of chronic T.b. gambiense and acute T.b. rhodesiense HAT is different. The analysis of 14 reports on T.b. gambiense HAT in Africans living in a non-endemic country shows that neurological symptoms such as somnolence (46.2%), motor deficit (64.3%) and reflex anomalies (14.3%) as well as psychiatric symptoms such as hallucinations (21.4%) or depression (21.4%) may dominate the clinical picture. Often, the diagnosis has been missed initially: some patients have even been hospitalized in psychiatric clinics. In travelers T.b. rhodesiense and gambiense present as acute illnesses and chancres are frequently seen. The diagnosis of HAT in Africans living outside the endemic region is often missed or delayed, leading to presentation with advanced stages of the disease.

Highlights

The increasing tourism to Africa is accompanied by an increasing number of imported tropical diseases including rare cases of Human African Trypanosomiasis (HAT)
HAT, known as Sleeping Sickness, is caused by the protozoan parasites Trypanosoma brucei gambiense (T.b. gambiense = West African form) and Trypanosoma brucei rhodesiense (T.b. rhodesiense = East African form), which are transmitted by the bite of the tsetse fly, Glossina spp
We systematically reviewed the existing literature, collected 95 cases of Human African Sleeping Sickness in travelers and expatriates from non-endemic countries, and observed that Sleeping Sickness in travelers generally presents as an acute febrile illness irrespective of the causative species

Summary

Introduction

The increasing tourism to Africa is accompanied by an increasing number of imported tropical diseases including rare cases of Human African Trypanosomiasis (HAT). HAT, known as Sleeping Sickness, is caused by the protozoan parasites Trypanosoma brucei gambiense (T.b. gambiense = West African form) and Trypanosoma brucei rhodesiense (T.b. rhodesiense = East African form), which are transmitted by the bite of the tsetse fly, Glossina spp. The T.b. gambiense HAT is characterized by a chronic progressive course, lasting months to years, leading to death if left untreated. The disease appears in two stages: the first being the early or haemo-lymphatic stage, and the second being the late or meningo-encephalitic stage, characterized by the trypanosome invasion of the central nervous system (CNS). A trypanosomal chancre (local infection at the location of the tsetse fly bite) is only seen as an exception in T.b. gambiense; it is seen in 19% of T.b. rhodesiense patients. In the second stage sleep disturbances and neuro-psychiatric disorders dominate the clinical presentation

Objectives

Results

Discussion

Conclusion