TRYPANOSOMIASIS - POLAND ex UGANDA (QUEEN ELIZABETH NATIONAL PARK)

Date: Mon 10 Aug 2009
From: Malgorzata Paul <mpaul@ump.edu.pl> [edited]


[Rhodesian trypanosomiasis] in a Polish tourist returning from Uganda
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On 28 Jul 2009, a 61 year old Polish man was admitted to the Department and
Clinic of Tropical and Parasitic Diseases, University of Medical Sciences
in Poznan, Poland, with high-grade fever and multi-organ failure after a
tourist travel to Africa.

The patient spent 16 days in a tourist journey (no hunting) in Uganda and
Rwanda, and returned to Poland on 24 Jul 2009. He was travelling with his
wife in an 18-person group; the remaining travellers are all healthy.

He had been bitten by a tsetse fly during his visit in the Queen Elizabeth
National Park on 16 Jul 2009. On 20 Jul 2009, he noted a painful
erythematous skin lesion with central cupping on his left arm. Two days
later, he developed fever up to 40 deg C [104 deg F] with chills and
general weakness.

On admission on 28 Jul 2009, he presented with clinical signs of
generalized disease with fever, tachycardia, jaundice, respiratory
distress, dehydration, significant bleeding with DIC [disseminated
intravascular coagulation], skin rash, peripheral swelling,
hepatosplenomegaly, and oliguria.

The patient was conscious, very well oriented but seemed to be "too slow".
His general status was [of severe illness] and a clinical picture similar
to hemorrhagic fever, with spontaneous bleeding from the gums and oral
mucosa, numerous ecchymoses, petechiae on a large area of the skin of the
abdomen and chest, and abnormal bleeding on the sites of vein punctures.

A typical chancre with a black centre was still visible. Laboratory tests
showed thrombocytopenia, leucopenia, hypoglycemia, elevated liver enzymes,
metabolic (lactic) acidosis, electrolyte disturbances, highly elevated
concentrations of procalcitonin, and CRP [C-reactive protein],
hypoproteinemia, hyperbilirubinemia, beginning of renal failure with high
levels of urea and creatinine, proteinuria, and coagulation abnormalities
consistent with symptomatic DIC.

The diagnosis of acute African trypanosomiasis due to _Trypanosoma brucei
rhodesiense_ with a massive parasitaemia was made on the basis of blood
film examination. A thin blood smear showed 40-50 trypomastigotes (!) in a
high power field (1000x) and average of 116 parasites in a 400x
magnification field. When the Carpentier's cell was used for measurement,
we calculated 100 000 parasites per 1 microliter of blood. There were no
trypanosomes in the CSF [cerebrospinal fluid].

The patient received 7 doses of pentamidine, every 2 days (the last dose
today [10 Aug 2009]) with good tolerance. He required passive oxygen
therapy because of moderate ARDS [acute respiratory distress syndrome], and
intensive management including antihemorrhagic treatment, many transfusions
of plasma, albumins, ATIII and platelets, as well as antifebrile,
hepatoprotective, and diuretic therapy, correction of electrolyte and
gasometric disturbances. There were no signs of hemorrhages in the retina
and CNS [central nervous system].

He has qualified for haemodialysis but he has undergone 4 cycles of
plasmapheresis. The trypanosomes were not detectable in peripheral blood
after the 2nd dose of pentamidine. During the parasite clearance on the 3rd
day of hospitalization, he was hypotensive and required administration of
dopamine.

At present, the patient feels well and is improving very quickly; he
requires the supportive hepatoprotective therapy, slight correction of
fluids, and respiratory rehabilitation.