Sleeping Sickness

Definition

Sleeping sickness (also called trypanosomiasis) is an infection caused by Trypanosoma protozoa; it is passed to humans through the bite of the tsetse fly. If left untreated, the infection progresses to death within months or years.

Description

Protozoa are single-celled organisms considered to be the simplest life form in the animal kingdom. The protozoa responsible for sleeping sickness are a variety that bears numerous flagella (hair-like projections from the cell that help the cell to move). These protozoa exist only on the continent of Africa. The type of protozoa causing sleeping sickness in humans is referred to as the Trypanasoma brucei complex, which can be divided further into Rhodesian (Central and East African) and Gambian (Central and West African) subspecies.

The Rhodesian variety lives within antelopes in savanna and woodland areas, and it causes no problems with the antelope's health. The protozoa are then acquired by tsetse flies when they bite and suck the blood of an infected antelope or cow.

Within the tsetse fly, the protozoa cycle through several different life forms; ultimately they migrate to the salivary glands of the tsetse fly. Once the protozoa are harbored in the salivary glands, they are ready to be deposited into the bloodstream of the fly's next source of a blood meal.

DAVID BRUCE (1855–1931)

David Bruce was born in Melbourne, Australia, on May 29,1855, to Scottish immigrants. Bruce's family moved back to Scotland when he was five years old. Bruce attended the University of Edinburgh where he studied natural history and medicine. Following graduation, he accepted a position working with a doctor. In 1883, Bruce married Mary Elizabeth Steele who would help him with his work throughout his life.

In 1884, Bruce began to study the disease called Malta or Mediterranean fever when he and Mary were stationed in Malta with the Army Medical Service. Using a microscope, Bruce discovered that the disease was caused by a microccus that grew in the individual's spleen. The organism responsible for this disease was ultimately isolated by Bernhard L. F. Bang. In 1905, Bruce led a scientific team that discovered that the soldiers who contracted the disease had ingested the milk of infected goats. The disease disappeared when the soldiers quit drinking goat's milk. Many physicians began calling the disease brucellosis in honor of Bruce's discoveries. Bruce also conducted research in Africa where he found that the tsetse fly could infect humans, as well as animals, with the nagana disease. Ultimately, his work would prove that sleeping sickness was caused by the tsetse fly.

In 1903, Bruce became the director of the Royal Society's Sleeping Sickness Commission and, in 1908, he was knighted. He served as commandant of the Royal Army Medical College after he and his wife returned to England. Bruce died on November 20, 1931.

Humans most likely to become infected by Rhodesian trypanosomes are people such as game wardens and visitors to game parks in East Africa, who may be bitten by a tsetse fly that has fed on game (antelope) carrying the protozoa. The Rhodesian variety of sleeping sickness causes a much more severe illness, with even greater likelihood of eventual death than the Gambian form.

The Gambian variety of Trypanosoma thrives in tropical rain forests throughout Central and West Africa; it does not infect game or cattle and is primarily a threat to people dwelling in such areas, rarely infecting visitors.

Causes and symptoms

Stage I illness

Two to three weeks later, Stage I disease develops as a result of the protozoa's being carried through the blood and lymph circulation of the host. This systemic (meaning that symptoms affect the whole body) phase of the illness is characterized by a fever that rises quite high then falls to normal, then spikes (rises rapidly). A rash with intense itching may be present, and headache and mental confusion may occur. The Gambian form, in particular, includes extreme swelling of lymph tissue, with enlargement of both the spleen and liver, and greatly swollen lymph nodes. Winterbottom's sign is classic of Gambian sleeping sickness and consists of a visibly swollen area of lymph nodes located behind the ear and just above the base of the neck. During this stage, the heart may be affected by a severe inflammatory reaction, particularly when the infection is caused by the Rhodesian variety of trypanosomiasis.

Many of the symptoms of sleeping sickness are actually the result of attempts by the patient's immune system to get rid of the invading organism. The heightened activity of the cells of the immune system results in damage to the patient's own organs, anemia, and leaky blood vessels. These leaks in the blood vessels ultimately help to spread the protozoa throughout the afflicted person's body.

One reason for the intense reaction of the immune system to the presence of the trypanosomes also provides the reason why the trypanosomes survive so well despite the efforts of the immune system to eradicate them. The protozoa causing sleeping sickness are able to rapidly change specific markers (unique proteins) on their outer coats. These kinds of markers usually serve to stimulate the host's immune system to produce immune cells that will specifically target the marker, allowing quick destruction of those cells bearing the markers. Trypanosomes, however, are able to express new markers at such a high rate of change that the host's immune system is constantly trying to catch up.

Stage II illness

Stage II sleeping sickness involves the nervous system. Gambian sleeping sickness, in particular, has a clearly delineated phase in which the predominant symptoms involve the brain. The patient's speech becomes slurred, mental processes are slow, and the patient sits and stares for long periods of time or sleeps. Other symptoms resemble Parkinson's disease, including imbalance when walking, slow and shuffling gait, trembling of the limbs, involuntary movements, muscle tightness, and increasing mental confusion. Untreated, these symptoms eventually lead to coma and then to death.

KEY TERMS
Immune system—
The network of tissues and cells throughout the body that is responsible for ridding the body of any invaders, such as viruses, bacteria, and protozoa.
Protozoa—
Single-celled organisms considered to be the simplest life form in the animal kingdom.

Diagnosis

Diagnosis of sleeping sickness can be made by microscopic examination of fluid from the original sore at the site of the tsetse fly bite. Trypanosomes will be present in the fluid for a short period following the bite. If the sore has already resolved, fluid can be obtained from swollen lymph nodes for examination. Other methods of trypanosome diagnosis involve culturing blood, lymph node fluid, bone marrow, or spinal fluid. These cultures are then injected into rats, which develop blood-borne protozoa infection that can be detected in blood smears within one to two weeks. However, this last method is effective only for the Rhodesian variety of sleeping sickness.

Treatment

Without treatment, sleeping sickness will lead to death. Unfortunately, however, those medications effective against the Trypanosoma brucei complex protozoa all have significant potential side effects for the patient. Suramin, eflornithine, pentamidine, and several drugs that contain arsenic (a chemical which in higher doses is highly poisonous to humans) are all effective antitrypanosomal agents. Each of these drugs, however, requires careful monitoring to ensure that the drugs themselves do not cause serious complications such as fatal hypersensitivity (allergic) reaction, kidney or liver damage, or inflammation of the brain.

Prevention

See also Zoonoses .

Resources

BOOKS

Zeibig, Elizabeth. Clinical Parasitology: A Practical Approach, 2nd ed. Philadelphia: W. B. Saunders, 2012.

PERIODICALS

Brun, R., et al. “Human African Trypanosomiasis.” Lancet 375, no. 9709 (2010): 148–59.

Malvy, D., and F. Chappuis. “Sleeping Sickness.” Clinical Microbiology and Infection 17, no. 7 (2011): 986–95.

WEBSITES

Odero, Randy O. “African Trypanosomiasis (Sleeping Sickness).” http://emedicine.medscape.com/article/228613-overview (accessed September 24, 2012).

“Parasites: African Trypanosomiasis (also known as Sleeping Sickness).” Centers for Disease Control and Prevention. http://www.cdc.gov/parasites/sleepingsickness/index.html (accessed September 24, 2012).

“Trypanosomiasis, African.” World Health Organization. http://www.who.int/topics/trypanosomiasis_african/en/ (accessed September 24, 2012).

ORGANIZATIONS

Centers for Disease Control and Prevention, 1600 Clifton Rd., Atlanta, GA, 30333, (800) 232-4636, cdcinfor@cdc.gov, http://www.cdc.gov .

Rosalyn Carson-DeWitt, MD

  This information is not a tool for self-diagnosis or a substitute for professional care.