Sleeping sickness (patient information)

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 * Assistant Editor(s)-in-Chief: Ethan Leeman

Overview
Sleeping sickness, also called Human African trypanosomiasis is an infection with organisms carried by certain flies. It is a parasitic disease of people and animals, caused by protozoa of the species Trypanosoma brucei and transmitted by the tsetse fly. The disease is endemic in some regions of sub-Saharan Africa, covering about 36 countries and 60 million people. It is estimated that 50,000 to 70,000 people are currently infected, the number having declined somewhat in recent years. It is believed that many cases go unreported. About 48,000 people died of it in 2008. Four major epidemics have occurred in recent history: one from 1896–1906 primarily in Uganda and the Congo Basin, two epidemics in 1920 and 1970 in several African countries, and a recent 2008 epidemic in Uganda. Sleeping sickness is caused by two organisms, Trypanosoma brucei rhodesiense and Trypanosomoa brucei gambiense. The more severe form of the illness is caused by rhodesiense.

What are the symptoms of Sleeping sickness?
African trypanosomiasis symptoms occur in two stages. The first stage is known as the haemolymphatic phase and is characterized by fever, headaches, and joint pains, and itching. Invasion of the circulatory and lymphatic system by the parasites is associated with severe swelling of lymph nodes, often to tremendous sizes. Winterbottom's sign, the tell-tale swollen lymph nodes along the back of the neck, may appear. If left untreated, the disease overcomes the host's defenses and can cause more extensive damage, broadening symptoms to include anaemia, endocrine, cardiac, and kidney disfunctions. The second stage, called the neurological phase, begins when the parasite invades the central nervous system by passing through the blood-brain barrier. The term 'sleeping sickness' comes from the symptoms of the neurological phase. The symptoms include confusion, reduced coordination, and disruption of the sleep cycle, with bouts of fatigue punctuated with manic periods leading to daytime slumber and night-time insomnia. Without treatment, the disease is invariably fatal, with progressive mental deterioration leading to coma and death. Damage caused in the neurological phase can be irreversible. General symptoms include:
 * Anxiety
 * Drowsiness
 * Fever
 * Headache
 * Increased sleepiness
 * Insomnia at night
 * Mood changes
 * Sweating
 * Swollen lymph nodes all over the body
 * Swollen, red, painful nodule at site of fly bite
 * Uncontrollable urge to sleep

What causes Sleeping sickness?
Tsetse flies carry the infection. When an infected fly bites you, painful, red swelling occurs at the site of the bite. The infection then spreads through your blood, causing episodes of fever, headache, sweating, and swelling of the lymph nodes. When the infection spreads to the central nervous system, it causes the symptoms typical of sleeping sickness. When it reaches the brain, behavioral changes such as fear and mood swings occur, followed by headache, fever, and weakness. Inflammation of the heart (myocarditis) may develop. In addition to the bite of the tsetse fly, the disease can be transmitted in the following ways:
 * Mother to child infection: the trypanosome can sometimes cross the placenta and infect the fetus.
 * Laboratories: accidental infections, for example, through the handling of blood of an infected person and organ transplantation, although this is uncommon.
 * Blood transfusion
 * Sexual contact (might be possible, but happens rarely)

Who is at highest risk?
Risk factors include living in parts of Africa where the disease is found and being bitten by tsetse flies. The disease is extremely rare in the United States, and is only found in travelers who have visited or lived in those African areas.

Diagnosis
The gold standard for diagnosis is identification of trypanosomes in a patient sample by microscopic examination. Patient samples that can be used for diagnosis include chancre fluid, lymph node aspirates, blood, bone marrow, and, during the neurological stage, cerebrospinal fluid. Detection of trypanosome-specific antibodies can be used for diagnosis, but the sensitivity and specificity of these methods are too variable to be used alone for clinical diagnosis. Further, seroconversion occurs after the onset of clinical symptoms during a T. b. rhodesiense infection, and therefore is of limited diagnostic use. Most antibody and antigen test are not very helpful because they can't distinguish between current and previous infection. Specific IgM levels in the cerebrospinal fluid may be helpful, however. Other methods include:
 * A physical examination: may show signs of meningoencephalitis (inflammation of the brain and its covering, the meninges)
 * Albumin levels
 * Blood smear
 * Cerebrospinal fluid tests
 * Complete blood count (CBC)
 * Globulin levels
 * Lymph node aspiration

When to seek urgent medical care?
Call your health care provider if you have symptoms of this disorder. It is important to begin treatment as soon as possible.

Treatment options
Medications, both for first stage and second stage of the disease, used to treat this disorder include:
 * Eflornithine (for gambiense only)
 * Melarsoprol
 * Pentamidine
 * Suramin (Antrypol)

Where to find medical care for Sleeping sickness?
Directions to Hospitals Treating Sleeping Sickness

Prevention of Sleeping sickness
Pentamidine injections protect against gambiense, but not against rhodesiense. Insect control measures can help prevent the spread of sleeping sickness in high-risk areas.

What to expect (Outlook/Prognosis)?
Without treatment, death may occur within 6 months from cardiac failure or from rhodesiense infection itself. Gambiense infection causes the classic "sleeping sickness" disease and gets worse more quickly, often over a few weeks. Both diseases should be treated immediately.