Case Study 3Case Study 3

Presented by: Presented by:

Lisa, Jennifer and EsmeraldaLisa, Jennifer and Esmeralda

Case BackgroundCase Background

Simon, a student, presents with ulcerated, raised Simon, a student, presents with ulcerated, raised lesions on his neck, calves, and feet. These lesions lesions on his neck, calves, and feet. These lesions have drained, ulcerated, healed and then broken have drained, ulcerated, healed and then broken open again. He traveled to the Middle East last open again. He traveled to the Middle East last summer (4 months ago) and spent June and July in summer (4 months ago) and spent June and July in Israel followed by several weeks in Egypt . During Israel followed by several weeks in Egypt . During this time he remembers being bitten by numerous this time he remembers being bitten by numerous ““small black flies.” While in Egypt, he noticed the small black flies.” While in Egypt, he noticed the first neck lesions. first neck lesions.

Etiologies and Differential Etiologies and Differential DiagnosisDiagnosis

► Differential diagnosis:Differential diagnosis:

► African Sleeping SicknessAfrican Sleeping Sickness► HIV with CryptococcosisHIV with Cryptococcosis► Leishmania InfectionLeishmania Infection► MalariaMalaria► MelanomaMelanoma

Etiologies and Differential Etiologies and Differential DiagnosisDiagnosis

► Etiological agents:Etiological agents:

► Trypanosoma bruceiTrypanosoma brucei► Human Immunodeficiency Virus Human Immunodeficiency Virus with with

Cryptococcus neoformanCryptococcus neoforman► LeishmaniaLeishmania► Plasmoduim spPlasmoduim sp..► UV light UV light

Acquired Patient HistoryAcquired Patient History

Are you sexually activeAre you sexually active Have you had a blood transfusionHave you had a blood transfusion Do you or anyone in your family have diabetes, Do you or anyone in your family have diabetes,

high blood pressure, cancer, or heart conditionhigh blood pressure, cancer, or heart condition Have you put any ointment on the rashHave you put any ointment on the rash Do you have any allergiesDo you have any allergies Do you use needlesDo you use needles Do you do drugsDo you do drugs Have you come in contact with anyone that has Have you come in contact with anyone that has

a similar rasha similar rash Are you sleepy most of the timeAre you sleepy most of the time Do you feel tiredDo you feel tired

Lab TestsLab Tests

● ● CBCCBC

●●Blood Smear- a wet smear of Blood Smear- a wet smear of unstained bloodunstained blood

●●Culture of lesion and placed on wet Culture of lesion and placed on wet mountmount

●●CT or MRICT or MRI

●●

Lab Test FindingsLab Test Findings

Normal WBC countNormal WBC count

Lesion revealed hemoflagellate Lesion revealed hemoflagellate protozoanprotozoan

Etiological AgentEtiological Agent

East African TrypanosomiasisEast African Trypanosomiasis

Trypanosoma brucei rhodesienseTrypanosoma brucei rhodesiense

DiagnosisDiagnosis

African Sleeping African Sleeping SicknessSickness

Signs and SymptomsSigns and Symptoms

Stage 1 ( early or hemolymphatic stage )Stage 1 ( early or hemolymphatic stage )

●● Painless skin lesions that appear 5- 15 Painless skin lesions that appear 5- 15 days after the bitedays after the bite

● ● Skin lesions in light skinned peopleSkin lesions in light skinned people

●●LymphadenopathyLymphadenopathy

●●Fever, tachycardia, rash, edema and Fever, tachycardia, rash, edema and weight lossweight loss

●●

Signs and SymptomsSigns and Symptoms

Stage 2 ( late or CNS stage )Stage 2 ( late or CNS stage )

● ● Irritability, tremors, muscle rigidityIrritability, tremors, muscle rigidity● ● Mood swings, depression, seizuresMood swings, depression, seizures●●Stupor and Coma (Hence the name Stupor and Coma (Hence the name

sleeping sickness)sleeping sickness)

Mode of TransmissionMode of Transmission

Tsetse FlyTsetse Fly

Why are infections typically Why are infections typically seen on the head and neck ?seen on the head and neck ?

Portal of EntryPortal of Entry

Treatment PlanTreatment Plan

Anthelmintic drugs—Inhibits biochemical Anthelmintic drugs—Inhibits biochemical pathways of parasites.pathways of parasites.

Hospital care for acute symptoms of fever Hospital care for acute symptoms of fever andand

malaise and continual monitoring of malaise and continual monitoring of neurological conditions.neurological conditions.

Regular blood smears to monitor patasitemiaRegular blood smears to monitor patasitemia

Recommended MedicationsRecommended Medications

TrypanosomiaTrypanosomiasissis

MedicationsMedications

Stage 1Stage 1MedicationsMedications

Stage 2Stage 2

Tryoanosoma Tryoanosoma brucei brucei rhodesienserhodesiense

Suramin 100-Suramin 100-200 mg IV test 200 mg IV test dose, then 1 g dose, then 1 g IV on days 1, IV on days 1, 3, 7, 14, 213, 7, 14, 21

Melarsoprol 2-Melarsoprol 2-3.6 mg/kg/d IV 3.6 mg/kg/d IV for 3 d; after 1 for 3 d; after 1 wk, 3.6 wk, 3.6 mg/kg/d for 3 mg/kg/d for 3 days; after 10-days; after 10-21 d, repeat 21 d, repeat the cyclethe cycle

Recommended MedicationsRecommended Medications

Drug Name: SuraminDrug Name: Suramin

Antiparasitic agent used IV in early-stage African Antiparasitic agent used IV in early-stage African trypanosomiasis and onchocerciasis. Suramin is trypanosomiasis and onchocerciasis. Suramin is trypanocidal and works by inhibiting parasitic trypanocidal and works by inhibiting parasitic enzymes and growth factors. Highly bound to serum enzymes and growth factors. Highly bound to serum proteins and, thus, crosses the blood-brain barrierproteins and, thus, crosses the blood-brain barrier poorly. Serum levels are approximately 100 poorly. Serum levels are approximately 100 mcg/mL. Suramin is effective and less toxic thanmcg/mL. Suramin is effective and less toxic thanpentamidine. Excreted in the urine at a slow rate. pentamidine. Excreted in the urine at a slow rate.

Recommended MedicationsRecommended Medications

Drug Name: Melarsoprol Drug Name: Melarsoprol Trivalent arsenical used in the late or CNS stage of African trypanosomiasis. Trypanocidal, inhibiting parasitic glycolysis. Water insoluble and has a half-life of 35 h. Serum levels range from 2-5 mcg/mL, but CSF levels are 50-fold lower. The drug is primarily excreted by the kidneys. Clinical improvement is usually observed within 4 d after starting the drug. Therapy is as high as 90-95% successful in clearing the parasitemia. However, it can be toxic and even fatal in 4-6% of cases.

Patient PrognosisPatient Prognosis

Since Simon was diagnosed in Stage 1, Since Simon was diagnosed in Stage 1, we we

feel that his prognosis is good.feel that his prognosis is good.

Early treatment usually results in the Early treatment usually results in the

resolution of symptoms and clearance of resolution of symptoms and clearance of the the

parasite.parasite.

The EndThe End