1. Case Study 3 Presented by: Lisa, Jennifer and Esmeralda

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

3. Etiologies and Differential Diagnosis ► Differential diagnosis: ► African Sleeping Sickness ► HIV with Cryptococcosis ► Leishmania Infection ► Malaria ► Melanoma

4. Etiologies and Differential Diagnosis ► Etiological agents: ► Trypanosoma brucei ► Human Immunodeficiency Virus with Cryptococcus neoforman ► Leishmania ► Plasmoduim sp. ► UV light

5. Acquired Patient History  Are you sexually active  Have you had a blood transfusion  Do you or anyone in your family have diabetes, high blood pressure, cancer, or heart condition  Have you put any ointment on the rash  Do you have any allergies  Do you use needles  Do you do drugs  Have you come in contact with anyone that has a similar rash  Are you sleepy most of the time  Do you feel tired

6. Lab Tests ● CBC ●Blood Smear- a wet smear of unstained blood ●Culture of lesion and placed on wet mount ●CT or MRI ●

7. Lab Test Findings Normal WBC count Lesion revealed hemoflagellate protozoan

8. Etiological Agent East African Trypanosomiasis Trypanosoma brucei rhodesiense

9. Diagnosis African Sleeping Sickness

10. Signs and Symptoms Stage 1 ( early or hemolymphatic stage ) Stage 1 ( early or hemolymphatic stage ) ● Painless skin lesions that appear 5- 15 days after the bite ● Skin lesions in light skinned people ●Lymphadenopathy ●Fever, tachycardia, rash, edema and weight loss ●

11. Signs and Symptoms Stage 2 ( late or CNS stage ) ● Irritability, tremors, muscle rigidity ● Mood swings, depression, seizures ●Stupor and Coma (Hence the name sleeping sickness)

12. Mode of Transmission Tsetse Fly

13. Why are infections typically seen on the head and neck ? Portal of Entry

14. Treatment Plan Anthelmintic drugs—Inhibits biochemical pathways of parasites. Hospital care for acute symptoms of fever and malaise and continual monitoring of neurological conditions. Regular blood smears to monitor patasitemia

15. Recommended Medications TrypanosomiasisMedications Stage 1 Medications Stage 2 Tryoanosoma brucei rhodesiense Suramin 100- 200 mg IV test dose, then 1 g IV on days 1, 3, 7, 14, 21 Melarsoprol 2- 3.6 mg/kg/d IV for 3 d; after 1 wk, 3.6 mg/kg/d for 3 days; after 10-21 d, repeat the cycle

16. Recommended Medications Drug Name: Suramin Antiparasitic agent used IV in early-stage African trypanosomiasis and onchocerciasis. Suramin is trypanocidal and works by inhibiting parasitic enzymes and growth factors. Highly bound to serum proteins 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 than pentamidine. Excreted in the urine at a slow rate.

17. Recommended Medications 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.

18. Patient Prognosis Since Simon was diagnosed in Stage 1, we feel that his prognosis is good. Early treatment usually results in the resolution of symptoms and clearance of the parasite.

19. The End