African sleeping sickness in a young American tourist

Travel can make the world a much smaller place for medical practice. Even though many parasitic diseases are not endemic to the continental United States, emergency rooms and clinical laboratories must be prepared to recognize and treat the most exotic varieties of parasitic diseases. With abundant parasitic organisms evident in the peripheral smear and recent travel to a geographic area where trypanosomiasis is endemic, this particular case was not difficult to diagnose. This patient demonstrated a significant thrombocytopenia that required platelet transfusion, moderate leukopenia, but only a mild decrease in RBC count and hemoglobin concentration. The patient had notable splenomegaly, but only marginal hepatomegaly. Blood and protein were found in the urine along with abnormal liver function test values which quickly returned to normal with appropriate treatment. Coagulation studies showed abnormalities in fibrinogen and D-dimer. The elevated fibrinogen levels were most likely due to its role as an acute-phase reactant. This patient's disease was detected very early in its course. The fact that the CSF was normal with no elevation in protein or lymphocytosis most likely indicates that the disease had not yet progressed to the CNS. Since no organisms were seen in the CSF sample and the patient dramatically improved with suramin therapy, melarsoprol or eflornithine treatment was deemed unnecessary. As in this case, spinal taps should be performed periodically during therapy and continue for 1 to 2 years to ensure that treatment has been successful. A final diagnosis of T.b. rhodesiense was made based on the patient's travel history, the acute course of the disease, and the response to suramin rather than pentamidine therapy. The patient was closely monitored over the next few months for the possibility of relapse, but no further symptoms were noted. The patient returned to his normal activities and was considered to have made a full recovery.