Uganda guidelines for the treatment of Trypanosomiasis
Uganda Clinical Guidelines 2023 · all from source →
General Adult
Diagnosis
T. Rhodesiense — Clinical Features
Incubation is 2-3 weeks. Early stage (haemolymphatic stage): headache not responding to common analgesics, fever, generalised lymphadenopathy, joint pains. Late stage (meningoencephalitis stage): after some weeks, neurological and psychiatric symptoms like apathy, day sleepiness, paralysis, seizures. If not treated: cachexia, lethargy, coma and death within 3-6 months.
T. gambiense — Clinical Features
Similar to the rhodesiense but less acute and with slower progression. Incubation can last several years.
Differential diagnosis
Malaria, meningitis, TB, HIV/AIDS.
Investigations
Blood: Slides for trypanosomes. CSF: For trypanosomes, lymphocyte count. Aspirate from chancre/lymph node: for trypanosomes.
Disease Staging (CSF Findings) — Early (first) stage
CSF is normal. Lymphocytes <5 cells/mm3. Total protein <37 mg/dl (by dye-binding protein assay) or < 25 mg/dl (by Double Standard & Centrifuge Metod). Absence of trypanosomes (by Double Standard and Centrifuge Method).
Disease Staging (CSF Findings) — Late (second) stage
Lymphocytes > 5 cell/ mm3 And/or Presence of trypanosomes.
Screening
Trapping of tsetse flies.
Clearing of bushes around homes and paths.
Early detection and treatment of cases.
Treatment
Early (first) stage — T. rhodesiense (Children and Adults, RR)
Suramin IV: A test dose of 5 mg/kg of body weight should first be administered to test for anaphylactic reaction. Followed by five injections of 20 mg/kg every 5 days interval (Day 0: 5 mg/kg, Day 3: 20 mg/kg, Day 8: 20 mg/kg, Day 13: 20 mg/kg, Day 18: 20 mg/kg, Day 23: 20 mg/kg). If anaphylaxis: do not administer. Do not use this medicine for early or late stage T. gambiense treatment in onchocerciasis-endemic areas as it may cause blindness.
Early (first) stage — T. gambiense (Children and Adults)
Pentamidine IM 4 mg/kg daily for 7 days. Give food 1 hour before to prevent hypoglycaemia. The patient should be in a supine position during administration and 1 hour after to prevent hypotension.
Late (second) stage — T. rhodesiense (Children and Adults, RR)
IV Melarsoprol 2.2 mg/kg body weight daily for 10 days.
Late (second) stage — T. gambiense (Children ≤ 12 years and <35 kg, RR)
Eflornithine IV 150 mg/kg 6 hourly for 14 days (total dose of 600 mg/kg/day). Dilute 150 mg/kg dose into 100 ml of distilled water. Administer the infusion over at least 2 hours.
Late (second) stage — T. gambiense (Children >12 years up to 15 years, RR)
Eflornithine IV 100 mg/kg 6 hourly for 14 days (total dose of 400 mg/kg per day). Dilute 100 mg/kg dose into 100 ml of distilled water. Administer the infusion over at least 2 hours (rate 20 drops/minute).
Late (second) stage — T. gambiense (Adults >15 years, RR)
Nifurtimox/Elfornithine combination therapy (NECT). Nifurtimox: 5 mg/kg every 8 hours orally for 10 days (15 mg/kg/day). Plus Eflornithine 200 mg/kg 12 hourly for 7 days (400 mg/kg/day). Dilute Eflornithine dose of 200 mg/kg into 250 ml of distilled water and administer infusion over at least 2 hours (50 drops/minute). Infusions are given slowly to prevent convulsions.
Corticosteroids Adjuvant Therapy
Should be given to patients with late trypanosomiasis on melarsoprol who may have hypoadrenalism - the steroids may also reduce any drug reactions. Do not give hydrocortisone after day 24, even though melarsoprol treatment is not yet complete. If prednisolone is used instead of hydrocortisone, anti-inflammatory action is similar but correction of hypoadrenalism will be much less marked.
General Management Note
Patient with suspected or diagnosed sleeping sickness should be managed at referral facilities.
Clinical Tools