Sleeping With the Enemy

1. Sleeping With the Enemy

2. Patient: Simon Conditions: Ulcerated, raised lesions on neck, calves, and feet. Lesions have drained, ulcerated, healed, and broken open again. Traveled to Middle East 4 months ago during summer (Israel and Egypt). Remembers being bitten by “small black flies” Blood work shows normal WBC count. Culture of neck lesion reveals a hemoflagellate protozoan.

3. Differential Diagnosis African sleeping sickness- Symptoms: Begins with lesions, swelling of the lymph nodes, fever, headache, rash, weakness and chills Transmission: via the bite of a bloodsucking tsetse fly Leishmaniasis- Symptoms: fever, malaise, weight loss, anemia, swelling of the spleen, liver, and lymph nodes. Also simple skin lesions which heal within a few months. When they heal, they cause serious disabilities and permanent scaring. Transmission: via the bite of sand flies (tiny sand colored flies) Chagas’ Disease- Caused bythe parasite Trypanosoma cruzi. It’s found mostly in South America, Central America, and sometimes in the United States. It’s carried by a “kissing bug”. Transmission: The most common way people become infected is by unknowingly touching their eyes, mouth, or open cuts after having come into contact with infective bug feces. Symptoms: The first symptom of acute Chagas infection is when the person's eye on one side of the face swells. Other symptoms are fatigue, fever, enlarged liver or spleen, and swollen lymph glands, rash, loss of appetite, diarrhea, and vomiting. Most serious symptoms, such as cardiac problems, and enlargement of the esophagus or large bowel.

4. Malaria- Symptoms: flu-like, high fever, chills, muscle aches Transmission: by a female Anopheles mosquito • Aspergillosis- Fungal infection that affects internal organs and travels to the skin via the blood stream. Symptoms: fever, chills, headache, chest pain, weight loss cough wheezing, and on the skin: few or many lesions that spread rapidly

5. Information Needed... In order for it to be an accurate diagnosis, there is more information needed from the patient. Are there any other symptoms besides the lesions? Weakness Headache Fever Rash Is there any previous medical conditions prior to the appearance of the skin lesions?

6. Etiological Agent Trypanosoma brucei

7. Diagnosis Simon is showing signs of Sleeping Sickness which is caused by Trypanosoma brucei. The other diseases were ruled out because… Leishmaniasis causes disabilities once the lesions heal. Also, the vector (Fly) is sand color, not black. Chagas’ is found in South America, Central America, and sometimes in the US. Also, the symptoms don’t include lesions since the bug doesn’t bite the person. Malaria does not cause lesions and is transmitted by a mosquito. Aspergillosis causes lesions, however it’s a fungus, not a protozoan.

8. "Small Black Flies" Tsetse. Large biting flies from Africa which live by feeding on the blood of vertebrate animals. Tsetse includes all the species in the genus Glossinia. Have been extensively studied because they are biological vectors of the African trypanosomiasis, deadly diseases which include sleeping sickness in people.

9. If the disease is diagnosed early, the chances of cure are high. • The type of treatment depends on the phase of the disease: initial or neurological. • The drug needs to be able to cross the blood-brain barrier to reach the parasite. • Without treatment, sleeping sickness will lead to death. • The most common drug used to treat this disease is Melarsoprol, and other alternative drugs are Suramin, Eflornithine, Pentamidine. Treatment