Objective: To present the clinico-imaging progression of parkinsonism from Human African Trypanosomiasis (HAT; sleeping sickness), and discuss the diagnostic and treatment challenges.

Background: East African trypanosomiasis, the form of HAT  endemic in eastern Africa, is a zoonosis caused by Trypanosoma brucei rhodesiense and is fatal unless treated. It is characterized by a haemolymphatic stage, followed by central nervous system involvement in stage 2. Melarsoprol is the treatment  for stage 2 Rhodesian trypanosomiasis but the drug leads to  fatal reactive-encephalopathy in 5% of patients. Clinical, and specially imaging, features of HAT and drug-related-encephalopthy are not well described.

Methods:  Case-report

Results:  A 46 year old man from Zambia, Africa developed repeated episodes of fever, pruritic rash, lethargy and weight loss over an eight month period. Screens for various infections were negative. In the subsequent 4 weeks, he developed severe dysarthria, symmetrical parkinsonism, unsteady gait and confusion and, was transferred from Zambia to our centre in India. Brain magnetic resonance imaging (MRI) revealed asymmetric, swollen lentiform and globus pallidus nuclei with a FLAIR hyperintense signal. Blood and centrifuged cerebrospinal fluid (CSF) screens for infections, including HAT, were negative. Over the next 3 weeks he became bedbound from severe parkinsonism and hypersomnolence. Serial MRIs revealed extension of FLAIR signal in the basal ganglia, thalami, adjoining cortex and dorsal brainstem with mild contrast enhancement. HAT was the considered diagnosis, however, melarsoprol was unavailable in India and could not be procured from  WHO or CDC without a confirmed diagnosis. The patient was  scheduled for transfer to Zambia (air ambulance) when he developed diarrhoea and fever.  Blood smear done at that time revealed trypanosomes, confirming the HAT diagnosis. Melarsoprol could then be obtained from Zambia. Unfortunately, the patient developed fatal drug-related encephalopathy with right basal ganglion haemorrhage and massive cerebral oedema seen on CT.

Conclusions: Our case-report documents the clinico-imaging progression of HAT. It highlights the difficulty in confirming the diagnosis in early and even late stages, and problems in timely drug procurement in countries where HAT is non-endemic

References: Squarre D, Kabongo I, Munyeme M, Mumba C, Mwasinga W, Hachaambwa L, Sugimoto C, Namangala B.Human African Trypanosomiasis in the Kafue National Park, Zambia. PLoS Negl Trop Dis. 2016, 10(5):e0004567

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MDS Abstracts - https://www.mdsabstracts.org/abstract/parkinsonism-in-human-african-trypanosomiasis-clinical-course-imaging-findings-and-treatment-related-challenges/