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African sleeping sickness.

During my recent trip to Africa, two of my personal goals were to learn about the state of sleep medicine in Tanzania and see firsthand African sleeping sickness. Sleep centers are non-existent, but Tanzania seems to be an endemic area for sleeping sickness.

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Sleeping sickness is a disease that one studies during medical school and sleep medicine fellowship as interesting trivia or a "zebra" to be asked during one's board certification exam. I must confess that my narcissistic delusional paranoia (not sure if this is a DSM-IV diagnosis but it is a real disorder) has me believe that my destiny includes an ironic death-the sleep specialist falling asleep at the wheel or contracting sleeping sickness. Of course the chances of my demise from complications of obstructive sleep apnea are higher, but it is not as morbidly romantic as the above.

Each night we slept under the cover of a mosquito net, a constant reminder of insect born disease, not necessarily sleeping sickness, but malaria. These nets also had a certain sense of romanticism until I remembered sleeping with these mosquito nets during my youth and still being eaten up mercilessly.

My research for this article led me to different pathways even though I was only interested in the science of this sleep disorder. At times I wasn't sure if I was getting a history, geography, political, or social studies lesson. It was at times confusing as many of the countries in Africa had different names only a few decades ago. It was also interesting to learn that in the early part of the twentieth century trypanosomiasis decimated the population in many parts of the sub-Saharan Africa.

Trypanosomiasis is described by some as a neglected disease. By definition, neglected diseases are those disorders which affect people from among the world's poorest populations, for which there is no satisfactory treatment and the investment required to bring new medicines to market have proven to be a major disincentive to drug development. It was also noteworthy that there has been a rise in this disorder in the last thirty years and it was felt to be due not to the lack of science, but to other factors including social upheavals, wars with the displacement of populations, and an increase in poverty. Sleeping sickness should not to be confused with American trypanosomiasis or Chaga's Disease, which is a chronic and debilitating parasitic infection affecting an estimated 11 million people, predominantly in Mexico, Central America, and South American. Caused by Trypanosoma cruzi which are transmitted to humans by "kissing bugs" (hemato-phagous triatomine). These bugs live in the crevices of poor homes in rural areas. Noteworthy, there have been cases documenting transmission through blood transfusion, organ transplantation, and congenitally through the placenta. Chaga's Disease may have three clinical presentations: 1. Development of mega syndromes (massive dilatation of the esophagus or colon) 2. Development of myocardis with fibrosis and high mortality or 3. Completely asymptomatic. No vaccine is available and treatment in the acute phase consists of Nifurtimox or Benznidazole (not available in the US). Nifurtimox is available under the investigational new drug protocol from CDC Parasitic Disease Drug Service.

Trypanosomiasis is a systemic disease caused by the parasite Trypanosoma brucei. There are two types of African sleeping sickness or African trypanosomiasis; each simply enough named for the region of Africa in which it was found. Specifically, East African trypanosomiasis is caused by T.b. rhodesiense and West African trypanosomiasis by T.b. gambiense. Both are transmitted by the bite of the tsetse fly only found in Africa and described as a gray-brown insect about the size of a honeybee. Tsetse proboscis is thick and saw tooth causing painful bites. Most victims can often recall the bite. However, it must be noted that not all tsetse flies carry the parasite, as a matter of fact the proportion infected is very low. One reference source claims these flies keep the Maasai tribe and other cattle herders out of the park sanctuaries thereby insuring these parks are not disturbed. It is estimated that the warthog, one of the tsetse's favorite feeding animals, donates an estimated 0.75 ounces of blood a day.

From a geographical standpoint, trypanosomiasis is confined to tropical Africa between 15[degrees] north latitude and 20[degrees] south latitude, or from north of South Africa to south of Nigeria, Libya, and Egypt. There are between 15-20,000 new cases of trypanosomiasis reported every year to the World Health Organization. However, the consensus is that this number is grossly underestimated with the true prevalence between 50-70,000 cases a year.

Most of the reported cases of West African Trypanosomiasis are found in Central Africa (Democratic Republic of Congo, Angola, Sudan, Central Africa Republic, Chad, and Northern Uganda). Symptoms include fever, rash, swelling of the face and hands, headaches, fatigue, myalgia, pruritis, and swollen lymph nodes. Weight loss can also occur as the disease progresses. Once there is CNS involvement there is progressive confusion, personality changes, daytime sleepiness with circadian disturbances and other neurological problems. If it remains untreated, death will occur after several years. Unfortunately there is no vaccine or prophylaxis for West African trypanosomiasis.

On the other hand, since 1967, 37 cases of East African trypanosomiasis have been diagnosed in the US. All of the victims had a history of traveling to Eastern African. More than 95% of cases are reported from Uganda, Tanzania, Malayi, and Zambia. The bite site, as already stated, is often very painful and develops into a chancre. Some develop a skin rash. Symptoms include fever, severe headaches, irritability, extreme fatigue, swollen lymph nodes, myalgia, and arthralgia. Later on progressive confusion, personality changes, and other neurological problems appear. If untreated, death occurs within months. As with West African trypanosomiasis no vaccine or prophylaxis is available.

As part of the suggestions for travelers to Africa, it is recommended that one wear neutral colored clothing as the tsetse fly is attracted to bright and very dark colors. Of course, I did not follow these recommendations as my wardrobe consisted of very contrasting dark colors and we traveled in moving jeeps at all times and of course, the local bushes were used as our prn restrooms. I even tempted fate by having my picture taken next to a 3 X 2 ft. black and blue flag which apparently is a tsetse fly trap.

During my two weeks in Africa, I fortunately did not see any patient with sleeping sickness. As a matter of fact, the local doctors had only seen one case, a Maasai tribesman with severe neurological sequelae. This made sense since most Maasai tribesmen would not go to a western trained physician for an insect bit of skin rash. Despite the irrational thoughts of my demise in an unusual and ironic manner, I did not contract sleeping sickness. For that I am grateful and I pray that sleeping sickness once again becomes a historical footnote or a trivia question on a sleep medicine exam. Until next time, La La Salama.

Frank Roman MD is a diplomat of the American Board of Sleep Medicine and a Partner, Neurosurgery & Neurology Associates of Massillon, OH. He received his law degree from the Univ of Akron Law School.

by Frank Roman MD JD
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Title Annotation:SLEEP MEDICINE
Author:Roman, Frank
Publication:FOCUS: Journal for Respiratory Care & Sleep Medicine
Date:Sep 1, 2008
Words:1207
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