Monday, March 5, 2018

Case of the Week 484

It's the first of the month again - time for a case from Idzi Potters and the Institute of Tropical Medicine, Antwerp!


The patient is a frequent traveler who recently returned from Kenya where he participated in a game tracking excursion. He now presents with high fever, malaise and headache. The following were seen in a preparation of unfixed blood:


You can also see the video on YouTube: https://youtu.be/IGadYEsc5rA


A Giemsa-stained thin blood film was also performed and showed the following:
Identification?
 

16 comments:

Atiya Kausar said...

African trypanosomiasis with history that patient has visited Kenya and been on tracking excursion .He has got infection from bite of tsetse fly . Trapanosoma brucei infection subspecies t brucei gambience probably as it is cause of 98% of infections. Symptoms suggest he is in initial stage of disease and he can be started with suramin or pentamidine

Anonymous said...

Definitely T.brucei gambiense/rhodesiene. I would favor Atiya's answer.
Florida Fan

William Sears said...

Old world trypanosomes. Trypanosoma Brucei, likely rhodesiense given that he went to kenya. You can tell that they aren't new world trypanosomes (although the travel history makes it rather obvious they are not) because they don't have that big kinetoplast headlight. Lovely little critters.

Anonymous said...


Tripanosoma gambiense/rhodesiense

Carlo Alberto Varlani

Anonymous said...


Ooooops: Tripanosoma brucei gambiense/rhodesiense.

C.A.Varlani

Idzi P. said...

Hi Dr. Sears! You're right, Kenya kind of gives it away, doesn't it? ;-)
When exclusively considering New World species, the morphology of the tryps in the picture is also consistent with T. rangeli however, which is considered non-pathogenic to humans.
In this case, we are looking at Old World trypanosomes, causing HAT (Human African Trypanosomiasis).
The short patient’s history contains several hints, allowing (very presumptive) identification up to subspecies level!
Please, give it a shot everybody!
Try to find as many hints as possible (also take the vector into consideration)!
Cheerio!
Idzi

Santiago Delgado Fernandez said...

Trypanosoma brucei :) trypomastigotes with tiny posterior kinetoplast, as opposed to the larger one of Trypanosoma cruzi. Also, the travel history is helpful, since T. cruzi is limited to America, and T. brucei to Africa. If the patient went specifically to Kenya, then he probably has an infection by T. brucei rhodesiense, although by morphology we cannot distinguish it from T. brucei gambiense.
I'm originally from Venezuela and we got lots of Chagas and chipos down there!
Happy week!
Santiago

Idzi P. said...

Hi Santiago! Chipos are the kissing bugs, no? Official name: Triatomes. They transmit T. cruzi (cause of Chagas’ disease in New World) by defecating while feeding. Nasty! Imagine us doing that... sorry... no... don’t...
;-)

Idzi P. said...

Santiago is right! Morphologically no distinction can be made between T.b.gambiense or rhodesiense. Geographically, rhodesiense is suspected. But which other hints from the patient’s history push us towards this?

ali mokbel said...

Well, by now we all know it's a Trypanosoma brucei infection. The question is: which subspecies is it?
I say it's Gambiense because the presented symptoms are considered mild compared to the ones presented by a T.b.rhodesiense infection (more aggressive with neurological complications which may lead to septic shock or even multi-organ failure within days of the onset of fever).
Moreover,knowing that this patient is a "frequent" traveller and that T.b.gambiense infection is characterized by a very long incubation period, so even though his last trip was to Kenya (east african country), that doesn't mean he's never been to a west african country where he had most likely acquired the infection.

Anonymous said...

Acute onset of haemolymphatic stage in suspected HAT would be suggestive of Rhodesian trypanosomiasis, but perhaps the fact this patient participated in a game tracking excursion also supports T b rhodesiense? The reservoir for this subspecies is animals (hence the game tracking is the exposure) while the reservoir for T b gambiense is humans. Would consider eflornithine-nifurtimox as therapy.

- LS

Ozgur KORU said...

Trypomastigotes are seen in the Giemsa stained blood preparation of the patient. Considering the region in which the patient traveled, it is thought that this case may be the case of east african trypanosomiasis. And East African trypanosomiasis is caused by the Trypanosoma b. rhodesiense parasite. So, it is Trypanosoma b. rhodesiense.
Greetings from Turkey.

Anonymous said...

Yaaaay Trypanosoma brucei!!! Responsible for sleeping sickness or HAT, such a parasitological charm <3 Most probably early infection by T. brucei rhodesiense by geographic clue, wish we could know if there was a dermatological finding on inoculation site or rash... Most probably Glossinia morsitans as the vector aaand that would sugest an "accidental" transmission during the game tracking (Reservoir are savannah and some domestic animals). Suramin would be preferable as treatment if tolerable

T. brucei gambiense could be considered but i would expect more severe symptoms if no other relevant clinical information, because the early phase although slow would be reported as chronic symptoms... Well, that we don't know...

Anyways... nature selection at its finest =)

Anonymous said...

I would probably also have a low threshold for doing a lumbar puncture in this case, given that if it were Rhodesian HAT in the meningoencephalitic stage, we would have to use melarsoprol instead of suramin or NECT. Fever + headache does not guarantee meningitis, but I would prefer to be cautious in such a situation, including in the absence of more classic CNS signs (excessive daytime sleeping etc.)

- LS

Jan Van Erps said...

My best bet is that game tracker excursions in Kenya suggest walks in the savannah tracking antelopes or wildebeeste hence exposure to the savannah Glossinae : morsitans, pallidipes,etc. vectors of T.b. rhodesiense whose reservoir is wild ungulates.
From the scarce (:-) clinical hints I bet on a rather acute onset with (specified) HIGH fever, both presumptive of rhodesiense subspecies and no mention of the lymph nodes or CNS involvement which would have hinted toward gambiense.

Jan Van Erps said...

... and the central eastern african location of course...