This week's case was generously donated by Dr. Manohar Mutnal. The following were seen in a peripheral blood smear from a patient with an unknown travel history. What is your differential diagnosis? What additional information would you like?
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7 comments:
Trypanosoma brucei. I don't think we can tell the subspp apart.
This is definitely a case of trypanosomiasis. The flagellate doesn’t show a prominent kinetoplast nor assumes a C shape in general. This rule out Chaga’s disease caused by T. cruzi. We have Trypanosoma brucei, yet morphology alone doesn’t warrant a differential diagnosis of subspecies gambiense nor rhodesienne.
Florida Fan
Trypanosoma brucei. A better travel history and/or molecular testing is needed to tell the subspecies apart. Additional testing (lumbar puncture?) is also needed to determine the stage of the disease before starting treatment.
Very nice pictures of Trypanosoma brucei sp.
Although theoretically it could be both subspecies (T.b.gambiense or T.b.rhodesiense), chances are very very big that this is T.b.rhodesiense because this is the subspecies that will get quickly to a parasitemia high enough to be able to detect the trypanosomes in a thin bloodfilm. One could also look at the moment of exposure and how the disease evolved: T.b.gambiense has a more chronic evolution, while T.b.rhodesiense will be more acute.
A lumbar puncture will be able to tell us if the patient has evolved to stage II of the disease, where the parasite has invaded the central nervous system. Even if no tryps are found in the CSF, a raised number of WBCs in the CSF will still be indicative of stage II disease (when tryps are found in the blood).
In the first picture we can also clearly see the difference between the two morphologies of T. brucei: the "short stumpy" form (adapted for survival in the tsetse fly vector --> transmission) versus the "long slender" form (which multiplies in the host)!
Thanks for sharing this very nice case!
“Bene dixit” Idzi, your elaboration gave us a lot of insights.
Florida Fan
Trypanosoma brucei... In the lab, I would have looked for more information, particularly about the country and area of exposure, as well as the timing of exposure if possible. The first species infecting humans discovered by Dr. Bruce, T. gambiense, develops over several months to years, compared to just a few weeks for T. rhodesiense. I assume a PCR test would allow for a quick differentiation, but I'm not sure whether this is important for management and treatment...
Thanks for this great case!
trypanosoma brucei... /Patrik
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