Found predominantly in Africa, sleeping sickness or trypanosomiasis is a tropical disease transmitted mostly through the bite of an infected tsetse fly. Without treatment, sleeping sickness leads to death as a result of destruction of the central nervous system.
What is sleeping sickness?
Sleeping sickness (trypanosomiasis) is a parasitic disease of humans and animals caused by protozoa of the genus Trypanosoma brucei. The vector of the disease is the tsetse fly. The endemic sleeping sickness occurs mainly south of the Sahara in more than 35 countries. It is estimated that at least 100,000 – 300,000 people are infected annually. In 2008 alone, 48,000 people died from sleeping sickness. The term “sleeping sickness” is derived from the symptoms of the neurological phase:
Confusion, reduced coordination and disruption of the sleep cycle, bouts of fatigue with manic episodes, interrupted sleep for days at a time, and insomnia at night. Without treatment, sleeping sickness progresses from progressive mental decline to coma and death.
Causes
The causative agent of sleeping sickness is the parasite Trypanosoma brucei, transmitted by a bite of the tsetse fly (genus Glossina). For further treatment, infection by Trypanosoma brucei gambiense, Trypanosoma brucei brucei, and Trypanosoma brucei rhodesiense must be distinguished. The large, brown tsetse fly transmits metacyclic trypomastigote cells to the host at a risk of 1:1,000 during bloodsucking into the skin tissue. In the intercellular space, the cells transform into unicellular parasites that penetrate deeper and deeper into the host via the lymphatic system and the bloodstream, constantly multiplying. Furthermore, sleeping sickness can be transmitted by mother-to-child infection if the placenta is infested. Contaminated medical equipment or blood transfusions and sexual contact can also be sources of sleeping sickness infection.
Symptoms, complaints, and signs
Sleeping sickness is transmitted by the bite of the tsetse fly. Several days or even weeks may pass before the bite site becomes red and begins to hurt. The technical term for this is trypanosome chancre. The stitches are often found on the neck or face. After the puncture, the germs spread throughout the body. The lymph nodes swell and fever attacks occur. The affected person feels listless and experiences headaches and aching limbs. In addition to chills, kidney complaints may also occur if the organ is affected. As the disease progresses, the central nervous system is affected. The disease owes its name to the disturbances of the sleep-wake cycle that now occur. The patient suffers convulsions and paralysis. The symptomatology also spreads to general behavior. The affected person reacts moodily and irritably. In the final stage of the disease, the patient falls into a coma. If left untreated, sleeping sickness is fatal. A distinction is made between West African and East African sleeping sickness. The West African form is slower and weeks may pass before symptoms appear. It can take years for changes in personality to become noticeable. The East African sleeping sickness is faster and more aggressive. The described symptoms appear after only days, and death from organ failure occurs after several months.
Diagnosis and course
After infection, several months can often pass before the first symptoms of sleeping sickness appear. Initially, the multiplication of trypanosomes (hemolymphatic phase) brings on episodes of fever; headache, joint pain, and itching may also occur. In the second stage of sleeping sickness (neurological phase), the parasites cross the blood–brain barrier and infect the central nervous system. At this stage, the symptoms of sleeping sickness are obvious: changes in behavior, confusion, perceptual disturbances, and poor coordination. The most important feature of the second stage of sleeping sickness is the disruption of the sleep cycle. After possible infection (visible redness of the skin), screening with microscopic examination of lymph node punctate, blood or bone marrow, and review of clinical symptoms (swollen lymph nodes along the neck) can be performed. If sleeping sickness is present, a diagnosis of disease status can be made by CSF puncture.The earlier the disease is detected, the better the chance of recovery. Diagnosis before the onset of the neurological phase can avoid complicated and risky treatment of sleeping sickness.
Complications
Sleeping sickness is transmitted by a bite from the tsetse fly, and the bite is already a very painful affair. Of course, sleeping sickness is also associated with various complications, which should usually always be treated by a doctor. In many cases, severe swelling occurs immediately after the sting. Permanent cooling of the affected area can counteract this complication very well. Sleeping sickness progresses in episodes. This means that even a short-term improvement can occur. Nevertheless, various complications can occur afterwards, which require urgent medical treatment. Frequently, an increased temperature occurs in connection with sleeping sickness, which can cause a general feeling of malaise. In addition, there may be swelling of the lymph nodes, pain in the limbs and headaches. If an appropriate doctor is not consulted for these symptoms, then further complications are definitely to be expected. The elevated temperature may develop into a very severe fever. Bacteria and viruses spread throughout the body, so that a serious infection can occur. In general, if you want to avoid possible complications of sleeping sickness, you should seek medical and drug treatment early.
When should you go to the doctor?
Occasional daytime sleepiness is not yet a cause for concern and may be normal. If severe sleep compulsion occurs, possibly associated with loss of muscle control (cataplexy), unusual sleep/wake rhythms, and sleep paralysis, sleeping sickness (narcolepsy) should be considered. If these symptoms are present, it is advisable to consult a physician. People affected by narcolepsy may also be overcome by sleep while walking, which is dangerous in traffic. It is not easy for doctors to clearly diagnose narcolepsy because the symptoms cannot be clearly distinguished from depression or epilepsy, or can be misinterpreted as laziness. Sometimes it can take years before the correct diagnosis is made. In any case, those affected should always go to the doctor if they observe several of the symptoms in themselves and are severely restricted in their everyday lives as a result. This is particularly the case if, in addition to drowsiness, cataplexies and short-term paralysis occur. The sooner the diagnosis can be made, the better it is for patients.
Treatment and therapy
The medication-only type of inpatient treatment depends on the stage of sleeping sickness. The drugs used in the first stage of treatment have lower toxicity and are easier to manage. Despite not insignificant side effects, pentamidine (Tb gambiense) used intravenously or intramuscularly is generally well tolerated. Suramin (Tb rhodesiense), used intravenously, may cause urinary tract side effects or allergic reactions. The current standard therapy for the second stage (neurologic phase) of sleeping sickness is daily intravenous administration of 2.2 mg/kg body weight melarsoprol for 12 consecutive days, but this can cause significant side effects-at worst, fatal encephalopathy. The newer drug eflornithine (Tb gambiense) – previously used only as an alternative treatment for sleeping sickness due to its labor-intensive administration and cost intensity – is more tolerable and highly successful. The combination treatment of nifurtimox and eflornithine introduced in 2009 for the treatment of sleeping sickness further simplifies the use of eflornithine in monotherapy.
Prevention
Currently, there is no vaccine or preventive medication available to avoid sleeping sickness infection. Although preventive administration of pentamidine has been shown to be effective, this is medically controversial. Travelers are therefore advised to avoid insect bites by wearing light-colored clothing that completely covers the body and by using insect nets.
Aftercare
Independent follow-up of the person affected by narcolepsy is particularly related to cataplexy.Despite taking medication, acute muscle failure can occur in conjunction with a strong need for sleep. Since these are unpredictable, one’s own actions should be adapted as far as possible so that no injuries or as few injuries as possible occur in the event of a fall. The “right” way to fall to avoid pain can be professionally learned, for example, from a physiotherapist. Furthermore, in public – if possible – a person should always accompany the person concerned in order to be able to intervene in dangerous situations if necessary. However, if this cannot be implemented on a permanent basis, strangers should also be informed in potentially dangerous places, such as long (rolling) staircases, so that they can act correctly in an emergency and prevent accidents. Despite sleep attacks during the day, it is important to maintain regular night rest in order to maintain the natural sleep rhythm and not provoke avoidable narcoleptic seizures due to missed sleep overnight the next day. If narcolepsy occurs in public without an accompanying person, the name as well as a small description of the disease in the form of a small piece of paper in the pocket of the jacket or pants can quickly provide information to the rescuers or paramedics and prevent unnecessary treatment.
What you can do yourself
There is nothing that can be done to prevent sleeping sickness, or narcolepsy, nor can it be cured according to current scientific knowledge. Nevertheless, in addition to medical care, patients have some options for taking care of themselves to cope better at work and in everyday life. First of all, those affected should realize that they are not alone. To this end, it may be useful to join a self-help group. Since narcolepsy patients often tend to withdraw socially, mutual exchange in a group can give sufferers new courage. On this occasion, patients also receive tips and coping strategies that can make life with the disease easier for them. Patients should also inform their social environment about the disease. This creates understanding, and in dicey situations, such as sudden sleep attacks or cataplexies (seizures), help is quickly on hand. Several daily sleep episodes of five to fifteen minutes can improve the ability to concentrate. In addition, frequent eating of smaller meals and abstaining from alcohol relieve the body. Sporting activities can have a positive effect on longer periods of wakefulness. It is very important to choose a competent specialist. In the best case, this is a trained sleep physician. The doctor should address personal needs and questions of the narcolepsy patient.
