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African trypanosomiasis in a Caucasian associated with anaphylactic shock
578
TRANSACTIONSOF THE ROYAL SOCIETY OF TROPICAL MEDICINE AND HYGIENE (1988) 82, 578
1 Short ReDort 1 African trypanosomiasis in a Caucasian associated with anaphylactic shock A. D. Harries and J. J. Wirima Depatnnent of Medicine, Kamuzu Central Hospital, P.O. Box 149, Lilongwe, Malawi
Sleeping sickness, from infection with Ttypatwsoma bwcei rhodesiense, is endemic in Malawi with annual
notifications being more freauent in districts near national parks and-gamereserves(NYASULU & PUGH, 1987). The most imoortant svmntom of invasion of the blood is fever which, par&larlv in Caucasians, may be accompanied by fugitive, erythematous rashes. Diagnosis demands a high index of suspicion. We present a case of trypanosomiasis in a Caucasian which was initially associated with anaphylactic shock. A 42 year old British man, resident in Malawi for 18 months, thought that he had been bitten by a tick while spending the weekend in bush country. The following day he noticed a circumscribed, indurated lesion on the right ankle which was relatively rainless, accompanied b? fever and arthralgia. A blood film for malaria parasites was negative. 24 h later he developed a widespread itchy, urticarial rash, and shortly afterwards became progressively unable to breathe. There was a family history of allergy. The patient kept beesin the UK, and had been frequently stung without ill effect. However, 9 months previously at Lake Malawi he sustained numerous insect bites associatedwith an attack of “asthma”, which resolved swntaneouslv over 2 d. The patient was examined at home. There was respiratory distress and stridor. Temperature was 38°C and pulse rate 130 beats/ minute., Chest auscultation revealed expiratory wheezes; During the examination the patient collapsed. He became clammy and systolic blood pressure was 60 mm Hg. A diagnosis of anaphylactic sheik was made. and adrenaline 1:1000 05 ml given bv deep subcutaneous injection with good effectrThe patient was transferred to hospital where respiratory distress returned 1 h later and was effectively treated with subcutaneous adrenaline, intravenous corticosteroids and oral chlornheniramine. After 10 h all abnormal physical signs had disappeared, and the patient was discharged on chlorpheniramine and a reducing dose of prednisolone. Address for correspondence: Dr A. D. Harries, Department of Medicine, Kamuzu Central Hospital, P.O. Box 149, Lilongwe, Malawi.
On the evening of his discharge he had a hot bath and almost immediatelv develoned a florid urticarial rash associatedwith st&dor and audible wheezing. He was re-admitted to hospital, and required subcutaneous adrenaline for symptomatic relief. At this stage investigations were- unhelpful: haemoglobin 174 g/litre, white cell count 6.1~ lO’/litre (polymorphs 85%, lymphocytes lo%), erythrocyte sedimentation rate 5 mm/h. a blood film for malaria parasiteswas negative and chest X-ray, electrocardiogram, stool and urine microscopy were normal. Over the following 2 d he developed an increasingly severe headache and had a sustained fever of 38-39°C. The respiratory problem improved, and the urticarial rash was replaced by a diffuse erythematous rash. 2 weeks before the present illness he had visited a national park and had sustained numerous tsetse (Glossina spp.) bites. A thick blood fihn revealed S-10 trypanosomes per high power field, and a diagnosis of trypanosomiasis was made. Cerebrospinal fluid was normal. Suramin was given intravenously: O-25 g on day 1, 0.5 g on day 3, 1-O g on day 5, and 1-O g weekly thereafter to a total of 5.75 g without ill effect; all abnormal physical signs resolved 5 d after commencement of theranv. The confounding story of a possible tick bite, a historv of bee-keenine. a nositive familv historv of atopy ” and the d&&c &n&l presentation with urticaria and anaphylaxis led to an initial diagnosis of allergic disease-possibly a hypersensitivity response to the tick bite. The continuation of allergic manifestations led us also to consider invasive hehninthiasis, although the absenceof eosinophilia made this diagnosis unlikely. The presence of headache, fever, and erythematous rash and the realization that the ankle lesion was a chancre made us eventually consider trypanosomiasis. Urticaria may occur in Caucasians with trypanosomiasis (GREENWOOD, 1983), but we are unaware of an association with anaphylaxis. The reasons for this particular mode of presentation in our patient remain speculative, but his “allergic” history may have rendered him hypersensitive to invasive trypanosomes. Although we see sporadic casesof trypanosomiasis (usually with central nervous system involvement) in the indigenous population, this is only the second case seen in Caucasiansin 3 years. In a patient with a puzzling, febrile illness it behoves the clinician to be knowledgeable about the geographical distribution of disease and to take a careful travel history. References Greenwood, B. M. (1983). African trypanosomiasis. In: Oxford Textbook of Medicine, Weatherall, D. J., Ledingham, J. G. G. & Warrell, D. A. (editors). Oxford University Press, pp. 5.406-5.410. Nyasulu, y. Z. .& Pugh,, R. N. H. (1987). Medical aspects. FOalauz Eprdemrologwal Quarmlj-T~panosmaam, 1, Received February
I Februay 1988
1988; accepted
for publication
18
TRANSACTIONSOF THE ROYAL SOCIETY OF TROPICAL MEDICINE AND HYGIENE (1988) 82, 578
1 Short ReDort 1 African trypanosomiasis in a Caucasian associated with anaphylactic shock A. D. Harries and J. J. Wirima Depatnnent of Medicine, Kamuzu Central Hospital, P.O. Box 149, Lilongwe, Malawi
Sleeping sickness, from infection with Ttypatwsoma bwcei rhodesiense, is endemic in Malawi with annual
notifications being more freauent in districts near national parks and-gamereserves(NYASULU & PUGH, 1987). The most imoortant svmntom of invasion of the blood is fever which, par&larlv in Caucasians, may be accompanied by fugitive, erythematous rashes. Diagnosis demands a high index of suspicion. We present a case of trypanosomiasis in a Caucasian which was initially associated with anaphylactic shock. A 42 year old British man, resident in Malawi for 18 months, thought that he had been bitten by a tick while spending the weekend in bush country. The following day he noticed a circumscribed, indurated lesion on the right ankle which was relatively rainless, accompanied b? fever and arthralgia. A blood film for malaria parasites was negative. 24 h later he developed a widespread itchy, urticarial rash, and shortly afterwards became progressively unable to breathe. There was a family history of allergy. The patient kept beesin the UK, and had been frequently stung without ill effect. However, 9 months previously at Lake Malawi he sustained numerous insect bites associatedwith an attack of “asthma”, which resolved swntaneouslv over 2 d. The patient was examined at home. There was respiratory distress and stridor. Temperature was 38°C and pulse rate 130 beats/ minute., Chest auscultation revealed expiratory wheezes; During the examination the patient collapsed. He became clammy and systolic blood pressure was 60 mm Hg. A diagnosis of anaphylactic sheik was made. and adrenaline 1:1000 05 ml given bv deep subcutaneous injection with good effectrThe patient was transferred to hospital where respiratory distress returned 1 h later and was effectively treated with subcutaneous adrenaline, intravenous corticosteroids and oral chlornheniramine. After 10 h all abnormal physical signs had disappeared, and the patient was discharged on chlorpheniramine and a reducing dose of prednisolone. Address for correspondence: Dr A. D. Harries, Department of Medicine, Kamuzu Central Hospital, P.O. Box 149, Lilongwe, Malawi.
On the evening of his discharge he had a hot bath and almost immediatelv develoned a florid urticarial rash associatedwith st&dor and audible wheezing. He was re-admitted to hospital, and required subcutaneous adrenaline for symptomatic relief. At this stage investigations were- unhelpful: haemoglobin 174 g/litre, white cell count 6.1~ lO’/litre (polymorphs 85%, lymphocytes lo%), erythrocyte sedimentation rate 5 mm/h. a blood film for malaria parasiteswas negative and chest X-ray, electrocardiogram, stool and urine microscopy were normal. Over the following 2 d he developed an increasingly severe headache and had a sustained fever of 38-39°C. The respiratory problem improved, and the urticarial rash was replaced by a diffuse erythematous rash. 2 weeks before the present illness he had visited a national park and had sustained numerous tsetse (Glossina spp.) bites. A thick blood fihn revealed S-10 trypanosomes per high power field, and a diagnosis of trypanosomiasis was made. Cerebrospinal fluid was normal. Suramin was given intravenously: O-25 g on day 1, 0.5 g on day 3, 1-O g on day 5, and 1-O g weekly thereafter to a total of 5.75 g without ill effect; all abnormal physical signs resolved 5 d after commencement of theranv. The confounding story of a possible tick bite, a historv of bee-keenine. a nositive familv historv of atopy ” and the d&&c &n&l presentation with urticaria and anaphylaxis led to an initial diagnosis of allergic disease-possibly a hypersensitivity response to the tick bite. The continuation of allergic manifestations led us also to consider invasive hehninthiasis, although the absenceof eosinophilia made this diagnosis unlikely. The presence of headache, fever, and erythematous rash and the realization that the ankle lesion was a chancre made us eventually consider trypanosomiasis. Urticaria may occur in Caucasians with trypanosomiasis (GREENWOOD, 1983), but we are unaware of an association with anaphylaxis. The reasons for this particular mode of presentation in our patient remain speculative, but his “allergic” history may have rendered him hypersensitive to invasive trypanosomes. Although we see sporadic casesof trypanosomiasis (usually with central nervous system involvement) in the indigenous population, this is only the second case seen in Caucasiansin 3 years. In a patient with a puzzling, febrile illness it behoves the clinician to be knowledgeable about the geographical distribution of disease and to take a careful travel history. References Greenwood, B. M. (1983). African trypanosomiasis. In: Oxford Textbook of Medicine, Weatherall, D. J., Ledingham, J. G. G. & Warrell, D. A. (editors). Oxford University Press, pp. 5.406-5.410. Nyasulu, y. Z. .& Pugh,, R. N. H. (1987). Medical aspects. FOalauz Eprdemrologwal Quarmlj-T~panosmaam, 1, Received February
I Februay 1988
1988; accepted
for publication
18