Human West African trypanosomiasis with chancre presentation

European Journal of Dermatology. Volume 10, Number 7, 561-2, October - November 2000, Votre diagnostic !

Author(s) : D. Malvy, F. Djossou, M. Longy-Boursier, M. Le Bras, F.X. Weill, P. Chapuis, Department of Internal Medicine, Infectious and Tropical Diseases, Hôpital St-André, Bordeaux, France..

Summary : A 53-year-old French Caucasian man living in Conakry (Guinea) and working as a manager to build a golf course in a mangrove area, was evacuated to France and referred to our clinic in March 1997, with a recent history of a painless erythematous papule on the dorsal side of the right ankle with fever accompanied by chills and weakness, and followed by a second lesion on the left lower leg. The patient was unaware of being bitten by a tsetse fly during the previous weeks. At clinical examination, the body temperature was 39.5°C, and two respectively 12 cm and 9 cm indurated pruritic, erythematous and purpuric plaques were found on the right ankle and the left foot (Figs. 1 and 2). There was a satellite inflammatory lymphadenopathy located at the right inguinal site. The liver and the spleen were palpable. The remaining integument and the other physical findings, including those of the neurological examination, were unremarkable. Laboratory investigations reported a moderate thrombopenia and a marked leucopenia. Examination of a CSF specimen demonstrated a normal cell count (less than 1 element/mm3). Laboratory evaluation of blood specimens is showed (Fig. 3).

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In this case, evaluation of a peripherical blood smear confirmed the diagnosis and showed trypanosomes. Indeed, the patient had two trypanosomal chancres and examination of blood specimens revealed West African trypanosomiasis due to Trypanosoma brucei. Diagnosis of West African trypanosomiasis at the very early hemolymphatic stage was retained, and the patient received a regimen of five doses of iv pentamidine isethionate (4 mg/kg) over 10 days. The symptoms and blood parasitic involvement improved within two days. The immunological evaluation by immunofluorescence antibodies test (IFAT) showed an elevated serum specific IgM and IgG antibody titer level accounting at 1/50, 1/2500 respectively.

Our observation is remarkable as chancres to T. brucei gambiense are rarely reported, with frequency varying from 25 to 40% in a few small size series of European patients. Lesions have rarely been described as unique erythematous or violaceous circumscribed indurated nodules, measuring 5-15 cm in diameter, with or without local adenopathy [1, 2].

Unlikely trypanosomal chancres occur frequently in infections due to Trypanosoma rhodensiense suggesting a higher virulence of the parasite and consist of rubbery inflammatory nodules, measuring 2-5 cm in diameter, usually desquamating and resolving in 2 or 3 weeks [3].

Indeed, West African trypanosomiasis must be suspected among patients with lymphadenopathy and fever and living in a recognized endemic area, or even occurring in potential emergent conditions, and similarly be recognized at the early stage of the disease when the trypanosomal chancre is present, and a convenient and efficient therapeutic approach is possible before the stage of CNS involvement.

Article accepted on 5/6/00

REFERENCES

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