WHO recommends fexinidazole for rhodesiense HAT
The World Health Organization (WHO) has updated its guidelines for the management of human African trypanosomiasis (HAT). HAT is a serious, life-threatening disease, with approximately 55 million people at risk of infection in 36 sub-Saharan countries.
The updated guidelines now include recommendations for the management of rhodesiense HAT, previously missing from the 2019 guidelines, which only covered the management of gambiense HAT.
The updated guidelines recommend fexinidazole, an orally administered antitrypanosomal drug, as a first-line treatment for rhodesiense HAT. Fexinidazole is therefore now recommended for either gambiense HAT or rhodesiense HAT in patients older than 6 years of age who weigh more than 20 kg.
The new recommendations improve the management options for rhodesiense HAT. Many patients will no longer:
require injectable treatments
require a lumbar puncture for disease staging (in eligible patients)
be exposed to melarsoprol, a highly toxic drug.
Fexinidazole has a high efficacy rate; in one study the cure rate was 100% in first-stage disease, and 94.3% in second-stage disease. The mortality rate was substantially lower compared with melarsoprol.
Summary
Definition
History and exam
Key diagnostic factors
- previous stay in rural west and central Africa (Trypanosoma brucei gambiense)
- previous stay in game parks in east and southern Africa (T b rhodesiense)
- enlarged cervical lymph nodes/Winterbottom sign (T b gambiense)
- chancre (T b rhodesiense)
- disturbances of consciousness and sleep
Other diagnostic factors
- history of several treatments against malaria with no improvement
- headache
- fever
- fatigue and general malaise
- history of infertility, menstrual disorders, high miscarriage rate (women)
- reduced libido, impotence (men)
- pruritus
- edema
- impaired motor functions
- mental changes
- signs of cardiac failure (T b rhodesiense)
- rash
- hepatosplenomegaly
- sensory disorders
Risk factors
- exposure to tsetse fly
- living or working in an area with people infected with gambiense trypanosomiasis
- living or working in an area with animals infected with rhodesiense trypanosomiasis
Diagnostic tests
1st tests to order
- complete blood count
- erythrocyte sedimentation rate
- serum immunoglobulins (Ig)
- rapid diagnostic tests
- card agglutination test for trypanosomiasis (CATT)
- immunofluorescence
- enzyme-linked immunosorbent assay (ELISA)
- chancre aspirate microscopy
- lymph node aspirate microscopy
- blood microscopy
- microhematocrit centrifugation technique
- quantitative buffy coat technique
- mini-anion exchange centrifugation technique (mAECT)
Tests to consider
- electrocardiogram
- cerebrospinal fluid (CSF) white blood cell (WBC) count
- CSF microscopy
- double centrifugation of CSF
- modified single centrifugation of CSF
- CSF protein
Emerging tests
- polymerase chain reaction (PCR)
- reverse transcriptase real-time PCR (RT-PCR)
- intrathecal immunoglobulin production
- stage biomarkers
- immune trypanolysis
- T b gambiense inhibition ELISA (g-iELISA)
- MRI brain
Treatment algorithm
gambiense human African trypanosomiasis (HAT)
rhodesiense human African trypanosomiasis (HAT)
relapse
Contributors
Authors
Veerle Lejon, PhD
Director of Research
Institut de Recherche pour le Développement
Montpellier
France
Disclosures
VL is an author of several references cited in this topic. VL declares that she has no competing interests.
José Ramón Franco, MD, MPH
Medical Officer
Control of Neglected Tropical Diseases
Human African Trypanosomiasis Control Program
World Health Organization
Geneva
Switzerland
Disclosures
JRF is an author of several references cited in this topic. JRF declares that he has no competing interests.
Pere P. Simarro, MD, PhD
Former head of WHO HAT control and surveillance programme
WHO temporary advisor
World Health Organization
Geneva
Switzerland
Disclosures
PPS is an author of several references cited in this topic.
Peer reviewers
Sanjeev Krishna, MA (Cantab), BMChB (Oxon), DPhil, FRCP, ScD (Cantab), FMedSci
Professor of Molecular Parasitology and Medicine
Centre for Infection
Division of Cellular and Molecular Medicine
St. George's
University of London
London
UK
Disclosures
SK is a consultant for the Foundation for Innovative Diagnostics, a non-profit organization developing diagnostics for neglected diseases such as HAT. SK is an author of a reference cited in this topic.
Mike Barrett, BSc, PhD
Professor
Division of Infection and Immunity
Institute of Biomedical and Life Sciences
The Glasgow Biomedical Research Centre
University of Glasgow
Glasgow
UK
Disclosures
MB declares that he has no competing interests.
Differentials
- Malaria
- Typhoid fever
- Relapsing fever
More DifferentialsGuidelines
- Guidelines for the treatment of human African trypanosomiasis
- Clinical care of human African trypanosomiasis
More Guidelines
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