The unknown risk of vertical transmission in sleeping sickness--a literature review.

BACKGROUND: Children with human African trypanosomiasis (HAT) present with a range of generally non-specific symptoms. Late diagnosis is frequent with often tragic outcomes. Trypanosomes can infect the foetus by crossing the placenta. Unequivocal cases of congenital infection that have been reported include newborn babies of infected mothers who were diagnosed with HAT in the first 5 days of life and children of infected mothers who had never entered an endemic country themselves. METHODS: This review systematically summarizes the literature on the vertical transmission of HAT, to our knowledge for the first time. To approach the broader aspects of the subject, articles considering the epidemiology of childhood HAT and HAT in pregnancy were also included. The HAT guidelines and technical reports of the World Health Organisation, Médecins Sans Frontières, Institut de Recherche pour le Développement, and of one endemic country were reviewed. RESULTS: Publications describing congenital HAT are very limited and consist only of single case reports and small case series. Generally it is assumed to be a rare event, but it has never been systematically investigated. In two publications, it is hypothesized that congenital HAT occurs more often than suspected. Not all guidelines and not all HAT literature mention this transmission route. CONCLUSIONS: The risk of vertical transmission is unknown. Awareness of congenital HAT is insufficient, and as a result opportunities for an early diagnosis in newborns may be missed. All HAT guidelines and local HAT protocols should stress that in endemic areas pregnant women should be systematically checked for HAT and that newborns of HAT infected mothers should be assessed for the disease as soon as possible. Studies on the impact of HAT on fertility and pregnancy and studies on congenital HAT are long overdue.

[The use of difluoromethylornithine in congenital trypanosomiasis due to Trypanosoma brucei-gambiense]. / Utilisation de la difluorométhylornithine dans la trypanosomiase congénitale à Trypanosoma brucei-gambiense.

The authors describe their experience with two cases of congenital Trypanosoma brucei-gambiense trypanosomiasis treated with orally administered difluoromethylornithine. The first case tolerated well his treatment (35 days of DFMO) and has probably been definitively cured. The second case, already in a desperate condition upon admission, died after only 4 days of difluoromethylornithine (DFMO). The authors hypothesize that difluoromethylornithine (DFMO) may be the drug of choice for congenital trypanosomiasis because of its good absorption by the oral route, its ability to penetrate the cerebrospinal fluid especially in presence of meningeal inflammation and its activity against Trypanosoma brucei-gambiense.

[Congenital trypanosomiasis and leishmaniasis]. / Trypanosomoses et leishmanioses congénitales.

Trypanosomas and leishmanias can cross the placenta. Trypanosoma cruzi (American trypanosomiasis or Chagas' disease) may infect the placenta, with or without fetal transmission (congenital trypanosomiasis). Congenital transmission of Chagas' disease is a real problem of public health. Risk of congenital infections is less important for African trypanosomiasis and leishmaniasis. However, physicians should always think of this diagnosis in individual cases, since these diseases may occur in any part of the world, including outside the endemic areas.

[Report on l7 years of studies of human African trypanosomiasis caused by T. gambiense in children 0-6 years of age]. / Bilan de 17 années d'étude de la trypanosomiase humaine africaine à"T. gambiense" chez les enfants de 0 à 6 ans. A propos de 227 cas.

The authors present 227 cases of human African trypanosomiasis in children between 0 and 6 years, which have been observed for 17 years in the hyperendemic area of Fontem, Cameroon. These cases deal with a subject seldom described in medical literature. The authors especially insist on the velocity of both the contamination and involvement of the nervous system, as well as on the difficulty in settling a diagnosis when failing consider the notion of endemic area. On the other hand, they stress the fact that the efficiency of arsenical treatment is not more dangerous for children than for adults. Finally, they confirm the existence of congenital trypanosomiasis, which proves to be as important from the epidemiological point of view than from the strategical means to be used to identify this disease.

Congenital transmission of Trypanosoma congolense in mice.

Pregnant mice were infected with a strain of T. congolense which produces a chronic infection, to determine if congenital infection can occur. Some of the mice were killed before delivery and tissues of foetuses injected into clean male mice. Other mothers were allowed to deliver and the tissues of some of the 1-day-old young inoculated into male mice while the remaining members of each litter were suckled by the infected mother until weaning. Some but not all males infected from foetuses and 1-day-old young became infected, while the litter-mates suckled normally by their mothers did not show any infection. It seems that T. congolense, though not commonly found in tissues of the host, can cross the placental barrier and infect the foetus, but that young suckled by infected mothers may be protected from infection.

Effects of parasitic infections in pregnant women.

This review focuses on the parasitic diseases which occur frequently in the tropics and which affect pregnant women. Clinical disease of the mother during pregnancy, vertical transmission of parasites and transplacental passage of soluble parasitic antigens are discussed in relation to their immunopathological significance for the fetus. The incidences of congenital malaria, African trypanosomiasis and Chagas' disease are reviewed, together with vertical transmission of filarial infection, involvement of the female genital tract in schistosomiasis, and fulminant colitis due to Entamoeba histolytica infection during pregnancy.

[Some new cases of congenital human African trypanosomiasis (T. gambiense) (author's transl)]. / Quelques nouvelles observations de trypanosomiase humaine africaine congénitale à Trypanosoma gambiense.

The authors report three cases of congenital transmission of T. gambiense. In two cases, the parasite has been found in the blood of the umbilical cord. In the third case, it has been found twenty hours after birth in the peripherical blood of a new born child whose mother was affected by trypanosomiasis. They report also two cases of pregnant mothers with sleeping sickness, whose children were born-unaffected by the disease. The authors believe that the placental transmission of the human african trypanosomiasis is more frequent than thought.

A case of congenital trypanosomiasis in Lagos.

A 17-day old baby girl presented with signs and symptoms of neonatal meningitis, except that she did not respond to the usual drugs. Intensive investigations showed that she had trypanosomal meningo-encephalitis or sleeping sickness. Her CSF was full of T. gambiense. Her mother's blood, but not her CSF, also contained the parasites. The clinical features and laboratory findings of the disease in this neonate were very different from those usually found in adults. Furthermore, her infection was complicated by the syndrome of inappropriate anti-diuretic hormone secretion. She died of the disease and its complications probably aggravated by the drug (suramin) with which she was treatedmthis is believed to be the first case of congenital trypanosomiasis described in Nigeria, and it occurred in Lagos where it was least expected;