Sleep

Last week I was seeing patients with the Consultants, talking to and examining people with everything from muscle aches to malaria. A forty-five-year-old man and his family member appeared at the door. The patient had a blank look on his face and was being led by his younger brother. Our patient was staring, his eyes slowly wandering around the room. He visually fixed on objects, holding his gaze in one spot for 30 seconds, and then moving his eyes. He shuffled slowly and was settled by his brother into a chair.
Djogo, one of the Consultants, took the medical history. The brother did all of the talking. Two weeks ago the illness started with a change in personality. With further questions it became clear that symptoms dated from months earlier, with the patient becoming quieter and passive. When asked questions, it would take him several seconds to reply, if the answer came at all. His responses were only tangentially related to the questions asked. There had been nothing else—no fever, no seizures, no head trauma. Other than his passive staring state, his physical and neurological examinations were normal.
What was this?
The first thing that came to my mind was a chronic meningitis. Most people think of meningitis as an acute illness with high fever, a stiff neck, and quick death. But there are infections of the meninges (coverings of the brain) that are slower, so called chronic meningitides. Tuberculosis or Cryptococcus infection of the meninges can cause this. These infections are treatable but must be diagnosed by spinal tap. Or perhaps this was a brain tumor, likely in the frontal lobe, the seat of personality and motivation. But the patient didn't have other symptoms of a brain tumor like headaches, changes in eye movements, vomiting, or seizures. Maybe it was an unusual type of seizure, but for two or more weeks? That seemed unlikely.
So it was probably a chronic meningitis. As he needed a spinal tap and treatment, I brought him back with me to the hospital. When we arrived, I discussed the case with my fellow physicians. They agreed with my differential diagnosis but added another possibility I had not considered—maladie de sommeil or sleeping sickness.

African sleeping sickness is caused by infection with a parasite, Trypanasoma brucei. Transmission to humans is by the bite of tsetse flies. There are both acute and chronic types, caused by different subspecies. In my patient's case, it was would be Trypanasoma brucei gamiense, found in Central and Western Africa.
For the first two years after the infecting bite, the symptoms are mild. Slowly, behavioral changes appear. People who used to be fastidious become careless about their appearance. Tempers flare unpredictably. Even delusions or hallucinations can develop. Patients begins sleeping more, eventually spending little time awake. Finally, they stop eating.
The diagnosis of central nervous system disease is made by finding the organisms or white blood cells (a sign of infection) in the spinal fluid. Therapy is a real challenge. Older medications that treated the infection were very toxic. Between 1 and 5 percent of patients died from the therapy. Fortunately, a new drug (éflornithine) doesn't have as many associated deaths, but is still toxic and difficult to administer.

My patient with the personality changes had a spinal tap. It was completely normal. This makes both sleeping sickness and chronic meningitis (like tuberculosis) much less likely. The next phase in diagnosis is a scan of the brain (to look for tumor or other changes) and an EEG (to see if this is a seizure variation). Neither of these tests is available here in Lubutu.
After a few days in the hospital, my patient was sent home without diagnosis or treatment. The car carried the two brothers back to Mungele. They walked home, one silently staring at nothing in particular.