Melarsoprol-associated multifocal inflammatory CNS illness in African trypanosomiasis

A 62-year-old woman was evaluated for an undiagnosed febrile illness. Four weeks after returning from an African safari to Kenya and Tanzania, she became symptomatic with intermittent high-grade fever that persisted despite a trial of quinine and antimicrobials (levofloxacin, azithromycin, metronidazole, doxycycline, and vancomycin). The fever was accompanied by an erythematous abdominal rash. She recalled an insect bite on her left foot while in Africa. East African trypanosomiasis was diagnosed based on the presence of Trypanosoma brucei rhodesiense on a peripheral smear. She was given one dose of IV pentamidine. Suramin was procured from the Centers for Disease Control and administered. CSF showed increased white cell count (164 cells/μL) and proteins (191 mg/dL). Though the patient did not have neurologic symptoms, because of CSF evidence of CNS involvement, therapy was changed to IV melarsoprol (week 1: 108 mg daily for 3 days, week 2: 144 mg daily for 3 days, week 3: 216 mg daily for 3 days). Melarsoprol was administered with prednisone to prevent encephalopathy. Clinical improvement was associated with resolution of the pyrexia, progressive decrease in the CSF cell count, clearance of parasitemia on serial blood smears, and continued absence of the parasite on CSF …