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Tripanosomiasi africana-Malattia del sonno

 

Malattia del sonno africana trasmessa dalla puntura della mosca tse-tse
Tripanosomiasi: malattia del sonno




Che cos’è la triposomiasi?

La tripanosomiasi africana o malattia del sonno è una parssitosi da protozoi del genere Trypanosoma brucei, trasmessa dalla mosca tse-tse, caratterizzata da una febbre irregolare,  adenopatie e disturbi nervosi che possono andare fino allo stato letargico.

 

Eziologia

Gli agenti patogeni sono emoflagellati, di 15-30 micron di lunghezza, che si moltiplicano per divisione longitudinale e secernono una endotossina.

  1. Trypanosoma brucei gambiense: trasmesso da una mosca idrofila, “Glossina palpalis” in Asia occidentale e centrale, soprattutto lungo i fiumi.
  2. Trypanosoma brucei rhodesiense: trasmesso da “Glossina morsitans” nella savana dell’Africa occidentale e intorno al Lago Vittoria.

Un’altra forma di tripanosomiasi si verifica principalmente in America Latina ed è conosciuta come tripanosomiasi Americana o malattia di Chagas.

Epidemiologia

La tripanosomiasi africana è diffusa esclusivamente nelle aree dove è presente il vettore (la mosca tse-tse) appartenente alla specie Glossina. La malattia è endemica in circa 200 focolai in 36 Paesi dell’Africa subsahariana in un’area di circa 10 milioni di km² ( un terzo del continente africano) dove coesistono il vettore, il parassita e gli ospiti naturali.

Trypanosoma brucei gambiense è diffuso in Africa centrale e occidentale nelle zone umide vicino ai corsi d’acqua e laghi dove il vettore è Glossina palpalis.

Trypanosoma brucei rhodesiense è endemico nelle regioni orientali e sud-orientali dell’Africa associate alla savana e viene trasmesso da Glossina morstans. A differenza di T. brucei gambiense che riconosce un serbatoio umano,T. b. rhodesiense, è una zoonosi con un serbatoio animale sia domestico (bovini, ovini)  sia selvatico carnivori. Il ciclo di maturazione del parassita nell’insetto vettore richiede circa 3-4 settimane e si conclude con la formazione dello stadio metaciclico infettivo nel lume delle ghiandole salivari della mosca tse-tse.

 




Quali sono i sintomi della tripanosomiasi?

Il quadro clinico varia a seconda della specie di tripanosoma coinvolta. Nell’infezione da T.b. gambiense, dopo un periodo di incubazione di circa 2-3 settimane insorge febbre che si presenta a cicli irregolari, di durata variabile (da uno a qualche giorno), accompagnata da sintomi aspecifici (cefalea, mialgie, astenia, malessere generale) e da linfoadenopatia. In particolare si osserva in più dell’ 80% dei casi un ingrandimento dei linfonodi cervicali posteriori (segno di Winterbottom). In questa fase è inoltre possibile rilevare edema transitorio al volto e prurito oltre un quadro di grave anemia. L’invasione del sistema nervoso centrale che caratterizza il II stadio di malattia porta a un progressivo deterioramento dello stato mentale fino al coma. La cefalea diviene costante e poco responsiva agli analgesici e si accompagna a disturbi del linguaggio. Tremori di tipo simile parkinsoniano e quadri di psicosi acuta (delirio,allucinazioni,comportamento aggressivo, apatia).

Il coinvolgimento delle aree deputate al controllo del sonno è responsabile delle alterazioni del ciclo sonno-veglia che hanno fatto dare un nome alla malattia. L’inversione del ritmo nictemerale e il frequente esordio di episodi di sonno REM caratterizzano questa fase. Sono inoltre usuali prurito generalizzato, importante calo ponderale e la comparsa di lesioni da decubito. Le alterazioni neurologiche indotte da T.b. gambiense sono considerate reversibili anche dopo lungo tempo nei pazienti sottoposti a terapia ma senza trattamento il paziente evolve verso il coma che conduce alla morte.

La tripanosomiasi indotta da Trypanosoma brucei rhodesiense esordisce  dopo un periodo di incubazione di 5- 15 giorni spesso con la comparsa della tipica lesione cutanea (tripanoma) nella sede di inoculo dei parassiti. La lesione si presenta come una papula eritematosa, dura e dolente di 2-5 cm di diametro; può andare incontro a ulcerazione e guarisce in genere nel volgere di 2-3 settimane. La febbre elevata può simulare un attacco malarico acuto e si accompagna al linfoadenopatia generalizzata anche se il segno di Winterbottom in questi casi spesso è assente.

Nei viaggiatori e negli espatriati, rispetto alla popolazione autoctona, si può osservare un esantema maculopapulare. Sono inoltre frequenti e clinicamente rilevanti le manifestazioni cliniche: tachicardia (non correlata alla febbre), aritmie, segni di miocardite con scompenso cardiaco acuto che possono portare a morte prima dell’insorgenza dei sintomi neurologici. Il coinvolgimento a carico del sistema nervoso centrale è simile a quello per la forma da gambiense ma a insorgenza ed evoluzione più rapida.

 

Tripanosomiasi:diagnosi

  1. Anamnesi di soggiorno in zona endemica. 
  2. Infiammazione nella sede della puntura della mosca tse-tse.
  3. Sindrome tossinfettiva, tachicardia elevata, adenopatia, epatosplenomegalia.
  4. Insonnia, apatia, sonnolenza.
  5. Diagnosi confermata dalla ricerca del tripanosoma nel sangue e nel liquido cefalorachidiano.

 

 




Terapia per la cura della tripanosomiasi

Il trattamento della tripanosomiasi africana è dipendente dalla specie in causa e dallo stadio della malattia. Per la forma gambiense si impiegano la pentamidina nel I stadio e l’eflornitina nel II stadio. La terapia della forma rhodesiense e si basa sull’utilizzo dei due farmaci associati a maggiore tossicità la suramina I stadio  in melarsoprol nel II stadio. Quest’ultimo contiene arsenico che può indurre un’encefalopatia letale.

 

Prevenzione 

Si basa sul riconoscimento dei casi, il loro trattamento e sull’eliminazione del vettore. Non sono disponibili vaccini e la chemioprofilassi non è raccomandata per la tossicità dei farmaci disponibili.

 




 

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