Prognosis

Human African trypanosomiasis (HAT) is usually considered lethal without treatment, but treatment of the disease is effective. Some rare cases of spontaneous recovery have been reported.[148][149][150]

Relapses are possible, and their frequency depends on the drug used and differs from one area to another, reaching up to 60% of relapses to melarsoprol in some foci in some areas.[151][152]​ Although there is no test of cure, treatment outcome assessment is recommended, including cerebrospinal fluid (CSF) examination in symptomatic patients.[32]​ Reappearance of trypanosomes within 24 months after treatment is considered as a relapse and not a re-infection.[153] For clinical trials, a follow-up period of 18 months is maintained to assess drug efficacy.[154] Nevertheless, patients should be followed up for 24 months to assess cure. Follow-up is based on parasitological diagnosis and the analysis of CSF parameters.

Gambiense HAT

The disease has a chronic course with an evolution of several months to years from infection to first stage, to second stage, and finally death as a result of complications of the disease (infections, wasting situation, and cardiac or neurological problems).[31]

Treatment in first-stage disease with pentamidine has good results in terms of safety and efficacy, with low lethality (<0.5%) and high cure rate (around 95%).​[133][134]​​​ Fexinidazole presents equivalent efficacy to pentamidine in first-stage disease.[130]

Treatment in second-stage disease shows variable efficacy depending on the area and drugs used (70% to 95% cure rate), with considerable lethality depending on the drug used (0.15% to 10%). Eflornithine treatment has a mortality of 0.7% to 2% and an efficacy of around 90%, but in some areas (Kasai province in Democratic Republic of the Congo [DRC]) this efficacy is decreasing (80%).[135] The combination of nifurtimox plus eflornithine has shown a lower mortality (0.15% to 0.5%) and a cure rate of 95% to 98%.[32][155][156]​​​​​ Fexinidazole presents equivalent efficacy to nifurtimox plus eflornithine in non-severe second-stage disease (<100 white blood cells [WBC]/microlitre in CSF), and inferior efficacy to nifurtimox plus eflornithine in severe second-stage disease (≥100 WBC/microlitre in CSF). The mortality rate is around 1.5%.[131][132]​​ Melarsoprol shows a high mortality (3% to 10%) with variable efficacy. The level of treatment failure increased after the year 2000, reaching 59% in some areas of the DRC.[136][137]

Rhodesiense HAT

The disease has an acute course with an evolution of several weeks from infection to first stage to second-stage disease, and finally death as a result of complications of the disease (cardiac or neurological problems, infections).[157] Treatment in the first stage with suramin has good results in terms of safety and efficacy, with low lethality (<0.5%) and high cure rate (around 95%).[158] Treatment in the second stage with melarsoprol shows an adequate efficacy (90% to 97% cure rate) but with considerable lethality (5% to 10%).[138] Treatment outcome assessment is limited to patients in whom symptoms reappear.

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