Severity of Human African Trypanosomiasis in East Africa Is Associated with Geographic Location, Parasite Genotype, and Host Inflammatory Cytokine Response Profile

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Abstract
The mechanisms underlying virulence in human African trypanosomiasis are poorly understood, although studies with experimental mice suggest that unregulated host inflammatory responses are associated with disease severity. We identified two trypanosomiasis foci with dramatically different disease virulence profiles. In Uganda, infections followed an acute profile with rapid progression to the late stage (meningoencephalitic infection) in the majority of patients (86.8%). In contrast, infections in Malawi were of a chronic nature, in which few patients progressed to the late stage (7.1%), despite infections of several months' duration. All infections were confirmed to beTrypanosoma brucei rhodesienseby testing for the presence of the serum resistance-associated (SRA) gene, but trypanosomes isolated from patients in Uganda or Malawi were distinguished by anSRAgene polymorphism. The two disease profiles were associated with markedly different levels of tumor necrosis factor alpha (TNF-α) and transforming growth factor β (TGF-β) in plasma. In Uganda but not Malawi early-stage TNF-α was elevated, while in Malawi but not Uganda early-stage TGF-β was elevated. Thus, rapid disease progression in Uganda is associated with TNF-α-mediated inflammatory pathology, whereas in the milder disease observed in Malawi this may be ameliorated by counterinflammatory cytokines. These differing host responses may result either from differing virulence phenotypes of northern and southern trypanosomes or from immune response polymorphisms in the different host populations.