Current situation and perspectives regarding human Chagas disease in midwestern of the state of Minas Gerais, Brazil

Recognising the importance of Chagas disease in Brazil, Bambuí set up epidemiological surveillance for Chagas disease in 1974 and was the first municipality to do so. To ascertain the current epidemiology of Chagas disease in this municipality, 1.782 blood samples from the general population were analysed; 7.7% of samples were found to be seropositive for Chagas disease. A strong positive correlation between increasing age and Chagas disease was evident in both genders, with the highest prevalence in individuals aged over 60 years. Clinically, the cardiodigestive form of Chagas disease was the most common in these samples. These data confirm the interruption of Trypanosoma cruzi transmission, in parallel with a still important residual morbidity of Chagas disease in the county, thus supporting political decisions that will prioritise epidemiological surveillance and medical treatment of Chagas disease in the coming years.

Metallothionein-1 and nitric oxide expression are inversely correlated in a murine model of Chagas disease

Chagas disease, caused by Trypanosoma cruzi, represents an endemic among Latin America countries. The participation of free radicals, especially nitric oxide (NO), has been demonstrated in the pathophysiology of seropositive individuals with T. cruzi. In Chagas disease, increased NO contributes to the development of cardiomyopathy and megacolon. Metallothioneins (MTs) are efficient free radicals scavengers of NO in vitro and in vivo. Here, we developed a murine model of the chronic phase of Chagas disease using endemic T. cruzi RyCH1 in BALB/c mice, which were divided into four groups: infected non-treated (Inf), infected N-monomethyl-L-arginine treated (Inf L-NAME), non-infected L-NAME treated and non-infected vehicle-treated. We determined blood parasitaemia and NO levels, the extent of parasite nests in tissues and liver MT-I expression levels. It was observed that NO levels were increasing in Inf mice in a time-dependent manner. Inf L-NAME mice had fewer T. cruzi nests in cardiac and skeletal muscle with decreased blood NO levels at day 135 post infection. This affect was negatively correlated with an increase of MT-I expression (r = -0.8462, p < 0.0001). In conclusion, we determined that in Chagas disease, an unknown inhibitory mechanism reduces MT-I expression, allowing augmented NO levels.

Genetic susceptibility to Chagas disease cardiomyopathy: involvement of several genes of the innate immunity and chemokine-dependent migration pathways

BACKGROUND

Chagas disease, caused by the protozoan Trypanosoma cruzi is endemic in Latin America. Thirty percent of infected individuals develop chronic Chagas cardiomyopathy (CCC), an inflammatory dilated cardiomyopathy that is, by far, the most important clinical consequence of T. cruzi infection. The others remain asymptomatic (ASY). A possible genetic component to disease progression was suggested by familial aggregation of cases and the association of markers of innate and adaptive immunity genes with CCC development. Migration of Th1-type T cells play a major role in myocardial damage.

METHODS

Our genetic analysis focused on CCR5, CCL2 and MAL/TIRAP genes. We used the Tag SNPs based approach, defined to catch all the genetic information from each gene. The study was conducted on a large Brazilian population including 315 CCC cases and 118 ASY subjects.

RESULTS

The CCL2rs2530797A/A and TIRAPrs8177376A/A were associated to an increase susceptibility whereas the CCR5rs3176763C/C genotype is associated to protection to CCC. These associations were confirmed when we restricted the analysis to severe CCC, characterized by a left ventricular ejection fraction under 40%.

CONCLUSIONS

Our data show that polymorphisms affecting key molecules involved in several immune parameters (innate immunity signal transduction and T cell/monocyte migration) play a role in genetic susceptibility to CCC development. This also points out to the multigenic character of CCC, each polymorphism imparting a small contribution. The identification of genetic markers for CCC will provide information for pathogenesis as well as therapeutic targets.

Design or screening of drugs for the treatment of Chagas disease: what shows the most promise?

INTRODUCTION

Endemic in Latin America, Chagas disease is now becoming a serious global health problem, and yet has no financial viability for the pharmaceutical industry and remains incurable. In 2012, two antimycotic drugs inhibitors of fungal sterol 14α-demethylase (CYP51) - posaconazole and ravuconazole - entered clinical trials. Availability of the X-ray structure of the orthologous enzyme from the causative agent of the disease, protozoan parasite Trypanosoma cruzi, determined in complexes with posaconazole as well as with several experimental protozoa-specific CYP51 inhibitors opens an excellent opportunity to improve the situation.

AREAS COVERED

This article summarizes the information available in PubMed and Google on the outcomes of treatment of the chronic Chagas disease. It also outlines the major features of the T. cruzi CYP51 structure and the possible structure-based strategies for rational design of novel T. cruzi specific drugs.

EXPERT OPINION

There is no doubt that screenings for alternative drug-like molecules as well as mining the T. cruzi genome for novel drug targets are of great value and might eventually lead to groundbreaking discoveries. However, all newly identified molecules must proceed through the long, expensive and low-yielding drug optimization process, and all novel potential drug targets must be validated in terms of their essentiality and druggability. CYP51 is already a well-validated and highly successful target for clinical and agricultural antifungals. With minimal investments into the final stages of their development/trials, T. cruzi-specific CYP51 inhibitors can provide an immediate treatment for Chagas disease, either on their own or in combination with the currently available drugs.

Is conventional cardiac pacing harmful in patients with normal ventricular function?

BACKGROUND

Right ventricular pacing may be deleterious in patients with left ventricular dysfunction, but in patients with normal function the impact of this stimulation triggering clinically relevant ventricular dysfunction is not fully established.

OBJECTIVES

To evaluate the clinical, echocardiographic findings of patients with previously normal left ventricular function underwent implantation of a pacemaker.

METHODS

Observational, cross-sectional study with 20 patients, who underwent implantation of pacemaker, prospectively followed-up, with the following inclusion criteria: normal left ventricular function defined by echocardiography and ventricular pacing higher than 90%. Were evaluated functional class (FC) (New York Heart Association), 6-minute walk test (6MWT), B-type natriuretic peptide (BNP), echocardiographic assessment (conventional and dyssynchrony parameters), and quality of life questionnaire (QLQ) (SF-36). The assessment was performed at ten days (t1), four months (t2), eight months (t3), 12 months (t4) and 24 months (t5).

RESULTS

Conventional echocardiographic parameters and dyssynchrony parameters showed statistically significant variation over time. The 6MWT, FC, and BNP showed worsening at the end of two years. QLQ showed initial improvement and worsening at the end of two years.

CONCLUSION

The implantation of conventional pacemaker was associated with worsening in functional class, worsening in walk test, increased BNP levels, increased duration of QRS, and worsening in some domains of the QLQ at the end of two years. There were no changes in echocardiography measurements (conventional and asynchrony measures).

A country bug in the city: urban infestation by the Chagas disease vector Triatoma infestans in Arequipa, Peru

BACKGROUND

Interruption of vector-borne transmission of Trypanosoma cruzi remains an unrealized objective in many Latin American countries. The task of vector control is complicated by the emergence of vector insects in urban areas.

METHODS

Utilizing data from a large-scale vector control program in Arequipa, Peru, we explored the spatial patterns of infestation by Triatoma infestans in an urban and peri-urban landscape. Multilevel logistic regression was utilized to assess the associations between household infestation and household- and locality-level socio-environmental measures.

RESULTS

Of 37,229 households inspected for infestation, 6,982 (18.8%; 95% CI: 18.4 - 19.2%) were infested by T. infestans. Eighty clusters of infestation were identified, ranging in area from 0.1 to 68.7 hectares and containing as few as one and as many as 1,139 infested households. Spatial dependence between infested households was significant at distances up to 2,000 meters. Household T. infestans infestation was associated with household- and locality-level factors, including housing density, elevation, land surface temperature, and locality type.

CONCLUSIONS

High levels of T. infestans infestation, characterized by spatial heterogeneity, were found across extensive urban and peri-urban areas prior to vector control. Several environmental and social factors, which may directly or indirectly influence the biology and behavior of T. infestans, were associated with infestation. Spatial clustering of infestation in the urban context may both challenge and inform surveillance and control of vector reemergence after insecticide intervention.

Comparison of the infectivity of Trypanosoma cruzi insect-derived metacyclic trypomastigotes after mucosal and cutaneous contaminative challenges

Trypanosoma cruzi infects humans when infected triatomine vector excreta contaminate breaks in skin or mucosal surfaces. T. cruzi insect-derived metacyclic trypomastigotes (IMT) invade through gastric mucosa after oral challenges without any visible inflammatory changes, while cutaneous and conjunctival infections result in obvious local physical signs. In this study we compared the infectivity of T. cruzi IMT in mice after cutaneous and oral contaminative challenges simulating natural infections. The 50% infective dose (ID50) for oral challenge was 100 fold lower than the ID50 for cutaneous challenge, indicating that oral mucosal transmission is more efficient than cutaneous transmission.

Comparison of insecticidal paint and deltamethrin against Triatoma infestans (Hemiptera: Reduviidae) feeding and mortality in simulated natural conditions

The vector of Chagas disease, Triatoma infestans, is largely controlled by the household application of pyrethroid insecticides. Because effective, large-scale insecticide application is costly and necessitates numerous trained personnel, alternative control techniques are badly needed. We compared the residual effect of organophosphate-based insecticidal paint (Inesfly 5A IGR™ (I5A)) to standard deltamethrin, and a negative control, against T. infestans in a simulated natural environment. We evaluated mortality, knockdown, and ability to take a blood meal among 5(th) instar nymphs. I5A paint caused significantly greater mortality at time points up to nine months compared to deltamethrin (Fisher's Exact Test, p < 0.01 in all instances). A year following application, mortality among nymphs in the I5A was similar to those in the deltamethrin (χ2 = 0.76, df=1, p < 0.76). At months 0 and 1 after application, fewer nymphs exposed to deltamethrin took a blood meal compared to insects exposed to paint (Fisher's Exact Tests, p < 0.01 and p < 0.01, respectively). Insecticidal paint may provide an easily-applied means of protection against vectors of Chagas disease.

Novel polymerase chain reaction-restriction fragment length polymorphism assay to determine internal transcribed spacer-2 group in the Chagas disease vector, Triatoma dimidiata (Latreille, 1811)

Triatoma dimidiata is the most important Chagas disease insect vector in Central America as this species is primarily responsible for Trypanosoma cruzi transmission to humans, the protozoan parasite that causes Chagas disease. T. dimidiata sensu lato is a genetically diverse assemblage of taxa and effective vector control requires a clear understanding of the geographic distribution and epidemiological importance of its taxa. The nuclear ribosomal internal transcribed spacer 2 (ITS-2) is frequently used to infer the systematics of triatomines. However, oftentimes amplification and sequencing of ITS-2 fails, likely due to both the large polymerase chain reaction (PCR) product and polymerase slippage near the 5' end. To overcome these challenges we have designed new primers that amplify only the 3'-most 200 base pairs of ITS-2. This region distinguishes the ITS-2 group for 100% of known T. dimidiata haplotypes. Furthermore, we have developed a PCR-restriction fragment length polymorphism (RFLP) approach to determine the ITS-2 group, greatly reducing, but not eliminating, the number of amplified products that need to be sequenced. Although there are limitations with this new PCR-RFLP approach, its use will help with understanding the geographic distribution of T. dimidiata taxa and can facilitate other studies characterising the taxa, e.g. their ecology, evolution and epidemiological importance, thus improving vector control.

Comparison of the infectivity of Trypanosoma cruzi insect-derived metacyclic trypomastigotes after mucosal and cutaneous contaminative challenges

Trypanosoma cruzi infects humans when infected triatomine vector excreta contaminate breaks in skin or mucosal surfaces. T. cruzi insect-derived metacyclic trypomastigotes (IMT) invade through gastric mucosa after oral challenges without any visible inflammatory changes, while cutaneous and conjunctival infections result in obvious local physical signs. In this study we compared the infectivity of T. cruzi IMT in mice after cutaneous and oral contaminative challenges simulating natural infections. The 50% infective dose (ID50) for oral challenge was 100 fold lower than the ID50 for cutaneous challenge, indicating that oral mucosal transmission is more efficient than cutaneous transmission.

Improved chemical control of Chagas disease vectors in the dry Chaco region

The effectiveness of two doses of suspension concentrate (SC) pyrethroid insecticides in suppressing peridomestic populations of Triatoma infestans (Klug) was evaluated in 28 rural communities located in Santiago del Estero province, northwestern Argentina, including 388 houses and 1,516 identified sites. Four treatments were randomly assigned to peridomiciles within each community: 5% SC beta-cypermethrin at standard (S, 50 mg active ingredient [AI]/m2) and double dose (2S), and 2.5% SC deltamethrin at standard (D, 25 mg [AI]/m2) and double dose (2D). Simultaneously, we assessed the effects of both pyrethroids applied at standard doses against domestic infestations. Bug infestation at the site level was assessed by timed manual collections with a dislodging agent at baseline, 13 and 21 mo postspraying (MPS). In domiciles, D and S nearly suppressed all T. infestans infestations up to 21 MPS. In peridomestic sites infested before interventions, multiple logistic regression analysis showed that site-level reinfestation at 13 MPS was significantly lower for treatment 2D (1%) than for other treatments, whereas 2S (6%), D (5%), and S (14%) did not differ significantly between them. The risk of reinfestation after spraying was significantly greater in goat or pig corrals than in other peridomestic ecotopes (in which treatments did not differ significantly), and in sites infested before interventions than in uninfested sites. The application of SC deltamethrin at double dose in goat or pig corrals may suppress T. infestans foci and achieve more sustained effects in the dry Chaco.

Discrete typing units of Trypanosoma cruzi identified in rural dogs and cats in the humid Argentinean Chaco

The discrete typing units (DTUs) of Trypanosoma cruzi that infect domestic dogs and cats have rarely been studied. With this purpose we conducted a cross-sectional xenodiagnostic survey of dog and cat populations residing in 2 infested rural villages in Pampa del Indio, in the humid Argentine Chaco. Parasites were isolated by culture from 44 dogs and 12 cats with a positive xenodiagnosis. DTUs were identified from parasite culture samples using a strategy based on multiple polymerase-chain reactions. TcVI was identified in 37 of 44 dogs and in 10 of 12 cats, whereas TcV was identified in 5 dogs and in 2 cats -a new finding for cats. No mixed infections were detected. The occurrence of 2 dogs infected with TcIII -classically found in armadillos- suggests a probable link with the local sylvatic transmission cycle involving Dasypus novemcinctus armadillos and a potential risk of human infection with TcIII. Our study reinforces the importance of dogs and cats as domestic reservoir hosts and sources of various DTUs infecting humans, and suggests a link between dogs and the sylvatic transmission cycle of TcIII.

Serological and parasitological response in chronic Chagas patients 3 years after nifurtimox treatment

BACKGROUND

With declining vectorial transmission, Chagas disease predominantly affects adults nowadays. The efficacy of nifurtimox in the chronic phase in adult patients is poorly known, particularly in regions where there is no risk of reinfection. Recommendations for treatment outcome assessment rely on serological follow-up. We evaluated the serological and parasitological response to nifurtimox in a cohort of adult patients three years post-treatment in Switzerland.

METHODS

Patients treated with nifurtimox in 2008 during a cross-sectional study in Geneva, Switzerland, were contacted for follow-up in 2011. Two ELISAs and a rapid immunochromatographic test were used to test 2008 and 2011 serum samples simultaneously. In addition, conventional and real-time PCR were performed on 2011 samples.

RESULTS

Thirty-seven (84.1%) of 44 eligible patients, predominantly female, middle-aged, Bolivians at the indeterminate stage, were enrolled. All 2011 ELISA and immunochromatographic tests were positive. Twenty-eight (75.7%) patients presented a lower optical density (OD) in 2011 compared to 2008. This OD difference was significant in both commercial (P < 0.001) and in-house (P = 0.002) ELISAs. Agreement between the two ELISAs was low (Kappa = 0.469). All patients had negative conventional PCR results but one (2.7%) was positive with real-time PCR.

CONCLUSION

Our results highlight the inadequacy of serology for assessing response in adults, three years after treatment. In our cohort, 97.3% had results that could either indicate treatment failure or persistant humoral response despite treatment. The lack of accurate early post-treatment tests of cure prevents appropriate patients information and councelling. New follow-up tests are needed to assess treatments efficacy given the large adult population in need of antiparasitic therapy.

Solid dispersion of ursolic acid in Gelucire 50/13: a strategy to enhance drug release and trypanocidal activity

Solid dispersions (SDs) are an approach to increasing the water solubility and bioavailability of lipophilic drugs such as ursolic acid (UA), a triterpenoid with trypanocidal activity. In this work, Gelucire 50/13, a surfactant compound with permeability-enhancing properties, and silicon dioxide, a drying adjuvant, were employed to produce SDs with UA. SDs and physical mixtures (PMs) in different drug/carrier ratios were characterized and compared using differential scanning calorimetry, hot stage microscopy, Fourier transform infrared spectroscopy (FTIR), X-ray diffraction (XRD), particle size, water solubility values, and dissolution profiles. Moreover, LLC-MK2 fibroblast cytotoxicity and trypanocidal activity evaluation were performed to determine the potential of SD as a strategy to improve UA efficacy against Chagas disease. The results demonstrated the conversion of UA from the crystalline to the amorphous state through XRD. FTIR experiments provided evidence of intermolecular interactions among the drug and carriers through carbonyl peak broadening in the SDs. These findings helped explain the enhancement of water solubility from 75.98 μg/mL in PMs to 293.43 μg/mL in SDs and the faster drug release into aqueous media compared with pure UA or PMs, which was maintained after 6 months at room temperature. Importantly, improved SD dissolution was accompanied by higher UA activity against trypomastigote forms of Trypanosoma cruzi, but not against mammalian fibroblasts, enhancing the potential of UA for Chagas disease treatment.

Unexpected failures to control Chagas Disease vectors with pyrethroid spraying in northern Argentina

Effectiveness of the elimination efforts against Triatoma infestans (Klug) in South America through residual application of pyrethroid insecticides has been highly variable in the Gran Chaco region. We investigated apparent vector control failures after a standard community-wide spraying with deltamethrin SC in a rural area of northeastern Argentina encompassing 353 houses. Insecticide spraying reduced house infestation less than expected: from 49.5% at baseline to 12.3 and 6.7% at 4 and 8 mo postspraying, respectively. Persistent infestations were detected in 28.4% of houses, and numerous colonies with late-stage bugs were recorded after the interventions. Laboratory bioassays showed reduced susceptibility to pyrethroids in the local bug populations. Eleven of 14 bug populations showed reduced mortality in diagnostic dose assays (range, 35 +/- 5% to 97 +/- 8%) whereas the remainder had 100% mortality. A fully enclosed residual bug population in a large chicken coop survived four pyrethroid sprays, including two double-dose applications, and was finally suppressed with malathion. The estimated resistance ratio of this bug population was 7.17 (range, 4.47-11.50). Our field data combined with laboratory bioassays and a residual foci experiment demonstrate that the initial failure to suppress T. infestans was mainly because of the unexpected occurrence of reduced susceptibility to deltamethrin in an area last treated with pyrethroid insecticides 12 yr earlier. Our results underline the need for close monitoring of the impact of insecticide spraying to provide early warning of possible problems because of enhanced resistance or tolerance and determine appropriate responses.

Highly conserved CDR3 region in circulating CD4(+)Vβ5(+) T cells may be associated with cytotoxic activity in Chagas disease

Human infection with Trypanosoma cruzi leads to Chagas disease, which presents as several different clinical conditions ranging from an asymptomatic form to a severe dilated cardiomyopathy. Several studies have demonstrated that T cells play a critical role in the development of cardiac pathology, as well as in immunoregulation during chronic disease. However, the mechanisms that drive protective or pathogenic T cell response are not known. We have shown that CD4(+) T cells from chagasic patients preferentially express T cell receptor (TCR) β-chain variable region (Vβ) 5. The aim of this work was to determine whether T cells expressing this particular Vβ region displayed variable or restricted CDR3 sequences, as an indicator of the nature of the stimulus leading to the activation of these T cells in vivo. Additionally, we aimed to evaluate phenotypic characteristics of these cells that might be associated with pathology. CDR3 junctional region sequencing of Vβ5·1 expressing CD4(+) T cells revealed the occurrence of a highly homologous CDR3 region with conserved TCR Jβ region usage among patients with cardiac, but not indeterminate, Chagas disease. Moreover, correlation analysis indicated that the frequency of CD4(+)Vβ5·1(+) cells is associated with granzyme A expression, suggesting that these cells might display cytotoxic function. Together these results provide new insight into T cell recognition of antigens involved in Chagas disease and suggest that these cells may be implicated in the pathogenesis of chagasic cardiomyopathy.

Blood leukocytes from benznidazole-treated indeterminate chagas disease patients display an overall type-1-modulated cytokine profile upon short-term in vitro stimulation with Trypanosoma cruzi antigens

BACKGROUND

Benznidazole (Bz)-chemotherapy is recommended to prevent Chagas disease progression, despite its limited efficacy during chronic disease. However, the host mechanisms underlying these benefits still remain to be elucidated.

METHODS

In this study, we have used short-term whole blood cultures to describe the cytokine profile of Bz-treated Indeterminate Chagas disease patients-(INDt) as compared to untreated patients-(IND).

RESULTS

Our findings showed that IND presented increased levels of IL-10+neutrophils, IL-12⁺ and IL-10⁺ monocytes and IFN-γ⁺NK-cells. Moreover, IND showed slight increase of IL-4⁺CD4⁺T-cells and enhanced levels of IL-10⁺CD8⁺T-cells and B-cells. Additional analysis of cytokine Low and High producers also highlighted the presence of High cytokine producers within IND, including IL-10 from CD4⁺ T-cells and IFN-γ from CD8⁺ T-cells, as compared to NI. The Bz-treatment lead to an overall cytokine down-regulation in the innate and adaptive compartments, including low levels of IL-12⁺ and IL-10⁺ neutrophils and monocytes, IFN-γ⁺NK-cells, IL-12⁺, TNF-α⁺, IFN-γ⁺ and IL-5⁺CD4⁺T-cells and IL-10⁺B-cells, along with basal levels of cytokine-expressing CD8⁺T-cells in INDt as compared to IND. The in vitro antigen stimulation shifted the cytokine profile toward a type 1-modulated profile, with increased levels of IL-12⁺ and IL-10⁺ monocytes, IFN-γ⁺ and IL-4⁺NK-cells along with TNF-α⁺ and IFN-γ⁺CD8⁺T-cells. Analysis of Low and High cytokine producers, upon in vitro antigen stimulation, further confirm these data.

CONCLUSION

Together, our findings showed that the Bz treatment of Indeterminate Chagas' disease patients shifts the cytokine patterns of peripheral blood monocytes, NK-cells and CD8⁺ T-cells towards a long-lasting Type-1-modulated profile that could be important to the maintenance of a non-deleterious immunological microenvironment.

An insight into the sialotranscriptome of Triatoma rubida (Hemiptera: Heteroptera)

The kissing bug Triatoma rubida (Uhler, 1894) is found in southwestern United States and parts of Mexico where it is found infected with Trypanosoma cruzi, invades human dwellings and causes allergies from their bites. Although the protein salivary composition of several triatomine species is known, not a single salivary protein sequence is known from T. rubida. Furthermore, the salivary diversity of related hematophagous arthropods is very large probably because of the immune pressure from their hosts. Here we report the sialotranscriptome analysis of T. rubida based on the assembly of 1,820 high-quality expressed sequence tags, 51% of which code for putative secreted peptides, including lipocalins, members of the antigen five family, apyrase, hemolysin, and trialysin families. Interestingly, T. rubida lipocalins are at best 40% identical in primary sequence to those of T. protracta, a kissing bug that overlaps its range with T. rubida, indicating the diversity of the salivary lipocalins among species of the same hematophagous genus. We additionally found several expressed sequence tags coding for proteins of clear Trypanosoma spp. origin. This work contributes to the future development of markers of human and pet exposure to T. rubida and to the possible development of desensitization therapies. Supp. Data 1 and 2 (online only) of the transcriptome and deducted protein sequences can be obtained from http://exon.niaid.nih.gov/transcriptome/Trubida/Triru-S1-web.xlsx and http://exon.niaid.nih.gov/transcriptome/Trubida/Triru-S2-web.xlsx.

Global trends in the use of insecticides to control vector-borne diseases

BACKGROUND

Data on insecticide use for vector control are essential for guiding pesticide management systems on judicious and appropriate use, resistance management, and reduction of risks to human health and the environment.

OBJECTIVE

We studied the global use and trends of insecticide use for control of vector-borne diseases for the period 2000 through 2009.

METHODS

A survey was distributed to countries with vector control programs to request national data on vector control insecticide use, excluding the use of long-lasting insecticidal nets (LNs). Data were received from 125 countries, representing 97% of the human populations of 143 targeted countries.

RESULTS

The main disease targeted with insecticides was malaria, followed by dengue, leishmaniasis, and Chagas disease. The use of vector control insecticides was dominated by organochlorines [i.e., DDT (dichlorodiphenyltrichloroethane)] in terms of quantity applied (71% of total) and by pyrethroids in terms of the surface or area covered (81% of total). Global use of DDT for vector control, most of which was in India alone, was fairly constant during 2000 through 2009. In Africa, pyrethroid use increased in countries that also achieved high coverage for LNs, and DDT increased sharply until 2008 but dropped in 2009.

CONCLUSIONS

The global use of DDT has not changed substantially since the Stockholm Convention went into effect. The dominance of pyrethroid use has major implications because of the spread of insecticide resistance with the potential to reduce the efficacy of LNs. Managing insecticide resistance should be coordinated between disease-specific programs and sectors of public health and agriculture within the context of an integrated vector management approach.

Chagas heart disease: report on recent developments

Chagas disease, caused by the parasite Trypanosoma cruzi, is an important cause of cardiac disease in endemic areas of Latin America. It is now being diagnosed in nonendemic areas because of immigration. Typical cardiac manifestations of Chagas disease include dilated cardiomyopathy, congestive heart failure, arrhythmias, cardioembolism, and stroke. Clinical and laboratory-based research to define the pathology resulting from T. cruzi infection has shed light on many of the cellular and molecular mechanisms leading to these manifestations. Antiparasitic treatment may not be appropriate for patients with advanced cardiac disease. Clinical management of Chagas heart disease is similar to that used for cardiomyopathies caused by other processes. Cardiac transplantation has been successfully performed in a small number of patients with Chagas heart disease.

Elimination of Rhodnius prolixus in Central America

Rhodnius prolixus is one of the main vectors of Trypanosoma cruzi, causative agent of Chagas disease. In Central America, it was first discovered in 1915 in El Salvador, from where it spread northwest to Guatemala and Mexico, and southeast to Nicaragua and Costa Rica, arriving also in Honduras in the late 1950s. Indoor residual spraying (IRS) by the antimalaria services of Costa Rica prevented its spread southwards, and similar IRS programmes appear to have eliminated it from El Salvador by the late 1970s. In 1997, by resolution of the Ministers of Health of the seven Central American countries, a multinational initiative against Chagas disease (IPCA) was launched with one of the specific objectives being the elimination of R. prolixus from the region. As a result, more and more infested areas were encountered, and progressively sprayed using an IRS strategy already deployed against Triatoma infestans in the southern cone countries of South America. In 2008, Guatemala became the first of these countries to be formally certified as free of Chagas disease transmission due to R. prolixus. The other infested countries have since been similarly certified, and none of these has reported the presence of R. prolixus since June 2010. Further surveillance is required, but current evidence suggests that R. prolixus may now been eliminated from throughout the mesoamerican region, with a corresponding decline in the incidence of T. cruzi infections.

Management of trypanosomiasis and leishmaniasis

BACKGROUND

The current treatments for human African trypanosomiasis (HAT), Chagas disease and leishmaniasis (collectively referred to as the kinetoplastid diseases) are far from ideal but, for some, there has been significant recent progress. For HAT the only advances in treatment over the past two decades have been the introduction of an eflornithine/nifurtimox co-administration and a shorter regime of the old standard melarsoprol.

SOURCES OF DATA

PubMed.

AREAS OF AGREEMENT

There is a need for new safe, oral drugs for cost-effective treatment of patients and use in control programmes for all the trypanosomatid diseases.

AREAS OF CONTROVERSY

Cutaneous leishmaniasis is not on the agenda and treatments are lagging behind.

GROWING POINTS

There are three compounds in development for the treatment of the CNS stage of HAT: fexinidazole, currently due to entry into phase II clinical studies, a benzoxaborole (SCYX-7158) in phase I trials and a diamidine derivative (CPD-0802), in advanced pre-clinical development. For Chagas disease, two anti-fungal triazoles are now in clinical trial. In addition, clinical studies with benznidazole, a drug previously recommended only for acute stage treatment, are close to completion to determine the effectiveness in the treatment of early chronic and indeterminate Chagas disease. For visceral leishmaniasis new formulations, therapeutic switching, in particular AmBisome, and the potential for combinations of established drugs have significantly improved the opportunities for the treatment in the Indian subcontinent, but not in East Africa.

AREAS TIMELY FOR DEVELOPING RESEARCH

Improved diagnostic tools are needed to support treatment, for test of cure in clinical trials and for monitoring/surveillance of populations in control programmes.

Trypanosoma cruzi in dogs: electrocardiographic and echocardiographic evaluation, in Malinalco, State of Mexico

Chagas disease caused by Trypanosoma cruzi is an important public health problem in Latin America. Dogs are considered a risk factor for human Chagas disease, a sentinel for T. cruzi infection in endemic regions and an animal model to study pathological aspects of the disease. The potential use of dogs as indicators of human cardiac pathogenicity of local T. cruzi strains has been studied insufficiently. We studied electrocardiographic (EKG) and echocardiographic (ECG) alteration frequencies observed in an open population of dogs in Malinalco, Mexico, and determined if such frequencies were statistically associated with T. cruzi infection in dogs. Animals (n = 139) were clinically examined and owners were asked to answer a questionnaire about dogs' living conditions. Two commercial serological tests (IHA, ELISA) were conducted to detect anti-T. cruzi serum antibodies. Significant differences between seropositive and seronegative animals in cardiomyopathic frequencies were detected through EKG and ECG (P < 0.05). Thirty dogs (21.58%) were serologically positive to anti-T. cruzi antibodies (to ELISA and IHA assays), of which nine (30%) had EKG and/or ECG alterations. From the remaining 104 (78.42%) seronegative animals, five (4.5%) had EKG and/or ECG abnormalities. Our data support the hypothesis that most EKG and ECG alterations found in dogs from Malinalco could be associated with T. cruzi infection. Considering the dog as a sentinel and as an animal model for Chagas disease in humans, our findings suggest that the T. cruzi strains circulating in Malinalco have the potential to produce cardiomyopathies in infected humans.

Expression, crystallization and preliminary X-ray crystallographic analysis of glucose-6-phosphate dehydrogenase from the human pathogen Trypanosoma cruzi in complex with substrate

An N-terminally truncated version of the enzyme glucose-6-phosphate dehydrogenase from Trypanosoma cruzi lacking the first 37 residues was crystallized both in its apo form and in a binary complex with glucose 6-phosphate. The crystals both belonged to space group P2(1) and diffracted to 2.85 and 3.35 Å resolution, respectively. Self-rotation function maps were consistent with point group 222. The structure was solved by molecular replacement, confirming a tetrameric quaternary structure.

High Trypanosoma cruzi (Kinetoplastida: Trypanosomatidae) prevalence in Triatoma sanguisuga (Hemiptera: Redviidae) in southeastern Louisiana

From May through November 2007, intensive weekly surveys at the site of a previously reported autochthonous human case of Chagas parasite infection resulted in the collection of 298 Triatoma sanguisuga (Leconte) specimens, of which 60.4% (180) were polymerase chain reaction positive for Trypanosoma cruzi Chagas. All were adults, in a ratio of approximately 1:1 female to male, indicating that the domicile was not colonized, but was a destination for these host-seeking adults. We report on seasonal activity pattern, T. cruzi prevalence in T. sanguisuga, and attempts at insect exclusion and control at the case residence.

Secondary kill effect of deltamethrin on Triatoma infestans

Control of the Chagas disease vector, Triatoma infestans, relies on the application of pyrethroid insecticides, especially deltamethrin. We performed laboratory studies to determine whether a T. infestans nymph that comes into contact with a deltamethrin-treated surface horizontally transfers the insecticide to subsequent triatomines. We found that a triatomine that walks on a deltamethrin-treated surface for a short period of time has the ability to transport the insecticide in concentrations sufficient to kill other triatomines with which it comes into contact. The effect was limited to high-density environments, and mortality as a result of secondary exposure was greater among second-instar nymphs compared with fifth-instar nymphs. Our results suggest that deltamethrin could be killing triatomines through both direct and indirect contact, although it remains unclear whether the phenomenon occurs in natural conditions.

Reversion of gene expression alterations in hearts of mice with chronic chagasic cardiomyopathy after transplantation of bone marrow cells

Chronic chagasic cardiomyopathy is a leading cause of heart failure in Latin American countries, being associated with intense inflammatory response and fibrosis. We have previously shown that bone marrow mononuclear cell (BMC) transplantation improves inflammation, fibrosis, and ventricular diameter in hearts of mice with chronic Chagas disease. Here we investigated the transcriptomic recovery induced by BMC therapy by comparing the heart transcriptomes of control, chagasic, and BMC transplanted mice. Out of the 9390 unique genes quantified in all samples, 1702 had their expression altered in chronic chagasic hearts compared to those of normal mice. Major categories of significantly upregulated genes were related to inflammation, fibrosis and immune responses, while genes involved in mitochondrion function were downregulated. When BMC-treated chagasic hearts were compared to infected mice, 96% of the alterations detected in infected hearts were restored to normal levels, although an additional 109 genes were altered by treatment. Transcriptomic recovery, a new measure that considers both resotrative and side effects of treatment, was remarkably high (84%). Immunofluorescence and morphometric analyses confirmed the effects of BMC therapy in the pattern of inflammatory-immune response and expression of adhesion molecules. In conclusion, by using large-scale gene profiling for unbiased assessment of therapeutic efficacy we demonstrate immunomodulatory effects of BMC therapy in chronic chagasic cardiomyopathy and identify potentially relevant factors involved in the pathogenesis of the disease that may provide new therapeutic targets.

Predictors of low cardiac output in decompensated severe heart failure

OBJECTIVE

To identify predictors of low cardiac output and mortality in decompensated heart failure.

INTRODUCTION

Introduction: Patients with decompensated heart failure have a high mortality rate, especially those patients with low cardiac output. However, this clinical presentation is uncommon, and its management is controversial.

METHODS

We studied a cohort of 452 patients hospitalized with decompensated heart failure with an ejection fraction of <0.45. Patients underwent clinical-hemodynamic assessment and Chagas disease immunoenzymatic assay. Low cardiac output was defined according to L and C clinical-hemodynamic profiles. Multivariate analyses assessed clinical outcomes. P<0.05 was considered significant.

RESULTS

The mean age was 60.1 years; 245 (54.2%) patients were >60 years, and 64.6% were men. Low cardiac output was present in 281 (63%) patients on admission. Chagas disease was the cause of heart failure in 92 (20.4%) patients who had higher B type natriuretic peptide levels (1,978.38 vs. 1,697.64 pg/mL; P = 0.015). Predictors of low cardiac output were Chagas disease (RR: 3.655, P<0.001), lower ejection fraction (RR: 2.414, P<0.001), hyponatremia (RR: 1.618, P = 0.036), and renal dysfunction (RR: 1.916, P = 0.007). Elderly patients were inversely associated with low cardiac output (RR: 0.436, P = 0.001). Predictors of mortality were Chagas disease (RR: 2.286, P<0.001), ischemic etiology (RR: 1.449, P = 0.035), and low cardiac output (RR: 1.419, P = 0.047).

CONCLUSIONS

In severe decompensated heart failure, predictors of low cardiac output are Chagas disease, lower ejection fraction, hyponatremia, and renal dysfunction. Additionally, Chagas disease patients have higher B type natriuretic peptide levels and a worse prognosis independent of lower ejection fraction.

Enhanced classification of Chagas serologic results and epidemiologic characteristics of seropositive donors at three large blood centers in Brazil

BACKGROUND

A major problem in Chagas disease donor screening is the high frequency of samples with inconclusive results. The objective of this study was to describe patterns of serologic results among donors to the three Brazilian REDS-II blood centers and correlate with epidemiologic characteristics.

STUDY DESIGN AND METHODS

The centers screened donor samples with one Trypanosoma cruzi lysate enzyme immunoassay (EIA). EIA-reactive samples were tested with a second lysate EIA, a recombinant-antigen based EIA, and an immunfluorescence assay. Based on the serologic results, samples were classified as confirmed positive (CP), probable positive (PP), possible other parasitic infection (POPI), and false positive (FP).

RESULTS

In 2007 to 2008, a total of 877 of 615,433 donations were discarded due to Chagas assay reactivity. The prevalences (95% confidence intervals [CIs]) among first-time donors for CP, PP, POPI, and FP patterns were 114 (99-129), 26 (19-34), 10 (5-14), and 96 (82-110) per 100,000 donations, respectively. CP and PP had similar patterns of prevalence when analyzed by age, sex, education, and location, suggesting that PP cases represent true T. cruzi infections; in contrast the demographics of donors with POPI were distinct and likely unrelated to Chagas disease. No CP cases were detected among 218,514 repeat donors followed for a total of 718,187 person-years.

CONCLUSION

We have proposed a classification algorithm that may have practical importance for donor counseling and epidemiologic analyses of T. cruzi-seroreactive donors. The absence of incident T. cruzi infections is reassuring with respect to risk of window phase infections within Brazil and travel-related infections in nonendemic countries such as the United States.

Risedronate metal complexes potentially active against Chagas disease

In the search for new metal-based drugs for the treatment of Chagas disease, the most widespread Latin American parasitic disease, novel complexes of the bioactive ligand risedronate (Ris, (1-hydroxy-1-phosphono-2-pyridin-3-yl-ethyl)phosphonate), [M(II)(Ris)(2)]·4H(2)O, where M═Cu, Co, Mn and Ni, and [Ni(II)(Ris)(2)(H(2)O)(2)]·H(2)O were synthesized and characterized by using analytical measurements, thermogravimetric analyses, cyclic voltammetry and infrared and Raman spectroscopies. Crystal structures of [Cu(II)(Ris)(2)]·4H(2)O and [Ni(II)(Ris)(2)(H(2)O)(2)]·H(2)O were solved by single crystal X-ray diffraction methods. The complexes, as well as the free ligand, were evaluated in vitro against epimastigotes and intracellular amastigotes of the parasite Trypanosoma cruzi, causative agent of Chagas disease. Results demonstrated that the coordination of risedronate to different metal ions improved the antiproliferative effect against T. cruzi, exhibiting growth inhibition values against the intracellular amastigotes ranging the low micromolar levels. In addition, this strong activity could be related to high inhibition of farnesyl diphosphate synthase enzyme. On the other hand, protein interaction studies showed that all the complexes strongly interact with albumin thus providing a suitable means of transporting them to tissues in vivo.

Artificial lighting as a vector attractant and cause of disease diffusion

BACKGROUND

Traditionally, epidemiologists have considered electrification to be a positive factor. In fact, electrification and plumbing are typical initiatives that represent the integration of an isolated population into modern society, ensuring the control of pathogens and promoting public health. Nonetheless, electrification is always accompanied by night lighting that attracts insect vectors and changes people's behavior. Although this may lead to new modes of infection and increased transmission of insect-borne diseases, epidemiologists rarely consider the role of night lighting in their surveys.

OBJECTIVE

We reviewed the epidemiological evidence concerning the role of lighting in the spread of vector-borne diseases to encourage other researchers to consider it in future studies.

DISCUSSION

We present three infectious vector-borne diseases-Chagas, leishmaniasis, and malaria-and discuss evidence that suggests that the use of artificial lighting results in behavioral changes among human populations and changes in the prevalence of vector species and in the modes of transmission.

CONCLUSION

Despite a surprising lack of studies, existing evidence supports our hypothesis that artificial lighting leads to a higher risk of infection from vector-borne diseases. We believe that this is related not only to the simple attraction of traditional vectors to light sources but also to changes in the behavior of both humans and insects that result in new modes of disease transmission. Considering the ongoing expansion of night lighting in developing countries, additional research on this subject is urgently needed.

Infection of kissing bugs with Trypanosoma cruzi, Tucson, Arizona, USA

Triatomine insects (Hemiptera: Reduviidae), commonly known as kissing bugs, are a potential health problem in the southwestern United States as possible vectors of Trypanosoma cruzi, the causative agent of Chagas disease. Although this disease has been traditionally restricted to Latin America, a small number of vector-transmitted autochthonous US cases have been reported. Because triatomine bugs and infected mammalian reservoirs are plentiful in southern Arizona, we collected triatomines inside or around human houses in Tucson and analyzed the insects using molecular techniques to determine whether they were infected with T. cruzi. We found that 41.5% of collected bugs (n = 164) were infected with T. cruzi, and that 63% of the collection sites (n = 22) yielded >or=1 infected specimens. Although many factors may contribute to the lack of reported cases in Arizona, these results indicate that the risk for infection in this region may be higher than previously thought.

Transcriptomic alterations in Trypanosoma cruzi-infected cardiac myocytes

Trypanosoma cruzi infection is a major cause of cardiomyopathy. Previous gene profiling studies of infected mouse hearts have revealed prominent changes in gene expression within many functional pathways. This variety of transcriptomic changes in infected mice raises the question of whether gene expression alterations in whole hearts are due to changes in infected cardiac myocytes or other cells or even to systemic effects of the infection on the heart. We employed microarrays to examine infected cardiac myocyte cultures 48 h post-infection. Statistical comparison of gene expression levels of 7624 well annotated unigenes in four independent cultures of infected and uninfected myocytes detected substantial (>or=1.5 absolute fold changes) in 420 (5.5%) of the sampled genes. Major categories of affected genes included those involved in immune response, extracellular matrix and cell adhesion. These findings on infected cardiac myocytes in culture reveal that alterations in cardiac gene expression described in Chagas disease are the consequence of both direct infection of the myocytes themselves as well as resulting from the presence of other cell types in the myocardium and systemic effects of infection.

Trypanosoma cruzi infection disturbs mitochondrial membrane potential and ROS production rate in cardiomyocytes

In this study, we investigated the role of Trypanosoma cruzi invasion and inflammatory processes in reactive oxygen species (ROS) production in a mouse atrial cardiomyocyte line (HL-1) and primary adult rat ventricular cardiomyocytes. Cardiomyocytes were incubated with T. cruzi (Tc) trypomastigotes, Tc lysate (TcTL), or Tc secreted proteins (TcSP) for 0-72 h, and ROS were measured by amplex red assay. Cardiomyocytes infected by T. cruzi (but not those incubated with TcTL or TcSP) exhibited a linear increase in ROS production for 2-48 h postinfection (max 18-fold increase), which was further enhanced by recombinant cytokines (IL-1beta, TNF-alpha, and IFN-gamma). We observed no increase in NADPH oxidase, xanthine oxidase, or myeloperoxidase activity, and specific inhibitors of these enzymes did not block the increased rate of ROS production in infected cardiomyocytes. Instead, the mitochondrial membrane potential was perturbed and resulted in inefficient electron transport chain (ETC) activity and enhanced electron leakage and ROS formation in infected cardiomyocytes. HL-1 rho (rho) cardiomyocytes lacked a functional ETC and exhibited no increase in ROS formation in response to T. cruzi. Together, these results demonstrate that invasion by T. cruzi and an inflammatory milieu affect mitochondrial integrity and contribute to electron transport chain inefficiency and ROS production in cardiomyocytes.

The trypanocidal activity of naphthoquinones: a review

Naphthoquinones are compounds present in several families of higher plants. Their molecular structures confer redox properties, and they are involved in multiple biological oxidative processes. In folk medicine, especially among Indian populations, plants containing naphthoquinones have been employed for the treatment of various diseases. The biological redox cycle of quinones can be initiated by one electron reduction leading to the formation of semiquinones, unstable intermediates that react rapidly with molecular oxygen, generating free radicals. Alternatively, the reduction by two electrons, mediated by DT-diphorase, leads to the formation of hydroquinone. Lapachol, alpha-lapachone and beta-lapachone, which are isolated from the heartwood of trees of the Bignoniaceae family, are examples of bioactive naphthoquinones. In this review, we will discuss studies investigating the activity of these natural products and their derivatives in the context of the search for alternative drugs for Chagas disease, caused by Trypanosoma cruzi, a neglected illness that is endemic in Latin America.

Crystallization and preliminary crystallographic studies of dihydrofolate reductase-thymidylate synthase from Trypanosoma cruzi, the Chagas disease pathogen

Trypanosoma cruzi dihydrofolate reductase-thymidylate synthase (TcDHFR-TS) was crystallized in complexes with the dihydrotriazine-based or quinazoline-based antifolates C-448, cycloguanil (CYC) and Q-8 in order to gain insight into the interactions of this DHFR enzyme with classical and novel inhibitors. The TcDHFR-TS-C-448-NDP-dUMP crystal belonged to space group C222(1) with two molecules per asymmetric unit and diffracted to 2.37 angstrom resolution. The TcDHFR-TS-CYC, TcDHFR-TS-CYC-NDP and TcDHFR-TS-Q-8-NDP crystals belonged to space group P2(1) with four molecules per asymmetric unit and diffracted to 2.1, 2.6 and 2.8 angstrom resolution, respectively. Crystals belonging to the two different space groups were suitable for structure determination.

Crystallization and preliminary X-ray analysis of aspartate transcarbamoylase from the parasitic protist Trypanosoma cruzi

Aspartate transcarbamoylase (ATCase), the second enzyme of the de novo pyrimidine-biosynthetic pathway, catalyzes the production of carbamoyl aspartate from carbamoyl phosphate and L-aspartate. In contrast to Escherichia coli ATCase and eukaryotic CAD multifunctional fusion enzymes, Trypanosoma cruzi ATCase lacks regulatory subunits and is not part of the multifunctional fusion enzyme. Recombinant T. cruzi ATCase expressed in E. coli was purified and crystallized in a ligand-free form and in a complex with carbamoyl phosphate at 277 K by the sitting-drop vapour-diffusion technique using polyethylene glycol 3350 as a precipitant. Ligand-free crystals (space group P1, unit-cell parameters a = 78.42, b = 79.28, c = 92.02 A, alpha = 69.56, beta = 82.90, gamma = 63.25 degrees) diffracted X-rays to 2.8 A resolution, while those cocrystallized with carbamoyl phosphate (space group P2(1), unit-cell parameters a = 88.41, b = 158.38, c = 89.00 A, beta = 119.66 degrees) diffracted to 1.6 A resolution. The presence of two homotrimers in the asymmetric unit (38 kDa x 6) gives V(M) values of 2.3 and 2.5 A(3) Da(-1) for the P1 and P2(1) crystal forms, respectively.

First finding of melanic sylvatic Triatoma infestans (Hemiptera: Reduviidae) colonies in the Argentine Chaco

Triatoma infestans (Klug), the most important vector of Chagas disease in southern South America, is a highly domiciliated species with well-known sylvatic foci only in the Bolivian Andean valleys and in the Bolivian Chaco, where melanic insects designated as "dark morphs" were found. After the tentative identification of two melanic bugs collected from parrot nests in a forest reserve in the Argentine Chaco as T. infestans, we conducted an intensive search there using mouse-baited sticky traps in summer 2006 and 2007. Four live T. infestans bugs were collected in trees without parrot nests in 288 trap-nights, whereas no bug was collected from inside trees with active parrot nests in 51 trap-nights. To increase bug captures, hollow tree trunks that recently had had Amazona aestiva (Berlepsch) and Aratinga acuticaudata (Vieillot) parrot nests were treated with insecticide fumigant canisters exhibiting strong knockdown power. Four (22%) of 18 trees were positive for T. infestans with a dark phenotype. A fragment of the mitochondrial gene COI of 8 of the 14 triatomine bugs collected was successfully sequenced and confirmed as T. infestans. Most of the bugs were captured from Aspidosperma quebracho-blanco (Schlechter) hollow tree trunks harboring parrot nests. All of the T. infestans collected from the nearest house located at 10 km from the sylvatic foci displayed normal chromatic characters. The repeated finding of T. infestans in sylvatic habitats, albeit at very low density, shows that this species is capable of maintaining viable sylvatic foci in the absence of human hosts and immigration from domestic populations. These are the first confirmed findings of sylvatic T. infestans colonies in Argentina and of dark morphs in the Argentine Chaco.

Temporal dynamics of flight muscle development in Triatoma infestans (Hemiptera: Reduviidae)

Triatoma infestans Klug is dimorphic for flight muscles. This dimorphism may affect flight dispersal, reinfestation patterns, and transmission risk. To understand the contributions of genes and environment to morph determination, it is first necessary to characterize the temporal dynamics of flight muscle development. Field-collected T. infestans adults were dissected 20 or 100 d after collection, and those collected as nymphs were dissected at approximately 4, 15, or 44 d after the imaginal molt. The occurrence of flight muscles was additionally assessed by minimally invasive, repeated observations through the scutum of live bugs. Overall, 33.5% of 179 males and 7.8% of 179 females had no flight muscles. Neither dissections nor repeated observations evidenced changes in morph type during adult life, suggesting that the occurrence of flight muscles is mostly irreversible within the time span of observations and is determined before or during final ecdysis. Flight muscles were detectable at 4 d after emergence and achieved complete development within 4-15 d after emergence. The repeated observation of thoracic contents through the scutum showed very high sensitivity and specificity and apparently had minor effects on mortality. In another bug population located 360 km away, 16.4% of 177 males and 6.7% of 149 females had no flight muscles. Current results show that the sex-biased flight muscle dimorphism is a regionally widespread character in T. infestans. This character should be considered in field population studies that seek to measure reinfestation risk and dispersal in T. infestans and other Triatominae.

Enhanced parasympathetic activity in Chagas disease still stands in need of proof

Cardiac vagal modulation impairment is a typical feature of Chagas disease (ChD) and is correlated to antagonistic anti-M2 autoantibodies activity. In this letter, we analyze the hypothesis that, in ChD, anti-muscarinic antibody activity could simultaneously increase parasympathetic tonus (decreasing heart rate) and decrease vagal modulation over cardiac sinus node (reducing heart rate variability - HRV). Although attractive, this hypothesis is not supported by empirical data, since reduction of vagal-specific HRV indexes has been demonstrated in the absence of bradycardia. Moreover, anti-muscarinic antibody levels correlate with HRV indexes, but not with heart rate. In the absence of reduced heart rate and, consequently, of tonic vagal enhancement, it is impossible to explain the reduction of vagal-mediated HRV by continuous and strong muscarinic activity of autoantibodies in ChD.

Perspectives on Trypanosoma cruzi-induced heart disease (Chagas disease)

Chagas disease is caused by the parasite Trypanosoma cruzi. It is a common cause of heart disease in endemic areas of Latin America. The year 2009 marks the 100th anniversary of the discovery of T cruzi infection and Chagas disease by the Brazilian physician Carlos Chagas. Chagasic cardiomyopathy develops in from 10% to 30% of persons who are chronically infected with this parasite. Echocardiography and magnetic resonance imaging (MRI) are important modalities in the evaluation and prognostication of individuals with chagasic heart disease. The etiology of chagasic heart disease likely is multifactorial. Parasite persistence, autoimmunity, and microvascular abnormalities have been studied extensively as possible pathogenic mechanisms. Experimental studies suggest that alterations in cardiac gap junctions may be etiologic in the pathogenesis of conduction abnormalities. The diagnosis of chronic Chagas disease is made by serology. The treatment of this infection has shortcomings that need to be addressed. Cardiac transplantation and bone marrow stem cell therapy for persons with Chagas disease have received increasing research attention in recent years.

Trypanosoma cruzi: antiproliferative effect of indole phytoalexins on intracellular amastigotes in vitro

American trypanosomiasis (Chagas disease) continues to be a significant public health problem, and the therapeutic potential of current antichagasic agents (nifurtimox and benznidazole) is rather limited. Here we report on the antitrypanosomal effect of 1-methoxyspirobrassinol and other indole phytoalexins--secondary metabolites produced by Cruciferous plants. These compounds, that previously demonstrated antimicrobial and anticancer properties, displayed significant antiproliferative effects on intracellular amastigotes of Trypanosoma cruzi and may be prospective candidates for antichagasic drug design and development.

Catheter ablation of ventricular tachycardia in Chagasic Cardiomyopathy

There is a limited experience with catheter ablation for treatment of ventricular tachycardia (VT) in Chagasic cardiomyopathy. A 30-year-old woman experienced episodes of palpitations and syncope due to attacks of VT. A diagnosis of Chagas disease was established on a biological basis. Two-dimensional echo and contrast ventriculography showed an apical aneurysm with thrombus. Surgery was indicated to resect the aneurysm and ablate the VT. Ventricular tachycardia recurred 1 month later despite therapy, including amiodarone. Two clinical frequent and well-tolerated tachycardias were identified. The site of origin was located in the right ventricular apex and in the apical-lateral wall of the left ventricle, respectively. Catheter ablation was performed at two sites with DC shocks (total energy 600 J) after unsuccessful radiofrequency ablation. Holter recordings performed during the post-operative period showed only infrequent extrasystoles. After follow-up of 24 months the patient remains asymptomatic. Drug-refractory VT in Chagasic cardiomyopathy can be ablated by medium-energy DC shocks after failure of radiofrequency ablation.

Alterations in myocardial gene expression associated with experimental Trypanosoma cruzi infection

Chagas disease, characterized by acute myocarditis and chronic cardiomyopathy, is caused by infection with the protozoan parasite Trypanosoma cruzi. We sought to identify genes altered during the development of parasite-induced cardiomyopathy. Microarrays containing 27,400 sequence-verified mouse cDNAs were used to analyze global gene expression changes in the myocardium of a murine model of chagasic cardiomyopathy. Changes in gene expression were determined as the acute stage of infection developed into the chronic stage. This analysis was performed on the hearts of male CD-1 mice infected with trypomastigotes of T. cruzi (Brazil strain). At each interval we compared infected and uninfected mice and confirmed the microarray data with dye reversal. We identified eight distinct categories of mRNAs that were differentially regulated during infection and identified dysregulation of several key genes. These data may provide insight into the pathogenesis of chagasic cardiomyopathy and provide new targets for intervention.

Upscale or downscale: applications of fine scale remotely sensed data to Chagas disease in Argentina and schistosomiasis in Kenya

Depending on the research question or the public health application, the appropriate resolution of the data varies temporally, spatially, and, for satellite data, spectrally and radiometrically. Regardless of the scale used to address a research or public health question, the temptation is always there to extrapolate from fine-resolution data or to interpolate from coarse resolution studies. In both cases, the relevance of data and analyses conducted on one spatial level to other levels cannot be taken for granted. Spatial heterogeneity on the micro-scale may not be detected using coarse spatial resolution, and conversely, general patterns on the macro-scale may not be detected using fine spatial resolution. Two studies are described where the transmission dynamics and risk of infection was assessed on the micro-scale starting with household level studies in one community, and the study area was extended gradually to consider several communities and sources for vectors or intermediate hosts. In a study of Chagas disease in northwest Argentina, the reinfestation process of communities by the main domestic vector was analyzed using spatial statistics; sources within and outside communities as well as the distance of reinfestation were identified. In a study of urinary schistosomiasis in coastal Kenya, age dependent and directional focal clustering of infections was detected around some aquatic habitats, and a hydrological model was developed to detect least cost dispersal routes that allow snails to reinfest dried-up habitats. Some general aspects of focal statistics are discussed. Several general questions need to be considered in geospatial health studies, including the following: (i) what are the best criteria for selecting the spatial (and temporal) unit of intervention and analysis? (ii) how do the key measures of risk and transmission dynamics vary with scale? (iii) how do we integrate processes occurring at diverse spatial and temporal scales? All of these questions can only be addressed through solid biological, epidemiological and socio-economic understanding of the system in time and space.

Comparative trial of effectiveness of pyrethroid insecticides against peridomestic populations of Triatoma infestans in northwestern Argentina

The effects of different pyrethroid insecticides, formulations, and doses on peridomestic populations of Triatoma infestans (Klug) were evaluated in 128 houses with 148 identified infested peridomestic sites in northwestern Argentina between October 2003 and March 2005. Four treatments were randomly assigned within each community: two doses of 5% suspension concentrate beta-cypermethrin in water applied with manual compression sprayers, the standard dose (S) at 50 mg and a double dose (2S) at 100 mg active ingredient (AI)/m2; and two emulsifiable concentrates diluted in diesel fuel and applied with power sprayers, 25% cypermethrin (100 mg [AI] /m2) (CF) and 10% permethrin (170 mg [AI]/m2) (DF). Infestation was assessed by timed manual collections with a dislodging agent at baseline, 5, 12, and 17 mo postspraying, and the sites found to be reinfested at 5 mo postspraying were selectively resprayed. Only 2S eliminated T. infestans from all peridomestic sites up to 12 mo postspraying, and it was significantly more effective than all other treatments. At 5 mo postspraying, more sites treated with CF or DF rather than S had bug colonies that probably represented residual foci, which they also failed in eliminating after a second spray. At 17 mo postspraying, the prevalence of reinfested peridomestic sites was 5% for 2S, 29% for S, 43% for CF, and 54% for DF. The application of suspension concentrate pyrethroids in dose twice as large as that currently in use in the attack phase produces a greater initial impact and may eliminate peridomestic populations of T. infestans.

Abnormalities in fractal heart rate dynamics in Chagas disease

BACKGROUND AND METHODS

In order to study fractal HR dynamics in Chagas disease, we performed detrended fluctuation analysis (DFA)-along with analysis of power-law beta slope (beta index) and standard deviation of N-N intervals (SDNN)-in edited and unedited (with ventricular premature beats - VPBs, only in DFA analysis) series of R-R intervals from Holter monitoring of healthy controls (Group 0, n = 27) and Chagas disease patients with left ventricular (LV) ejection fraction >50% (Group 1, n = 137) and with LV ejection fraction <50% (Group 2, n = 23).

RESULTS

When analyzed from the edited R-R interval data, the long-term scaling exponent alpha(2) is altered both among the Chagas patients with and without LV dysfunction. The short-term scaling exponent alpha(1) was higher in Group 1 Chagas patients as compared to controls (P < 0.01) and did not differ between Group 2 and controls. In unedited R-R interval series, alpha(1) was significantly reduced in Group 2 Chagas patients (0.55 +/- 0.002) as compared to controls (0.90 +/- 0.002) and Group 1 (0.91 +/- 0.003) (P < 0.001), but did not differ between Group 1 and controls. Similarly alpha(2) was lower in Group 2 compared to other groups (P < 0.001). SDNN did not differ between the groups, but the beta index derived from 1/f model was reduced both in Group 1 and 2 Chagas patients as compared to controls (P < 0.01). There was strong correlation (rs = 0.82; P < 0.001) between the beta and alpha(2) index from edited series. There was an inverse correlation (rs =-0.63, P < 0.01) between the number of VPBs and alpha(1) index of unedited series.

CONCLUSIONS

The long-term fractal HR dynamics altered in chagasic patients with and without LV dysfunction could be an early sign of autonomic dysfunction. Patients with impaired LV function show marked alterations in short-term fractal HR dynamics toward more random behavior, mainly due to frequent ectopy. Prospective studies are necessary to define the value of these indices as predictors of death in Chagas disease.

Flight initiation of Triatoma infestans (Hemiptera: Reduviidae) under natural climatic conditions

Flight dispersal of Triatoma infestans Klug is probably the most important mechanism for house reinfestation at a village scale after residual spraying with insecticides. The aim of the current study was to estimate the flight initiation probability of field-collected T. infestans and to assess how this probability was affected by sex, adult age, partial bloodmeal, and the presence of a host inaccessible for feeding. Four experimental series, each consisting of three to six consecutive nights and repeated measurements of flight initiation on each individually marked bug, were carried out in experimental huts inside closed cages under natural climatic conditions. We demonstrate that flight initiation probability of T. infestans is much higher than previously reported, responds to temperature in a sigmoid manner, and is higher in females than males, and that the frequency distribution of the number of flights per individual is highly aggregated in female and male bugs. The age of adults had strong effects on flight initiation, whereas the presence of an inaccessible host and a partial bloodmeal exerted no significant effects in models controlling for the effects of bug weight-to-length ratio. The high flight potential found is consistent with the rapid changes in reinfestation patterns observed in the field. The present estimates of flight probabilities and the identification of factors modifying them provide essential knowledge for modeling reinfestation patterns and for improving control strategies of T.

Spatiotemporal patterns of reinfestation by Triatoma guasayana (Hemiptera: Reduviidae) in a rural community of northwestern Argentina

Triatoma guasayana (Wygodzinsky & Abalos) is a secondary vector of Trypanosoma cruzi (Chagas), the etiologic agent of Chagas disease, in the Chaco region of Argentina, Bolivia, and Paraguay. The spatial distribution of T. guasayana in a rural community in northwestern Argentina is described and analyzed using very high spatial resolution satellite imagery, geographic information systems, and spatial statistics. Since a 1992 residual spraying with insecticides of all houses, site-specific domestic and peridomestic reinfestations by triatomine bugs were monitored using various methods semiannually from 1993 to 2002. The reinfestation by T. guasayana started with finding of only adult bugs in a few sites. Bug abundance was significantly clustered and predominantly peridomestic in the southern and northern extremes of the community. The identified source of reinfestation in the northern cluster was a colonized wood pile, whereas no potential peridomestic source was found for the southern cluster. The spatial distribution of T. guasayana was positively associated with the abundance and spatial distribution of goats. Active dispersal from the hypothesized source and the surrounding sylvatic environment, and passive transport of bugs in wood piles seems to be the most likely mechanisms underlying the observed spatial pattern of T. guasayana. The absence of domestic colonization indicates that, to date, there is no trend toward increased local domiciliation of T. guasayana. The clustering zones can be considered "hot spots" where bug invasion from other sources is expected to be higher and where eventually, introduction of sylvatic T. cruzi to suitable hosts may occur.