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Clark EH, Messenger LA, Whitman JD, Bern C. Chagas disease in immunocompromised patients. Clin Microbiol Rev 2024; 37:e0009923. [PMID: 38546225 DOI: 10.1128/cmr.00099-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024] Open
Abstract
SUMMARYAs Chagas disease remains prevalent in the Americas, it is important that healthcare professionals and researchers are aware of the screening, diagnosis, monitoring, and treatment recommendations for the populations of patients they care for and study. Management of Trypanosoma cruzi infection in immunocompromised hosts is challenging, particularly because, regardless of antitrypanosomal treatment status, immunocompromised patients with Chagas disease are at risk for T. cruzi reactivation, which can be lethal. Evidence-based practices to prevent and manage T. cruzi reactivation vary depending on the type of immunocompromise. Here, we review available data describing Chagas disease epidemiology, testing, and management practices for various populations of immunocompromised individuals, including people with HIV and patients undergoing solid organ and hematopoietic stem cell transplantation.
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Affiliation(s)
- Eva H Clark
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Division of Tropical Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Louisa A Messenger
- Department of Environmental and Occupational Health, University of Nevada Las Vegas, Las Vegas, Nevada, USA
| | - Jeffrey D Whitman
- Department of Laboratory Medicine, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Caryn Bern
- Department of Epidemiology and Biostatistics, University of California San Francisco School of Medicine, San Francisco, California, USA
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Carvalho NB, de Freitas VLT, Seguro FS, Bezerra RC, Fatobene G, Nakanishi ÉYS, Visnadi H, Martinez G, Batista MV, Rocha V, Dulley FL, Costa SF, Shikanai-Yasuda MA. Multiple myeloma and Chagas disease: qPCR as a marker for preemptive antiparasitic therapy: a case reports series and review. Rev Inst Med Trop Sao Paulo 2024; 66:e10. [PMID: 38324876 PMCID: PMC10846554 DOI: 10.1590/s1678-9946202466010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 12/19/2023] [Indexed: 02/09/2024] Open
Abstract
Multiple myeloma (MM) associated with Chagas disease is rarely described. This disease and its therapy suppress T cell and macrophage functions and increase regulatory T cell function, allowing the increase of parasitemia and the risk of Chagas Disease Reactivation (CDR). We aimed to analyze the role of conventional (cPCR) and quantitative Polymerase Chain Reaction (qPCR) for prospective monitoring of T. cruzi parasitemia, searching for markers of preemptive antiparasitic therapy in MM patients with Chagas disease. Moreover, we investigated the incidence and management of hematological diseases and CDR both inside and outside the transplant setting in the MEDLINE database. We found 293 studies and included 31 of them. Around 1.9-2.0% of patients with Chagas disease were reported in patients undergoing Stem Cell Transplantation. One case of CDR was described in eight cases of MM and Chagas disease. We monitored nine MM and Chagas disease patients, seven under Autologous Stem Cell Transplantation (ASCT), during 44.56±32.10 months (mean±SD) using parasitological methods, cPCR, and qPCR. From these patients, three had parasitemia. In the first, up to 256 par Eq/mL were detected, starting from 28 months after ASCT. The second patient dropped out and died soon after the detection of 161.0 par Eq/mL. The third patient had a positive blood culture. Benznidazole induced fast negativity in two cases; followed by notably lower levels in one of them. Increased T. cruzi parasitemia was related to the severity of the underlying disease. We recommend parasitemia monitoring by qPCR for early introduction of preemptive antiparasitic therapy to avoid CDR.
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Affiliation(s)
- Noemia Barbosa Carvalho
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Divisão de Moléstias Infecciosas e Parasitarias, São Paulo, São Paulo, Brazil
| | - Vera Lúcia Teixeira de Freitas
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Moléstias Infecciosas e Parasitarias, São Paulo, São Paulo, Brazil
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Laboratório de Investigação Médica em Imunologia (LIM-48), São Paulo, São Paulo, Brazil
| | - Fernanda Salles Seguro
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Serviço de Hematologia, Transfusão e Terapia Celular, São Paulo, São Paulo, São Paulo, Brazil
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Laboratorio de Investigação Médica em Patogenese e Terapia Celular Dirigida em Onco-Imuno-Hematologia (LIM-31), São Paulo, São Paulo, Brazil
| | - Rita Cristina Bezerra
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Laboratório de Investigação Médica em Parasitologia (LIM-46), São Paulo, São Paulo, Brazil
| | - Giancarlo Fatobene
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Serviço de Hematologia, Transfusão e Terapia Celular, São Paulo, São Paulo, São Paulo, Brazil
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Laboratorio de Investigação Médica em Patogenese e Terapia Celular Dirigida em Onco-Imuno-Hematologia (LIM-31), São Paulo, São Paulo, Brazil
| | - Érika Yoshie Shimoda Nakanishi
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Laboratório de Investigação Médica em Imunologia (LIM-48), São Paulo, São Paulo, Brazil
| | - Helena Visnadi
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Serviço de Hematologia, Transfusão e Terapia Celular, São Paulo, São Paulo, São Paulo, Brazil
| | - Gracia Martinez
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Serviço de Hematologia, Transfusão e Terapia Celular, São Paulo, São Paulo, São Paulo, Brazil
| | - Marjorie Vieira Batista
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Divisão de Moléstias Infecciosas e Parasitarias, São Paulo, São Paulo, Brazil
- AC Camargo Cancer Center, Departamento de Infectologia, São Paulo, São Paulo, Brazil
| | - Vanderson Rocha
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Serviço de Hematologia, Transfusão e Terapia Celular, São Paulo, São Paulo, São Paulo, Brazil
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Laboratorio de Investigação Médica em Patogenese e Terapia Celular Dirigida em Onco-Imuno-Hematologia (LIM-31), São Paulo, São Paulo, Brazil
| | - Frederico Luis Dulley
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Serviço de Hematologia, Transfusão e Terapia Celular, São Paulo, São Paulo, São Paulo, Brazil
| | - Sílvia Figueiredo Costa
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Moléstias Infecciosas e Parasitarias, São Paulo, São Paulo, Brazil
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Laboratório de Investigação Médica em Protozoologia (LIM-49), São Paulo, São Paulo, Brazil
- Universidade de São Paulo, Faculdade de Medicina, Instituto de Medicina Tropical de São Paulo, São Paulo, São Paulo, Brazil
| | - Maria Aparecida Shikanai-Yasuda
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Moléstias Infecciosas e Parasitarias, São Paulo, São Paulo, Brazil
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Laboratório de Investigação Médica em Imunologia (LIM-48), São Paulo, São Paulo, Brazil
- Universidade de São Paulo, Faculdade de Medicina, Instituto de Medicina Tropical de São Paulo, São Paulo, São Paulo, Brazil
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Alahmdi B, Kaur A, Jacobs SE, Sullivan T, Barghash M, Taimur S. Trypanosoma cruzi Reactivation After Chimeric Antigen Receptor T-Cell Therapy. Open Forum Infect Dis 2024; 11:ofad698. [PMID: 38264096 PMCID: PMC10804802 DOI: 10.1093/ofid/ofad698] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Indexed: 01/25/2024] Open
Abstract
https://tidbitapp.io/tidbits/trypanosoma-cruzi-reactivation-post-chimeric-antigen-receptor-t-cell-therapy/update.
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Affiliation(s)
- Bayan Alahmdi
- Division of Infectious Diseases, Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Avneet Kaur
- Division of Infectious Diseases, Department of Medicine, City of Hope, Duarte, California, USA
| | - Samantha E Jacobs
- Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Timothy Sullivan
- Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Maya Barghash
- Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sarah Taimur
- Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Kaufman CD, Farré C, Biscari L, Pérez AR, Alloatti A. Trypanosoma cruzi, Chagas disease and cancer: putting together the pieces of a complex puzzle. Front Cell Dev Biol 2023; 11:1260423. [PMID: 38188016 PMCID: PMC10768204 DOI: 10.3389/fcell.2023.1260423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 11/27/2023] [Indexed: 01/09/2024] Open
Abstract
Considering the extensive and widespread impact on individuals, cancer can presently be categorized as a pandemic. In many instances, the development of tumors has been linked to endemic microbe infections. Among parasitic infections, Trypanosoma cruzi stands out as one of the most extensively discussed protozoans in the literature that explores the association between diseases of parasite origin and cancer. However, the effective association remains an unsolved paradox. Both the parasite, along with protozoan-derived molecules, and the associated antiparasitic immune response can induce alterations in various host cell pathways, leading to modifications in cell cycle, metabolism, glycosylation, DNA mutations, or changes in neuronal signaling. Furthermore, the presence of the parasite can trigger cell death or a senescent phenotype and modulate the immune system, the metastatic cascade, and the formation of new blood vessels. The interaction among the parasite (and its molecules), the host, and cancer undoubtedly encompasses various mechanisms that operate differentially depending on the context. Remarkably, contrary to expectations, the evidence tilts the balance toward inhibiting tumor growth or resisting tumor development. This effect is primarily observed in malignant cells, rather than normal cells, indicating a selective or specific component. Nevertheless, nonspecific bystander mechanisms, such as T. cruzi's adjuvancy or the presence of proinflammatory cytokines, may also play a significant role in this phenomenon. This work aims to elucidate this complex scenario by synthesizing the main findings presented in the literature and by proposing new questions and answers, thereby adding pieces to this challenging puzzle.
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Affiliation(s)
- Cintia Daniela Kaufman
- Instituto de Inmunología Clínica y Experimental de Rosario (IDICER), Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Universidad Nacional de Rosario, Rosario, Argentina
| | - Cecilia Farré
- Instituto de Inmunología Clínica y Experimental de Rosario (IDICER), Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Universidad Nacional de Rosario, Rosario, Argentina
- Centro de Investigación y Producción de Reactivos Biológicos, Facultad de Ciencias Médicas, Universidad Nacional de Rosario, Rosario, Argentina
| | - Lucía Biscari
- Instituto de Inmunología Clínica y Experimental de Rosario (IDICER), Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Universidad Nacional de Rosario, Rosario, Argentina
| | - Ana Rosa Pérez
- Instituto de Inmunología Clínica y Experimental de Rosario (IDICER), Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Universidad Nacional de Rosario, Rosario, Argentina
| | - Andrés Alloatti
- Instituto de Inmunología Clínica y Experimental de Rosario (IDICER), Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Universidad Nacional de Rosario, Rosario, Argentina
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Clark EH, Bern C. Chagas Disease in People with HIV: A Narrative Review. Trop Med Infect Dis 2021; 6:tropicalmed6040198. [PMID: 34842854 PMCID: PMC8628961 DOI: 10.3390/tropicalmed6040198] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 11/05/2021] [Accepted: 11/05/2021] [Indexed: 01/18/2023] Open
Abstract
Many questions remain unanswered regarding the epidemiology, pathophysiology, diagnosis, treatment, and monitoring of Trypanosoma cruzi infection in people with HIV (PWH). The reported prevalence of T. cruzi infection in PWH living in endemic countries ranges from 1-28% and is likely similar in at-risk US populations. While classic cardiac and gastrointestinal presentations of chronic Chagas disease occur in PWH, PWH are additionally at risk for a severe and often fatal form of T. cruzi-mediated disease called reactivation disease. T. cruzi reactivation typically occurs in PWH with low CD4 counts and poor virologic control. National HIV guidelines in several endemic South American countries recommend that all PWH be screened for T. cruzi infection at the time of HIV diagnosis; however, this recommendation is not widely implemented. The early detection of T. cruzi infection in PWH is critical as the sequelae of Chagas disease, including T. cruzi reactivation, may be preventable through the restoration of robust cellular immunity via the initiation of antiretroviral therapy and the appropriate use of antitrypanosomal therapy.
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Affiliation(s)
- Eva H. Clark
- Department of Medicine, Section of Infectious Diseases, Baylor College of Medicine, Houston, TX 77030, USA
- Department of Pediatrics, Section of Tropical Medicine, Baylor College of Medicine, Houston, TX 77030, USA
- Correspondence:
| | - Caryn Bern
- Department of Biostatistics and Epidemiology, University of California San Francisco, San Francisco, CA 94158, USA;
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Smith K, Marcos LA. Pathogenesis of Chagas Disease: an Emphasis for Transplant Patient Populations. CURRENT TROPICAL MEDICINE REPORTS 2019. [DOI: 10.1007/s40475-019-0168-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Clinical and epidemiological features of chronic Trypanosoma cruzi infection in patients with HIV/AIDS in Buenos Aires, Argentina. Int J Infect Dis 2017; 67:118-121. [PMID: 29196277 DOI: 10.1016/j.ijid.2017.11.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 11/21/2017] [Accepted: 11/23/2017] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVES Trypanosoma cruzi reactivation in HIV patients is considered an opportunistic infection, usually with a fatal outcome. The aim of this study was to describe the epidemiological and clinical features of T. cruzi infection in HIV patients and to compare these findings between patients with and without Chagas disease reactivation. METHODS The medical records of T. cruzi-HIV co-infected patients treated at the Muñiz Infectious Diseases Hospital from January 2005 to December 2014 were reviewed retrospectively. Epidemiological and clinical features were assessed and compared between patients with and without Chagas disease reactivation. RESULTS The medical records of 80 T. cruzi-HIV co-infected patients were reviewed. The most likely route of T. cruzi infection was vector-borne (32/80 patients), followed by intravenous drug use (12/80). Nine of 80 patients had reactivation. Patients without reactivation had a significantly higher CD4 T-cell count at diagnosis of T. cruzi infection (144 cells/μl vs. 30 cells/μl, p=0.026). Chagas disease serology was negative in two of nine patients with reactivation. CONCLUSIONS Serological assays for T. cruzi infection may be negative in severely immunocompromised patients. Direct parasitological techniques should be performed in the diagnosis of patients for whom there is a suspicion of T. cruzi reactivation. HIV patients with a lower CD4 count are at higher risk of reactivation.
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Reactivation of Chagas Disease: Implications for Global Health. Trends Parasitol 2015; 31:595-603. [PMID: 26458782 DOI: 10.1016/j.pt.2015.06.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 06/04/2015] [Accepted: 06/24/2015] [Indexed: 11/24/2022]
Abstract
Reactivation of Chagas Disease (CD) is a global public health issue. Reactivation of disease can affect the management of CD and its clinical outcome, adding pressure to global health systems because it exacerbates symptoms, leading to misdiagnosis and delays in the administration of correct treatments. Concurrent infections complicate the issue of reactivation, because there are various parasites and disease treatment regimens that are able to influence or suppress the immune system of the host, reactivating disease within infected individuals. The effect of delayed symptoms of chronic CD and the potential for disease reactivation are of great importance to nonendemic regions of the world, where knowledge about CD is lacking and the potential for vectorial transmission is not known.
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Pérez-Molina JA, Perez AM, Norman FF, Monge-Maillo B, López-Vélez R. Old and new challenges in Chagas disease. THE LANCET. INFECTIOUS DISEASES 2015; 15:1347-56. [PMID: 26231478 DOI: 10.1016/s1473-3099(15)00243-1] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Revised: 02/02/2015] [Accepted: 02/05/2015] [Indexed: 12/17/2022]
Abstract
Chagas disease, caused by the parasite Trypanosoma cruzi, is a neglected disease, which can lead to cardiomyopathy, arrhythmias, megaviscera, and more rarely, polyneuropathy in up to 30-40% of patients around 20 to 30 years after acute infection. Although it is endemic in the Americas, global population movements mean that it can be located wherever migrants from endemic areas settle. The disease was first described 100 years ago and still challenges clinicians worldwide, since diagnostic, therapeutic, and prognostic methods remain insufficient. Furthermore, factors such as HIV co-infection, immunosuppressive drugs, transplantation, and neoplastic disease can alter the natural course of the infection. We present the case of a Bolivian woman with chronic T cruzi infection diagnosed at our clinic in Madrid, Spain, who subsequently developed non-Hodgkin lymphoma. Our report illustrates the challenges of an increasingly common infection seen in non-endemic countries, and highlights both daily management dilemmas and associated difficulties that arise.
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Affiliation(s)
- Jose A Pérez-Molina
- National Referral Centre for Tropical Diseases, Infectious Diseases Department, Ramón y Cajal Hospital, Insituto Ramón y Cajal de Investgación Sanitaria, Madrid, Spain.
| | - Angela Martinez Perez
- National Referral Centre for Tropical Diseases, Infectious Diseases Department, Ramón y Cajal Hospital, Insituto Ramón y Cajal de Investgación Sanitaria, Madrid, Spain
| | - Francesca F Norman
- National Referral Centre for Tropical Diseases, Infectious Diseases Department, Ramón y Cajal Hospital, Insituto Ramón y Cajal de Investgación Sanitaria, Madrid, Spain
| | - Begoña Monge-Maillo
- National Referral Centre for Tropical Diseases, Infectious Diseases Department, Ramón y Cajal Hospital, Insituto Ramón y Cajal de Investgación Sanitaria, Madrid, Spain
| | - Rogelio López-Vélez
- National Referral Centre for Tropical Diseases, Infectious Diseases Department, Ramón y Cajal Hospital, Insituto Ramón y Cajal de Investgación Sanitaria, Madrid, Spain
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Vicco MH, César LI, Musacchio HM, Bar DO, Marcipar IS, Bottasso OA. Chagas disease reactivation in a patient non-Hodgkin's lymphoma. Rev Clin Esp 2014; 214:e83-5. [PMID: 24889774 DOI: 10.1016/j.rce.2014.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 03/26/2014] [Accepted: 04/14/2014] [Indexed: 10/25/2022]
Affiliation(s)
- M H Vicco
- Laboratorio de Tecnología Inmunológica, Facultad de Bioquímica y Ciencias Biológicas, Universidad Nacional del Litoral, Ciudad Universitaria, Santa Fe, Argentina; Servicio de Clínica Médica, Hospital J. B "Iturraspe", Santa Fe, Argentina.
| | - L I César
- Servicio de Hematología, Hospital J. B. "Iturraspe", Santa Fe, Argentina
| | - H M Musacchio
- Laboratorio de Tecnología Inmunológica, Facultad de Bioquímica y Ciencias Biológicas, Universidad Nacional del Litoral, Ciudad Universitaria, Santa Fe, Argentina
| | - D O Bar
- Servicio de Hematología, Hospital J. B. "Iturraspe", Santa Fe, Argentina
| | - I S Marcipar
- Laboratorio de Tecnología Inmunológica, Facultad de Bioquímica y Ciencias Biológicas, Universidad Nacional del Litoral, Ciudad Universitaria, Santa Fe, Argentina
| | - O A Bottasso
- Instituto de Inmunología, Facultad de Medicina, Universidad Nacional de Rosario, Santa Fe, Argentina
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Martinez-Perez A, Norman FF, Monge-Maillo B, Perez-Molina JA, Lopez-Velez R. An approach to the management of Trypanosoma cruzi infection (Chagas' disease) in immunocompromised patients. Expert Rev Anti Infect Ther 2014; 12:357-73. [PMID: 24484076 DOI: 10.1586/14787210.2014.880652] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The epidemiology of Chagas disease has changed in the last decades due to migration movements, population ageing and the emergence of new transmission routes. In endemic countries, health facilities and access to healthcare are improving and T. cruzi infected patients are also benefiting from medical advances. The HIV epidemic has spread to both endemic and non-endemic areas for T. cruzi, organ transplant rates have increased recently, especially in Latin America, and other medical conditions affecting the immune system are increasing their global burden. The natural course of Chagas disease is mainly determined by the host's cellular immune response. These conditions may therefore overlap with T. cruzi infection and alter the disease's natural history which may present with atypical clinical forms and a higher associated morbidity and mortality in immunocompromised patients. The present review aims to contribute to the management of immunosuppressed patients with T. cruzi infection.
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Affiliation(s)
- Angela Martinez-Perez
- Tropical Medicine and Clinical Parasitology, Infectious Diseases Department, Ramon y Cajal Hospital, Carretera Comenar 9.100 Km, 28034 Madrid, Spain
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Pérez AR, Fontanella GH, Nocito AL, Revelli S, Bottasso OA. Short treatment with the tumour necrosis factor-alpha blocker infliximab diminishes chronic chagasic myocarditis in rats without evidence of Trypanosoma cruzi reactivation. Clin Exp Immunol 2009; 157:291-9. [PMID: 19604269 DOI: 10.1111/j.1365-2249.2009.03946.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Tumour necrosis factor (TNF)-alpha is crucial for resistance to Trypanosoma cruzi acute infection, but there is scant information on its role during the chronic phase. To address this issue, we analysed whether a short treatment with a TNF-alpha blocker affected the course and characteristics of chronic disease in a rat experimental model of T. cruzi infection. An anti-TNF-alpha agent (infliximab) was administered during the chronic phase for a period of 4 weeks (3 mg/kg/week), while control infected rats were inoculated with saline physiological solution. Search for parasites yielded non-successful results in all infected groups, irrespective of treatment. Nevertheless, the presence of T. cruzi kDNA in heart tissue was detected in infected and infected plus treated animals. Because infliximab might induce changes in the anti-parasite cytokine response, circulating levels of interleukin (IL)-10, interferon-gamma and nitric oxide were evaluated. An increase in IL-10 levels was observed only in the infected group treated with the anti-TNF-alpha blocker compared to the remaining groups (P < 0.05). A clear attenuation of histological damage associated with a diminution of cardiac TNF-alpha mRNA expression was observed in the infected and treated animals compared to the infected and non-treated group. Blocking of TNF-alpha during a relatively short period in chronically infected rats did not lead to evident parasite reactivation but reduced myocarditis severity significantly, indicating a role of this cytokine in the pathogenesis of chronic myocardial damage.
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Affiliation(s)
- A R Pérez
- Instituto de Inmunologia, Facultad de Ciencias Médicas de Rosario, Universidad Nacional de Rosario, Argentina.
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Tanowitz HB, Machado FS, Jelicks LA, Shirani J, de Carvalho ACC, Spray DC, Factor SM, Kirchhoff LV, Weiss LM. Perspectives on Trypanosoma cruzi-induced heart disease (Chagas disease). Prog Cardiovasc Dis 2009; 51:524-39. [PMID: 19410685 PMCID: PMC2677559 DOI: 10.1016/j.pcad.2009.02.001] [Citation(s) in RCA: 110] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- Herbert B Tanowitz
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY 10461, USA.
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Preferential brain homing following intranasal administration of Trypanosoma cruzi. Infect Immun 2009; 77:1349-56. [PMID: 19168740 DOI: 10.1128/iai.01434-08] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The Chagas' disease parasite Trypanosoma cruzi commonly infects humans through skin abrasions or mucosa from reduviid bug excreta. Yet most studies on animal models start with subcutaneous or intraperitoneal injections, a distant approximation of the skin abrasion route. We show here that atraumatic placement of T. cruzi in the mouse nasal cavity produced low parasitemia, high survival rates, and preferential brain invasion compared to the case with subcutaneously injected parasites. Brain invasion was particularly prominent in the basal ganglia, peaked at a time when parasitemia was no longer detectable, and elicited a relatively large number of inflammatory foci. Yet, based on motor behavioral parameters and staining with Fluoro-Jade C, a dye that specifically recognizes apoptotic and necrotic neurons, brain invasion did not cause neurodegenerative events, in contrast to the neurodegeneration in the enteric nervous system. The results indicate that placement of T. cruzi on the mucosa in the mouse nasal cavity establishes a systemic infection with a robust yet harmless infection of the brain, seemingly analogous to disease progression in humans. The model may facilitate studies designed to understand mechanisms underlying T. cruzi infection of the central nervous system.
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16
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Lu B, Alroy J, Luquetti AO, PereiraPerrin M. Human autoantibodies specific for neurotrophin receptors TrkA, TrkB, and TrkC protect against lethal Trypanosoma cruzi infection in mice. THE AMERICAN JOURNAL OF PATHOLOGY 2008; 173:1406-14. [PMID: 18832578 DOI: 10.2353/ajpath.2008.080514] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Patients with Chagas' disease remain asymptomatic for many years, presumably by keeping the etiological agent Trypanosoma cruzi in check through protective immunity against. Recently, we found that T. cruzi uses TrkA, a receptor tyrosine kinase responsive to neurotrophin nerve growth factor in vertebrate nervous systems, to invade cells. We also found that TrkA, TrkB, and TrkC, but not T. cruzi, are targets of specific autoantibodies present in the sera of patients with chronic Chagas' disease. Here we show that TrkA-, TrkB-, and TrkC-specific autoantibodies isolated from the sera of four individuals with chronic indeterminate (asymptomatic) Chagas' disease potently blocked invasion of Trk-bearing neuronal PC12 cells, neuroglial astrocytes, enteroglial cells, and Schwann cells and Trk-expressing non-neural smooth muscle and dendritic cells. However, these autoantibodies did not inhibit T. cruzi invasion of mutant PC12 cells lacking TrkA or of normal cells lacking Trk receptors, suggesting that autoantibodies interfered with parasite/Trk cross talk to access the intracellular milieu. Passive immunization of susceptible and resistant mouse strains with very small doses of these autoantibodies reduced parasitemia and transferred resistance to an otherwise lethal trypanosome infection. Hence, this exquisitely sensitive and unique regulatory immunity against the host (instead of parasite) could benefit infected individuals by blocking cellular invasion of the obligatory intracellular pathogen, resulting in attenuation of tissue infection and clinical manifestations. Such action is contrary to the horror autotoxicus frequently associated with microbe-related autoimmune responses.
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Affiliation(s)
- Bo Lu
- Parasitology Research Center, Department of Pathology, Tufts University School of Medicine, Boston, Massachusetts 02111, USA
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17
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de Melo-Jorge M, PereiraPerrin M. The Chagas' disease parasite Trypanosoma cruzi exploits nerve growth factor receptor TrkA to infect mammalian hosts. Cell Host Microbe 2007; 1:251-61. [PMID: 18005706 DOI: 10.1016/j.chom.2007.05.006] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2007] [Revised: 04/04/2007] [Accepted: 05/21/2007] [Indexed: 11/28/2022]
Abstract
Trypanosoma cruzi, the agent of Chagas' disease, is an obligate intracellular parasite that invades various organs including several cell types in the nervous system that express the Trk receptor tyrosine kinase. Activation of Trk is a major cell-survival and repair mechanism, and parasites could use Trks to invade cells as a strategy to protect their habitat and prolong parasitism of vertebrate hosts. We show that T. cruzi binds to TrkA specifically and activates TrkA-dependent survival mechanisms. This interaction facilitates parasite adherence and promotes efficient invasion of neuronal, epithelial, and phagocytic cells via a process that requires TrkA kinase activity. Diffusible TrkA and TrkA-blocking agents neutralized infection in cellular and animal models of acute Chagas' disease, suggesting cellular receptors as therapeutic targets against parasitic diseases. Thus, TrkA, the nerve growth factor receptor commonly associated with neural survival and protection, may also underlie clinical progression of an important human parasitic disease.
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Affiliation(s)
- Milena de Melo-Jorge
- Parasitology Research Center, Department of Pathology, Tufts University School of Medicine, 150 Harrison Avenue, Boston, MA 02111, USA
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18
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Marchiori PE, Alexandre PL, Britto N, Patzina RA, Fiorelli AA, Lucato LT, Rosemberg S, Pereira SLA, Stolf NG, Scaff M. Late Reactivation of Chagas’ Disease Presenting in a Recipient as an Expansive Mass Lesion in the Brain after Heart Transplantation of Chagasic Myocardiopathy. J Heart Lung Transplant 2007; 26:1091-6. [DOI: 10.1016/j.healun.2007.07.043] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2007] [Revised: 07/18/2007] [Accepted: 07/23/2007] [Indexed: 11/25/2022] Open
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19
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Franco-Paredes C, Rouphael N, Méndez J, Folch E, Rodríguez-Morales AJ, Santos JI, Hurst JW. Cardiac manifestations of parasitic infections part 1: overview and immunopathogenesis. Clin Cardiol 2007; 30:195-9. [PMID: 17443654 PMCID: PMC6653029 DOI: 10.1002/clc.12] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Parasitic infections produce a wide spectrum of cardiac manifestations. They may involve various anatomic structures of the heart and are manifested clinically as myocarditis, cardiomyopathies, pericarditis, or pulmonary hypertension in many resource-constrained settings. However, many parasitic infections involving the heart may also be currently diagnosed in developed countries due to growing worldwide travel, blood transfusions, and increasing numbers of immunosuppression states such as organ transplantation, use of immunosuppressive agents, or HIV/AIDS. Clinicians anywhere in the globe need to be aware of the potential cardiac manifestations of parasitic diseases. This is part one of a three-part series discussing parasites of the heart. In this section, we provide a general overview and immunopathogenesis of parasitic infections of the heart.
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Affiliation(s)
- Carlos Franco-Paredes
- Department of Medicine, Division of Infectious Diseases, University School of Medicine, Atlanta, Georgia, USA.
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20
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Gallerano V, Consigli J, Pereyra S, Gómez Zanni S, Danielo C, Gallerano RH, Guidi A. Chagas? disease reactivation with skin symptoms in a patient with kidney transplant. Int J Dermatol 2007; 46:607-10. [PMID: 17550560 DOI: 10.1111/j.1365-4632.2007.03127.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Immunodepressed patients in the intermediate phase of Chagas' disease may undergo reactivation of the disease together with atypical symptoms. The case of an immunodepressed kidney transplant patient with reactivation of Chagas' disease with skin symptoms is reported. A 65-year-old man presented with infiltrated erythematous lesions on the anterior aspect of the right thigh of 2 weeks' duration. The lesions later extended to the abdomen, thorax, and lower limbs. In the histologic skin examination, amastigotes and Trypanosoma cruzi trypoamastigotes were observed. A fresh smear showed positive parasitemia. Using the Strout hemoconcentration method, multiple Trypanosoma cruzi trypoamastigotes with motility could be seen. Polymerase chain reaction was positive for Trypanosoma cruzi. An immunofluorescence test was positive (1 : 64) and there was hemoagglutination (1 : 32). Treatment was started with benznidazole, 7 mg/kg/day. The patient did not evolve favorably and died 20 days after hospitalization. Skin lesions may be a manifestation of the reactivation of Chagas' disease in immunosuppressed patients. All patients with positive Chagas' serology who require immunosuppressant drugs should receive specific treatment for Chagas' disease.
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Affiliation(s)
- Verónica Gallerano
- Department of Dermatology, Hospital Córdoba, and Department of Pathology, Reina Fabiola Clinic, Catholic University of Córdoba, Córdoba, Argentina
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21
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Abstract
Viruses are the most common cause of myocarditis in economically advanced countries. Enteroviruses and adenoviruses are the most common etiologic agents. Viral myocarditis is a triphasic process. Phase 1 is the period of active viral replication in the myocardium during which the symptoms of myocardial damage range from none to cardiogenic shock. If the disease process continues, it enters phase 2, which is characterized by autoimmunity triggered by viral and myocardial proteins. Heart failure often appears for the first time in phase 2. Phase 3, dilated cardiomyopathy, is the end result in some patients. Diagnostic procedures and treatment should be tailored to the phase of disease. Viral myocarditis is a significant cause of dilated cardiomyopathy, as proved by the frequent presence of viral genomic material in the myocardium, and by improvement in ventricular function by immunomodulatory therapy. Myocarditis of any etiology usually presents with heart failure, but the second most common presentation is ventricular arrhythmia. As a result, myocarditis is one of the most common causes of sudden death in young people and others without preexisting structural heart disease. Myocarditis can be definitively diagnosed by endomyocardial biopsy. However, it is clear that existing criteria for the histologic diagnosis need to be refined, and that a variety of molecular markers in the myocardium and the circulation can be used to establish the diagnosis. Treatment of myocarditis has been generally disappointing. Accurate staging of the disease will undoubtedly improve treatment in the future. It is clear that immunosuppression and immunomodulation are effective in some patients, especially during phase 2, but may not be as useful in phases 1 and 3. Since myocarditis is often selflimited, bridging and recovery therapy with circulatory assistance may be effective. Prevention by immunization or receptor blocking strategies is under development. Giant cell myocarditis is an unusually fulminant form of the disease that progresses rapidly to heart failure or sudden death. Rapid onset of disease in young people, especially those with other autoimmune manifestations, accompanied by heart failure or ventricular arrhythmias, suggests giant cell myocarditis. Peripartum cardiomyopathy in economically developed countries is usually the result of myocarditis.
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Affiliation(s)
- James T. Willerson
- The University of Texas Health Science Center in Houston, Houston, ,Texas Heart Institute, Houston, TX USA
| | - Hein J. J. Wellens
- Department of Cardiology, University of Maastricht, Masstricht, The Netherlands
| | - Jay N. Cohn
- Rasmussen Center for Cardiovascular Disease Prevention Cardiovascular Division, University of Minnesota, Minneapolis, MN USA
| | - David R. Holmes
- Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, MN USA
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22
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Abstract
Immune compromise can modify the severity and manifestation of some parasitic infections. More widespread use of newer immnosuppressive therapies, the growing population of individuals with immunocompromised states as well as the prolonged survival of these patients have altered the pattern of parasitic infection. This review article discusses the burden and immunology of parasitic infections in patients who are immunocompromised secondary to congenital immunodeficiency, malnutrition, malignancy, and immunosuppressive medications. This review does not address the literature on parasitic infections in the setting of HIV-1 infection.
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Affiliation(s)
- T Evering
- Department of Medicine (Division of Infectious Diseases), Albert Einstein College of Medicine, Bronx, New York 10461, USA
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23
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Huang H, Weiss LM, Nagajyothi F, Tanowitz HB, Wittner M, Orr GA, Bao Y. Molecular cloning and characterization of the protein kinase A regulatory subunit of Trypanosoma cruzi. Mol Biochem Parasitol 2006; 149:242-5. [PMID: 16815565 DOI: 10.1016/j.molbiopara.2006.05.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2005] [Revised: 04/24/2006] [Accepted: 05/23/2006] [Indexed: 10/24/2022]
Affiliation(s)
- Huan Huang
- Department of Pathology, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461, USA.
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24
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Fontes Rezende RE, Lescano MA, Zambelli Ramalho LN, de Castro Figueiredo JF, Oliveira Dantas R, Garzella Meneghelli U, Pimenta Módena JL. Reactivation of Chagas' disease in a patient with non-Hodgkin's lymphoma: gastric, oesophageal and laryngeal involvement. Trans R Soc Trop Med Hyg 2005; 100:74-8. [PMID: 16226286 DOI: 10.1016/j.trstmh.2005.07.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2005] [Revised: 07/03/2005] [Accepted: 07/04/2005] [Indexed: 11/22/2022] Open
Abstract
Changes in the natural course of Trypanosoma cruzi infection have been associated with immunosuppression. We report here a case of the reactivation of Chagas' disease in a patient with non-Hodgkin's lymphoma with gastric, oesophageal and laryngeal involvement. This is the first report describing the involvement of the larynx by T. cruzi.
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Affiliation(s)
- Rosamar Eulira Fontes Rezende
- Department of Medicine, Division of Gastroenterology, School of Medicine of Ribeirão Preto, University of São Paulo (FMRP-USP), Av. Bandeirantes, 3900, Monte Alegre 14048-900, Ribeirão Preto, São Paulo, Brazil.
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25
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Altclas J, Sinagra A, Dictar M, Luna C, Verón MT, De Rissio AM, García MM, Salgueira C, Riarte A. Chagas disease in bone marrow transplantation: an approach to preemptive therapy. Bone Marrow Transplant 2005; 36:123-9. [PMID: 15908978 DOI: 10.1038/sj.bmt.1705006] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The efficacy of preemptive therapy was evaluated in bone marrow transplantation (BMT) recipients associated with Chagas disease (CD). The criterion to include patients in the protocol was the serological reactivity for CD in recipients and/or donors before transplant. After BMT, the monitoring was performed using the direct Strout method (SM), which detects clinical levels of Trypanosome cruzi parasitemia, and CD conventional serological tests. Monitoring took place during 60 days in ABMT and throughout the immunosuppressive period in allogeneic BMT. Reactivation of CD was diagnosed by detecting T. cruzi parasites in blood or tissues. In primary T. cruzi infection, an additional diagnostic criterion was the serological conversion. A total of 25 CD-BMT patients were included. Two ABMT and four allogeneic BMT recipients showed CD recurrences diagnosed by SM. One patient also showed skin lesions with T. cruzi amastigotes. Benznidazole treatment (Roche Lab), an antiparasitic drug, was prescribed at a dose of 5 mg/kg/day during 4-8 weeks with recovery of patients. Primary T. cruzi infection was not observed. This report proves the relevance of monitoring CD in BMT patients and demonstrates that preemptive therapy was able to abrogate the development of clinical and systemic disease.
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Affiliation(s)
- J Altclas
- ICTEM Sanatorio Antártida, Buenos Aires, Argentina
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26
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Benson CA, Kaplan JE, Masur H, Pau A, Holmes KK. Treating Opportunistic Infections among HIV-Infected Adults and Adolescents: Recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association/Infectious Diseases Society of America. Clin Infect Dis 2005. [DOI: 10.1086/427906] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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27
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Santos-Neto LLD, Polcheira MF, Castro C, Lima RAC, Simaan CK, Corrêa-Lima FA. Alta parasitemia pelo Trypanosoma cruzi em paciente com lupus eritematoso sistêmico. Rev Soc Bras Med Trop 2003. [DOI: 10.1590/s0037-86822003000500012] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
É descrito um caso de doença de Chagas com alta parasitemia pelo Trypanosoma cruzi em paciente com lupus eritematoso sistêmico. O xenodiagnóstico foi útil na identificação da parasitemia e o benznidazol foi capaz de reduzir a alta e incomum parasitemia. Em indivíduos com doenças auto-imunes e immunossuprimidos, o benznidazol pode ser uma alternativa no controle da alta parasitemia por Trypanosoma cruzi.
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28
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Abstract
Impressive progress has been made in reducing the incidence of Chagas disease, or American trypanosomiasis, in many countries in which the illness is endemic. This has been achieved through expanded blood screening programs and low-technology vector control. Despite the progress made in reducing the number of new cases, the burden of disability and mortality in the endemic countries is enormous and will continue to be so for many years since a substantial portion of the 16 to 18 million persons already infected will develop chronic symptomatic Chagas disease. Unfortunately, no progress has been made in developing new drugs for Trypanosoma cruzi infection, and nifurtimox and benznidazole, both of which lack efficacy and often cause severe side effects, remain the only options for treatment.
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Affiliation(s)
- Louis V. Kirchhoff
- Departments of Internal Medicine (Infectious Diseases) and Epidemiology, 4-403 BSB, University of Iowa, Iowa City, IA 52242, USA.
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29
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Ferreira MS, Borges AS. Some aspects of protozoan infections in immunocompromised patients- a review. Mem Inst Oswaldo Cruz 2002; 97:443-57. [PMID: 12118272 DOI: 10.1590/s0074-02762002000400001] [Citation(s) in RCA: 117] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Protozoa are among the most important pathogens that can cause infections in immunocompromised hosts. These microorganisms particularly infect individuals with impaired cellular immunity, such as those with hematological neoplasias, renal or heart transplant patients, patients using high doses of corticosteroids, and patients with acquired immunodeficiency syndrome. The protozoa that most frequently cause disease in immunocompromised patients are Toxoplasma gondii, Trypanosoma cruzi, different Leishmania species, and Cryptosporidium parvum; the first two species cause severe acute meningoencephalitis and acute myocarditis, Leishmania sp. causes mucocutaneous or visceral disease, and Cryptosporidium can lead to chronic diarrhea with hepatobiliary involvement. Various serological, parasitological, histological and molecular methods for the diagnosis of these infections are currently available and early institution of specific therapy for each of these organisms is a basic measure to reduce the morbidity and mortality associated with these infections.
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Affiliation(s)
- Marcelo Simão Ferreira
- Faculdade de Medicina, Universidade Federal de Uberlândia, Uberlândia, MG, 38400-027, Brasil.
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30
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Lages-Silva E, Ramirez LE, Silva-Vergara ML, Chiari E. Chagasic meningoencephalitis in a patient with acquired immunodeficiency syndrome: diagnosis, follow-up, and genetic characterization of Trypanosoma cruzi. Clin Infect Dis 2002; 34:118-23. [PMID: 11731955 DOI: 10.1086/324355] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2001] [Revised: 06/22/2001] [Indexed: 11/03/2022] Open
Abstract
Early diagnosis of the clinical reactivation of Chagas' disease in human immunodeficiency virus- and Trypanosoma cruzi-coinfected persons is fundamental for a good prognosis. Polymerase chain reaction rapidly and efficiently demonstrated the presence and elimination of T. cruzi in the cerebrospinal fluid of a patient with chagasic meningoencephalitis. Characterization of T. cruzi, directly and indirectly in blood and cerebrospinal fluid samples, demonstrated homogeneity of kinetoplast DNA and the presence of lineage 1 (T. cruzi II) in both parasite populations.
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Affiliation(s)
- Eliane Lages-Silva
- Department of Biological Sciences, Triângulo Mineiro Faculty of Medicine, Uberaba, Minas Gerais, Brazil
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31
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Abstract
This article presents the various manifestations of cardiac infections found in the immunosuppressed host. Emphasis is placed on the correlation between specific impairments of host defenses and the occurrence of certain types of pathogens. The effect of immunosuppression on the clinical manifestations of these infections is discussed. Finally, appropriate diagnostic modalities are presented for the major types of infections.
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Affiliation(s)
- J L Brusch
- Department of Medicine, Infectious Disease Service, Cambridge Hospital, Massachusetts, USA
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32
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da Costa SC. Immunocompromised host: from the early events until the impact of acquired immunodeficiency syndrome. Mem Inst Oswaldo Cruz 2001; 95 Suppl 1:141-4. [PMID: 11142703 DOI: 10.1590/s0074-02762000000700023] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The concept that microorganisms can modulate the host resistance was historically reviewed in the present article. The importance of African trypanosomiasis in the development of the research on immunosuppression as well as the impact of human immunodeficiency virus infection are discussed. Each day new opportunistic organisms establish a constant challenge for the correct diagnosis of concomitant infections in acquired immunodeficiency syndrome. The importance of parasite infection in the balance of host resistance in the third world was emphasized. Finally, some aspects of Leishmania as opportunistic organisms were presented.
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Affiliation(s)
- S C da Costa
- Laboratório de Imunomodulação, Departamento de Protozoologia, Instituto Oswaldo Cruz, Av. Brasil 4365, 21045-900 Rio de Janeiro, RJ, Brasil.
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33
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Abstract
The epidemic in Latin America has placed an unexpected additional burden on the health care systems and national economies, already weak and affected by severe problems. Specific regional diseases in addition to common opportunistic infections, and particularly the high incidence of TB, produce a different picture compared with the United States and Europe. Access to ARV therapy is far from being universal in Latin America; nevertheless, some countries are providing HAART to all eligible patients, showing that it is not impossible to improve quality of care for people living with HIV infection in the region. Before assuming as definitive and irreversible that at least one or two generations will be sacrificed on the altar of inequity of our uneven world, we as acting scientists should join the struggle of millions of human beings claiming their right to be treated with the best drugs that science can offer today.
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Affiliation(s)
- P Cahn
- Department of Infectious Diseases, University of Buenos Aires School of Medicine, Argentina
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34
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Rassi A, Amato Neto V, de Siqueira AF, Ferriolli Filho F, Amato VS, Rassi Júnior A. [Protective effect of benznidazole against parasite reactivation in patients chronically infected with Trypanosoma cruzi and treated with corticoids for associated diseases]. Rev Soc Bras Med Trop 1999; 32:475-82. [PMID: 10881079 DOI: 10.1590/s0037-86821999000500002] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Patients in the chronic phase of Chagas' disease and receiving corticoid because of concommitant diseases were treated with benznidazole, which was initiated at the same time of the use of corticoid in a group of 12 patients or 15 days afterwards in 6 patients. It has been proved in another paper that in the chronic phase of Chagas' disease corticoid use is associated with increased parasitemia, as evaluated by xenodiagnosis. In this study benznidazole use prevented this increase, and we suggest that in immunocompromised patients with chronic Chagas' disease the use of this drug could be useful.
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Affiliation(s)
- A Rassi
- Departamento de Clínica Médica, Faculdade de Medicina, Universidade Federal de Goiás, Brasil
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35
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Altclas J, Sinagra A, Jaimovich G, Salgueira C, Luna C, Requejo A, Milovic V, De Rissio A, Feldman L, Riarte A. Reactivation of chronic Chagas' disease following allogeneic bone marrow transplantation and successful pre-emptive therapy with benznidazole. Transpl Infect Dis 1999; 1:135-7. [PMID: 11428981 DOI: 10.1034/j.1399-3062.1999.010207.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
This report shows the early detection of reactivation of chronic Chagas' disease (CCd) in a 27-year-old man with chronic myelogenous leukemia undergoing allogeneic bone marrow transplantation (ABMT). Pre-emptive therapy with benznidazole during a period of 7 weeks led to a rapid recovery of the patient, who remains free of parasitemia 2 years after the bone marrow transplantation.
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Affiliation(s)
- J Altclas
- Instituto de Criopreservación y Trasplante de médula ósea, IMA, Buenos Aires, Argentina.
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36
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Silva N, O'Bryan L, Medeiros E, Holand H, Suleiman J, de Mendonca JS, Patronas N, Reed SG, Klein HG, Masur H, Badaro R. Trypanosoma cruzi meningoencephalitis in HIV-infected patients. JOURNAL OF ACQUIRED IMMUNE DEFICIENCY SYNDROMES AND HUMAN RETROVIROLOGY : OFFICIAL PUBLICATION OF THE INTERNATIONAL RETROVIROLOGY ASSOCIATION 1999; 20:342-9. [PMID: 10096578 DOI: 10.1097/00042560-199904010-00004] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Five cases of Trypanosoma cruzi meningoencephalitis in HIV-infected patients are reported. All patients presented with mass lesions on head computed tomographic scan, trypanosomes in the cerebrospinal fluid and failure to respond to antitoxoplasmosis therapy. Benznidazole therapy was associated with clinical improvement in 1 patient. Another 4 patients had T cruzi identified in a peripheral smear. T cruzi needs to be considered in the differential diagnosis of HIV-infected patients with central nervous system mass lesions if they have a history of appropriate exposure.
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Affiliation(s)
- N Silva
- Hospital Espanhol-Bahia, Brazil
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37
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Rassi A, Neto VA, de Siqueira AF, Leite MS. [Nifurtimox as a prophylactic drug to prevent reactivation in chronic chagasic patients treated with corticoid for associated diseases]. Rev Soc Bras Med Trop 1998; 31:249-55. [PMID: 9612015 DOI: 10.1590/s0037-86821998000300001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Patients in the chronic phase of Chagas' disease and receiving corticoid because of concommitant diseases were treated with nifurtimox. We proved in another paper that in the chronic phase of Chagas' disease corticoid use is associated with increased parasitemia, as evaluated by xenodiagnosis. In this study nifurtimox use prevented this increase, and we suggest that in immunocompromised patients with chronic Chagas' disease the use of this drug could be useful.
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Affiliation(s)
- A Rassi
- Departamento de Clínica Médica, Faculdade de Medicina, Universidade Federal de Goiás, Brasil
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38
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Tomimori-Yamashita J, Deps PD, Almeida DR, Enokihara MM, De Seixas MT, Freymüller E. Cutaneous manifestation of Chagas' disease after heart transplantation: successful treatment with allopurinol. Br J Dermatol 1997; 137:626-30. [PMID: 9390344 DOI: 10.1111/j.1365-2133.1997.tb03800.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
We describe two patients who underwent cardiac transplantation for chronic cardiomyopathy of Chagas' disease, and in whom the disease was reactivated with the development of cutaneous lesions. In both cases, the skin lesions regressed completely after 2 months of therapy with allopurinol.
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39
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Rassi A, Amato Neto V, de Siqueira AF, Doles J, Leite MS, Silva OQ, Cardoso VM. [The influence of corticoids, in Chronic Chagas disease, administered in virtue of associated disorders]. Rev Soc Bras Med Trop 1997; 30:93-9. [PMID: 9148341 DOI: 10.1590/s0037-86821997000200002] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Patients with chronic Chagas' disease and simultaneous medical problems treated with corticosteroid were studied in order to evaluate steroid influence on chronic Trypanosoma cruzi infection. Parasitological assessment, radiological and electrocardiographic studies as well as non specific tests were performed in patients and in a control group that included chronic infected patients not treated with steroid. Xenodiagnosis showed a clear increase in T. cruzi parasitemia, related to the corticosteroid dosage, without clinical manifestations during the study follow-up period.
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Affiliation(s)
- A Rassi
- Departamento de Clínica Médica da Faculdade de Medicina da Universidade Federal de Goiás, Goiânia, Brasil
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Bocchi EA, Bellotti G, Mocelin AO, Uip D, Bacal F, Higuchi ML, Amato-Neto V, Fiorelli A, Stolf NA, Jatene AD, Pileggi F. Heart transplantation for chronic Chagas' heart disease. Ann Thorac Surg 1996; 61:1727-33. [PMID: 8651775 DOI: 10.1016/0003-4975(96)00141-5] [Citation(s) in RCA: 70] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Chagas' disease has been considered a contraindication to heart transplantation as Trypanosoma cruzi infection could recur after immunosuppression. METHODS We report the follow-up of 22 patients who underwent orthotopic heart transplantation for treatment of end-stage chronic Chagas' heart disease, divided in two groups. Group 1 consisted of 9 patients operated on from September 1985 to June 1991, and group 2 patients underwent transplantation from July 1991 to June 1995. After our early experience with group 1, we attempted to use a lower cyclosporine dosage in group 2. RESULTS Total actuarial survival at 24 months was 60%, and it was better for group 2 (33% for group 1, 80% for group 2, p = 0.008). Parasitemia occurred similarly in both groups, but Chagas' disease reactivation was seen in 5 group 1 patients and in 1 group 2 member (p < 0.002). Neoplasia developed in 5 group 1 patients and 1 group 2 patient, and contributed to death in 3 of them. CONCLUSIONS These data demonstrate satisfactory outcome of cardiac transplantation in patients with end-stage Chagas' heart disease in the second phase of our experience. Further progress is necessary to improve the results and evaluate its proper role in the management of this disease.
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Affiliation(s)
- E A Bocchi
- Heart Institute, São Paulo University Medical School, Brazil
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41
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Pimentel PC, Handfas BW, Carmignani M. Trypanosoma cruzi meningoencephalitis in AIDS mimicking cerebral metastases: case report. ARQUIVOS DE NEURO-PSIQUIATRIA 1996; 54:102-6. [PMID: 8736153 DOI: 10.1590/s0004-282x1996000100017] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
A case of Chagas' meningoencephalitis in a 47 year-old patient with AIDS is presented. The diagnosis was established by examination of the cerebrospinal fluid which showed the presence of Trypanosoma cruzi. CT-scan revealed multiple cerebral lesions which only became evident by contrast administration. A second CT after 13 days showed a severe evolution with displacement of the midline structures leading to the patient's death. This case, as well as other case reports published, has shown the fulminant evolution of Chagas' meningoencephalitis in AIDS patients and the importance of cerebrospinal fluid examination for the diagnosis.
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Affiliation(s)
- P C Pimentel
- Department of Neurology, Escola Paulista de Medicina, São Paulo, Brazil
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42
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Simões MV, Soares FA, Marin-Neto JA. Severe myocarditis and esophagitis during reversible long standing Chagas' disease recrudescence in immunocompromised host. Int J Cardiol 1995; 49:271-3. [PMID: 7649674 DOI: 10.1016/0167-5273(95)02290-d] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
An unusual form of reagudization of Chagas' disease, from its indeterminate phase, was documented in an immunocompromised patient. Long-standing progressive visceral aggression due to extensive intracellular proliferation of T. cruzi manifested by severe isolated right ventricular failure and esophageal ulcerations. Antiparasite chemotherapy was effective in the control of the disease.
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Affiliation(s)
- M V Simões
- Cardiology Division of Medical School of Ribeirão Preto, University of São Paulo, Brazil
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43
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Abstract
The role of heart transplants for treating Chagas' heart disease is not quite clear. Immunosuppression could lead to resurgence of T. cruzi infection with acute or chronic damage to the allograft. There are few publications regarding this issue. Thus we reported the follow-up of 18-patients with Chagas' heart disease submitted to orthotopic heart transplants from 1985 to 1993 at The Heart Institute. The patients were in functional class IV or II, with sustained ventricular tachycardia episodes. The mean left ventricular ejection fraction was 25 +/- 9% and the mean right ventricular ejection was 22 +/- 5% (MUGA). Immunosuppression was based on cyclosporin, azathioprine and corticosteroid. For specific post-transplant monitoring of T. cruzi infection, blood tests were performed (examination of blood or leukocyte concentrate, Giemsa-stained blood smears, blood culture, xenodiagnosis, mouse inoculation) and tissue biopsy (skin or myocardium). In addition, complement fixation hemagglutination and immunofluorescence assays were performed. T. cruzi parasitemias were detected in 18 circumstances in 13 patients. Resurgence of Chagas' disease was diagnosed in 11 circumstances in 5 patients. Fever, subcutaneous nodules and myocarditis predominated in these episodes. All episodes of parasitemia and Chagas' disease resurgence were successfully treated with benzonidazole. Al surviving patients had normal cardia function despite left ventricular function worsening during some myocarditis episodes. Neoplasias were important findings and 3 patients developed lymphoproliferative disease, 2 developed Karposi's sarcoma and 1 patient developed skin cancer. The survival rates of 4 and 12 months were 83% and 49% respectively. The survival of patients who underwent heart transplants from August 1991 to April 1993 was 100% at 4 months and 75% at 12 months. Heart transplants for Chagas' heart disease may be associated with episodes of parasitemia and a reoccurrence of episodes of Chaga's disease. The survival of heart transplanted patients has improved when associated with lower doses of cyclosporins and thus, fewer resurgences of the disease.
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Affiliation(s)
- E A Bocchi
- Heart Institute, Hospital das Clínicas, Faculdade de Medicina de Universidade de São Paulo, Brazil
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45
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Affiliation(s)
- L V Kirchhoff
- Department of Internal Medicine, University of Iowa, Iowa City 52242
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46
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Rocha A, Ferreira MS, Nishioka SA, Silva AM, Burgarelli MK, Silva M, Moura LP, Ugrinovich R, Raffin CN. Trypanosoma cruzi meningoencephalitis and myocarditis in a patient with acquired immunodeficiency syndrome. Rev Inst Med Trop Sao Paulo 1993; 35:205-8. [PMID: 8284607 DOI: 10.1590/s0036-46651993000200014] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
We report the case of a 52-year-old male heterosexual patient with acquired immunodeficiency syndrome (AIDS) and reactivation of Chagas' disease manifested by meningoencephalitis and myocarditis, diagnosed post-mortem. Unexplained reactivation of Chagas' disease should be included among the diagnostic criteria of AIDS in human immunodeficiency virus positive patients. On the other hand, AIDS should be considered in the differential diagnosis of patients with unexplained reactivation of Chagas' disease.
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Affiliation(s)
- A Rocha
- Centro de Ciências Biomédicas, Universidade Federal de Uberlândia, Brazil
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Pittella JE, Meneguette C, Barbosa AJ. Histopathological and immunohistochemical study of the brain and heart in the chronic cardiac form of Chagas' disease. ARQUIVOS DE NEURO-PSIQUIATRIA 1993; 51:8-15. [PMID: 8215935 DOI: 10.1590/s0004-282x1993000100002] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
A histopathological and immunohistochemical study of the brain and heart was made in 50 patients with the chronic cardiac form of Chagas' disease. The immunohistochemical technique used was the peroxidase-antiperoxidase method adapted for the demonstration of the T. cruzi amastigotes. Histological and immunohistochemical examination of the brain showed encephalitis in multiple foci, although sparse, in four patients (8%). In one of the patients the process was recent, active, and containing parasites. In the other three patients, the lesions were of minor intensity, with light exudative inflammatory changes, suggesting a process becoming inactive, or already inactive. The search for parasites in these three patients was negative, even with use of immunoperoxidase. The heart histological and immunohistochemical study showed, besides the chronic myocarditis in multiple foci associated with interstitial fibrosis, amastigotes in seven patients (14%). The absence of parasites and of inflammatory changes in the brain in the great majority of patients with chronic Chagas' disease, contrasting with the constant finding of inflammatory changes and the occasional finding of amastigotes in the myocardium of the same patients, allows us to state, in the same way other authors did, that there is no histopathological basis to support the existence of the chronic nervous form of Chagas' disease.
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Affiliation(s)
- J E Pittella
- Department of Pathology, Federal University of Minas Gerais (UFMG) Medical School, Belo Horizonte, Brasil
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48
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Abstract
Chagas' disease, caused by Trypanosoma cruzi, is an important cause of morbidity in many countries in Latin America. The important modes of transmission are by the bite of the reduviid bug and blood transfusion. The organism exists in three morphological forms: trypomastigotes, amastigotes, and epimastigotes. The mechanism of transformation and differentiation is currently being explored, and signal transduction pathways of the parasites may be involved in this process. Parasite adherence to and invasion of host cells is a complex process involving complement, phospholipase, penetrin, neuraminidase, and hemolysin. Two clinical forms of the disease are recognized, acute and chronic. During the acute stage pathological damage is related to the presence of the parasite, whereas in the chronic stage few parasites are found. In recent years the roles of tumor necrosis factor, gamma interferon, and the interleukins in the pathogenesis of this infection have been reported. The common manifestations of chronic cardiomyopathy are arrhythmias and thromboembolic events. Autoimmune, neurogenic, and microvascular factors may be important in the pathogenesis of the cardiomyopathy. The gastrointestinal tract is another important target, and "mega syndromes" are common manifestations. The diagnosis and treatment of this infection are active areas of investigation. New serological and molecular biological techniques have improved the diagnosis of chronic infection. Exacerbations of T. cruzi infection have been reported for patients receiving immuno-suppressive therapy and for those with AIDS.
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Affiliation(s)
- H B Tanowitz
- Department of Pathology, Albert Einstein College of Medicine, Bronx, New York
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Gallo P, Fabião Neto OM, Suarez JM, Borba RP. Acute central nervous system infection by Trypanosoma cruzi and AIDS. ARQUIVOS DE NEURO-PSIQUIATRIA 1992; 50:375-7. [PMID: 1308418 DOI: 10.1590/s0004-282x1992000300019] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The acute infection of the CNS by Trypanosoma cruzi acquired by blood transfusion is uncommon. The concomitance of AIDS in the patient reported shows the importance of cellular immunity in restriction of this parasite, and reinforces the problem of blood transfusion in endemic zones.
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50
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Milei J, Mautner B, Storino R, Sanchez JA, Ferrans VJ. Does Chagas' disease exist as an undiagnosed form of cardiomyopathy in the United States? Am Heart J 1992; 123:1732-5. [PMID: 1595572 DOI: 10.1016/0002-8703(92)90855-p] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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