Experimental Schizotrypanum cruzi myocarditis. Correlation between histopathologic and electrocardiographic findings in experimental Chagas' heart disease

ECG manifestations of the biggest outbreak of Chagas disease due to oral infection in Latin-America

Background

Chagas disease affects more than 15 million people worldwide. Although vector-borne transmission has decreased, oral transmission has become important. Recently, our group published the clinical and epidemiological characteristics of the largest outbreak of orally transmitted Chagas disease reported till date. Objective: To describe electrocardiographic changes occurring in the study population during the outbreak caused by ingestion of contaminated guava juice.

Methods

We evaluated 103 positive cases, of which 76 (74%) were aged ≤ 18 years (average age: 9.1 ± 3.1 years) and 27 (26%) were aged > 18 years (average age: 46 ± 11.8 years). All patients underwent clinical evaluations and ECG. If the patients had palpitations or evident alterations of rhythm at baseline, ambulatory ECG monitoring was performed.

Results

A total of 68 cases (66%; 53 children and 15 adults) had ECG abnormalities. Further, 69.7% (53/76) of those aged ≤ 18 years and 56% (15/27) of those aged >18 years showed some ECG alteration (p = ns). ST-T abnormalities were observed in 37.86% cases (39/103) and arrhythmias were evident in 28.16% cases (29/103). ST alterations occurred in 72% of those aged ≤18 years compared with 19% of th ose aged >18 years (p < 0.0001).

Conclusion

This study reports the largest number of cases in the same outbreak of acute Chagas disease caused by oral contamination, with recorded ECGs. ECG changes suggestive of acute myocarditis and arrhythmias were the most frequent abnormalities found.

Mechanisms of myocardial damage in Trypanosoma cruzi infection

A study of pathological lesions caused by Trypanosoma cruzi in human and experimental hosts indicated that the main mechanisms of myocardial damage in Chagas' disease are the following. (1) During acute infection inflammatory lesions are related to parasite-induced destruction of myocardial cells, with probable participation of immune-complex reactions. When parasitism decreases, inflammation subsides and may disappear completely. (2) After recovery from acute infection the hosts remain infected but asymptomatic for a prolonged period of time. Focal fibrotic areas may be present in the myocardium, conducting tissue and autonomic nervous system, representing sequelae from the acute phase. Such sequelae may have or may acquire functional significance in some special circumstances. (3) Some patients with latent T. cruzi infection may progress to show a diffuse, active and fibrosing myocarditis without an apparent change in parasitological and immunological status from the asymptomatic phase. The microscopic changes in the heart are compatible with the presence of a delayed-type hypersensitivity process. An abolition of the suppressive factors of delayed hypersensitivity which are present during latent infection may be involved.

Quantitative analysis of cardiac lesions in chronic canine chagasic cardiomyopathy

Lesions observed in chronic chagasic cardiopathy frequently produce electrocardiographic alterations and affect cardiac function. Through a computerized morphometrical analysis we quantified the areas occupied by cardiac muscle, connective and adipose tissues in the right atrium of dogs experimentally infected with Trypanosoma cruzi. All of the infected dogs showed chronic myocarditis with variable reduction levels of cardiac muscle, fibrosis and adipose tissue replacement. In the atrial myocardium of dogs infected with Be78 and Be62 cardiac muscle represented 34 and 50%, fibrosis 28 and 32% and adipose tissue 38 and 18%, respectively. The fibrosis observed was both diffuse and focal and mostly intrafascicular, either partially or completely interrupting the path of muscle bundles. Such histological alterations probably contributed to the appearance of electrocardiographic disturbances verified in 10 out 11 dogs which are also common in human chronic chagasic cardiopathy. Fibrosis was the most important microscopic occurrence found since it produces rearrangements of collagen fibers in relation to myocardiocytes which causes changes in anatomical physiognomy and mechanical behavior of the myocardium. These abnormalities can contribute to the appearance of cardiac malfunction, arrythmias and congestive cardiac insufficiency as observed in two of the analyzed dogs. Strain Be78 caused destruction of atrial cardiac muscle higher than that induced by strain Be62.

Chagas disease in dogs from endemic areas of Costa Rica

Dogs with the presumptive diagnosis of Chagas disease are commonly sent to our School of Veterinary Medicine by independent veterinarians. This prompted us to evaluate the prevalence of canine trypanosomiasis in some villages of the Central Valley of Costa Rica. A total of 54 dogs (21 males and 33 females) from five rural villages, with ages between 3 months and 10 years old, were bled and submitted to three serological tests: indirect immunofluorescence, indirect hemagglutination and ELISA. Among all animals, 15 (27.7%) revealed antibodies (6 pure bred and 9 mongrels) and in 3 of them the parasite was also demonstrated by xenodiagnosis. All positive animals except 1, and 9 negative animals (control group) were examined by X-rays and electrocardiography, revealing different degrees of cardiomegaly and ECG alteration, consistent with Chagas disease pathology in one dog (SA-11) of the infected ones. Examination of 50 inhabitants living in the houses where dogs and Triatoma dimidiata were found, yielded negative serological reactions. This was assumed to support the hypothesis that dogs are commonly infected by the oral route, a more effective means of infection compared with the vector transmission mechanism that occurs in humans.

The hamster (Mesocricetus auratus) as experimental model in Chagas' disease: parasitological and histopathological studies in acute and chronic phases of Trypanosoma cruzi infection

This research characterizes the acute and chronic phases of Chagas' disease in hamster through parasitological and histopathological studies. The acute phase was achieved with 44 young hamsters injected intraperitoneally with 100,000 blood trypomastigotes of Benedito and Y strains of T. cruzi. The chronic phase was induced in 46 hamsters injected intraperitoneally with 35,000 trypomastigotes of Vicentia, Benedito and Y strains. Animals were sacrificed at regular intervals of 24 hours of acute phase and from the 3rd to the 10th month of infection of chronic phase. In the acute phase, parasites were easily recovered from all animals and there was an inflammatory reaction characterized by mononuclear and polymorphous leukocyte infiltration of variable degree in the majority of tissues and organs, specially in the connective loose and fatty tissues, smooth muscle myocardium and skeletal muscle. In the chronic phase the lesions occurred in the same tissues and organs, but the inflammatory response was less severe and characterized by mononuclear infiltration mainly with focal or zonal fibrosis in the myocardium. In 50% of infected animals parasites were found in myocardium and recovered from pericardic, peritoneal and ascitic fluids in some animals. Signs of heart failure, sudden death and enlargement of bowel were observed regularly. We concluded that the hamster is an useful model for Chagas' disease studies.

Myocardial perfusion abnormalities in chronic Chagas' disease as detected by thallium-201 scintigraphy

Most patients with chronic Chagas' heart disease complain of chest pain. The pathophysiology of this symptom is unknown, although myocardial necrosis and fibrosis are frequent necropsy findings and cardiac autonomic impairment is a prominent feature of the disease. To evaluate the possibility of an ischemic cause for these abnormalities in 23 patients (18 men, aged 32 to 60 years, mean 42) with chronic Chagas' disease complaining of chest pain, thallium-201 myocardial scintigraphy was performed after maximal effort and 4-hour redistribution. Regional wall motion was assessed by radionuclide and contrast angiography. Heart rate responses to sinus respiratory arrhythmia, atropine, phenylephrine and Valsalva maneuver were evaluated in all patients and in 22 normal control subjects. Coronary angiography was performed in 16 patients. Only 1 patient had chest pain and no ischemic electrocardiographic changes occurred in any case during the effort test. Scintigraphic analysis of 7 segments per patient showed perfusion defects in at least 1 segment in all patients. Of 161 myocardial segments 16 showed fixed, 10 reversible, and 22 paradox defects (reverse redistribution). The majority (75%) of the fixed perfusion defects occurred in dyssynergic regions, whereas reverse redistribution predominated in regions with normal wall motion (82%). The reversible defects were present in normal or mildly hypokinetic regions. Markedly impaired parasympathetic cardiac control was present but no significant coronary abnormalities were seen in any of the 16 patients undergoing angiography. It is concluded that whereas fixed defects are likely to correspond to fibrotic or necrotic lesions, reversible and paradox perfusion defects may be caused by regional flow or metabolism derangements, possibly related to abnormal parasympathetic control of the coronary microcirculation.

Myocardial beta-adrenergic adenylate cyclase complex in a canine model of chagasic cardiomyopathy

Infection of beagles with an opossum-derived strain of Trypanosoma cruzi (Tc-O) results in features of early and chronic chagasic cardiomyopathy, that is, increases in PR interval, atrioventricular block, and frequent ventricular premature contractions, ventricular tachycardia, and decreased left ventricular ejection fraction. These signs are not observed in animals infected with a canine strain of T. cruzi (Tc-D). To understand the biochemical basis for these early cardiac effects, we examined the beta-adrenergic adenylate cyclase complex in myocardial membranes prepared from animals infected with either of the two strains. In animals infected with Tc-O (symptomatic), the maximum velocity (Vmax) decreased and concentration of agonist resulting in 50% of Vmax (Kact) increased for isoproterenol-dependent adenylate cyclase activity; in animals infected with Tc-D (asymptomatic), Vmax and Kact for isoproterenol were unchanged from control, uninfected animals. beta-Receptor density decreased by 20% in symptomatic animals with no change in affinity, whereas no differences were observed between uninfected and infected asymptomatic animals. A complex pattern of changes was apparent in the guanine nucleotide binding protein, Gs, in the setting of infection. Alterations in cholera toxin-dependent ADP-ribosylation patterns as well as immunochemical detection with anti-G alpha s antisera suggested a change in the biochemical nature of the Gs species and not necessarily a physical loss of this protein. Reconstitution of adenylate cyclase activity in cyc- membranes demonstrated a decrease in hormone-sensitive Gs activity in membranes prepared from symptomatic animals without a change in activity demonstrable in the presence of Gpp(NH)p. Collectively, the results suggest that the depression in beta-adrenergic adenylate cyclase activity associated with symptomatic infection of beagles with T. cruzi occurs primarily as a result of changes in the Gs protein complex, most likely resulting in an uncoupling of the beta-adrenergic receptor from the Gs protein.

The ajmaline test as a method to disclose latent experimental Chagas' heart disease

Forty-one chronically T. cruzi-infected male adult albino rats with normal resting ECG were submitted to the ajmaline test (1 mg/kg body weight injected into the dorsal vein of the penis). Twenty-one similar noninfected animals served as controls. Ajmaline induced the following ECG alterations in control rats: A decrease in heart rate, an increase in heart rate, an increase in P-wave duration, an increase in PR interval, lengthening of the QRS complex, and left axis deviation in 33%, 28%, 14%, 90%, 100%, and 33% of the animals, respectively. Ajmaline evoked similar alterations in 29 of 41 (71%) T. cruzi-infected rats. However, 12 of 41 (29%) infected rats showed ECG changes of a magnitude not seen in controls: P-wave enlargement, first-degree AV block, lengthened QRS complex, and first-degree AV block plus lengthened QRS complex in 7%, 12%, 14%, and 4% of the animals, respectively. Microscopical lesions were not found in control rats. However, 22 of 41 (53%) infected rats were found to have the following pathological lesions: mononuclear cell infiltrate, necrosis, myocyte vacuolization, and interstitial fibrosis in 56%, 39%, 29%, and 7% of the animals, respectively. By comparing the ECG changes evoked by ajmaline not seen in controls with the concomitant pathological lesions, the ajmaline test was found to have 54% sensitivity, 100% specificity, and 100% positive predictive value. Thus, the ajmaline test appears to be useful for unmasking myocardial disease and therefore may be considered a potential method for the full characterization of the indeterminate form of Chagas' disease in experimental animals.

The usefulness of the resting electrocardiogram for characterizing acute Chagas' heart disease in the rat

The present experiment was undertaken to characterize the resting electrocardiogram of rats in the acute stage of experimental T. cruzi infection. One-hundred-and-eighty-seven newly-weaned male albino rats were infected intraperitoneally with 1000 parasites/g body weight. Thirty-two similar but non-infected rats served as controls. Groups of eight randomly chosen rats were killed on day 8, and on days 15, 18, 22, 25 and 29 after infection. Groups of 8 control rats were killed on days 8, 15 and 22. Electrocardiographic changes were observed in 25 of 48 (52%) infected rats. P wave abnormalities indicating atrial chamber dilatation, QRS axis deviation, QRS complex changes compatible with left ventricular hypertrophy or myocardial damage, increased PR interval and ventricular repolarization alteration were detected in 24, 27, 18, 10, and 6% of infected rats, respectively. A mononuclear cell infiltrate and pseudocysts of amastigote forms of T. cruzi were found in 91, and 56% of infected animals, respectively. The sensitivity and the positive predictive value of the electrocardiographic changes were 66, 91, and 96%, respectively. Thus, the resting electrocardiogram is a reliable method for detecting myocardial lesions in the rat with acute Chagas' heart disease.

The resting electrocardiogram of T. cruzi-infected rats

A total of 125 rats were infected with the Colômbia strain of T. cruzi (2000 parasites/g) shortly after weaning. Of these, 58 survived the acute phase and were used in the present experiment. Twenty eight similar but not infected rats served as controls. All rats were submitted to the resting ECG When they were 6 months old. Classic and 3 precordial leads were employed in order to record the ECG as completely as possible. Electrocardiographic changes similar to those found in human chronic Chagas' heart disease and not previously described in this model were found in 44% of the T. cruzi-infected rats: left axis deviation (22%), right axis deviation (7%), lengthened and bizarre QRS complex (14%) and abnormal J point elevation (3%). On the basis of these results, we believe that the resting ECG constitutes a valuable tool for studying experimental chronic Chagas' heart disease in rats.

Absence of left ventricular dysfunction during acute chagasic myocarditis in the rhesus monkey

Recent studies suggest that intracellular Trypanosoma cruzi invasion with release of intracellular myocardial antigens during T. cruzi infection is crucial to the pathogenesis of chronic chagasic myocarditis. However, in areas endemic for Chagas' disease, the incidence of clinical acute chagasic myocarditis has been reported to be low among infected individuals, while the incidence of chronic chagasic myocarditis is relatively high. Thus, either acute chagasic myocarditis rarely complicates T. cruzi infection and is not important to the pathogenesis of chronic chagasic myocarditis, or acute chagasic myocarditis rarely impairs left ventricular function and therefore causes no symptoms. To investigate this question we innoculated T. cruzi from a human patient with Chagas' disease into the subconjuntivae of six rhesus monkeys (7.5 X 10(3) parasites each). Parasitemia was monitored and weekly two-dimensional echocardiograms (for determination of end-diastolic and fractional change in area, EDA and FCA) were obtained to quantify global left ventricular function for 10 weeks. Regional left ventricular function was assessed by visual analysis of two-dimensional echocardiograms. Extent of acute myocarditis was established at autopsy. All monkeys had the Romaña sign and detectable parasitemia in the second week. Parasitemia rose in all by the ninth week (mean = 1.8 X 10(5) parasites/ml); four monkeys lost weight (mean = -12%), three died, and three were killed. Two-dimensional echocardiographic EDA and FCA remained unchanged from control to the last study within 12 hr of death (EDA = 2.6 +/- 0.9 to 2.7 +/- 1.0 cm2, FCA = 80 +/- 6.8 to 74 +/- 7.6%, NS). Furthermore, regional left ventricular function remained unchanged throughout the period of study.(ABSTRACT TRUNCATED AT 250 WORDS)

Ajmaline-induced electrocardiographic changes in chronic Trypanosoma cruzi-infected rats

In the present study, the ajmaline test was applied to T. cruzi-infected rats and evaluated for the ability to reveal ECG disturbances. The test consists of intravenous injection of ajmaline (2 mg/kg body-weight) under ether anaesthesia, and continuous ECG monitoring (right precordial lead: V1 or V2, 100 mm/sec paper speed). The animals used for the test (n = 30) had been experimentally infected with the Colombia strain of T. cruzi (1,000 parasites/g body-weight, newly weaned rats) one year before the experiments. Control non-infected rats (n = 21) were similarly maintained and treated. The ECGs were analysed under baseline conditions, i.e., before ajmaline, and 15, 30, 60 and 180 seconds after completion of ajmaline injection through the dorsal vein of the penis. The following parameters were studied: heart rate, PR interval, QRS and Qat duration. Morphological changes of the QRS complex and ST-T segment were also recorded. Under baseline conditions, the two groups had comparable values for all parameters, except for the PR interval, which was significantly increased in infected rats. No changes in wave rhythm or morphology were detected under baseline conditions. The PR and QaT intervals and QRS duration were significantly longer in both groups after ajmaline injection, at all periods studied. When the two groups were compared for relative variations, consistently and significantly higher alterations (p less than 0.05) were observed in the T. cruzi-infected group, except for the QaT interval at 180 seconds. However, the severe rhythm and ventricular conduction disturbances detected in 30% of the infected rats represented clear-cut discriminative alterations.(ABSTRACT TRUNCATED AT 250 WORDS)

Chagas' heart disease: experimental models

An experimental model embodies an evaluation procedure that helps the investigator to choose between possible alternatives. In this paper, consideration is given to a variety of aspects related to the host-parasite relationship in Trypanosoma cruzi infection and disease. Although several animal species have been used, there is still a lack of consistent experimental studies. A few examples of investigations mainly in dogs, monkeys, and rabbits are briefly described, showing the diversity of methodological approaches and, therefore, the difficulty experienced in comparing results and interpretations. Emphasis was given to the need for a suitable model presenting all possible stage of the infection as seen in man, as well as the functional and organic disorders commonly seen in this disease. The alterations of the autonomic nervous system involving the heart and other organs in Chagas' disease was stressed.

Right ventricular endomyocardial biopsy in undetermined form of Chagas' disease

Right ventricular endomyocardial biopsy was carried out in thirty three patients with undetermined form of Chagas' disease. Fragments obtained by this method were analysed under light microscopy with hematoxilin-eosin, and Masson trichromic stains. Thirteen (39.4%) patients showed normal myocardial fragments and twenty patients (60.6%) had them altered. Alterations included fiber degeneration, volume changes, interstitial edema, inflammatory infiltrates and fibrosis. These data permit to conclude that only part of patients with this form of Chagas' disease have an incipient myocardial attack and that the alterations found in the fragments obtained are mild. The remaining patients would be either individuals with chagasic infection without cardiac disease or have spontaneous healing. This should be considered in the future treatment of the disease.

Right ventricular function in Chagas disease

To study right ventricular function, we performed cardiac catheterization, and right and left cineventriculograms in 60 chagasic patients and 15 non-chagasic, non-heart disease patients. Chagasic patients with normal electrocardiograms and left cineventriculograms also had normal right ventricular function. Nine of 14 chagasic patients with normal Ecg's and early left ventricular damage had right ventricular dilatation and/or segmental inferior-apical asynergy. Fourteen of 19 chagasic patients with abnormal Ecg's and advanced left ventricular damage, but without signs of congestive heart failure, and all chagasic patients with congestive heart failure, had marked right ventricular dilatation, severe right contractility depression and abnormal right apical or para-apical motion. These findings indicate that Chagas disease is a diffuse cardiomyopathy in which the left ventricle seems to be affected earlier and to a greater extent than the right ventricle. Since segmental abnormalities were predominantly observed in apical and para-apical areas of the ventricles, performance of right and left cineventriculograms is recommended before implantation of cardiac pacemakers.

Effect of Peruvosid (CD412) on excitability and functional refractory period of atrial and ventricular tissues in cardiomyopathy caused by Trypanosoma cruzi

Attempts were made to produce myocarditis by Trypanosoma cruzi inoculation in healthy dog puppies 6 to 8 weeks old. Significant electrocardiographic abnormalities were produced, coinciding with interstitial inflammatory processes in the cardiac tissue and with degenerative changes in the myocardial fibres. In puppies showing these changes, profound changes in the excitability and the functional refractory period of the atrial and ventricular muscular tissue were observed. The administration of Peruvosid in doses of 0.0240 to 0.0647 mg./kg. tended to diminish the excitability, previously increased by the inflammatory process, at the same time increasing the functional refractory period duration which had previously been shortened. The fact that Peruvosid corrects these fundamental factors in the genesis of cardiac arrhythmias suggests that the drug may be useful in the treatment of cardiac insufficiency produced by Chagas' myocardiopathy, in which arrhythmias are one of the basic characteristics.

Disturbances in the A-V conduction system in Chagas' myocarditis in the dog

Atrioventricular (A-V) conduction and the functional refractory period (FRP) of the A-V system were studied in 13 dogs chronically infected by T. cruzi that had ECG disturbances indicative of myocarditis. Histopathologic findings at the A-V node and the bundle of His were correlated with the FRP and with conduction times of the A-V propagation system. Retarded conduction was related to inflammatory and fibrotic processes localized at the bundle of His. At relatively slow rates of stimulation, conduction time was prolonged, but the ventricle was capable of following high atrial rates. With augmented FRP, mononuclear cell infiltrates were observed in the A-V node or in the septal muscle around the node. This suggests that the node was included in the inflammatory process. No correlation was found between inflammatory infiltrates of the bundle of His and changes in the FRP. At relatively slow rates of stimulation, normal A-V conduction time corresponded to prolonged FRP. A-V conduction became slow as the atrial rate increased. A point was reached when the ventricle could not follow the moderately increased atrial rates.

Excitability of cardiac tissues was so markedly altered in 5 dogs with severe inflammatory infiltrates that a similar study of the A-V system could not be made.