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Liempi D, Zulantay I, Varela NM, Canals M, Guevara A, Poulsen N, Apt W. Parasite Burden of Trypanosoma cruzi in Whole Blood and Buffy Coat Determined by Real-Time PCR in Individuals with Chronic Chagas Disease. Microorganisms 2024; 12:249. [PMID: 38399653 PMCID: PMC10893161 DOI: 10.3390/microorganisms12020249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 11/27/2023] [Accepted: 11/28/2023] [Indexed: 02/25/2024] Open
Abstract
The objective of this study was to compare, by qPCR, the circulating blood parasite load of Trypanosoma cruzi in the buffy coat, and in whole blood mixed with boiled and unboiled guanidine hydrochloride-EDTA buffer, of individuals with chronic ChD. The concentration and purity of DNA were evaluated in a Nanodrop Denovix DS-11FX Series Spectrophotometer (DeNovix Inc., Wilmington, NC, USA). The parasite load was determined with the Taqman® qPCR system using a Stratagene Mx3000P thermocycler (Agilent Technologies, Santa Clara, CA, USA) with Cruzi 1 and Cruzi 2 satellite primers. Student's t-test with Bonferroni correction, Chi-squared (χ2) tests and Spearman's correlation coefficient were applied. The concentration and purity of DNA were higher in the buffy coat. Parasite DNA was detected and quantifiable in the three types of samples in seven patients, without statistically significant differences in the parasite load obtained. Higher correlations were found between the total DNA concentrations and the parasite loads obtained in the samples of the buffy coat.
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Affiliation(s)
- Daniela Liempi
- Institute of Parasitology, Faculty of Medicine, Austral University of Chile, Valdivia 5090000, Chile
- Master’s Program in Parasitology, Graduate School, Faculty of Medicine, University of Chile, Santiago 8380453, Chile
| | - Inés Zulantay
- Basic-Clinical Parasitology Laboratory, Cellular and Molecular Biology Program, Institute of Biomedical Sciences, Faculty of Medicine, University of Chile, Santiago 8380453, Chile;
| | - Nelson M. Varela
- Basic-Clinical Oncology Department, Faculty of Medicine, University of Chile, Santiago 8500000, Chile;
| | - Mauricio Canals
- Department of Eastern Medicine and Environmental Health Program, School of Public Health, Faculty of Medicine, University of Chile, Santiago 8380453, Chile;
| | - Andrés Guevara
- School of Medical Technology, Faculty of Medicine, University of Chile, Santiago 8380000, Chile; (A.G.); (N.P.)
| | - Nicolás Poulsen
- School of Medical Technology, Faculty of Medicine, University of Chile, Santiago 8380000, Chile; (A.G.); (N.P.)
| | - Werner Apt
- Basic-Clinical Parasitology Laboratory, Cellular and Molecular Biology Program, Institute of Biomedical Sciences, Faculty of Medicine, University of Chile, Santiago 8380453, Chile;
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Scarim CB, Andrade CRD, Falcone R, Ambrozini LM, Senhorelli VI, Rosa JAD, Chin CM. Hydroxymethylnitrofurazone (NFOH) decreases parasitaemia, parasitism and tissue lesion caused by infection with the Bolivia Trypanosoma cruzi type I strain in Swiss and C57BL/6 mice. BRAZ J PHARM SCI 2022. [DOI: 10.1590/s2175-97902022e20277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Affiliation(s)
| | | | - Rossana Falcone
- Sao Paulo State University “Júlio de Mesquita Filho”, UNESP, Brazil
| | | | | | | | - Chung Man Chin
- Sao Paulo State University “Júlio de Mesquita Filho”, UNESP, Brazil
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Alonso-Vega C, Urbina JA, Sanz S, Pinazo MJ, Pinto JJ, Gonzalez VR, Rojas G, Ortiz L, Garcia W, Lozano D, Soy D, Maldonado RA, Nagarkatti R, Debrabant A, Schijman A, Thomas MC, López MC, Michael K, Ribeiro I, Gascon J, Torrico F, Almeida IC. New chemotherapy regimens and biomarkers for Chagas disease: the rationale and design of the TESEO study, an open-label, randomised, prospective, phase-2 clinical trial in the Plurinational State of Bolivia. BMJ Open 2021; 11:e052897. [PMID: 34972765 PMCID: PMC8720984 DOI: 10.1136/bmjopen-2021-052897] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Chagas disease (CD) affects ~7 million people worldwide. Benznidazole (BZN) and nifurtimox (NFX) are the only approved drugs for CD chemotherapy. Although both drugs are highly effective in acute and paediatric infections, their efficacy in adults with chronic CD (CCD) is lower and variable. Moreover, the high incidence of adverse events (AEs) with both drugs has hampered their widespread use. Trials in CCD adults showed that quantitative PCR (qPCR) assays remain negative for 12 months after standard-of-care (SoC) BZN treatment in ~80% patients. BZN pharmacokinetic data and the nonsynchronous nature of the proliferative mammal-dwelling parasite stage suggested that a lower BZN/NFX dosing frequency, combined with standard or extended treatment duration, might have the same or better efficacy than either drug SoC, with fewer AEs. METHODS AND ANALYSIS New ThErapies and Biomarkers for ChagaS infEctiOn (TESEO) is an open-label, randomised, prospective, phase-2 clinical trial, with six treatment arms (75 patients/arm, 450 patients). Primary objectives are to compare the safety and efficacy of two new proposed chemotherapy regimens of BZN and NFX in adults with CCD with the current SoC for BZN and NFX, evaluated by qPCR and biomarkers for 36 months posttreatment and correlated with CD conventional serology. Recruitment of patients was initiated on 18 December 2019 and on 20 May 2021, 450 patients (study goal) were randomised among the six treatment arms. The treatment phase was finalised on 18 August 2021. Secondary objectives include evaluation of population pharmacokinetics of both drugs in all treatment arms, the incidence of AEs, and parasite genotyping. ETHICS AND DISSEMINATION The TESEO study was approved by the National Institutes of Health (NIH), U.S. Food and Drug Administration (FDA), federal regulatory agency of the Plurinational State of Bolivia and the Ethics Committees of the participating institutions. The results will be disseminated via publications in peer-reviewed journals, conferences and reports to the NIH, FDA and participating institutions. TRIAL REGISTRATION NUMBER NCT03981523.
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Affiliation(s)
| | - Julio A Urbina
- Center for Biochemistry and Biophysics, Venezuelan Institute for Scientific Research (IVIC), Caracas, Distrito Capital, Venezuela, Bolivarian Republic of
| | - Sergi Sanz
- Biostatistics and Data Management Unit, Barcelona Institute for Global Health, Barcelona, Spain
- Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
- Department of Basic Clinical Practice, Universitat de Barcelona, Barcelona, Spain
| | - María-Jesús Pinazo
- Barcelona Institute for Global Health (ISGLOBAL), Barcelona, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
| | - Jimy José Pinto
- Fundación Ciencia y Estudios Aplicados para el Desarrollo en Salud y Medio Ambiente (CEADES), Cochabamba, Bolivia, Plurinational State of
| | - Virginia R Gonzalez
- Department of Biological Sciences, The University of Texas at El Paso, El Paso, Texas, USA
| | - Gimena Rojas
- Fundación Ciencia y Estudios Aplicados para el Desarrollo en Salud y Medio Ambiente (CEADES), Cochabamba, Bolivia, Plurinational State of
| | - Lourdes Ortiz
- Fundación Ciencia y Estudios Aplicados para el Desarrollo en Salud y Medio Ambiente (CEADES), Tarija, Bolivia, Plurinational State of
- Universidad Autónoma Juan Misael Saracho, Tarija, Bolivia, Plurinational State of
| | - Wilson Garcia
- Centro Plataforma Chagas Sucre, Fundación Ciencia y Estudios Aplicados para el Desarrollo en Salud y Medio Ambiente (CEADES), Sucre, Bolivia, Plurinational State of
- Programa Departamental de Chagas Chuquisaca, Servicio Departamental de Salud de Chuquisaca, Chuquisaca, Bolivia, Plurinational State of
| | - Daniel Lozano
- Fundación Ciencia y Estudios Aplicados para el Desarrollo en Salud y Medio Ambiente (CEADES), Cochabamba, Bolivia, Plurinational State of
| | - Dolors Soy
- Pharmacy Service, Division of Medicines, Hospital Clinic de Barcelona, Barcelona, Spain
- Institut de Investigació Biomèdica Agustí Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - Rosa A Maldonado
- Department of Biological Sciences, The University of Texas at El Paso, El Paso, Texas, USA
| | - Rana Nagarkatti
- Division of Emerging and Transfusion Transmitted Diseases, Center for Biologics Evaluation and Research, U.S. Food and Drug Administration (FDA), Silver Spring, Maryland, USA
| | - Alain Debrabant
- Division of Emerging and Transfusion Transmitted Diseases, Center for Biologics Evaluation and Research, U.S. Food and Drug Administration (FDA), Silver Spring, Maryland, USA
| | - Alejandro Schijman
- Laboratorio de Biología Molecular de la Enfermedad de Chagas, Instituto de Investigaciones en Ingeniería Genética y Biología Molecular, Buenos Aires, Argentina
- National Scientific and Technical Research Council (CONICET), Buenos Aires, Argentina
| | - M Carmen Thomas
- Consejo Superior de Investigaciones Científicas, Instituto de Parasitología y Biomedicina López-Neyra, Granada, Spain
| | - Manuel Carlos López
- Consejo Superior de Investigaciones Científicas, Instituto de Parasitología y Biomedicina López-Neyra, Granada, Spain
| | - Katja Michael
- Department of Chemistry and Biochemistry, The University of Texas at El Paso, El Paso, Texas, USA
| | - Isabela Ribeiro
- Dynamic Portfolio Unit, Drugs for Neglected Diseases initiative, Geneva, Switzerland
| | - Joaquim Gascon
- Barcelona Institute for Global Health (ISGLOBAL), Barcelona, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
| | - Faustino Torrico
- Fundación Ciencia y Estudios Aplicados para el Desarrollo en Salud y Medio Ambiente (CEADES), Cochabamba, Bolivia, Plurinational State of
| | - Igor C Almeida
- Department of Biological Sciences, The University of Texas at El Paso, El Paso, Texas, USA
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Scarim CB, Olmo F, Ferreira EI, Chin CM, Kelly JM, Fortes Francisco A. Image-Based In Vitro Screening Reveals the Trypanostatic Activity of Hydroxymethylnitrofurazone against Trypanosoma cruzi. Int J Mol Sci 2021; 22:ijms22136930. [PMID: 34203228 PMCID: PMC8268475 DOI: 10.3390/ijms22136930] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 06/14/2021] [Accepted: 06/23/2021] [Indexed: 12/23/2022] Open
Abstract
Hydroxymethylnitrofurazone (NFOH) is a therapeutic candidate for Chagas disease (CD). It has negligible hepatotoxicity in a murine model compared to the front-line drug benznidazole (BZN). Here, using Trypanosoma cruzi strains that express bioluminescent and/or fluorescent reporter proteins, we further investigated the in vitro and in vivo activity of NFOH to define whether the compound is trypanocidal or trypanostatic. The in vitro activity was assessed by exploiting the fluorescent reporter strain using wash-out assays and real-time microscopy. For animal experimentation, BALB/c mice were inoculated with the bioluminescent reporter strain and assessed by highly sensitive in vivo and ex vivo imaging. Cyclophosphamide treatment was used to promote parasite relapse in the chronic stage of infection. Our data show that NFOH acts by a trypanostatic mechanism, and that it is more active than BZN in vitro against the infectious trypomastigote form of Trypanosoma cruzi. We also found that it is more effective at curing experimental infections in the chronic stage, compared with the acute stage, a feature that it shares with BZN. Therefore, given its reduced toxicity, enhanced anti-trypomastigote activity, and curative properties, NFOH can be considered as a potential therapeutic option for Chagas disease, perhaps in combination with other trypanocidal agents.
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Affiliation(s)
- Cauê Benito Scarim
- School of Pharmaceutical Sciences, Sao Paulo State University (UNESP), Araraquara, Sao Paulo 14800-903, Brazil; (C.B.S.); (C.M.C.)
- Department of Infection Biology, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK; (F.O.); (J.M.K.)
| | - Francisco Olmo
- Department of Infection Biology, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK; (F.O.); (J.M.K.)
| | - Elizabeth Igne Ferreira
- LAPEN—Laboratory of Design and Synthesis of Chemotherapeutic Agents Potentially Active on Neglected Diseases, Department of Pharmacy, School of Pharmaceutical Sciences, University of Sao Paulo (USP), Sao Paulo 05508-9000, Brazil;
| | - Chung Man Chin
- School of Pharmaceutical Sciences, Sao Paulo State University (UNESP), Araraquara, Sao Paulo 14800-903, Brazil; (C.B.S.); (C.M.C.)
- Advanced Research Center in Medicine, School of Medicine, Union of the Colleges of the Great Lakes (UNILAGO), São José do Rio Preto, Sao Paulo 15030-070, Brazil
| | - John M. Kelly
- Department of Infection Biology, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK; (F.O.); (J.M.K.)
| | - Amanda Fortes Francisco
- Department of Infection Biology, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK; (F.O.); (J.M.K.)
- Correspondence: ; Tel.: +44-207-612-7864
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Scarim CB, Chin CM. Current Approaches to Drug Discovery for Chagas Disease: Methodological Advances. Comb Chem High Throughput Screen 2020; 22:509-520. [PMID: 31608837 DOI: 10.2174/1386207322666191010144111] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 07/31/2019] [Accepted: 09/06/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND In recent years, there has been an improvement in the in vitro and in vivo methodology for the screening of anti-chagasic compounds. Millions of compounds can now have their activity evaluated (in large compound libraries) by means of high throughput in vitro screening assays. OBJECTIVE Current approaches to drug discovery for Chagas disease. METHOD This review article examines the contribution of these methodological advances in medicinal chemistry in the last four years, focusing on Trypanosoma cruzi infection, obtained from the PubMed, Web of Science, and Scopus databases. RESULTS Here, we have shown that the promise is increasing each year for more lead compounds for the development of a new drug against Chagas disease. CONCLUSION There is increased optimism among those working with the objective to find new drug candidates for optimal treatments against Chagas disease.
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Affiliation(s)
- Cauê B Scarim
- Sao Paulo State University (UNESP), School of Pharmaceutical Sciences, Araraquara, SP, Brazil.,Lapdesf - Laboratory of Research and Development of Drugs, Araraquara, São Paulo, Brazil
| | - Chung M Chin
- Sao Paulo State University (UNESP), School of Pharmaceutical Sciences, Araraquara, SP, Brazil.,Lapdesf - Laboratory of Research and Development of Drugs, Araraquara, São Paulo, Brazil
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Moreira MDCV, Renan Cunha-Melo J. Chagas Disease Infection Reactivation after Heart Transplant. Trop Med Infect Dis 2020; 5:tropicalmed5030106. [PMID: 32610473 PMCID: PMC7558140 DOI: 10.3390/tropicalmed5030106] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 06/08/2020] [Accepted: 06/10/2020] [Indexed: 11/20/2022] Open
Abstract
Chagas disease, caused by a Trypanosona cruzi infection, is one of the main causes of heart failure in Latin America. It was originally a health problem endemic to South America, predominantly affecting residents of poor rural areas. With globalization and increasing migratory flows from these areas to large cities, the immigration of T. cruzi chronically-infected people to developed, non-endemic countries has occurred. This issue has emerged as an important consideration for heart transplant professionals. Currently, Chagas patients with end-stage heart failure may need a heart transplantation (HTx). This implies that in post-transplant immunosuppression therapy to avoid rejection in the recipient, there is the possibility of T. cruzi infection reactivation, increasing the morbidity and mortality rates. The management of heart transplant recipients due to Chagas disease requires awareness for early recognition and parasitic treatment of T. cruzi infection reactivation. This issue poses challenges for heart transplant professionals, especially regarding the differential diagnosis between rejection and reactivation episodes. The aim of this review is to discuss the complexity of the Chagas disease reactivation phenomenon in patients submitted to HTx for end-stage chagasic cardiomyopathy.
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Affiliation(s)
| | - José Renan Cunha-Melo
- Department of Surgery, School of Medicine, Federal University of Minas Gerais (UFMG), Av. Alfredo Balena 190, Belo Horizonte CEP 30130-110, MG, Brazil
- Correspondence:
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Petravicius PO, Costa-Martins AG, Silva MN, Reis-Cunha JL, Bartholomeu DC, Teixeira MM, Zingales B. Mapping benznidazole resistance in trypanosomatids and exploring evolutionary histories of nitroreductases and ABCG transporter protein sequences. Acta Trop 2019; 200:105161. [PMID: 31494121 DOI: 10.1016/j.actatropica.2019.105161] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 07/22/2019] [Accepted: 09/03/2019] [Indexed: 12/24/2022]
Abstract
The nitro-heterocyclic compound benznidazole (BZ) is the first-line drug for the treatment of Chagas disease, caused by the protozoan Trypanosoma cruzi. However, therapeutic failures are common for reasons that include the influences of parasite and host genetics, the effects of toxicity on adherence to treatment, and difficulties in demonstrating parasitological cure. To obtain information on the origin of the resistance to BZ and eliminate from the scenery the participation of the host, initially we mapped the susceptibility to the drug in thirteen species of seven genera of the family Trypanosomatidae. We verified that all Trypanosoma species are sensitive to low concentrations of the drug (IC50 2.7 to 25 µM) while Non-Trypanosoma species are highly resistant to these concentrations. The two groups of parasites correspond to the major phylogenetic lineages of trypanosomatids. Next, we searched in the trypanosomatid genome databases homologs of two type-I nitroreductases (NTR-1 and OYE) and an ABC transporter (ABCG1) that have been associated with BZ resistance in T. cruzi. The predicted proteins were characterized regarding domains and used for phylogenetic analyses. Homologous NTR-1 genes were found in all trypanosomatids investigated and the structural characteristics of the enzyme suggest that it may be functional. OYE genes were absent in BZ-sensitive African trypanosomes, which excludes the participation of this enzyme in BZ bio-activation. Two copies of ABCG1 genes were observed in most BZ resistant species, while Trypanosoma species exhibit only one copy per haploid genome. Functional studies are required to verify the involvement of these genes in BZ resistance. In addition, since multiple mechanisms can contribute to BZ susceptibility, our study poses a range of organisms highly resistant to BZ in which these aspects can be investigated. Preliminary studies on BZ uptake indicate marked differences between BZ-sensitive and BZ-resistant species.
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8
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Sulleiro E, Muñoz-Calderon AQ, Schijman AG. Role of nucleic acid amplification assays in monitoring treatment response in chagas disease: Usefulness in clinical trials. Acta Trop 2019; 199:105120. [PMID: 31376368 DOI: 10.1016/j.actatropica.2019.105120] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 07/23/2019] [Accepted: 07/30/2019] [Indexed: 12/12/2022]
Abstract
Chagas disease has become a global health problem due to migration of infected people out of Latin America to non-endemic countries. For more than 40 years, only the nitroimidazole compounds Benznidazole and Nifurtimox, have been used for specific treatment of Trypanosoma cruzi infection with disappointing results, specially due to the long duration of treatment and adverse events in the chronic phase. In the last years, ergosterol inhibitors have been also proposed for specific treatment. Different randomized clinical trials were performed for evaluating their treatment efficacy and safety. One of the greatest concerns in clinical trials is to provide an early surrogate biomarker of response to trypanocidal chemotherapy. Serological response is slow and the classical parasitological tests have poor sensitivity and are time-consuming. Nowadays, PCR is the most helpful tool for assessing treatment response in a short period of time. Different protocols of PCR have been developed, being quantitative real time PCR based on amplification of repetitive satellite or minicircle DNA sequences plus an internal amplification standard, the mostly employed strategies in clinical trials. Standardized protocols and the use of an external quality assessment ensure adequate technical procedures and reliable data. Clinical trials have shown a significant reduction in parasite loads, reaching undetectable DNA levels in bloodstream after specific treatment, however events of treatment failure have also been reported. Treatment failure could be due to inadequate penetrance of the drugs into the affected tissues, to the presence of primary or secondary drug resistance of the infecting strains as well as to the existence of dormant parasite variants reluctant to drug action. The early diagnosis of drug resistance would improve clinical management of Chagas disease patients, allowing dictating alternative therapies with a combination of existing drugs or new anti-T. cruzi agents. The aim of this review was to describe the usefulness of detecting T.cruzi DNA by means of real time PCR assays, as surrogate biomarker in clinical trials for evaluating new drugs for CD or new regimens of available drugs and the possibility to detect treatment failure.
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Caldas IS, Santos EG, Novaes RD. An evaluation of benznidazole as a Chagas disease therapeutic. Expert Opin Pharmacother 2019; 20:1797-1807. [PMID: 31456439 DOI: 10.1080/14656566.2019.1650915] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction: As benznidazole is the first-line treatment for patients with Chagas disease, rational chemotherapy strategies are required based on the critical analysis of the evidence on the relevance and applicability of this drug at different disease stages. Areas covered: The authors discuss the current understanding of benznidazole-based chemotherapy for Chagas disease, focusing specifically on epidemiology, pharmacokinetics, mechanism of action, clinical recommendations, cure criteria, and therapeutic efficacy in different phases of the disease. Expert opinion: Benznidazole shows high bioavailability after oral administration. Benznidazole at 5-8 mg/kg/day and 5-10 mg/kg/day for 30-60 days are consistent clinical recommendations for children and adults, respectively. A high correlation between negative parasitological, serological, and polymerase chain reaction (PCR) assays in long-term post-therapeutic follow-up has been consistently used to evaluate therapeutic efficacy. These methods support the evidence that the success of benznidazole-based chemotherapy is closely correlated with the phase of infection in which the treatment is administered. The greater therapeutic efficacy is obtained in acute infections, gradually worsening as the infection becomes chronic. When therapeutic failure is confirmed by any diagnostic assay, benznidazole treatment does not always ensure better long-term prognosis, and Chagas cardiomyopathy may develop as well as in untreated patients.
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Affiliation(s)
- Ivo S Caldas
- Department of Pathology and Parasitology, Institute of Biomedical Sciences, Universidade Federal de Alfenas (UNIFAL-MG) , Alfenas , Minas Gerais , Brazil
| | - Elda G Santos
- Department of Structural Biology, Institute of Biomedical Sciences, Universidade Federal de Alfenas (UNIFAL-MG) , Alfenas , Minas Gerais , Brazil
| | - Rômulo D Novaes
- Department of Structural Biology, Institute of Biomedical Sciences, Universidade Federal de Alfenas (UNIFAL-MG) , Alfenas , Minas Gerais , Brazil
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Scarim CB, de Andrade CR, da Rosa JA, dos Santos JL, Chin CM. Hydroxymethylnitrofurazone treatment in indeterminate form of chronic Chagas disease: Reduced intensity of tissue parasitism and inflammation-A histopathological study. Int J Exp Pathol 2018; 99:236-248. [PMID: 30320480 PMCID: PMC6302791 DOI: 10.1111/iep.12289] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Revised: 07/25/2018] [Accepted: 08/06/2018] [Indexed: 12/24/2022] Open
Abstract
Hydroxymethylnitrofurazone (NFOH) is a nitrofurazone prodrug effective in vivo during acute infections, and it has less hepatotoxicity effect than the standard drug benznidazole (BZN) which has been used during short- and long-term treatment. In the present study, we induced the indeterminate form of Chagas disease in mice with a Y strain of Trypanosoma cruzi and analysed the histopathological data about the effects of NFOH and BZN on different tissues, including the heart, skeletal muscle, liver, kidney, colon, spleen and brain. After infection, BALB/c mice were treated with NFOH (150 mg/kg) and BZN (60 mg/kg) for 60 days and then submitted to immunosuppression using dexamethasone (5 mg/kg) for 14 days. Two trained analysts, as part of a blind evaluation, examined the results using serial sections of 3 mm diameter in two different moments. The results showed reactivation of the disease only in the infected nontreated group (POS). After treatment, amastigote nests were found in the heart, colon, liver and skeletal muscle in the POS group and in the heart and liver of the BZN group. Interestingly, amastigote nests were not found in the NFOH and NEG groups. The histopathological analysis showed fewer tissue lesions and parasite infiltrates in the NFOH group when compared with the BZN and POS groups. We have not observed any increase in the levels of hepatocellular injury biomarkers (AST/ALT) in the NFOH group. These in vivo studies show the potential for NFOH as an effective and safe compound useful as an anti-T. cruzi agent.
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Affiliation(s)
- Cauê B. Scarim
- São Paulo State University (UNESP)School of Pharmaceutical SciencesDepartment of Drugs and MedicinesLapdesf ‐ Laboratory of Research and Development of DrugsAraraquaraSão PauloBrazil
| | - Cleverton R. de Andrade
- São Paulo State University (UNESP)Faculty of DentistryDepartment of Physiology and PathologyAraraquaraSão PauloBrazil
| | - João A. da Rosa
- São Paulo State University (UNESP)School of Pharmaceutical SciencesDepartment of Biological SciencesAraraquaraSão PauloBrazil
| | - Jean L. dos Santos
- São Paulo State University (UNESP)School of Pharmaceutical SciencesDepartment of Drugs and MedicinesLapdesf ‐ Laboratory of Research and Development of DrugsAraraquaraSão PauloBrazil
| | - Chung M. Chin
- São Paulo State University (UNESP)School of Pharmaceutical SciencesDepartment of Drugs and MedicinesLapdesf ‐ Laboratory of Research and Development of DrugsAraraquaraSão PauloBrazil
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11
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Schijman AG. Molecular diagnosis of Trypanosoma cruzi. Acta Trop 2018; 184:59-66. [PMID: 29476727 DOI: 10.1016/j.actatropica.2018.02.019] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 02/05/2018] [Accepted: 02/14/2018] [Indexed: 01/01/2023]
Abstract
Chagas disease, caused by the kinetoplastid protozoan Trypanosoma cruzi, affects millions of people, most of them neglected populations. The different phases of the disease, the transmission mode and the high genetic variability of the parasite determine that molecular detection methods display different degree of success. Molecular diagnostic tests may be employed during epidemiological surveys of transmission, for early diagnosis of congenital transmission and acute infections due to oral transmission, transfusion or transplantation routes, reactivation due to immunosuppression and monitoring of treatment response in chronically infected patients receiving trypanocidal chemotherapy. This manuscript summarizes the most widely used molecular tools to detect T. cruzi infection in different epidemiological and clinical scenarios.
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Affiliation(s)
- Alejandro G Schijman
- Laboratorio de Biología Molecular de la Enfermedad de Chagas, Instituto de Investigaciones en Ingeniería Genética y Biología Molecular "Dr. Hector Torres" (INGEBI-CONICET), Ciudad de Buenos Aires, Argentina.
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MacLean LM, Thomas J, Lewis MD, Cotillo I, Gray DW, De Rycker M. Development of Trypanosoma cruzi in vitro assays to identify compounds suitable for progression in Chagas' disease drug discovery. PLoS Negl Trop Dis 2018; 12:e0006612. [PMID: 30001347 PMCID: PMC6057682 DOI: 10.1371/journal.pntd.0006612] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 07/24/2018] [Accepted: 06/14/2018] [Indexed: 01/08/2023] Open
Abstract
Chagas' disease is responsible for significant mortality and morbidity in Latin America. Current treatments display variable efficacy and have adverse side effects, hence more effective, better tolerated drugs are needed. However, recent efforts have proved unsuccessful with failure of the ergosterol biosynthesis inhibitor posaconazole in phase II clinical trials despite promising in vitro and in vivo studies. The lack of translation between laboratory experiments and clinical outcome is a major issue for further drug discovery efforts. Our goal was to identify cell-based assays that could differentiate current nitro-aromatic drugs nifurtimox and benznidazole from posaconazole. Using a panel of T. cruzi strains including the six major lineages (TcI-VI), we found that strain PAH179 (TcV) was markedly less susceptible to posaconazole in vitro. Determination of parasite doubling and cycling times as well as EdU labelling experiments all indicate that this lack of sensitivity is due to the slow doubling and cycling time of strain PAH179. This is in accordance with ergosterol biosynthesis inhibition by posaconazole leading to critically low ergosterol levels only after multiple rounds of division, and is further supported by the lack of effect of posaconazole on the non-replicative trypomastigote form. A washout experiment with prolonged posaconazole treatment showed that, even for more rapidly replicating strains, this compound cannot clear all parasites, indicative of a heterogeneous parasite population in vitro and potentially the presence of quiescent parasites. Benznidazole in contrast was able to kill all parasites. The work presented here shows clear differentiation between the nitro-aromatic drugs and posaconazole in several assays, and suggests that in vitro there may be clinically relevant heterogeneity in the parasite population that can be revealed in long-term washout experiments. Based on these findings we have adjusted our in vitro screening cascade so that only the most promising compounds are progressed to in vivo experiments.
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Affiliation(s)
- Lorna M. MacLean
- Drug Discovery Unit, Wellcome Centre for Anti-Infectives Research, School of Life Sciences, University of Dundee, Dundee, United Kingdom
- * E-mail: (LML); (DWG)
| | - John Thomas
- Drug Discovery Unit, Wellcome Centre for Anti-Infectives Research, School of Life Sciences, University of Dundee, Dundee, United Kingdom
| | - Michael D. Lewis
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Ignacio Cotillo
- GlaxoSmithKline, Diseases of the Developing World, Tres Cantos, Madrid, Spain
| | - David W. Gray
- Drug Discovery Unit, Wellcome Centre for Anti-Infectives Research, School of Life Sciences, University of Dundee, Dundee, United Kingdom
- * E-mail: (LML); (DWG)
| | - Manu De Rycker
- Drug Discovery Unit, Wellcome Centre for Anti-Infectives Research, School of Life Sciences, University of Dundee, Dundee, United Kingdom
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Scarim CB, Jornada DH, Chelucci RC, de Almeida L, Dos Santos JL, Chung MC. Current advances in drug discovery for Chagas disease. Eur J Med Chem 2018; 155:824-838. [PMID: 30033393 DOI: 10.1016/j.ejmech.2018.06.040] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 06/14/2018] [Accepted: 06/15/2018] [Indexed: 12/29/2022]
Abstract
Chagas disease, also known as American trypanosomiasis, is one of the 17 neglected tropical diseases (NTDs) according to World Health Organization. It is estimated that 8-10 million people are infected worldwide, mainly in Latin America. Chagas disease is caused by the parasite Trypanosoma cruzi and is characterized by two phases: acute and chronic. The current therapy for Chagas disease is limited to drugs such as nifurtimox and benznidazole, which are effective in treating only the acute phase of the disease. In addition, several side effects ranging from hypersensitivity to bone marrow depression and peripheral polyneuropathy have been associated with these drugs. Therefore, the current challenge is to find new effective and safe drugs against this NTD. The aim of this review is to describe the advances in the medicinal chemistry of new anti-chagasic compounds reported in the literature in the last five years. We report promising prototypes for drug discovery identified through target-based and phenotype-based strategies and present some important targets for the development of new synthetic compounds.
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Affiliation(s)
- Cauê Benito Scarim
- Departamento de Fármacos e Medicamentos, Faculdade de Ciências Farmacêuticas, Universidade Estadual Paulista "Júlio de Mesquita Filho", UNESP, Araraquara, SP, Brazil.
| | - Daniela Hartmann Jornada
- Departamento de Fármacos e Medicamentos, Faculdade de Ciências Farmacêuticas, Universidade Estadual Paulista "Júlio de Mesquita Filho", UNESP, Araraquara, SP, Brazil
| | - Rafael Consolin Chelucci
- Departamento de Fármacos e Medicamentos, Faculdade de Ciências Farmacêuticas, Universidade Estadual Paulista "Júlio de Mesquita Filho", UNESP, Araraquara, SP, Brazil
| | - Leticia de Almeida
- Departamento de Biologia Celular e Molecular, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, USP, Brazil
| | - Jean Leandro Dos Santos
- Departamento de Fármacos e Medicamentos, Faculdade de Ciências Farmacêuticas, Universidade Estadual Paulista "Júlio de Mesquita Filho", UNESP, Araraquara, SP, Brazil
| | - Man Chin Chung
- Departamento de Fármacos e Medicamentos, Faculdade de Ciências Farmacêuticas, Universidade Estadual Paulista "Júlio de Mesquita Filho", UNESP, Araraquara, SP, Brazil
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14
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Sguassero Y, Roberts KN, Harvey GB, Comandé D, Ciapponi A, Cuesta CB, Aguiar C, Castro AMD, Danesi E, de Andrade AL, de Lana M, Escribà JM, Fabbro DL, Fernandes CD, Flores-Chávez M, Hasslocher-Moreno AM, Jackson Y, Lacunza CD, Machado-de-Assis GF, Maldonado M, Meira WSF, Molina I, Monje-Rumi MM, Muñoz-San Martín C, Murcia L, Nery de Castro C, Sánchez Negrette O, Segovia M, Silveira CAN, Solari A, Steindel M, Streiger ML, Vera de Bilbao N, Zulantay I, Sosa-Estani S. Course of serological tests in treated subjects with chronic Trypanosoma cruzi infection: A systematic review and meta-analysis of individual participant data. Int J Infect Dis 2018; 73:93-101. [PMID: 29879524 PMCID: PMC6069672 DOI: 10.1016/j.ijid.2018.05.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 05/26/2018] [Accepted: 05/29/2018] [Indexed: 12/30/2022] Open
Abstract
This is the first meta-analysis of individual data in chronic Trypanosoma cruzi infection after treatment. The probability of seroreversion is variable along the course of follow-up. An interaction was found between age at treatment and country setting. The course of parasitological/molecular tests after treatment needs to be assessed.
Objective To determine the course of serological tests in subjects with chronic Trypanosoma cruzi infection treated with anti-trypanosomal drugs. Methods A systematic review and meta-analysis was conducted using individual participant data. Survival analysis and the Cox proportional hazards regression model with random effects to adjust for covariates were applied. The protocol was registered in the PROSPERO database (http://www.crd.york.ac.uk/PROSPERO; CRD42012002162). Results A total of 27 studies (1296 subjects) conducted in eight countries were included. The risk of bias was low for all domains in 17 studies (63.0%). Nine hundred and thirteen subjects were assessed (149 seroreversion events, 83.7% censored data) for enzyme-linked immunosorbent assay (ELISA), 670 subjects (134 events, 80.0% censored) for indirect immunofluorescence assay (IIF), and 548 subjects (99 events, 82.0% censored) for indirect hemagglutination assay (IHA). A higher probability of seroreversion was observed within a shorter time span in subjects aged 1–19 years compared to adults. The chance of seroreversion also varied according to the country where the infection might have been acquired. For instance, the pooled adjusted hazard ratio between children/adolescents and adults for the IIF test was 1.54 (95% confidence interval 0.64–3.71) for certain countries of South America (Argentina, Bolivia, Chile, and Paraguay) and 9.37 (95% confidence interval 3.44–25.50) for Brazil. Conclusions The disappearance of anti-T. cruzi antibodies was demonstrated along the course of follow-up. An interaction between age at treatment and country setting was found.
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Affiliation(s)
- Yanina Sguassero
- Centro Rosarino de Estudios Perinatales, Rosario, Argentina; Instituto Nacional de Parasitología, Fatala Chaben-ANLIS, Buenos Aires, Argentina.
| | - Karen N Roberts
- Facultad de Ciencias Económicas y Estadística, Universidad Nacional de Rosario, Argentina
| | - Guillermina B Harvey
- Facultad de Ciencias Económicas y Estadística, Universidad Nacional de Rosario, Argentina
| | - Daniel Comandé
- Instituto de Efectividad Clínica y Sanitaria. CONICET, Buenos Aires, Argentina
| | - Agustín Ciapponi
- Instituto de Efectividad Clínica y Sanitaria. CONICET, Buenos Aires, Argentina
| | - Cristina B Cuesta
- Facultad de Ciencias Económicas y Estadística, Universidad Nacional de Rosario, Argentina
| | - Camila Aguiar
- Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Brazil
| | - Ana M de Castro
- Instituto de Patologia Tropical e Saúde Pública, Universidade Federal de Goiás, Goiânia, Goiás, Brazil
| | - Emmaría Danesi
- Centro Nacional de Investigación y Diagnóstico en Endemoepidemias (CeNDIE-ANLIS), Buenos Aires, Argentina
| | - Ana L de Andrade
- Departamento de Saúde Coletiva, Instituto de Patologia Tropical e Saúde Pública, Universidade Federal de Goiás, Goiânia, Goiás, Brazil
| | - Marta de Lana
- Departamento de Análise Clínica, Universidade Federal de Ouro Preto, Ouro Preto, Minas Gerais, Brazil
| | - Josep M Escribà
- Medical Department, Médecins sans Frontières, Barcelona, Spain
| | - Diana L Fabbro
- Centro de Investigaciones sobre Endemias Nacionales (CIEN), Facultad de Bioquímica y Ciencias Biológicas, Universidad Nacional del Litoral, Santa Fe, Argentina
| | - Cloé D Fernandes
- Instituto de Pesquisa Biológica, Laboratório Central, Fundação Estadual de Produção e Pesquisa em Saúde, Porto Alegre, RS, Brazil
| | - María Flores-Chávez
- Unidad de Leishmaniasis, Servicio de Parasitología, Instituto de Salud Carlos III, Madrid, España
| | | | - Yves Jackson
- Division of Primary Care Medicine, Geneva University Hospitals, Geneva, Switzerland; Institute of Global Health, University of Geneva, Geneva, Switzerland
| | - Carlos D Lacunza
- Dirección de Primer Nivel de Atención, Área Operativa N° LV, Salta, Argentina
| | - Girley F Machado-de-Assis
- Departamento de Ciências Básicas da Vida, Universidade Federal de Juiz de Fora, Campus Governador Valadares, Brazil
| | - Marisel Maldonado
- Departamento de Medicina Tropical, Instituto de Investigaciones en Ciencias de la Salud, Universidad Nacional de Asunción, Paraguay
| | - Wendell S F Meira
- Departamento de Microbiologia, Imunologia e Parasitologia, Universidade Federal do Triangulo Mineiro, Brazil
| | - Israel Molina
- Infectious Diseases Department, Hospital Universitario Vall d'Hebron, Barcelona, Spain; International Health Program of the Catalan Institute of Health (PROSICS), Barcelona, Spain
| | - María M Monje-Rumi
- Laboratorio de Patología Experimental, Universidad Nacional de Salta, Salta, Argentina
| | - Catalina Muñoz-San Martín
- Laboratorio de Ecología, Facultad de Ciencias Veterinarias y Pecuarias, Universidad de Chile, Santiago, Chile; Laboratorio de Parasitología Básico-Clínico Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Laura Murcia
- Unidad Regional de Medicina Tropical, Servicio de Microbiología, Hospital Universitario Virgen de la Arrixaca, El Palmar, Murcia, España; Departamento de Genética y Microbiología, Universidad de Murcia, Espinardo, Murcia, España
| | - Cleudson Nery de Castro
- Escola de Saúde e Medicina, Universidade Católica de Brasília, Brazil; Núcleo de Medicina Tropical, Faculdade de Medicina, Universidade de Brasília, Brazil
| | - Olga Sánchez Negrette
- Cátedra de Inmunología, Facultad de Ciencias Agrarias y Veterinarias, Universidad Católica de Salta, Argentina; Cátedra de Química Biológica, Facultad de Ciencias Exactas, Universidad Nacional de Salta, Argentina
| | - Manuel Segovia
- Unidad Regional de Medicina Tropical, Servicio de Microbiología, Hospital Universitario Virgen de la Arrixaca, El Palmar, Murcia, España; Departamento de Genética y Microbiología, Universidad de Murcia, Espinardo, Murcia, España
| | - Celeste A N Silveira
- Núcleo de Medicina Tropical, Faculdade de Medicina, Universidade de Brasília, Brazil
| | - Aldo Solari
- Programa de Biología Celular y Molecular, ICBM, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Mário Steindel
- Departamento de Microbiologia, Imunologia e Parasitologia, Universidade Federal de Santa Catarina, Brazil
| | - Mirtha L Streiger
- Centro de Investigaciones sobre Endemias Nacionales (CIEN), Facultad de Bioquímica y Ciencias Biológicas, Universidad Nacional del Litoral, Santa Fe, Argentina
| | - Ninfa Vera de Bilbao
- Departamento de Medicina Tropical, Instituto de Investigaciones en Ciencias de la Salud, Universidad Nacional de Asunción, Paraguay
| | - Inés Zulantay
- Laboratorio de Parasitología Básico-Clínico Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Sergio Sosa-Estani
- Instituto Nacional de Parasitología, Fatala Chaben-ANLIS, Buenos Aires, Argentina; Instituto de Efectividad Clínica y Sanitaria. CONICET, Buenos Aires, Argentina.
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15
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Scarim CB, Ribeiro AR, Rosa JAD, Chin CM. Response to different benznidazole doses in animal models of chronic phase Chagas disease: a critical review. Rev Soc Bras Med Trop 2018; 51:133-140. [DOI: 10.1590/0037-8682-0337-2017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 04/18/2018] [Indexed: 01/23/2023] Open
Affiliation(s)
| | | | | | - Chung Man Chin
- Universidade Estadual Paulista Júlio de Mesquita Filho, Brazil
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16
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Benznidazole and Posaconazole in Eliminating Parasites in Asymptomatic T. Cruzi Carriers: The STOP-CHAGAS Trial. J Am Coll Cardiol 2017; 69:939-947. [PMID: 28231946 DOI: 10.1016/j.jacc.2016.12.023] [Citation(s) in RCA: 193] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 12/08/2016] [Accepted: 12/19/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND Benznidazole is recommended for treatment of Chagas infection. Effects of combination therapy with benznidazole and posaconazole have not been tested in Trypanosoma cruzi carriers. OBJECTIVES The purpose of this study was to determine whether posaconazole alone or combined with benznidazole were superior to benznidazole monotherapy in eliminating T. cruzi parasites measured by real time polymerase chain reaction (RT-PCR) in asymptomatic Chagas carriers. METHODS A prospective, multicenter randomized placebo-controlled study was conducted in 120 subjects from Latin America and Spain who were randomized to 4 groups: posaconazole 400 mg twice a day (b.i.d.); benznidazole 200 mg + placebo b.i.d.; benznidazole 200 mg b.i.d. + posaconazole 400 mg b.i.d.; or placebo 10 mg b.i.d. T. cruzi deoxyribonucleic acid was detected by RT-PCR at 30, 60, 90, 120, 150, 180, and 360 days. The primary efficacy outcome is the proportion of subjects with persistent negative RT-PCR by day 180; the secondary outcome was negative RT-PCR at 360 days. RESULTS Only 13.3% of those receiving posaconazole and 10% receiving placebo achieved the primary outcome, compared with 80% receiving benznidazole + posaconazole and 86.7% receiving benznidazole monotherapy (p < 0.0001 vs. posaconazole/placebo). Posaconazole monotherapy or posaconazole combined with benznidazole achieved high RT-PCR conversion rates during treatment (30 days; 93.3% and 88.9% and 60 days; 90%, and 92.3%) that were similar to benznidazole (89.7% and 89.3%); all were superior to placebo or posaconazole (10% and 16.7%, p < 0.0001). This was not observed at 360 days; benznidazole + posaconazole and benznidazole monotherapy (both 96%) versus placebo (17%) and posaconazole (16%, p < 0.0001). Serious adverse events were rare (6 patients) and were observed in the benznidazole-treated patients. Permanent discontinuation was reported in 19 patients (31.7%) receiving either benznidazole monotherapy or combined with posaconazole. CONCLUSIONS Posaconazole demonstrated trypanostatic activity during treatment, but it is ineffective long-term in asymptomatic T. cruzi carriers. Benznidazole monotherapy is superior to posaconazole, with high RT-PCR conversion rates sustained at 1 year. Side effects lead to therapy discontinuation in 32%. No advantages were observed with combined therapy versus benznidazole monotherapy. (A Study of the Use of Oral Posaconazole [POS] in the Treatment of Asymptomatic Chronic Chagas Disease [P05267] [STOP CHAGAS]: NCT01377480).
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Monge-Maillo B, López-Vélez R. Challenges in the management of Chagas disease in Latin-American migrants in Europe. Clin Microbiol Infect 2017; 23:290-295. [PMID: 28428122 DOI: 10.1016/j.cmi.2017.04.013] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 03/09/2017] [Accepted: 04/11/2017] [Indexed: 12/27/2022]
Abstract
Chagas disease is endemic in Latin America. Due to migration the infection has crossed borders and it is estimated that 68,000-120,000 people with Chagas disease are currently living in Europe and 30% of them may develop visceral involvement. However, up to 90% of Chagas disease cases in Europe remain undiagnosed. The challenges which have to be overcome in Chagas disease in non-endemic countries are focused on related downing barriers to health care access, and related to screening, diagnostic tools and therapeutic management. The aim of this review is to highlight how healthcare management for Latin American migrants with Chagas disease in Europe may be improved. Medical literature was searched using PubMed. No limits were placed with respect to the language or date of publication although most of the articles selected were articles published in the last five years. Chosen search terms were "Chagas disease" AND ("migrants" OR "screening" OR "transmission" OR "treatment"; OR "knowledge" OR "non-endemic countries"); migrants AND ("Public health" OR "Health Service Accessibility" OR "Delivery of Health care"); and "Congenital Chagas disease". Healthcare management of migrant populations with Chagas disease in Europe has to be improved: -Surveillance programmes are needed to measure the burden of the disease; -screening programmes are needed; -administrative and cultural barriers in the access to health care for migrants should be reduced; -education programmes on Chagas disease should be performed -research on new diagnostic tools and therapeutic options are required. This review highlights the needs of profound changes in the health care of Latin American migrants with Chagas disease in Europe.
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Affiliation(s)
- B Monge-Maillo
- National Referral Unit for Tropical Diseases, Infectious Diseases Department, Ramón y Cajal University Hospital, IRICYS, Madrid, Spain
| | - R López-Vélez
- National Referral Unit for Tropical Diseases, Infectious Diseases Department, Ramón y Cajal University Hospital, IRICYS, Madrid, Spain.
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Alvarez MG, Bertocchi GL, Cooley G, Albareda MC, Viotti R, Perez-Mazliah DE, Lococo B, Castro Eiro M, Laucella SA, Tarleton RL. Treatment Success in Trypanosoma cruzi Infection Is Predicted by Early Changes in Serially Monitored Parasite-Specific T and B Cell Responses. PLoS Negl Trop Dis 2016; 10:e0004657. [PMID: 27128444 PMCID: PMC4851297 DOI: 10.1371/journal.pntd.0004657] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 03/31/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Chagas disease is the highest impact parasitic disease in Latin America. We have proposed that changes in Trypanosoma cruzi-specific immune responses might serve as surrogate indicators of treatment success. Herein, we addressed in a long-term follow-up study whether cure achieved after treatment can be predicted by changes in non-conventional indexes of anti-parasite serological and T cell activities. METHODOLOGY/PRINCIPAL FINDINGS T. cruzi-specific T cell responses, as measured by interferon-γ ELISPOT and T. cruzi-specific antibodies assessed by ELISA, hemagglutination and immunofluorescence tests as well as by a multiplex assay incorporating 14 recombinant T. cruzi proteins were measured in 33 patients at 48-150 months post-benznidazole treatment. Cure - as assessed by conventional serological tests - was associated with an early decline in T. cruzi-specific IFN-γ-producing T cells and in antibody titers measured by the multiplex serological assay. Changes in the functional status and potential of T. cruzi-specific T cells, indicative of reduced antigen stimulation, provided further evidence of parasitological cure following benznidazole treatment. Patients showing a significant reduction in T. cruzi-specific antibodies had higher pre-therapy levels of T. cruzi-specific IFN-γ- producing T cells compared to those with unaltered humoral responses post-treatment. CONCLUSIONS/SIGNIFICANCE Monitoring of appropriate immunological responses can provide earlier and robust measures of treatment success in T. cruzi infection.
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Affiliation(s)
- María G. Alvarez
- Hospital Interzonal General de Agudos Eva Perón, Buenos Aires, Argentina
| | | | - Gretchen Cooley
- Center for Tropical and Emerging Global Diseases, Athens, Georgia, United States of America
| | - María C. Albareda
- Instituto Nacional de Parasitología Dr. Mario Fatala Chaben, Buenos Aires, Argentina
| | - Rodolfo Viotti
- Hospital Interzonal General de Agudos Eva Perón, Buenos Aires, Argentina
| | | | - Bruno Lococo
- Hospital Interzonal General de Agudos Eva Perón, Buenos Aires, Argentina
| | - Melisa Castro Eiro
- Instituto Nacional de Parasitología Dr. Mario Fatala Chaben, Buenos Aires, Argentina
| | - Susana A. Laucella
- Hospital Interzonal General de Agudos Eva Perón, Buenos Aires, Argentina
- Instituto Nacional de Parasitología Dr. Mario Fatala Chaben, Buenos Aires, Argentina
| | - Rick L. Tarleton
- Center for Tropical and Emerging Global Diseases, Athens, Georgia, United States of America
- * E-mail:
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19
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Molecular Approaches for Diagnosis of Chagas' Disease and Genotyping of Trypanosoma cruzi. Mol Microbiol 2016. [DOI: 10.1128/9781555819071.ch36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Márquez ME, Concepción JL, González-Marcano E, Mondolfi AP. Detection of Trypanosoma cruzi by Polymerase Chain Reaction. Methods Mol Biol 2016; 1392:125-141. [PMID: 26843052 DOI: 10.1007/978-1-4939-3360-0_12] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
American Trypanosomiasis (Chagas disease) is an infectious disease caused by the hemoflagellate parasite Trypanosoma cruzi which is transmitted by reduviid bugs. T. cruzi infection occurs in a broad spectrum of reservoir animals throughout North, Central, and South America and usually evolves into an asymptomatic chronic clinical stage of the disease in which diagnosis is often challenging. This chapter describes the application of polymerase chain reaction (PCR) for the detection of Trypanosoma cruzi DNA including protocols for sample preparation, DNA extraction, and target amplification methods.
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Affiliation(s)
| | - Juan Luis Concepción
- Laboratorio de Enzimología de Parásitos, Universidad de Los Andes, Mérida, Venezuela.
| | - Eglys González-Marcano
- Laboratorio de Enzimología de Parásitos, Universidad de Los Andes, Mérida, Venezuela.
- Fundación Jacinto Convit, Caracas, Venezuela.
| | - Alberto Paniz Mondolfi
- Microbiology Laboratory, Department of Laboratory Medicine, Yale University School of Medicine/Yale New Haven Hospital, New Haven, CT, USA.
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Revisiting the Posttherapeutic Cure Criterion in Chagas Disease: Time for New Methods, More Questions, Doubts, and Polemics or Time to Change Old Concepts? BIOMED RESEARCH INTERNATIONAL 2015; 2015:652985. [PMID: 26583124 PMCID: PMC4637035 DOI: 10.1155/2015/652985] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 08/10/2015] [Indexed: 01/17/2023]
Abstract
One of the most relevant issues beyond the effectiveness of etiological treatment of Chagas disease is the lack of consensual/feasible tools to identify and certify the definitive parasitological cure. Several methods of distinct natures (parasitological, serological, and molecular) have been continuously proposed and novel perspectives are currently under investigation. Although the simultaneous use of distinct tests may offer better contributions and advances, it also leads to controversies of interpretation, with lack of mutual consent of cure criterion amongst researchers and physicians. In fact, when distinct host compartments (blood/tissues) are evaluated and explored, novel questions may arise due to the nature and sensitivity limit of each test. This short analytical review intends to present a chronological and critical overview and discuss the state-of-the-art distinct devices available for posttherapeutic cure assessment in Chagas disease, their contributions, meanings, and interpretation, aiming to point out the major gaps and propose novel insight for future perspectives of posttherapeutic management of Chagas disease patients.
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22
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Sguassero Y, Cuesta CB, Roberts KN, Hicks E, Comandé D, Ciapponi A, Sosa-Estani S. Course of Chronic Trypanosoma cruzi Infection after Treatment Based on Parasitological and Serological Tests: A Systematic Review of Follow-Up Studies. PLoS One 2015; 10:e0139363. [PMID: 26436678 PMCID: PMC4593559 DOI: 10.1371/journal.pone.0139363] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 09/11/2015] [Indexed: 12/24/2022] Open
Abstract
Background Chagas disease is caused by the flagellate protozoan Trypanosoma cruzi (T. cruzi). It is endemic in Latin American countries outside the Caribbean. The current criterion for cure in the chronic phase of the disease is the negativization of at least two serological tests such as enzyme-linked immunosorbent assay (ELISA), indirect immunofluorescence assay (IIF) and indirect hemagglutination assay (IHA). The serological evolution of treated subjects with chronic T. cruzi infection is variable. Treatment failure is indicated by a positive parasitological and/or molecular test (persistence of parasitemia). Objectives To summarize the pattern of response to treatment of parasitological, molecular and serological tests performed during the follow-up of subjects with chronic T. cruzi infection. Methods Electronic searches in relevant databases and screening of citations of potentially eligible articles were accomplished. Organizations focusing on neglected infectious diseases were asked for help in identifying relevant studies. Included studies were randomized controlled trials (RCTs), quasi-RCTs, and cohort studies involving adults and children with chronic infection who received trypanocidal treatment (benznidazole or nifurtimox) and were followed over time. The assessment of risk of bias was performed separately for each study design. The Cochrane Collaboration’s tool and the guidelines developed by Hayden et al. were used. Two reviewers extracted all data independently. A third review author was consulted in case of discordant opinion. Additional analyses were defined in ad-hoc basis. Scatter plots for percentage of positive parasitological and molecular tests and for negative serological tests were developed by using the lowess curve technique. Heterogeneity was measured by I2. The protocol was registered in PROSPERO, an international prospective register of systematic review protocols (Registration Number CRD42012002162). Results Out of 2,136 citations screened, 54 studies (six RCTs and 48 cohort studies) were included. The smoothed curves for positive xenodiagnosis and positive polymerase chain reaction (PCR) were characterized by a sharp decrease at twelve month posttreatment. Afterwards, they reached 10–20% and 40% for xenodiagnosis and PCR, respectively. The smoothed curves for negative conventional serological tests increased up to 10% after 48 months of treatment. In the long-term, the rate of negativization was between 20% and 45%. The main sources of bias identified across cohort studies were the lack of control for confounding and attrition bias. In general, RCTs were judged as low risk of bias in all domains. The level of heterogeneity across included studies was moderate to high. Additional analysis were incomplete because of the limited availability of data. In this regard, the country of origin of study participants might affect the results of parasitological and molecular tests, while the level of risk of bias might affect serological outcomes. Subgroup analysis suggested that seronegativization occurs earlier in children compared to adults. Conclusions We acknowledge that there is a dynamic pattern of response based on parasitological, molecular and serological tests in subjects chronically infected with T. cruzi after treatment. Our findings suggest a trypanocidal effect in the long-term follow-up. Further research is needed to explore potential sources of heterogeneity and to conduct reliable subgroup analysis.
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Affiliation(s)
- Yanina Sguassero
- Centro Rosarino de Estudios Perinatales (CREP), Cochrane Centre CREP, Rosario, Santa Fe, Argentina
- Instituto Nacional de Parasitología (INP), “Dr Mario Fatala Chaben”, Administración Nacional de Laboratorios e Institutos de Salud (ANLIS) Malbrán, Buenos Aires, Argentina
| | - Cristina B. Cuesta
- Facultad de Ciencias Económicas y Estadística, Universidad Nacional de Rosario, Santa Fe, Argentina
| | - Karen N. Roberts
- Facultad de Ciencias Económicas y Estadística, Universidad Nacional de Rosario, Santa Fe, Argentina
| | - Elizabeth Hicks
- Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Daniel Comandé
- Instituto de Efectividad Clínica y Sanitaria (IECS), Cochrane Centre IECS, Buenos Aires, Argentina
| | - Agustín Ciapponi
- Instituto de Efectividad Clínica y Sanitaria (IECS), Cochrane Centre IECS, Buenos Aires, Argentina
| | - Sergio Sosa-Estani
- Instituto Nacional de Parasitología (INP), “Dr Mario Fatala Chaben”, Administración Nacional de Laboratorios e Institutos de Salud (ANLIS) Malbrán, Buenos Aires, Argentina
- * E-mail:
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Pinazo MJ, Thomas MC, Bustamante J, Almeida ICD, Lopez MC, Gascon J. Biomarkers of therapeutic responses in chronic Chagas disease: state of the art and future perspectives. Mem Inst Oswaldo Cruz 2015; 110:422-32. [PMID: 25946151 PMCID: PMC4489480 DOI: 10.1590/0074-02760140435] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 02/25/2015] [Indexed: 01/10/2023] Open
Abstract
The definition of a biomarker provided by the World Health Organization is any
substance, structure, or process that can be measured in the body, or its products
and influence, or predict the incidence or outcome of disease. Currently, the lack of
prognosis and progression markers for chronic Chagas disease has posed limitations
for testing new drugs to treat this neglected disease. Several molecules and
techniques to detect biomarkers in Trypanosoma cruzi-infected
patients have been proposed to assess whether specific treatment with benznidazole or
nifurtimox is effective. Isolated proteins or protein groups from different
T. cruzi stages and parasite-derived glycoproteins and synthetic
neoglycoconjugates have been demonstrated to be useful for this purpose, as have
nucleic acid amplification techniques. The amplification of T. cruzi
DNA using the real-time polymerase chain reaction method is the leading test
for assessing responses to treatment in a short period of time. Biochemical
biomarkers have been tested early after specific treatment. Cytokines and surface
markers represent promising molecules for the characterisation of host cellular
responses, but need to be further assessed.
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Affiliation(s)
- Maria-Jesus Pinazo
- Barcelona Institute for Global Health, Barcelona Centre for International Health Research, Barcelona, Spain
| | - Maria-Carmen Thomas
- Institute of Parasitology and Biomedicine López Neyra, National Research Council Institute, Granada, Spain
| | - Juan Bustamante
- Barcelona Institute for Global Health, Barcelona Centre for International Health Research, Barcelona, Spain
| | - Igor Correia de Almeida
- Department of Biological Sciences, Border Biomedical Research Center, University of Texas at El Paso, El Paso, TX, USA
| | - Manuel-Carlos Lopez
- Institute of Parasitology and Biomedicine López Neyra, National Research Council Institute, Granada, Spain
| | - Joaquim Gascon
- Barcelona Institute for Global Health, Barcelona Centre for International Health Research, Barcelona, Spain
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Machado-de-Assis GF, Diniz GA, Montoya RA, Dias JCP, Coura JR, Machado-Coelho GLL, Albajar-Viñas P, Torres RM, Lana MD. A serological, parasitological and clinical evaluation of untreated Chagas disease patients and those treated with benznidazole before and thirteen years after intervention. Mem Inst Oswaldo Cruz 2015; 108:873-80. [PMID: 24037109 PMCID: PMC3970640 DOI: 10.1590/0074-0276130122] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Accepted: 07/04/2013] [Indexed: 01/05/2023] Open
Abstract
The etiological treatment of Chagas disease is recommended for all patients with acute or recent chronic infection, but controversies remain regarding the benefit of chemotherapy and interpretations of the parasitological cure after etiological treatment. This study compares the laboratory and clinical evaluations of Chagas disease patients who were diagnosed 13 years earlier. Fifty-eight Chagas disease patients (29 treated with benznidazole and 29 untreated) were matched at the time of treatment based on several variables. Conventional serology revealed the absence of seroconversion in all patients. However, lower serological titres were verified in the treated group, primarily among patients who had the indeterminate form of the disease. Haemoculture performed 13 years after the intervention was positive for 6.9% and 27.6% of the treated and untreated patients, respectively. Polymerase chain reaction tests were positive for 44.8% and 13.8% of the treated and untreated patients, respectively. Patients who presented with the indeterminate form of the disease at the beginning of the study exhibited less clinical progression (17.4%) compared with the untreated group (56.5%). Therefore, this global analysis revealed that etiological treatment with benznidazole may benefit patients with respect to the clinical progression of Chagas disease and the prognosis, particularly when administered to patients with the indeterminate form of the disease.
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Pinazo MJ, Thomas MC, Bua J, Perrone A, Schijman AG, Viotti RJ, Ramsey JM, Ribeiro I, Sosa-Estani S, López MC, Gascon J. Biological markers for evaluating therapeutic efficacy in Chagas disease, a systematic review. Expert Rev Anti Infect Ther 2015; 12:479-96. [PMID: 24621252 DOI: 10.1586/14787210.2014.899150] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The most neglected aspects of Chagas disease (CD) have been patient care and treatment. Despite recent progress in the development of potentially improved drugs, there is no consensus among different research groups on the lack of therapeutic response markers to evaluate efficacy of newly proposed drugs early after treatment. A systematic review of current evidence regarding molecules which are potential biomarkers for therapeutic response has been conducted using quality assessment and target responses as primary criteria. The review provides a panorama of the cumulative evidence and specific needs for development of a battery of complementary biomarkers which together fulfill ideal or acceptable criteria to evaluate early responses to treatment for chronic CD. There are several marker candidates which together may fulfill acceptable criteria to indicate the efficacy of a trypanocidal treatment. Data from ongoing studies are considered essential to improve assessment of existing markers and to identify those for early follow-up of treated patients.
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Affiliation(s)
- Maria-Jesús Pinazo
- Barcelona Centre for International Health Research (CRESIB, Hospital Clínic-Universitat de Barcelona), 132 Rosello st 4°,08036, Barcelona, Spain
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Trypanocide treatment of women infected with Trypanosoma cruzi and its effect on preventing congenital Chagas. PLoS Negl Trop Dis 2014; 8:e3312. [PMID: 25411847 PMCID: PMC4239005 DOI: 10.1371/journal.pntd.0003312] [Citation(s) in RCA: 127] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Accepted: 10/02/2014] [Indexed: 11/19/2022] Open
Abstract
With the control of the vectorial and transfusional routes of infection with Trypanosoma cruzi, congenital transmission has become an important source of new cases. This study evaluated the efficacy of trypanocidal therapy to prevent congenital Chagas disease and compared the clinical and serological evolution between treated and untreated infected mothers. We conducted a multicenter, observational study on a cohort of mothers infected with T. cruzi, with and without trypanocidal treatment before pregnancy. Their children were studied to detect congenital infection. Among 354 "chronically infected mother-biological child" pairs, 132 were treated women and 222 were untreated women. Among the children born to untreated women, we detected 34 infected with T. cruzi (15.3%), whose only antecedent was maternal infection. Among the 132 children of previously treated women, no infection with T. cruzi was found (0.0%) (p<0.05). Among 117 mothers with clinical and serological follow up, 71 had been treated and 46 were untreated. The women were grouped into three groups. Group A: 25 treated before 15 years of age; Group B: 46 treated at 15 or more years of age; Group C: untreated, average age of 29.2 ± 6.2 years at study entry. Follow-up for Groups A, B and C was 16.3 ± 5.8, 17.5 ± 9.2 and 18.6 ± 8.6 years respectively. Negative seroconversion: Group A, 64.0% (16/25); Group B, 32.6% (15/46); Group C, no seronegativity was observed. Clinical electrocardiographic alterations compatible with chagasic cardiomyopathy: Group A 0.0% (0/25); B 2.2% (1/46) and C 15.2% (7/46). The trypanocidal treatment of women with chronic Chagas infection was effective in preventing the congenital transmission of Trypanosoma cruzi to their children; it had also a protective effect on the women's clinical evolution and deparasitation could be demonstrated in many treated women after over 10 years of follow up.
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Urbina JA. Recent clinical trials for the etiological treatment of chronic chagas disease: advances, challenges and perspectives. J Eukaryot Microbiol 2014; 62:149-56. [PMID: 25284065 DOI: 10.1111/jeu.12184] [Citation(s) in RCA: 123] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Revised: 09/18/2014] [Accepted: 09/18/2014] [Indexed: 01/02/2023]
Abstract
Chagas disease, a chronic systemic parasitosis caused by the Kinetoplastid protozoon Trypanosoma cruzi, is the first cause of cardiac morbidity and mortality in poor rural and suburban areas of Latin America and the largest parasitic disease burden in the continent, now spreading worldwide due to international migrations. A recent change in the scientific paradigm on the pathogenesis of chronic Chagas disease has led to a consensus that all T. cruzi-seropositive patients should receive etiological treatment. This important scientific advance has spurred the rigorous evaluation of the safety and efficacy of currently available drugs (benznidazole and nifurtimox) as well as novel anti-T. cruzi drug candidates in chronic patients, who were previously excluded from such treatment. The first results indicate that benznidazole is effective in inducing a marked and sustained reduction in the circulating parasites' level in the majority of these patients, but adverse effects can lead to treatment discontinuation in 10-20% of cases. Ergosterol biosynthesis inhibitors, such as posaconazole and ravuconazole, are better tolerated but their efficacy at the doses and treatment duration used in the initial studies was significantly lower; such results are probably related to suboptimal exposure and/or treatment duration. Combination therapies are a promising perspective but the lack of validated biomarkers of response to etiological treatment and eventual parasitological cures in chronic patients remains a serious challenge.
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Affiliation(s)
- Julio A Urbina
- Venezuelan Institute for Scientific Research, Caracas, Venezuela
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28
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Villar JC, Perez JG, Cortes OL, Riarte A, Pepper M, Marin‐Neto JA, Guyatt GH. Trypanocidal drugs for chronic asymptomatic Trypanosoma cruzi infection. Cochrane Database Syst Rev 2014; 2014:CD003463. [PMID: 24867876 PMCID: PMC7154579 DOI: 10.1002/14651858.cd003463.pub2] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Prevention of chronic chagasic cardiomyopathy (CCC) by treating infected populations with trypanocidal therapy (TT) remains a challenge. Despite a renewed enthusiasm for TT, uncertainty regarding its efficacy, concerns about its safety and limited availability remain barriers for a wider use of conventional drugs. We have updated a previous version of this review. OBJECTIVES To systematically search, appraise, identify and extract data from eligible studies comparing the outcome of cohorts of seropositive individuals to Trypanosoma cruzi exposed to TT versus placebo or no treatment. SEARCH METHODS We sought eligible studies in electronic databases (Cochrane Central Register of Controlled Trials (CENTRAL), Issue 1, 2014); MEDLINE (Ovid, 1946 to January week 5 2014); EMBASE (Ovid, 1980 to 2014 week 6) and LILACS (up to 6 May 2010)) by combining terms related with the disease and the treatment. The search also included a Google search, handsearch for references in review or selected articles, and search of expert files. We applied no language restrictions. SELECTION CRITERIA Review authors screened the retrieved references for eligibility (those dealing with human participants treated with TT) and then assessed the pre-selected studies in full for inclusion. We included randomised controlled trials (RCTs) and observational studies that provided data on either mortality or clinical progression of CCC after at least four years of follow-up. DATA COLLECTION AND ANALYSIS Teams of two review authors independently carried out the study selection, data extraction and risk of bias assessment, with a referee resolving disagreement within the pairs. Data collection included study design, characteristics of the population and interventions or exposures and outcome measures. We defined categories of outcome data as parasite-related (positive serology, xenodiagnosis or polymerase chain reaction (PCR) after TT) and participant-related (including efficacy outcomes such as progression towards CCC, all-cause mortality and side effects of TT). We reported pooled outcome data as Mantel-Haenszel odds ratios (OR) or standardised mean differences (SMD) along with 95% confidence intervals (CI), using a random-effects model. I(2) statistics provided an estimate of heterogeneity across studies. We conducted an exploratory meta-regression analysis of the relationship between positive-serology and progression of CCC or mortality. MAIN RESULTS We included 13 studies involving 4229 participants (six RCTs, n = 1096, five RCTs of intermediate risk of bias, one RCT of high risk of bias; four non-randomised experiments, n = 1639 and three observational studies, n = 1494). Ten studies tested nitroderivative drugs nifurtimox or benznidazole (three exposed participants to allopurinol, one to itraconazole). Five studies were conducted in Brazil, five in Argentina, one in Bolivia, one in Chile and one in Venezuela.TT was associated with substantial, but heterogeneous reductions on parasite-related outcomes such as positive serology (9 studies, OR 0.21, 95% CI 0.10 to 0.44, I(2) = 76%), positive PCR (2 studies, OR 0.50, 95% CI 0.27 to 0.92, I(2) = 0%), positive xenodiagnosis after treatment (6 studies, OR 0.35, 95% CI 0.14 to 0.86, I(2) = 79%), or reduction on antibody titres (3 studies, SMD -0.56, 95% CI -0.89 to -0.23, I(2) = 28%). Efficacy data on patient-related outcomes was largely from non-RCTs. TT with nitroderivatives was associated with potentially important, but imprecise and inconsistent reductions in progression of CCC (4 studies, 106 events, OR 0.74, 95% CI 0.32 to 1.73, I(2) = 66%) and mortality after TT (6 studies, 99 events, OR 0.55, 95% CI 0.26 to 1.14, I(2) = 48%). The overall median incidence of any severe side effects among 1475 individuals from five studies exposed to TT was 2.7%, and the overall discontinuation of this two-month therapy in RCTs (5 studies, 134 events) was 20.5% (versus 4.3% among controls) and 10.4% in other five studies (125 events). AUTHORS' CONCLUSIONS Despite the evidence that TT reduced parasite-related outcomes, the low quality and inconsistency of the data for patient-important outcomes must be treated with caution. More geographically diverse RCTs testing newer forms of TT are warranted in order to 1. estimate efficacy more precisely, 2. explore factors potentially responsible for the heterogeneity of results and 3. increase knowledge on the efficacy/tolerance balance of conventional TT.
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Affiliation(s)
- Juan Carlos Villar
- Universidad Autónoma de Bucaramanga (Colombia)Department of MedicineGrupo de Cardiología PreventivaUNAB Campus el Bosque Calle 157 No. 19‐55BucaramangaSantanderColombia
| | | | | | - Adelina Riarte
- Instituto Nacional de Parasitología Dr M Fatala ChabenDepartamento de Clínica, Patología y TratamientoAv. Paseo Colon 568Buenos AiresBuenos AiresArgentina1063
| | - Micah Pepper
- Boston UniversitySchool of Public HealthBostonUSA
| | - Jose Antonio Marin‐Neto
- University of Sao PauloMedical School of Ribeirao PretoAv. Bandeirantes, 3900Ribeirao PretoSao PauloBrazil14025‐640
| | - Gordon H Guyatt
- McMaster UniversityDepartment of Clinical Epidemiology and Biostatistics1200 Main Street WestHamiltonOntarioCanadaL8N 3Z5
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Molina I, Gómez i Prat J, Salvador F, Treviño B, Sulleiro E, Serre N, Pou D, Roure S, Cabezos J, Valerio L, Blanco-Grau A, Sánchez-Montalvá A, Vidal X, Pahissa A. Randomized trial of posaconazole and benznidazole for chronic Chagas' disease. N Engl J Med 2014; 370:1899-908. [PMID: 24827034 DOI: 10.1056/nejmoa1313122] [Citation(s) in RCA: 425] [Impact Index Per Article: 42.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Current therapeutic options for Chagas' disease are limited to benznidazole and nifurtimox, which have been associated with low cure rates in the chronic stage of the disease and which have considerable toxicity. Posaconazole has shown trypanocidal activity in murine models. METHODS We performed a prospective, randomized clinical trial to assess the efficacy and safety of posaconazole as compared with the efficacy and safety of benznidazole in adults with chronic Trypanosoma cruzi infection. We randomly assigned patients to receive posaconazole at a dose of 400 mg twice daily (high-dose posaconazole), posaconazole at a dose of 100 mg twice daily (low-dose posaconazole), or benznidazole at a dose of 150 mg twice daily; all the study drugs were administered for 60 days. We assessed antiparasitic activity by testing for the presence of T. cruzi DNA, using real-time polymerase-chain-reaction (rt-PCR) assays, during the treatment period and 10 months after the end of treatment. Posaconazole absorption was assessed on day 14. RESULTS The intention-to-treat population included 78 patients. During the treatment period, all the patients tested negative for T. cruzi DNA on rt-PCR assay beyond day 14, except for 2 patients in the low-dose posaconazole group who tested positive on day 60. During the follow-up period, in the intention-to-treat analysis, 92% of the patients receiving low-dose posaconazole and 81% receiving high-dose posaconazole, as compared with 38% receiving benznidazole, tested positive for T. cruzi DNA on rt-PCR assay (P<0.01 for the comparison of the benznidazole group with either posaconazole group); in the per-protocol analysis, 90% of the patients receiving low-dose posaconazole and 80% of those receiving high-dose posaconazole, as compared with 6% receiving benznidazole, tested positive on rt-PCR assay (P<0.001 for the comparison of the benznidazole group with either posaconazole group). In the benznidazole group, treatment was discontinued in 5 patients because of severe cutaneous reactions; in the posaconazole groups, 4 patients had aminotransferase levels that were more than 3 times the upper limit of the normal range, but there were no discontinuations of treatment. CONCLUSIONS Posaconazole showed antitrypanosomal activity in patients with chronic Chagas' disease. However, significantly more patients in the posaconazole groups than in the benznidazole group had treatment failure during follow-up. (Funded by the Ministry of Health, Spain; CHAGASAZOL ClinicalTrials.gov number, NCT01162967.).
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Affiliation(s)
- Israel Molina
- From the Infectious Disease Department (I.M., F.S., A.S.-M., A.P.), Microbiology Department (E.S.), the Drug Monitoring Unit, Clinical Laboratory (A.B.-G.), and the Clinical Pharmacology Service (X.V.), Vall d'Hebron Teaching Hospital, Special Program for Infectious Diseases, Vall d'Hebron Drassanes (J.G.P., B.T., N.S., D.P., J.C.), International Health Program of the Catalan Institute of Health (PROSICS) Barcelona (I.M., J.G.P., F.S., B.T., E.S., N.S., D.P., J.C., A.S.-M., A.P.), International Health Unit Metropolitana Nord, Infectious Disease Unit, Internal Medicine Department, Germans Trias i Pujol Teaching Hospital (S.R.), and International Health Unit Metropolitana Nord (L.V.), PROSICS Metropolitana Nord, and the Department of Pharmacology, Therapeutics, and Toxicology, Universitat Autònoma de Barcelona, and Fundació Institut Català de Farmacologia, WHO Collaborating Center for Research and Training in Pharmacoepidemiology (X.V.) - all in Barcelona
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Mubiru JN, Yang A, Dick EJ, Owston M, Sharp RM, VandeBerg JF, Shade RE, VandeBerg JL. Correlation between presence of Trypanosoma cruzi DNA in heart tissue of baboons and cynomolgus monkeys, and lymphocytic myocarditis. Am J Trop Med Hyg 2014; 90:627-33. [PMID: 24567317 DOI: 10.4269/ajtmh.13-0448] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Trypanosoma cruzi, the causative agent of Chagas' disease, preferentially infects cardiac and digestive tissues. Baboons living in Texas (Papio hamadryas) and cynomolgus monkeys (Macaca fascicularis) have been reported to be infected naturally with T. cruzi. In this study, we retrospectively reviewed cases of animals that were diagnosed with lymphocytic myocarditis and used a polymerase chain reaction (PCR)-based method (S36/S35 primer set) to amplify T. cruzi DNA from archived frozen and formalin-fixed paraffin-embedded (FFPE) cardiac tissues. We show that the PCR method is applicable in archived frozen and FFPE tissues and the sensitivity is in the femtogram range. A positive correlation between PCR positivity and lymphocytic myocarditis in both baboons and cynomolgus monkeys is shown. We also show epicarditis as a common finding in animals infected with T. cruzi.
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Affiliation(s)
- James N Mubiru
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, Texas; Department of Biology, St. Mary's University, San Antonio, Texas
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Guedes PMM, Silva GK, Gutierrez FRS, Silva JS. Current status of Chagas disease chemotherapy. Expert Rev Anti Infect Ther 2014; 9:609-20. [DOI: 10.1586/eri.11.31] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Gilber SR, Alban SM, Gobor L, Bescrovaine JDO, Myiazaki MI, Thomaz-Soccol V. Comparison of conventional serology and PCR methods for the routine diagnosis of Trypanosoma cruzi infection. Rev Soc Bras Med Trop 2013; 46:310-5. [DOI: 10.1590/0037-8682-0046-2013] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 06/03/2013] [Indexed: 11/21/2022] Open
Affiliation(s)
- Soraia Reda Gilber
- Universidade Federal do Parana, Brasil.; Laboratorio Central do Estado do Parana, Brasil
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Pérez-Molina JA, Norman F, López-Vélez R. Chagas disease in non-endemic countries: epidemiology, clinical presentation and treatment. Curr Infect Dis Rep 2012; 14:263-74. [PMID: 22477037 DOI: 10.1007/s11908-012-0259-3] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Imported Chagas disease (Trypanosoma cruzi infection) is increasingly recognized as an emerging problem in the USA and Europe due to immigration from Latin America. Most migrants from endemic countries will have been infected during childhood. Based on the natural history of the disease, up to 35 % of those infected may develop cardiac and/or gastrointestinal manifestations during the third or fourth decade of life. This disease was described more than 100 years ago, yet many challenges still remain such as the identification of risk factors for visceral involvement, effective treatment for chronic cases, and reliable markers of cure following treatment. Transmission of the infection may occur even in non-endemic areas through non-vectorial routes and many countries are therefore currently facing the challenge of this emerging public health problem.
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Affiliation(s)
- José A Pérez-Molina
- Tropical Medicine, Infectious Diseases Department, Hospital Universitario Ramón y Cajal, IRYCIS, Carretera de Colmenar Km 9,1, 28034, Madrid, Spain,
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Machado-de-Assis GF, Silva AR, Do Bem VAL, Bahia MT, Martins-Filho OA, Dias JCP, Albajar-Viñas P, Torres RM, Lana M. Posttherapeutic cure criteria in Chagas' disease: conventional serology followed by supplementary serological, parasitological, and molecular tests. CLINICAL AND VACCINE IMMUNOLOGY : CVI 2012; 19:1283-91. [PMID: 22739694 PMCID: PMC3416099 DOI: 10.1128/cvi.00274-12] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2012] [Accepted: 06/15/2012] [Indexed: 11/20/2022]
Abstract
We performed a critical study of conventional serology, followed by supplementary serological, parasitological, and molecular tests, to assess the response to etiologic treatment of Chagas' disease. A group of 94 Chagas' disease patients treated with benznidazole at least 10 years earlier were evaluated from the laboratory and clinical points of view. When conventional serology (enzyme-linked immunosorbent assay [ELISA], indirect immunofluorescence [IIF], and indirect hemagglutination [IHA]) and classic criteria (consistent results with any two of the three tests) or more rigorous criteria (consistent results from the three tests) were used, 10.6% and 8.5% of patients were considered treated and cured (TC) by classic and rigorous criteria, respectively. Patients were then evaluated using supplementary (recombinant ELISA and Trypanosoma cruzi excreted-secreted antigen blotting [TESA-blot]), parasitological (hemoculture), and molecular (PCR) tests. The results of recombinant ELISA were similar to those with the rigorous criterion (three consistent test results). The TESA-blot group showed a higher percentage (21.3%) of negative results than the groups defined by either cure criterion. Hemoculture and PCR gave negative results for all treated and cured (TC) patients, regardless of the criterion used. Recombinant ELISA and TESA-blot tests showed negative results for 70% and 87.5% of the patients categorized as TC by the classic and three-test criteria, respectively. For patients with discordant conventional serology, the supplementary serological and molecular tests were the decisive factor in determining therapeutic failure. Clinical evaluation showed that 62.5% of TC patients presented with the indeterminate form of the disease. Additionally, treated patients with negative TESA-blot results should be reevaluated later with all methodologies used here to verify whether TESA-blot is a reliable way to determine early parasitological cure of Chagas' disease.
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Affiliation(s)
- G F Machado-de-Assis
- Núcleo de Pesquisas em Ciências Biológicas (NUPEB), Instituto de Ciências Exatas e Biológicas (ICEB), Universidade Federal de Ouro Preto (UFOP), Ouro Preto, Brazil.
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Qvarnstrom Y, Schijman AG, Veron V, Aznar C, Steurer F, da Silva AJ. Sensitive and specific detection of Trypanosoma cruzi DNA in clinical specimens using a multi-target real-time PCR approach. PLoS Negl Trop Dis 2012; 6:e1689. [PMID: 22802973 PMCID: PMC3389027 DOI: 10.1371/journal.pntd.0001689] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Accepted: 04/30/2012] [Indexed: 11/19/2022] Open
Abstract
Background The laboratory diagnosis of Chagas disease is challenging because the usefulness of different diagnostic tests will depend on the stage of the disease. Serology is the preferred method for patients in the chronic phase, whereas PCR can be successfully used to diagnose acute and congenital cases. Here we present data using a combination of three TaqMan PCR assays to detect T. cruzi DNA in clinical specimens. Methods/Principal Findings Included in the analysis were DNA extracted from 320 EDTA blood specimens, 18 heart tissue specimens, 6 umbilical cord blood specimens, 2 skin tissue specimens and 3 CSF specimens. For the blood specimens both whole blood and buffy coat fraction were analyzed. The specimens were from patients living in the USA, with suspected exposure to T. cruzi through organ transplantation, contact with triatomine bugs or laboratory accidents, and from immunosuppressed patients with suspected Chagas disease reactivation. Real-time PCR was successfully used to diagnose acute and Chagas disease reactivation in 20 patients, including one case of organ-transmitted infection and one congenital case. Analysis of buffy coat fractions of EDTA blood led to faster diagnosis in six of these patients compared to whole blood analysis. The three real-time PCR assays produced identical results for 94% of the specimens. The major reason for discrepant results was variable sensitivity among the assays, but two of the real-time PCR assays also produced four false positive results. Conclusions/Significance These data strongly indicate that at least two PCR assays with different performances should be combined to increase the accuracy. This evaluation also highlights the benefit of extracting DNA from the blood specimen's buffy coat to increase the sensitivity of PCR analysis. Chagas disease is endemic in several Latin American countries and affects approximately 8 to 11 million people. The protozoan parasite, Trypanosoma cruzi, is the agent of Chagas disease, a zoonotic disease that can be transmitted to humans by blood-sucking triatomine bugs. Other routes of infection include congenital transmission, blood transfusion, organ transplantation, accidental inoculation of the parasite during laboratory research and by consuming food and juice contaminated with the parasite. This study focused on the evaluation of three quantitative PCR (QPCR) assays for the diagnosis of Chagas disease. The evaluation was based on the analysis of 349 specimens submitted for confirmatory diagnosis of Chagas disease to the Centers for Disease Control and Prevention from 2008 to 2010. By using such assays we were able to diagnose acute and Chagas disease reactivation in 20 patients, including one case of organ-transmitted infection and one congenital case. The paper also highlights the benefit of extracting DNA from the blood specimen's buffy coat to increase the sensitivity of diagnostic PCR analysis. The results obtained in this study strongly indicate that at least two QPCR assays with different performance characteristics should be combined to increase diagnostic accuracy.
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Affiliation(s)
- Yvonne Qvarnstrom
- Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | | | - Vincent Veron
- Laboratoire hospitalier et Universitaire-CH Andrée Rosemon, Faculté de Médecine H. Bastaraud-EA 3593, Cayenne, Guyane Française
| | - Christine Aznar
- Laboratoire hospitalier et Universitaire-CH Andrée Rosemon, Faculté de Médecine H. Bastaraud-EA 3593, Cayenne, Guyane Française
| | - Francis Steurer
- Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Alexandre J. da Silva
- Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- * E-mail:
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Matta Guedes PM, Gutierrez FRS, Nascimento MSL, Do-Valle-Matta MA, Silva JS. Antiparasitical chemotherapy in Chagas' disease cardiomyopathy: current evidence. Trop Med Int Health 2012; 17:1057-65. [PMID: 22686518 DOI: 10.1111/j.1365-3156.2012.03025.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Chronic chagasic cardiomyopathy affects 20% of Chagas' disease patients. At present, Chagas' disease chemotherapy uses nitrofurans, benznidazole (Rochagan®, Rodanil®, Roche) or nifurtimox (Lampit®, Bayer). Treatment during acute and recent chronic phases in childhood effects 71.5% and 57.6%, respectively, of parasitological cure. However, in clinical trials during the late chronic phase, only 5.9% of parasitological cure were achieved. This review focuses on the benefit from aetiological treatment to avoid, stop or revert myocarditis. Divergent data gathered from clinical practice are not convincing to support prescription of aetiological treatment as routine for indeterminate and cardiac chronic patients.
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Affiliation(s)
- Paulo Marcos Matta Guedes
- Department of Microbiology and Parasitology, Bioscience Center, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil.
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Aguiar C, Batista AM, Pavan TBS, Almeida EA, Guariento ME, Wanderley JS, Costa SCB. Serological profiles and evaluation of parasitaemia by PCR and blood culture in individuals chronically infected by Trypanosoma cruzi treated with benzonidazole. Trop Med Int Health 2011; 17:368-73. [PMID: 22212647 DOI: 10.1111/j.1365-3156.2011.02936.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate the serological and parasitological status of patients with chronic Chagas disease (CD) after chemotherapy with benzonidazole. METHODS Retrospective study of patients treated with benzonidazole (5 mg/kg/day for 60 days) between 1980 and 2010. Twenty-nine patients who had CD confirmed by two reagent immunological tests and/or one positive xenodiagnosis before treatment were included. Conventional serology (ELISA and IIF) and parasitological tests (haemoculture and N-PCR) were performed. RESULTS At the time of treatment, the mean age of patients was 36 ± 7.24 years (20-39 years) and the time post-treatment varied from 1 to 29 years. After chemotherapy, all individuals had reagent ELISA and 93.1% had positive results for the IIF test. T. cruzi DNA was detected by N-PCR in 48.3%. Negative results were observed in 41.4% and inconclusive ones in 10.3%. Haemoculture was negative for all individuals. CONCLUSIONS Our results suggest that N-PCR may be useful in the early identification of therapeutic failure of CD. Although it is difficult to determine parasitological cure in negative N-PCR cases, we can infer that this condition represents a declination of parasitaemia as a favourable consequence of aetiological treatment.
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Affiliation(s)
- Camila Aguiar
- Universidade Estadual de Campinas - UNICAMP, São Paulo, Brazil
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Quijano-Hernandez I, Dumonteil E. Advances and challenges towards a vaccine against Chagas disease. HUMAN VACCINES 2011; 7:1184-91. [PMID: 22048121 DOI: 10.4161/hv.7.11.17016] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Chagas disease is major public health problem, affecting nearly 10 million people, characterized by cardiac alterations leading to congestive heart failure and death of 20-40% of the patients infected with Trypanosoma cruzi, the protozoan parasite responsible for the disease. A vaccine would be key to improve disease control and we review here the recent advances and challenges of a T. cruzi vaccine. There is a growing consensus that a protective immune response requires the activation of a Th1 immune profile, with the stimulation of CD8 (+) T cells. Several vacines types, including recombinant proteins, DNA and viral vectors, as well as heterologous prime-boost combinations, have been found immunogenic and protective in mouse models, providing proof-of-concept data on the feasibility of a preventive or therapeutic vaccine to control a T. cruzi infection. However, several challenges such as better end-points, safety issues and trial design need to be addressed for further vaccine development to proceed.
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Affiliation(s)
- Israel Quijano-Hernandez
- Laboratorio de Parasitología, Centro de Investigaciones Regionales 'Dr. Hideyo Noguchi', Universidad Autónoma de Yucatán, Merida, Mexico
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Viotti R, Vigliano C, Alvarez MG, Lococo B, Petti M, Bertocchi G, Armenti A, De Rissio AM, Cooley G, Tarleton R, Laucella S. Impact of aetiological treatment on conventional and multiplex serology in chronic Chagas disease. PLoS Negl Trop Dis 2011; 5:e1314. [PMID: 21909451 PMCID: PMC3167788 DOI: 10.1371/journal.pntd.0001314] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2011] [Accepted: 07/27/2011] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The main criterion for treatment effectiveness in Chagas Disease has been the seronegative conversion, achieved many years post-treatment. One of the main limitations in evaluating treatment for chronic Chagas disease is the lack of reliable tests to ensure parasite clearance and to examine the effects of treatment. However, declines in conventional serological titers and a new multiplex assay can be useful tools to monitor early the treatment impact. METHODOLOGY/PRINCIPAL FINDINGS Changes in antibody levels, including seronegative conversion as well as declines in titers, were serially measured in 53 benznidazole-treated and 89 untreated chronic patients in Buenos Aires, Argentina with a median follow-up of 36 months. Decrease of titers (34/53 [64%] treated vs. 19/89 [21%] untreated, p<0.001) and seronegative conversion (21/53, [40%] treated vs. 6/89, [7%] untreated, p<0.001) in at least one conventional serological test were significantly higher in the benznidazole-treated group compare with the untreated group. When not only complete seronegative conversion but also seronegative conversion on 2 tests and the decreases of titers on 2 or 3 tests were considered, the impact of treatment on conventional serology increased from 21% (11/53 subjects) to 45% (24/53 subjects). A strong concordance was found between the combination of conventional serologic tests and multiplex assay (kappa index 0.60) to detect a decrease in antibody levels pos-treatment. CONCLUSIONS/SIGNIFICANCE Treatment with benznidazole in subjects with chronic Chagas disease has a major impact on the serology specific for T. cruzi infection in a shorter follow-up period than previously considered, reflected either by a complete or partial seronegative conversion or by a significant decrease in the levels of T. cruzi antibodies, consistent with a possible elimination or reduction of parasite load.
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Affiliation(s)
- Rodolfo Viotti
- Chagas Disease and Heart Failure Section, Cardiology Department, Hospital Eva Perón, San Martín, Buenos Aires, Argentina.
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Pinazo MJ, Miranda B, Rodríguez-Villar C, Altclas J, Serra MB, García-Otero EC, de Almeida EA, de la Mata García M, Gascon J, Rodríguez MG, Manito N, Camacho AM, Oppenheimer F, Puente SP, Riarte A, Coronas JS, Lletí MS, Sanz GF, Torrico F, Tendero DT, Ussetti P, Shikanai-Yasuda MA. Recommendations for management of Chagas disease in organ and hematopoietic tissue transplantation programs in nonendemic areas. Transplant Rev (Orlando) 2011; 25:91-101. [DOI: 10.1016/j.trre.2010.12.002] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2010] [Accepted: 12/15/2010] [Indexed: 12/22/2022]
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Tolerance of benznidazole in treatment of Chagas' disease in adults. Antimicrob Agents Chemother 2010; 54:4896-9. [PMID: 20823286 DOI: 10.1128/aac.00537-10] [Citation(s) in RCA: 136] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Chagas' disease is an emerging public health problem in areas where the disease is not endemic. Treatment with benznidazole has shown efficacy in the acute stage of the disease, but its efficacy in the chronic stage remains controversial, and unwanted side effects are more frequent and severe in adults than in children. This study describes the profile of side effects of benznidazole in a cohort of Trypanosoma cruzi-infected patients in a European country.
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Urbina JA. Specific chemotherapy of Chagas disease: relevance, current limitations and new approaches. Acta Trop 2010; 115:55-68. [PMID: 19900395 DOI: 10.1016/j.actatropica.2009.10.023] [Citation(s) in RCA: 321] [Impact Index Per Article: 22.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2009] [Revised: 10/22/2009] [Accepted: 10/26/2009] [Indexed: 01/31/2023]
Abstract
A critical review of the development of specific chemotherapeutic approaches for the management of American Trypanosomiasis or Chagas disease is presented, including controversies on the pathogenesis of the disease, the initial efforts that led to the development of currently available drugs (nifurtimox and benznidazole), limitations of these therapies and novel approaches for the development of anti-Trypanosoma cruzi drugs, based on our growing understanding of the biology of this parasite. Among the later, the most promising approaches are ergosterol biosynthesis inhibitors such as posaconazole and ravuconazole, poised to enter clinical trials for chronic Chagas disease in the short term; inhibitors of cruzipain, the main cysteine protease of T. cruzi, essential for its survival and proliferation in vitro and in vivo; bisphosphonates, metabolic stable pyrophosphate analogs that have trypanocidal activity through the inhibition of the parasite's farnesyl-pyrophosphate synthase or hexokinase; inhibitors of trypanothione synthesis and redox metabolism and inhibitors of hypoxanthine-guanine phosphoribosyl-transferase, an essential enzyme for purine salvage in T. cruzi and related organisms. Finally, the economic and political challenges faced by development of drugs for the treatment of neglected tropical diseases, which afflict almost exclusively poor populations in developing countries, are analyzed and recent potential solutions for this conundrum are discussed.
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Murcia L, Carrilero B, Munoz MJ, Iborra MA, Segovia M. Usefulness of PCR for monitoring benznidazole response in patients with chronic Chagas' disease: a prospective study in a non-disease-endemic country. J Antimicrob Chemother 2010; 65:1759-64. [DOI: 10.1093/jac/dkq201] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Pinazo MJ, Espinosa G, Gállego M, López-Chejade PL, Urbina JA, Gascón J. Successful treatment with posaconazole of a patient with chronic Chagas disease and systemic lupus erythematosus. Am J Trop Med Hyg 2010; 82:583-7. [PMID: 20348503 PMCID: PMC2844568 DOI: 10.4269/ajtmh.2010.09-0620] [Citation(s) in RCA: 107] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
American Trypanosomiasis or Chagas disease (CD) is a neglected disease that affects Latin American people worldwide. Two old antiparasitic drugs, benznidazole and nifurtimox, are currently used for specific CD treatment with limited efficacy in chronic infections and frequent side effects. New drugs are needed for patients with chronic CD as well as for immunosuppressed patients, for whom the risk of reactivation is life-threatening. We describe a case of chronic CD and systemic lupus erythematosus (SLE) that required immunosuppression to control the autoimmune process. It was found that benznidazole induced a reduction, but not an elimination, of circulating Trypanosoma cruzi levels, whereas subsequent treatment with posaconazole led to a successful resolution of the infection, despite the maintenance of immunosuppressive therapy.
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Affiliation(s)
- María-Jesús Pinazo
- Tropical Care Section, Barcelona Centre for International Health Research (CRESIB), Hospital Clínic/Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain.
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Urbina JA. Ergosterol biosynthesis and drug development for Chagas disease. Mem Inst Oswaldo Cruz 2010; 104 Suppl 1:311-8. [PMID: 19753490 DOI: 10.1590/s0074-02762009000900041] [Citation(s) in RCA: 146] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2009] [Accepted: 05/18/2009] [Indexed: 12/13/2022] Open
Abstract
This article presents an overview of the currently available drugs nifurtimox (NFX) and benznidazole (BZN) used against Trypanosoma cruzi, the aetiological agent of Chagas disease; herein we discuss their limitations along with potential alternatives with a focus on ergosterol biosynthesis inhibitors (EBI). These compounds are currently the most advanced candidates for new anti-T. cruzi agents given that they block de novo production of 24-alkyl-sterols, which are essential for parasite survival and cannot be replaced by a host's own cholesterol. Among these compounds, new triazole derivatives that inhibit the parasite's C14alpha sterol demethylase are the most promising, as they have been shown to have curative activity in murine models of acute and chronic Chagas disease and are active against NFX and BZN-resistant T. cruzi strains; among this class of compounds, posaconazole (Schering-Plough Research Institute) and ravuconazole (Eisai Company) are poised for clinical trials in Chagas disease patients in the short term. Other T. cruzi-specific EBI, with in vitro and in vivo potency, include squalene synthase, lanosterol synthase and squalene epoxidase-inhibitors as well as compounds with dual mechanisms of action (ergosterol biosynthesis inhibition and free radical generation), but they are less advanced in their development process. The main putative advantages of EBI over currently available therapies include their higher potency and selectivity in both acute and chronic infections, activity against NFX and BZN-resistant T. cruzi strains, and much better tolerability and safety profiles. Limitations may include complexity and cost of manufacture of the new compounds. As for any new drug, such compounds will require extensive clinical testing before being introduced for clinical use, and the complexity of such studies, particularly in chronic patients, will be compounded by the current limitations in the verification of true parasitological cures for T. cruzi infections.
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Affiliation(s)
- Julio A Urbina
- Instituto Venezolano de Investigaciones Científicas, Caracas, Venezuela.
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Laucella SA, Mazliah DP, Bertocchi G, Alvarez MG, Cooley G, Viotti R, Albareda MC, Lococo B, Postan M, Armenti A, Tarleton RL. Changes in Trypanosoma cruzi-specific immune responses after treatment: surrogate markers of treatment efficacy. Clin Infect Dis 2010; 49:1675-84. [PMID: 19877967 DOI: 10.1086/648072] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND As many as 20 million people are living with Trypanosoma cruzi infection in Latin American, yet few receive any treatment. The major limitation in developing and evaluating potential new drugs for their efficacy is the lack of reliable tests to assess parasite burden and elimination. METHODS Adults volunteers with chronic T. cruzi infection were evaluated clinically and stratified according to the Kuschnir classification. Individuals with group 0 and group 1 clinical status were treated with benznidazole (5 mg/kg per day for 30 days). The changes in T. cruzi-specific T cell and antibody responses, as well as in clinical status, were measured periodically over the 3-5-year follow-up period and were compared with pretreatment conditions and with values in an untreated control group. RESULTS The frequency of peripheral interferon (IFN)-gamma-producing T cells specific for T. cruzi declined as early as 12 months after benznidazole treatment and subsequently became undetectable in a substantial proportion of treated subjects. In addition, decreases in antibody responses to a pool of recombinant T. cruzi proteins also decreased in many of these same subjects. The shift to negative IFN-gamma T cell responses was highly associated with an early increase in IFN-gamma-producing T cells with phenotypic features of effector/effector memory cells in a subset of subjects. Benznidazole treatment also resulted in an increase in naive and early differentiated memory-like CD8(+) T cells in a majority of subjects. CONCLUSIONS Benznidazole treatment during chronic Chagas disease has a substantial impact on parasite-specific immune response that is likely indicative of treatment efficacy and cure.
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Affiliation(s)
- Susana A Laucella
- Instituto Nacional de Parasitología Dr Mario Fatala Chabén, Buenos Aires, San Martín, Provincia de Buenos Aires, Argentina
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Yun O, Lima MA, Ellman T, Chambi W, Castillo S, Flevaud L, Roddy P, Parreño F, Albajar Viñas P, Palma PP. Feasibility, drug safety, and effectiveness of etiological treatment programs for Chagas disease in Honduras, Guatemala, and Bolivia: 10-year experience of Médecins Sans Frontières. PLoS Negl Trop Dis 2009; 3:e488. [PMID: 19582142 PMCID: PMC2700957 DOI: 10.1371/journal.pntd.0000488] [Citation(s) in RCA: 114] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2009] [Accepted: 06/17/2009] [Indexed: 12/04/2022] Open
Abstract
Background Chagas disease (American trypanosomiasis) is a zoonotic or anthropozoonotic disease caused by the parasite Trypanosoma cruzi. Predominantly affecting populations in poor areas of Latin America, medical care for this neglected disease is often lacking. Médecins Sans Frontières/Doctors Without Borders (MSF) has provided diagnostic and treatment services for Chagas disease since 1999. This report describes 10 years of field experience in four MSF programs in Honduras, Guatemala, and Bolivia, focusing on feasibility protocols, safety of drug therapy, and treatment effectiveness. Methodology From 1999 to 2008, MSF provided free diagnosis, etiological treatment, and follow-up care for patients <18 years of age seropositive for T. cruzi in Yoro, Honduras (1999–2002); Olopa, Guatemala (2003–2006); Entre Ríos, Bolivia (2002–2006); and Sucre, Bolivia (2005–2008). Essential program components guaranteeing feasibility of implementation were information, education, and communication (IEC) at the community and family level; vector control; health staff training; screening and diagnosis; treatment and compliance, including family-based strategies for early detection of adverse events; and logistics. Chagas disease diagnosis was confirmed by testing blood samples using two different diagnostic tests. T. cruzi-positive patients were treated with benznidazole as first-line treatment, with appropriate counseling, consent, and active participation from parents or guardians for daily administration of the drug, early detection of adverse events, and treatment withdrawal, when necessary. Weekly follow-up was conducted, with adverse events recorded to assess drug safety. Evaluations of serological conversion were carried out to measure treatment effectiveness. Vector control, entomological surveillance, and health education activities were carried out in all projects with close interaction with national and regional programs. Results Total numbers of children and adolescents tested for T. cruzi in Yoro, Olopa, Entre Ríos, and Sucre were 24,471, 8,927, 7,613, and 19,400, respectively. Of these, 232 (0.9%), 124 (1.4%), 1,475 (19.4%), and 1,145 (5.9%) patients, respectively, were diagnosed as seropositive. Patients were treated with benznidazole, and early findings of seroconversion varied widely between the Central and South American programs: 87.1% and 58.1% at 18 months post-treatment in Yoro and Olopa, respectively; 5.4% by up to 60 months in Entre Ríos; and 0% at an average of 18 months in Sucre. Benznidazole-related adverse events were observed in 50.2% and 50.8% of all patients treated in Yoro and Olopa, respectively, and 25.6% and 37.9% of patients in Entre Ríos and Sucre, respectively. Most adverse events were mild and manageable. No deaths occurred in the treatment population. Conclusions These results demonstrate the feasibility of implementing Chagas disease diagnosis and treatment programs in resource-limited settings, including remote rural areas, while addressing the limitations associated with drug-related adverse events. The variability in apparent treatment effectiveness may reflect differences in patient and parasite populations, and illustrates the limitations of current treatments and measures of efficacy. New treatments with improved safety profiles, pediatric formulations of existing and new drugs, and a faster, reliable test of cure are all urgently needed. Chagas disease was discovered 100 years ago by the Brazilian physician Carlos Chagas. Predominantly affecting poor populations throughout Latin America, recognition and treatment of this parasitic disease are often neglected. Since 1999, the international medical humanitarian aid organization Médecins Sans Frontières (Doctors Without Borders) has offered diagnostic and therapeutic care for Chagas disease, and here we describe four of our programs in Honduras, Guatemala, and Bolivia, 1999–2008. The earliest programs focused on treating young children and in subsequent programs expanded up to 18 years of age. We identified six program components essential for project viability: information, education, and communication; vector control; health staff training; screening and diagnosis; treatment and compliance; and logistics. The number of children and adolescents screened for Chagas disease ranged from over 7,500 to nearly 25,000 in each program. Early analysis of cure rates ranged widely: from 87% and 58%, respectively, in Honduras and Guatemala, to 0%–5% in Bolivia. No deaths occurred in any of the programs, though drug-related side effects were observed in a quarter to half of all patients. Through our findings and experience, we discuss the feasibility, safety, and effectiveness of treatment programs for Chagas disease in resource-limited settings.
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Affiliation(s)
- Oliver Yun
- Médecins Sans Frontières/Doctors Without Borders, New York, New York, United States of America
| | - M. Angeles Lima
- Médecins Sans Frontières, Operational Center Barcelona-Athens (OCBA), Barcelona, Spain
- * E-mail:
| | - Tom Ellman
- Médecins Sans Frontières/Médicos Sin Fronteras, La Paz, Bolivia
| | - Wilma Chambi
- Médecins Sans Frontières/Médicos Sin Fronteras, La Paz, Bolivia
| | - Sandra Castillo
- Médecins Sans Frontières/Médicos Sin Fronteras, La Paz, Bolivia
| | - Laurence Flevaud
- Médecins Sans Frontières, Operational Center Barcelona-Athens (OCBA), Barcelona, Spain
| | - Paul Roddy
- Médecins Sans Frontières, Operational Center Barcelona-Athens (OCBA), Barcelona, Spain
| | - Fernando Parreño
- Médecins Sans Frontières, Operational Center Barcelona-Athens (OCBA), Barcelona, Spain
| | - Pedro Albajar Viñas
- Laboratory of Parasitological Diseases, Oswaldo Cruz Institute, FIOCRUZ, Rio de Janeiro, Brazil
| | - Pedro Pablo Palma
- Médecins Sans Frontières, Operational Center Barcelona-Athens (OCBA), Barcelona, Spain
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