Four cases of acute chagasic myocarditis in French Guiana

Fatal acute Chagas disease by Trypanosoma cruzi DTU TcI, Ecuador

Background

Chagas disease is caused by the haemoflagellate protozoan Trypanosoma cruzi. Currently, T. cruzi recognizes seven discrete typing units (DTUs): TcI to TcVI and Tcbat. The genetic diversity of T. cruzi is suspected to influence the clinical outcome. Acute clinical manifestations, which include myocarditis and meningoencephalitis, are sometimes fatal; occur most frequently in children and in immunocompromised individuals. Acute disease is often overlooked, leading to a poor prognosis.

Case presentation

A 38-year-old man from a subtropical area of the Andes mountains of Ecuador was hospitalized after 3 weeks of evolution with high fever, chills, an enlarged liver, spleen, and lymph nodes, as well as facial edema. ECG changes were also observed. T. cruzi was identified in blood smears, culture and amplification of DNA by PCR. Tests for anti-T. cruzi IgG and IgM and HIV were negative. Molecular typing by restriction fragment length polymorphism (PCR-RFLP) determined the parasite to DTU TcI. In the absence of a timely anti-T. cruzi medication, the patient died.

Conclusions

This is a case of severe pathogenicity and the virulence of a DTU TcI strain in an adult patient. The severe acute Chagas disease was probably overlooked due to limited awareness and its low incidence. Our findings suggest that T. cruzi DTU TcI strains circulating in Ecuador are capable of causing fatal acute disease. Early diagnosis and prompt treatment is of paramount importance to avoid fatalities in acute infections.

A review on the occurrence of companion vector-borne diseases in pet animals in Latin America

Companion vector-borne diseases (CVBDs) are an important threat for pet life, but may also have an impact on human health, due to their often zoonotic character. The importance and awareness of CVBDs continuously increased during the last years. However, information on their occurrence is often limited in several parts of the world, which are often especially affected. Latin America (LATAM), a region with large biodiversity, is one of these regions, where information on CVBDs for pet owners, veterinarians, medical doctors and health workers is often obsolete, limited or non-existent. In the present review, a comprehensive literature search for CVBDs in companion animals (dogs and cats) was performed for several countries in Central America (Belize, Caribbean Islands, Costa Rica, Cuba, Dominican Republic, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, Panama, Puerto Rico) as well as in South America (Argentina, Bolivia, Brazil, Chile, Colombia, Ecuador, French Guiana, Guyana (British Guyana), Paraguay, Peru, Suriname, Uruguay, Venezuela) regarding the occurrence of the following parasitic and bacterial diseases: babesiosis, heartworm disease, subcutaneous dirofilariosis, hepatozoonosis, leishmaniosis, trypanosomosis, anaplasmosis, bartonellosis, borreliosis, ehrlichiosis, mycoplasmosis and rickettsiosis. An overview on the specific diseases, followed by a short summary on their occurrence per country is given. Additionally, a tabular listing on positive or non-reported occurrence is presented. None of the countries is completely free from CVBDs. The data presented in the review confirm a wide distribution of the CVBDs in focus in LATAM. This wide occurrence and the fact that most of the CVBDs can have a quite severe clinical outcome and their diagnostic as well as therapeutic options in the region are often difficult to access and to afford, demands a strong call for the prevention of pathogen transmission by the use of ectoparasiticidal and anti-feeding products as well as by performing behavioural changes.

Chagas Cardiomyopathy: An Update of Current Clinical Knowledge and Management: A Scientific Statement From the American Heart Association

Background:

Chagas disease, resulting from the protozoan Trypanosoma cruzi , is an important cause of heart failure, stroke, arrhythmia, and sudden death. Traditionally regarded as a tropical disease found only in Central America and South America, Chagas disease now affects at least 300 000 residents of the United States and is growing in prevalence in other traditionally nonendemic areas. Healthcare providers and health systems outside of Latin America need to be equipped to recognize, diagnose, and treat Chagas disease and to prevent further disease transmission.

Methods and Results:

The American Heart Association and the Inter-American Society of Cardiology commissioned this statement to increase global awareness among providers who may encounter patients with Chagas disease outside of traditionally endemic environments. In this document, we summarize the most updated information on diagnosis, screening, and treatment of T cruzi infection, focusing primarily on its cardiovascular aspects. This document also provides quick reference tables, highlighting salient considerations for a patient with suspected or confirmed Chagas disease.

Conclusions:

This statement provides a broad summary of current knowledge and practice in the diagnosis and management of Chagas cardiomyopathy. It is our intent that this document will serve to increase the recognition of Chagas cardiomyopathy in low-prevalence areas and to improve care for patients with Chagas heart disease around the world.

Acute Chagas outbreaks: molecular and biological features of Trypanosoma cruzi isolates, and clinical aspects of acute cases in Santander, Colombia

BACKGROUND

Outbreaks of acute Chagas disease associated with oral transmission are easily detected nowadays with trained health personnel in areas of low endemicity, or in which the vector transmission has been interrupted. Given the biological and genetic diversity of Trypanosoma cruzi, the high morbidity, mortality, and the observed therapeutic failure, new characteristics of these outbreaks need to be addressed at different levels, both in Trypanosoma cruzi as in patient response. The aim of this work was to evaluate the patient's features involved in six outbreaks of acute Chagas disease which occurred in Santander, Colombia, and the characteristics of Trypanosoma cruzi clones isolated from these patients, to establish the potential relationship between the etiologic agent features with host behavior.

METHODS

The clinical, pathological and epidemiological aspects of outbreaks were analyzed. In addition, Trypanosoma cruzi clones were biologically characterized both in vitro and in vivo, and the susceptibility to the classical trypanocidal drugs nifurtimox and benznidazole was evaluated. Trypanosoma cruzi clones were genotyped by means of mini-exon intergenic spacer and cytochrome b genes sequencing.

RESULTS

All clones were DTU I, and based on the mini-exon intergenic spacer, belong to two genotypes: G2 related with sub-urban, and G11 with rural outbreaks. Girón outbreak clones with higher susceptibility to drugs presented G2 genotype and C/T transition in Cyt b. The outbreaks affected mainly young population (±25.9 years), and the mortality rate was 10 %. The cardiac tissue showed intense inflammatory infiltrate, myocardial necrosis and abundant amastigote nests. However, although the gastrointestinal tissue was congestive, no inflammation or parasites were observed.

CONCLUSIONS

Although all clones belong to DTU I, two intra-DTU genotypes were found with the sequencing of the mini-exon intergenic spacer, however there is no strict correlation between genetic groups, the cycles of the parasite or the clinical forms of the disease. Trypanosoma cruzi clones from Girón with higher sensitivity to nifurtimox presented a particular G2 genotype and C/T transition in Cyt b. When the diagnosis was early, the patients responded well to antichagasic treatment, which highlights the importance of diagnosis and treatment early to prevent fatal outcomes associated with these acute episodes.

AKT network of genes and impaired myocardial contractility during murine acute Chagasic myocarditis

Chagasic disease is associated with high morbidity in Latin America. Acute Chagasic myocarditis is consistently found in acute infections, but little is known about its contribution to chronic cardiomyopathy. The aim of the study was to phenotypically characterize two strains of mice with differential Chagas infection susceptibility and correlate strain myocarditis phenotypes with heart tissue gene expression. C57BL/6J and Balb/c mice were injected intraperitoneally with 0 or 150-200 tissue-derived trypomastigotes (Tulahuen strain). Echocardiograms, brain natriuretic peptide, and troponin were measured. Heart tissue was harvested for histopathological analysis and gene expression profiling on microarrays. Genes differently expressed between infected Balb/c and C57BL/6J mice were identified. Echocardiograms showed differences in Balb/c versus C57BL/6J infected mice in heart rate (413 versus 476 beats per minute; P = 0.0001), stroke volume (31.9 ± 9.3 versus 39.2 ± 5.5 μL; P = 0.03), and cardiac output (13.1 ± 3.5 versus 18.7 ± 3.2 μL/min; P = 0.002). Gene expression at 4 weeks analysis showed 32 statistically significant (q value < 0.05) differentially expressed genes between infected Balb/c and C57BL/6J mice that were enriched for genes related to the protein kinase B (AKT) pathway. These specific phenotypic features of cardiac response during acute Chagasic myocarditis may, in part, be related to host AKT network regulation.

Parasitic infections and myositis

Infectious myositis may be caused by a wide variety of bacterial, fungal, viral, and parasitic agents. Parasitic myositis is most commonly a result of trichinosis, cystericercosis, or toxoplasmosis, but other parasites may be involved. A parasitic cause of myositis is suggested by history of residence or travel to endemic area and presence of eosinophilia. The diagnosis of parasitic myositis is suggested by the clinical picture and radiologic imaging, and the etiologic agent is confirmed by parasitologic, serologic, and molecular methods, together with histopathologic examination of tissue biopsies. Therapy is based on the clinical presentation and the underlying pathogen. Drug resistance should be put into consideration in different geographic areas, and it can be avoided through the proper use of anti-parasitic drugs.

Clinical outcomes of thirteen patients with acute chagas disease acquired through oral transmission from two urban outbreaks in northeastern Brazil

BACKGROUND

Outbreaks of orally transmitted Trypanosoma cruzi continue to be reported in Brazil and are associated with a high mortality rate, mainly due to myocarditis.

METHODS

This study is a detailed report on the disease progression of acute Chagas disease in 13 patients who were infected during two micro-outbreaks in two northeastern Brazilian towns. Clinical outcomes as well as EKG and ECHO results are described, both before and after benznidazole treatment.

RESULTS

Fever and dyspnea were the most frequent symptoms observed. Other clinical findings included myalgia, periorbital edema, headache and systolic murmur. Two patients died of cardiac failure before receiving benznidazole treatment. EKG and ECHO findings frequently showed a disturbance in ventricular repolarization and pericardial effusion. Ventricular dysfunction (ejection fraction <55%) was present in 27.3% of patients. After treatment, EKG readings normalized in 91.7% of patients. Ventricular repolarization abnormalities persisted in 50% of the patients, while sinus bradycardia was observed in 18%. The systolic ejection fraction normalized in two out of three patients with initially depressed ventricular function, while pericardial effusion disappeared.

CONCLUSIONS

Myocarditis is frequently found and potentially severe in patients with acute Chagas disease. Benznidazole treatment may improve clinical symptoms, as well as EKG and ECHO findings.

Cardiac involvement in African and American trypanosomiasis

American trypanosomiasis (Chagas disease) and human African trypanosomiasis (HAT; sleeping sickness) are both caused by single-celled flagellates that are transmitted by arthropods. Cardiac problems are the main cause of morbidity in chronic Chagas disease, but neurological problems dominate in HAT. Physicians need to be aware of Chagas disease and HAT in patients living in or returning from endemic regions, even if they left those regions long ago. Chagas heart disease has to be taken into account in the differential diagnosis of cardiomyopathy, primarily in patients with pathological electrocardiographic (ECG) findings, such as right bundle branch block or left anterior hemiblock, with segmental wall motion abnormalities or aneurysms on echocardiography, and in young patients with stroke in the absence of arterial hypertension. In HAT patients, cardiac involvement as seen by ECG alterations, such as repolarisation changes and low voltage, is frequent. HAT cardiopathy in general is benign and does not cause relevant congestive heart failure and subsides with treatment. We review the differences between the American and African trypanosomiasis with the main focus on the heart.

Chagas disease, France

Chagas Disease, France

Chagas disease (CD) is endemic to Latin America; its prevalence is highest in Bolivia. CD is sometimes seen in the United States and Canada among migrants from Latin America, whereas it is rare in Europe. We report 9 cases of imported CD in France from 2004 to 2006.

Echocardiography in Chagas heart disease

BACKGROUND

Chagas heart disease is a frequent cause of morbidity and mortality in Latin America. Echocardiography provides useful diagnostic and prognostic information and is an important tool in the management of patients with Chagas disease.

METHODS AND RESULTS

A search for relevant publications was obtained from MEDLINE, LILACS, and SCIELO sources. Acute Chagas myocarditis is a rare disorder in which pericardial effusion is frequent. Echocardiography may exclude pericardial tamponade in case of heart failure. Chronic Chagas cardiomyopathy evolves for several decades after the infection. Epidemiological history, positive serology, and suggestive clinical and ECG abnormalities establish the diagnosis. About three quarters of chronic Chagas cardiomyopathy subjects remain asymptomatic with normal (indeterminate form) or abnormal ECGs. Early Doppler abnormalities includes prolongation of isovolumic contraction and relaxation times. Systolic function frequently is normal, but dysfunction may be elicited by stress tests. Half or more of symptomatic patients have a left ventricular apical aneurysm and other segmental contractile abnormalities similar to those seen in coronary heart disease. The dilated nonsegmental form is indistinguishable from dilated cardiomyopathy. Results from univariate and multivariate Cox survival analyses indicate that impaired systolic function and increased ventricular dimensions have significant value in predicting cardiac morbidity and mortality. Cardiac ultrasound commonly is used in the follow-up of patients and in the assessment of various therapeutic modalities.

CONCLUSIONS

Echocardiographic and Doppler techniques provide useful structural and functional information in the detection of early myocardial damage, risk assessment of prognosis, disease progression, and management of patients with Chagas disease.

Measures to prevent transfusion-associated protozoal infections in non-endemic countries

To understand the risk of protozoa transmission by blood is critical as: (i) the world has become globalized with extensive travel, and increased immigration; (ii) blood-borne protozoa is common in inter-Tropical areas; (iii) protozoa develop biological means to escape hosts' immune systems, together with complicated detection, surveillance, and biological testing; and (iv) life threatening-parasites are inadequately controlled by treatment or prevention. This question is relevant in France, with it's non-continental territories, such as French Guiana, located in the Amazon Basin, which is endemic for various Plasmodium ssp. responsible for malaria, and for Trypanosoma cruzi, which is responsible for Chagas disease. In France, specific questioning of blood donors is haphazard despite the increase in population migration over the last three decades: specific questioning must be emphasized and 'at-risk' donors should be identified and subsequently excluded from donation. Donor exclusion alone would only be partially efficient, there is also a need for relevant biological testing of blood donations and in particular for T. cruzi through the CE-marked test to organize a coherent prevention policy: precise studies would thus define which blood donations are subjected to this additional qualifying test when available.

Le risque parasitaire transfusionnel : quels contrôles au regard de la directive européenne ?

Blood transfusion has become extremely safe regarding the transmission of infectious pathogens, some of them having been responsible for mostly severe complications and a certain loss of confidence from practitioners and patients over the last decades. This may result from the strict observance of ethical principles, of a better medical selection of donors, of technical steps for preparing and qualifying blood components for therapeutic use. The transfusion systems--which vary in their constitution and missions depending on the countries or even regions--have imposed themselves strict security rules and guidelines in industrialized countries. Further, governmental sanitary authorities have set up additional surveillance systems to make the transfusion systems the safest as possible. In addition, the Council of Europe has edicted directives to redefine guidelines to the preparation, use and quality assurance of blood products, that are mandatory in countries of the European Community. Regarding the infectious risks, most recommendations have focused more on the bacterial (immediate) and the viral (mostly delayed) risks than on the parasitic risks because these risks are not only less frequent in industrialized countries, but also far less well known and even much more complex. However, because travel habits and immigrations are increasing fast, most transfusion systems or blood banks must revisit their practices and controls towards hemoparasite transmission by blood transfusion. This review aims at discussing the present controls set up in most industrialized countries and particularly in Europe regarding the risk of post-transfusion transmission of hemoparasites, and the robustness of such controls as well as how these controls may be secured by the European Directive.

Seroprevalence of Trypanosoma cruzi infection in French Guiana

A survey was carried out on 1487 individuals to assess the seroprevalence of Trypanosoma cruzi infection in French Guiana. The overall prevalence of T. cruzi specific IgG was 0.5%. In multivariate analysis, residence in areas where housing is favorable for the presence of triatomine bugs was the only factor associated with the presence of T. cruzi antibodies. These results have implications for public health since blood donors are not routinely screened for T. cruzi infection in French Guiana.