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Chagas Disease

Chagas' Disease

Chagas disease or american trypanosomiasis is a zoonosis caused by the protozoan parasite Trypanosoma cruzi. Its major manifestations involve the gastrointestinal and cardiac systems. It is currently the most common cause of non-ischemic cardiomyopathy in South America.


Presentation

Acute phase: There is an incubation period of approximately two weeks after which the acute phase begins. The acute phase is characterized by non-specific symptoms such as fever and malaise. The acute phase may last eight to twelve weeks. Less than 10% of individuals get diagnosed during this phase. In a few, a chagoma may form. Inoculation via the conjunctiva causes unilateral swelling of the eyelids classically known as Romana’s sign.

Severe acute disease may occur in very few patients which presents with acute myocarditis which is clinically similar to myocarditis caused by viruses. It may also present with meningoencephalitis. Severe disease is associated with significant mortality [6].

Chronic phase: After 8-12 weeks, the patients enter the chronic phase; the intermediate phase of which is usually asymptomatic and may persist for decades. Later on, such patients progress to overt disease either in the gastrointestinal system, cardiac system or both.

Chronic Chagas cardiomyopathyPatients that eventually develop this complication may be asymptomatic but eventually present with features of heart failure such as exertional dyspnea, palpitations and edema. They present with biventricular failure but the first presentation may be a stroke, thromboembolism or cardiac arrhythmia.

Gastrointestinal Chagas disease: This may present with esophageal manifestations such as motility disorders to mild achalasia to the most severe form being mega-esophagus. The most common symptom is dysphagia. There may also be severe regurgitation of food with risk of aspiration. Food may also lodge with the esophagus and cause local ulceration. There is an increased risk of esophageal cancer.

Colonic Chagas disease: The most common manifestation is slowly progressive constipation associated with bloating, abdominal distention and pain. There is also risk for developing intestinal obstruction due to volvulus.

Fever
  • The manifestations included sudden fever, myalgia, dyspnea and signs of heart failure. Diagnosis was confirmed by specific exams, especially QBC (Quantitative Buffy Coat) and natural xenodiagnosis.[ncbi.nlm.nih.gov]
  • As the parasite spreads from the bite site, the patient develops fever, malaise, and generalized swelling of the lymph nodes. The liver and spleen may become enlarged.[web.archive.org]
  • If you notice symptoms, they might include Fever Flu-like symptoms A rash A swollen eyelid These early symptoms usually go away. However, if you don't treat the infection, it stays in your body.[nlm.nih.gov]
Congestive Heart Failure
  • Our Markov model structure had a 1 year cycle length and consisted of five states: acute disease, indeterminate disease, cardiomyopathy with or without congestive heart failure, megaviscera, and death.[ncbi.nlm.nih.gov]
  • In its acute form, the usual symptoms can include depression, diarrhea, anemia, lethargy, seizures, difficulty walking, increased heart rate, enlarged spleen, swollen lymph nodes, and congestive heart failure.[diamondbackdrugs.com]
  • This stage occurs years after the exposure and may include abnormal enlargement of the esophagus or colon and congestive heart failure. Persons with weakened immune systems may have more severe symptoms.[ok.gov]
Fatigue
  • Some people do get mild symptoms, such as Fever Fatigue Body aches Headache Loss of appetite Diarrhea Vomiting A rash A swollen eyelid These early symptoms usually go away. However, if you don't treat the infection, it stays in your body.[nlm.nih.gov]
  • During the first, or the acute phase, the patient may contract common symptoms such as fever, fatigue, body aches, headache, rash, diarrhea, and vomiting.[health.utah.gov]
  • […] chiefly by blood-sucking insects (genus Triatoma, Rhodnius, and Panstrongylus ) and that occurs in both an acute and chronic form Note: The acute form of Chagas disease lasts for several weeks to months and is marked by mild symptoms (such as fever, fatigue[merriam-webster.com]
  • When the heart or digestive tract are affected, the most common symptoms are: dizziness fainting spells palpitations chest pain fatigue constipation difficulty swallowing Most children and adults who have Chagas disease do not know when they were infected[infochagas.org]
  • Caused by the organism Trypanosoma cruzi and spread by the feces of insects commonly called “kissing bugs,” Chagas disease may initially produce an array of vague signs, including headache, fatigue and swollen lymph nodes.[equusmagazine.com]
Splenomegaly
  • […] unilateral purplish orbital oedema (Romaña’s sign) with local lymphadenopathy and fever over several weeks More general symptoms include: headache pallor myalgia dyspnoea oedema in inferior limbs or face abdominal pain cough hepatomegaly rash painful nodules splenomegaly[gov.uk]
  • On days 14 and 21, all three strains continued to develop increasing splenomegaly, but the Jα18 / spleens appeared the largest (Fig. 2C ).[dx.doi.org]
  • Hepatomegaly and splenomegaly may occur in children with acute Chagas disease, often accompanied by generalized lymphadenopathy. Varying degrees of generalized edema may occur in acutely infected persons, particularly children.[web.archive.org]
  • CD1d-restricted NKT cells contribute to malarial splenomegaly and enhance parasite-specific antibody responses. Eur. J. Immunol. 33 : 2588-2598. [ PubMed ] [ Google Scholar ] 35. Hesse, M., C. A. Piccirillo, Y. Belkaid, J. Prufer, M.[ncbi.nlm.nih.gov]
Generalized Lymphadenopathy
  • Read more Symptoms The disease has two clinical stages: – Acute (in which 5% of children die) characterized by fever, malaise, facial oedema, generalized lymphadenopathy, and hepatosplenomegaly – often spontaneously resolves in four to six weeks – Chronic[dndi.org]
  • Symptoms after a Triatominae bite typically begin with a skin lesion or unilateral periorbital edema, then progress to fever, malaise, generalized lymphadenopathy, and hepatosplenomegaly; years later, some patients develop chronic cardiomyopathy, megaesophagus[merckmanuals.com]
  • Hepatomegaly and splenomegaly may occur in children with acute Chagas disease, often accompanied by generalized lymphadenopathy. Varying degrees of generalized edema may occur in acutely infected persons, particularly children.[web.archive.org]
Dyspnea
  • The manifestations included sudden fever, myalgia, dyspnea and signs of heart failure. Diagnosis was confirmed by specific exams, especially QBC (Quantitative Buffy Coat) and natural xenodiagnosis.[ncbi.nlm.nih.gov]
  • Snapshot A 58-year-old man presents to the clinic with a 2 month history of cough, dyspnea on exertion, palpitations, and orthopnea. He immigrated from rural Bolivia when he was 25 years of age and visits Bolivia regularly.[medbullets.com]
  • Chronic Chagas cardiomyopathy: Patients that eventually develop this complication may be asymptomatic but eventually present with features of heart failure such as exertional dyspnea, palpitations and edema.[symptoma.com]
  • Chronic-phase symptoms and signs of Chagas disease may be irregular heartbeats, EKG changes, palpitations, fainting ( syncope ), cardiomyopathy, congestive heart failure, shortness of breath (dyspnea), emphysema, stroke, sudden death, chronic abdominal[medicinenet.com]
Nausea
  • The predominant symptoms were: rash (37.9%), itching (33.7%), epigastric pain (26.4%), abdominal bloating (24.2%) and nausea (22.1%). ADRs were mild (57.4%), moderate (35.5%) and severe (7.3%).[ncbi.nlm.nih.gov]
  • Stomach pain, rash, decreased weight, headache, nausea, vomiting, abnormal white blood cell count, urticaria, and pruritus were among the most commonly seen adverse reactions with benznidazole.[empr.com]
  • The most common adverse reactions in patients taking benznidazole were stomach pain, rash, decreased weight, headache, nausea, vomiting, abnormal white blood cell count, urticaria (hives), pruritus (itching) and decreased appetite.[fda.gov]
  • The most common adverse reactions in patients taking benznidazole were stomach pain, rash, decreased weight, headache, nausea, vomiting, abnormal white blood cell count, urticaria (hives), pruritus (itching), and decreased appetite.[pharmacytimes.com]
  • Other symptoms that may manifest include fatigue, rash, headache, nausea, diarrhea, vomiting, enlargement of the spleen and swollen glands.[news-medical.net]
Constipation
  • Patients who have parasitic infection of the colon may experience abdominal pain and constipation. Death is usually caused by heart disease.[web.archive.org]
  • When the heart or digestive tract are affected, the most common symptoms are: dizziness fainting spells palpitations chest pain fatigue constipation difficulty swallowing Most children and adults who have Chagas disease do not know when they were infected[infochagas.org]
  • Chagas' disease often goes undiagnosed because its symptoms are associated with heart disease, volulus, achlasia, and constipation. Laboratory tests are necessary to detect the presence of T. cruzi.[uta.edu]
  • When symptoms finally develop, they may include: Constipation Digestive problems Heart failure Pain in the abdomen Pounding or racing heart Swallowing difficulties Physical examination can confirm the symptoms.[nlm.nih.gov]
Abdominal Pain
  • Patients who have parasitic infection of the colon may experience abdominal pain and constipation. Death is usually caused by heart disease.[web.archive.org]
  • pain; in severe cases, there may be several weeks between bowel movements Histology shows ganglionitis with neuronal cell depopulation Terminology Also known as American trypanosomiasis ICD coding B57.3 Chagas disease (chronic) with digestive system[pathologyoutlines.com]
  • ., focal neurological deficit secondary to thromboembolism formation in dilated cardiac chambers) gastrointestinal megaesophagus progressive dysphagia and regurgitation of food megacolon progressive constipation, colicky abdominal pain, and bloating Studies[medbullets.com]
  • pain cough hepatomegaly rash painful nodules splenomegaly generalized oedema diarrhoea multiple lymphadenopathy myocarditis (chest pain, heart failure) more rarely meningoencephalitis (seizures, paralysis) Chronic phase The chronic phase is associated[gov.uk]
  • These changes can result in weakness, difficulty swallowing, abdominal pain, and death. Other organs may also malfunction (ureters, bile duct, for example). What research is being done for Chagas disease? Research is progressing on Chagas disease.[medicinenet.com]
Hepatosplenomegaly
  • In October 1986, 7 to 22 days after a meeting at a farm in Paraíba state, 26 individuals presented with a febrile illness associated with bilateral eyelid and lower limb edema, mild hepatosplenomegaly, lymphadenopathy and, occasionally a skin rash.[ncbi.nlm.nih.gov]
  • Read more Symptoms The disease has two clinical stages: Acute (in which 5% of children die) - characterised by fever, malaise, facial oedema, generalised lymphadenopathy, and hepatosplenomegaly – often spontaneously resolves in four to six weeks Chronic[web.archive.org]
  • Hepatosplenomegaly, particularly in children. Diarrhoea, vomiting and anorexia. Other classical features include: Unilateral conjunctivitis and swelling around the eye, called Romaña's sign, occurs if infection was via the eye.[patient.info]
Hepatomegaly
  • In the hospital admission, physical examination showed tachycardia, hepatomegaly, bipalpebral edema and anasarca. Trypanosoma cruzi trypomastigotes were found in microscopy during blood cell count.[ncbi.nlm.nih.gov]
  • […] a skin chancre (chagoma) unilateral purplish orbital oedema (Romaña’s sign) with local lymphadenopathy and fever over several weeks More general symptoms include: headache pallor myalgia dyspnoea oedema in inferior limbs or face abdominal pain cough hepatomegaly[gov.uk]
  • Hepatomegaly and splenomegaly may occur in children with acute Chagas disease, often accompanied by generalized lymphadenopathy. Varying degrees of generalized edema may occur in acutely infected persons, particularly children.[web.archive.org]
Palpitations
  • Snapshot A 58-year-old man presents to the clinic with a 2 month history of cough, dyspnea on exertion, palpitations, and orthopnea. He immigrated from rural Bolivia when he was 25 years of age and visits Bolivia regularly.[medbullets.com]
  • When the heart or digestive tract are affected, the most common symptoms are: dizziness fainting spells palpitations chest pain fatigue constipation difficulty swallowing Most children and adults who have Chagas disease do not know when they were infected[infochagas.org]
  • Chronic Chagas cardiomyopathy: Patients that eventually develop this complication may be asymptomatic but eventually present with features of heart failure such as exertional dyspnea, palpitations and edema.[symptoma.com]
  • 30% progress from the latent to the chronic phase but, those who do, have serious pathology that may well prove fatal: Cardiac abnormalities can produce Arrhythmias Heart failure Thromboemboli This will result in symptoms which include : Chest pain Palpitations[patient.info]
Cardiomegaly
  • Chest X-ray may reveal cardiomegaly. In the latent and chronic phases, serology is required.[patient.info]
  • There are bibasilar crackles on chest exam and a chest radiograph shows cardiomegaly. Echocardiogram revealed biventricular dilatation with an EF of 25%. Serological testing was positive for Trypanosoma cruzi.[medbullets.com]
  • In 1928, Chagas detected fibrosis of the conductive system, and pointed out the presence of marked cardiomegaly at the chest X-Ray associated with minimal symptomatology.[ncbi.nlm.nih.gov]
  • Fatal cases during the acute phase of CHD in Panama are characterized by severe dyspnea and progressive myocarditis with arrhythmia, cardiomegaly, vomiting, and anuria.[dx.doi.org]
S3 Gallop
  • Cardiovascular exam reveals an elevated JVD, S3 gallop, and pitting edema of both ankles. There are bibasilar crackles on chest exam and a chest radiograph shows cardiomegaly. Echocardiogram revealed biventricular dilatation with an EF of 25%.[medbullets.com]
Hypotension
  • The next day after the surgery (4th postoperative day) the patient presented a decreased level of consciousness (Glasgow coma scale   8), hypotension and hypoxemia. In two samples of blood cultures there was growth of Leuconostoc mesenteroides.[ncbi.nlm.nih.gov]
Cutaneous Manifestation
  • We present two transplant patients who underwent reactivation of Chagas' disease with cutaneous manifestations after an augmentation in their immunosuppressive therapy.[ncbi.nlm.nih.gov]
Facial Edema
  • Clinical findings such as facial edema, gingivitis, and dry cough are probably the consequence of the penetration of the parasite throughout the oral cavity, lips or pharyngeal mucosa.[doi.org]
  • The most frequent symptoms are fever, dyspnea, myalgias, and generalized and facial edema; ECG changes are also common.[dx.doi.org]
Headache
  • If symptoms are present, they may include headache, fever, muscle pain, difficulty breathing, and abdominal or chest pain. During the second or “chronic” phase, the parasites are concentrated mainly in the heart and digestive tissue.[web.archive.org]
  • Some people do get mild symptoms, such as Fever Fatigue Body aches Headache Loss of appetite Diarrhea Vomiting A rash A swollen eyelid These early symptoms usually go away. However, if you don't treat the infection, it stays in your body.[nlm.nih.gov]
  • During the first, or the acute phase, the patient may contract common symptoms such as fever, fatigue, body aches, headache, rash, diarrhea, and vomiting.[health.utah.gov]
  • In the early stage, symptoms are typically either not present or mild, and may include fever, swollen lymph nodes, headaches, or local swelling at the site of the bite.[dbpedia.org]

Workup

  • Acute phase: During the acute phase, the level of parasitemia is high and the parasites are visible on fresh preparations of blood (anti-coagulated or buffy coat). The level of parasitemia decreases with the next two months. Polymerase chain reaction is very sensitive for detecting infection even before the parasites circulate into the blood.
  • Chronic phase: Usually serological methods are used to detect immunoglobulins towards the parasite. Methods used include enzyme-linked immunosorbent assay and immunofluorescent antibody assay. There is no gold standard test for the chronic phase as all the currently available test are not sensitive enough to detect infection [7].
  • Imaging: Echocardiography is used to assess the structure and function of the heart in patients with chronic Chagas cardiomyopathy. Electrocardiogram is also indicated to assess for conduction abnormalities. For gastrointestinal disease, barium swallows and enemas are used to assess the extent of disease [8].
Cardiomegaly on Chest X-ray
  • […] at chest X-Ray, 15 with abnormal ECG but normal chest X-Ray, and 11 with abnormalities in the ECG and in the chest X-Ray.[ncbi.nlm.nih.gov]
Prolonged PR Interval
  • ECG abnormalities include sinus tachycardia in 30-80% of cases, prolonged PR interval, T-wave changes and a low QRS voltage.[patient.info]
Trypanosoma Cruzi
  • The life cycle of Trypanosoma cruzi; K.M. Tyler, et al. Novel cell biology of Trypanosoma cruzi; W.de Souza. Trypanosoma cruzi surface proteins; A.C.C. Frasch. Signaling in Trypanosoma cruzi; R. Docampo, S.N.J. Moreno.[worldcat.org]
  • Trypanosoma cruzi isolates from Mexican and Guatemalan acute and chronic chagasic cardiopathy patients belong to Trypanosoma cruzi I.[ncbi.nlm.nih.gov]
  • Congenital Trypanosoma cruzi transmission in Santa Cruz. Bolivia.[dx.doi.org]
Right Bundle Branch Block
  • The most common disorders include right bundle branch block alone or in association with left anterior fascicular block. We present an unusual case of a patient with Chagas' cardiomyopathy in association with a preexcitation syndrome.[ncbi.nlm.nih.gov]

Treatment

Acute and indeterminate disease: Antitrypanosomal therapy is recommended to treat acute Chagas disease. The drugs include benznidazole and nifurtimox. These are the only drug that have been shown to be efficacious in humans [9].

Chronic disease: There is no role of antitrypanosomal drugs in treating chronic disease since such therapy will not reverse existing pathology. Focus is on supportive management of cardiac or gastrointestinal disease.

Prognosis

The prognosis in the non-severe acute phase is better as compared to the severe form that has a variable outcome. The chronic phase of the disease is potentially fatal if no intervention is instituted, with cardiac failure or fatal arrhythmias being the cause of mortality.

Etiology

The parasite Trypanosoma cruzi is transmitted into the human host by an insect vector known as reduviid bug.

Epidemiology

Chagas disease is only found in the American continent. It is found in wild animals from the Southern part of the United States to the southern parts of Argentina. Due to the nature of transmission by infected triatomines, it tends to be a disease of the poor. Most infections occur in childhood. The true incidence is difficult to determine because most cases remain undiagnosed [2]. Blood transfusion used to be a major source of transmission in endemic areas but this has dramatically declined after screening of donated blood was implemented [3].

Sex distribution
Age distribution

Pathophysiology

Trypanosoma cruzi is transmitted to it hosts (mammals) by hematophagous triatomine insect better known as reduviid bug. The insect gets infected when it feeds on a blood meal from an infected mammal. The parasites mature in the insect's gut and the infective forms of the parasite are excreted in its droppings. The infective parasite usually gains access, through broken skin or mucous membranes like the conjunctiva. This usually occurs after blood meal of the reduviid bug [4]. The parasites may also be transmitted via blood transfusions and organ transplants or orally from contaminated utensils or food. They can also be transmitted from an infected mother to her unborn child.

The parasites then infect the cells of the nearby muscles and subcutaneous tissues. These infected cells soon rupture and the infection spreads systemically. The parasites may reach the cardiac muscles and infect them causing inflammation which is initially acute but eventually becomes chronic. Aggregates of amastigotes may be seen on histology of the heart muscles. The chronic manifestations are caused by a chronic inflammatory response that eventually leads to the pathologic changes observed microscopically and clinically as organ dysfunction [5].

Prevention

The best mode of prevention is breaking the transmission cycle and this may be done by using long lasting residual insecticides in the dwellings that are at risk and improving the living conditions for the inhabitants in endemic zones [10].

Summary

Chagas disease is a parasitic disease which is initially acute and treatable. If left untreated, the disease progresses into a chronic phase with primary damage to the heart and the gastrointestinal tract [1].

Patient Information

Chagas disease is caused by the parasite Trypanosoma cruzi that is transmitted by a bug. Chagas disease may either be acute or chronic; both of which have differet features and are managed differently. The disease can be prevented if proper measures are taken in the areas where the disease is endemic. The treatment for the acute phase is to kill the parasite by using specific medications; whereas in the chronic phase, the treatment is only supportive.

References

Article

  1. Brun R, Blum J, Chappuis F, Burri C. Human African trypanosomiasis. Lancet 375:148, 2010
  2. Carabarin-Lima A, González-Vázquez MC, Rodríguez-Morales O, et al. Chagas disease (American trypanosomiasis) in Mexico: an update. Acta Trop. Aug 2013;127(2):126-35
  3. Kirchhoff LV, Paredes P, Lomelí-Guerrero A, et al. Transfusion-associated Chagas' disease (American trypanosomiasis) in Mexico: Implications for transfusion medicine in the United States. Transfusion 46:298, 2006
  4. Maguire JH. Trypanosoma. In: Infectious Diseases, 2nd ed, Gorbach S, Bartlett J, Blacklow N (Eds), Lippincott, Williams & Wilkins, Philadelphia 2004.
  5. Lent H, Wygodzinsky P. Revision of the Triatominae (Hemiptera, Reduviidae), and their significance as vectors of Chagas' disease. Bull Am Museum Natural History. 1979
  6. Secretaria de Vigilancia em Saude de Brasil. Doenca de Chagas Aguda. Nota Tecnica, 9 de outubro de 2007. Brasilia, Brasil, 2007.
  7. Bern C, Montgomery SP, Herwaldt BL, et al. Evaluation and treatment of chagas disease in the United States: a systematic review. JAMA 2007; 298:2171.
  8. Acquatella H. Echocardiography in Chagas heart disease. Circulation 2007; 115:1124.
  9. Rodriques Coura J, de Castro SL. A critical review on Chagas disease chemotherapy. Mem Inst Oswaldo Cruz 2002; 97:3.
  10. Moncayo A, Ortiz Yanine MI. An update on Chagas disease (human American trypanosomiasis). Ann Trop Med Parasitol 2006; 100:663.

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Last updated: 2019-07-11 22:04