Chagas disease

Chagas disease is a chronic and neglected infectious disease associated with poverty, migration, and poor housing conditions with a high burden of morbidity and mortality.

Leading cause of cardiac lesions in young, economically productive adults in endemic Latin American countries in terms of disability-adjusted life years lost. It is a frequent cause of sudden cardiac death, but often goes undiagnosed.

Patients with acute-phase disease are generally asymptomatic or present with mild symptoms, although these may be more severe in immunocompromised patients, or in disease due to oral transmission. Chronic-phase disease has cardiac, gastrointestinal, indeterminate, and mixed (cardiac and gastrointestinal) forms. Reactivation occurs in immunosuppressed patients and presents as myocarditis or severe meningoencephalitis.

Objectives of aetiological treatment include parasite elimination and reduction of disease progression. Careful management of the different clinical syndromes resulting from irreversible lesions is important, as well as comprehensive multidisciplinary care encompassing psychosocial support.

Chagas disease, also known as American trypanosomiasis, is an anthropozoonosis (a disease maintained by animals and transmitted from animals to humans) caused by the obligate intracellular flagellate protozoon Trypanosoma cruzi(T. cruzi), which infects humans and other mammals.[1]Pérez-Molina JA, Molina I. Chagas disease. Lancet. 2018 Jan 6;391(10115):82-94. http://www.ncbi.nlm.nih.gov/pubmed/28673423?tool=bestpractice.com

It is a heterogeneous condition with a wide variation in clinical presentation, and the majority of patients remain asymptomatic throughout their life. The American Heart Association has warned that it is a frequent cause of sudden cardiac death, but often goes undiagnosed.[2]Nunes MCP, Beaton A, Acquatella H, et al. Chagas cardiomyopathy: an update of current clinical knowledge and management: a scientific statement from the American Heart Association. Circulation. 2018 Sep 18;138(12):e169-209. https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000000599?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed http://www.ncbi.nlm.nih.gov/pubmed/30354432?tool=bestpractice.com [3]Gómez-Ochoa SA, Rojas LZ, Echeverría LE, et al. Global, regional, and national trends of Chagas disease from 1990 to 2019: comprehensive analysis of the Global Burden of Disease study. Glob Heart. 2022;17(1):59. https://globalheartjournal.com/articles/10.5334/gh.1150 http://www.ncbi.nlm.nih.gov/pubmed/36051318?tool=bestpractice.com

Clinically, there are acute and chronic phases. If the acute phase remains untreated, T. cruzi infection is lifelong. The chronic phase can manifest in various forms: indeterminate, cardiac, gastrointestinal, and mixed (cardiac and gastrointestinal).[1]Pérez-Molina JA, Molina I. Chagas disease. Lancet. 2018 Jan 6;391(10115):82-94. http://www.ncbi.nlm.nih.gov/pubmed/28673423?tool=bestpractice.com [4]Dias JC, Ramos AN Jr, Gontijo ED, et al. 2 nd Brazilian Consensus on Chagas disease, 2015. Rev Soc Bras Med Trop. 2016 Dec;49Suppl 1(Suppl 1):3-60. https://www.scielo.br/j/rsbmt/a/mNgRbrGjpwwc9dSF73PdMHt/?lang=en http://www.ncbi.nlm.nih.gov/pubmed/27982292?tool=bestpractice.com ​​​​​ Reactivation of infection can occur in patients with induced or acquired immunosuppression (such as in advanced HIV infection or after organ transplantation), causing myocarditis or severe meningoencephalitis.​​​[5]Pierrotti LC, Ibrahim KY. Chagas disease: coming to a transplanted patient near you. Springer, Cham. 2020 Mar 09;1-47​.​​[6]Shikanai-Yasuda MA, Mediano MFF, Novaes CTG, et al. Clinical profile and mortality in patients with T. cruzi/HIV co-infection from the multicenter data base of the "Network for healthcare and study of Trypanosoma cruzi/HIV co-infection and other immunosuppression conditions". PLoS Negl Trop Dis. 2021 Sep 30;15(9):e0009809. https://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0009809 http://www.ncbi.nlm.nih.gov/pubmed/34591866?tool=bestpractice.com [7]National Institutes of Health, Centers for Disease Control and Prevention, HIV Medicine Association, and Infectious Diseases Society of America. Panel on Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV: Chagas disease. 2023 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-opportunistic-infections/chagas-disease [8]Shikanai-Yasuda MA, de Almeida EA, López MC, et al. Chagas disease: a parasitic infection in an immunosuppressed host. Springer, Cham. 2020 Jul 21;213-34.​​

The term ‘Chagas disease’ is used for the general disease, whereas the term ‘Chagas cardiomyopathy’ encompasses all cases of Chagas disease with cardiac involvement.[2]Nunes MCP, Beaton A, Acquatella H, et al. Chagas cardiomyopathy: an update of current clinical knowledge and management: a scientific statement from the American Heart Association. Circulation. 2018 Sep 18;138(12):e169-209. https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000000599?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed http://www.ncbi.nlm.nih.gov/pubmed/30354432?tool=bestpractice.com