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. Frequent cause of sudden cardiac death, but often goes undiagnosed.

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

Treatment objectives include parasite elimination, reducing disease progression, and careful management of the various clinical syndromes that result from irreversible lesions, as well as psychosocial support for the patient and their family.

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, which infects humans and other mammals.[1]Pérez-Molina JA, Molina I. Chagas disease. Lancet. 2018 Jan 6;391(10115):82-94. https://www.doi.org/10.1016/S0140-6736(17)31612-4 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 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 neuro-autonomic.[3]Siqueira Batista R, Gomes AP, Corrêa AD, et al. Moléstia de Chagas. 2nd ed. Rio de Janeiro: Rubio;2007:248.[4]Rassi A Jr, Rassi A, Marin-Neto JA. Chagas disease. Lancet. 2010 Apr 17;375(9723):1388-402. http://www.ncbi.nlm.nih.gov/pubmed/20399979?tool=bestpractice.com [5]Rassi A Jr, Rassi A, Marcondes de Rezende J. American trypanosomiasis (Chagas disease). Infect Dis Clin North Am. 2012 Jun;26(2):275-91. http://www.ncbi.nlm.nih.gov/pubmed/22632639?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.[6]Sartori AM, Ibrahim KY, Nunes Westphalen EV, et al. Manifestations of Chagas disease (American trypanosomiasis) in patients with HIV/AIDS. Ann Trop Med Parasitol. 2007 Jan;101(1):31-50. http://www.ncbi.nlm.nih.gov/pubmed/17244408?tool=bestpractice.com [7]Cordova E, Maiolo E, Corti M, et al. Neurological manifestations of Chagas' disease. Neurol Res. 2010 Apr;32(3):238-44. http://www.ncbi.nlm.nih.gov/pubmed/20406601?tool=bestpractice.com [8]Almeida EA, Lima JN, Lages-Silva E, et al. Chagas' disease and HIV co-infection in patients without effective antiretroviral therapy: prevalence, clinical presentation and natural history. Trans R Soc Trop Med Hyg. 2010 Jul;104(7):447-52. http://www.ncbi.nlm.nih.gov/pubmed/20303560?tool=bestpractice.com [9]Almeida EA, Ramos AN Jr, Correia D, et al. Co-infection Trypanosoma cruzi/HIV: systematic review (1980-2010). Rev Soc Bras Med Trop. 2011 Nov-Dec;44(6):762-70. http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0037-86822011000600021&lng=en&nrm=iso&tlng=en http://www.ncbi.nlm.nih.gov/pubmed/22231251?tool=bestpractice.com

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