Trypanosoma cruzi – ABC CARDIOL

IJCS

Review Article

Maternal Deaths by Chagas’ Disease in Brazil

Danielle Kaiser de Souza et al. Vinicius Medina Lopes Ana Luiza Cafe-Lopes Maria das Dores Medina-Lopes

Abstract

Introduction

Chagas’ Disease is responsible for a high rate of morbimortality in Brazil however its real relevance on the maternal mortality is unknown.

Objective

The aim of this study is to review the literature on the impact of Chagas’ Disease on the Brazilian maternal mortality during the pregnancy-puerperal cycle.

Method

A review of literature was conducted to identify publications about maternal mortality and Chagas’ Disease. Documents were also searched in the websites of the Brazilian Ministry of Health, World Health Organization (WHO), System of Information about Mortality (SIM) and Brazilian Society of Cardiology (SBC). Manuscripts, master’s degree and PhD thesis, consensus, epidemiologic bulletins and manuals were analyzed.

Results

Initially were found 1326 paper, however just 14 answered the objective. Five epidemiologic bulletins, 4 manuals of Ministry of Health, 3 consensuses of SBC, 1 book and 3 master’s degree thesis were also used. There is no description of the number of deaths of pregnant women per year caused by complications of Chagas’ Disease in the data of the Ministry of Health and in the SIM. According to the data found, one third of pregnant women with Chagas’ Disease are cardiac patients and the mortality among them is 3.5%, therefore is expected a mortality of about 1% in the pregnant-puerperal cycle. There is evidence of underreporting of maternal mortality among chagasic pregnant women.

Conclusion

The maternal mortality caused by Chagas’ Disease is not known, therefore more studies about it are necessary, in all clinical forms of the disease.

Read Full Article

ABCHF

Original Article

Evaluation the In Vitro Action of Ciprofloxacin Hydrochloride, Naproxen, and Folic Acid on Trypanosoma cruzi, using Benznidazole as a Gold Standard

Cristiane Castro Faccini et al. Angela Maria Lourenço Abilio Augusto Fragata Filho

Abstract

Background:

Benznidazole is the only drug against Trypanosoma cruzi (T. cruzi) available in Brazil. However, it has limited efficacy and frequent side effects. Recent studies suggest that ciprofloxacin hydrochloride, naproxen, and folic acid may have beneficial effects in treating the Chagas disease.

Objective:

To assess the in vitro parasiticidal action of ciprofloxacin, naproxen, and folic acid on the Y strain of T. cruzi, using benznidazole as a gold standard.

Methods:

Tablets of benznidazole, ciprofloxacin hydrochloride, naproxen, and folic acid were macerated, weighed, and added to test tubes with a culture medium containing 100,000 forms per ml of T. cruzi trypomastigotes (strain Y). Samples from each tube were analyzed and counted in a Neubauer hemocytometer under an optical microscope for four days after adding the drugs. Thus, the minimum effective dose of each drug was determined.

Results:

As compared with benznidazole, higher concentrations of ciprofloxacin and naproxen were effective as in vitro parasiticides. In contrast, folic acid showed no direct in vitro parasiticidal action. Hence, previous observations reporting its effectiveness are probably due to indirect action.

Conclusion:

In our experiment, ciprofloxacin and naproxen showed a trypanosomicidal effect in vitro, but folic acid did not show this effect.

Read Full Article

ABCIC

Editorial

Role of Strain Echocardiography in the Evaluation of Patients with Chagas Disease

Vinicius Tostes Carvalho et al. Luís Henrique Coelho Pinto Maria Carmo Pereira Nunes

Chagas disease continues to be a significant public health challenge, affecting approximately six million people worldwide. With increasing globalization, Trypanosoma cruzi has already been detected in regions that were not previously considered endemic for the transmission vector, thus becoming one of the main neglected parasites. Although a percentage of infected individuals remain asymptomatic in the chronic indeterminate form of the disease, it is estimated that 2% to 3% of all patients annually progress to the cardiac form. Chagas heart disease was the most severe manifestation of Chagas disease, clinically appearing with heart failure, ventricular and supraventricular arrhythmias, conduction disorders, and embolic events.

The echocardiogram is an important propaedeutic method in the evaluation of patients with Chagas disease, especially in the presence of Chagas heart disease. In general, the echocardiogram investigates parameters related to the analysis of segmental contractility and global systolic function, which is essential for the treatment and prognosis of the disease. However, even well-established variables in the literature, such as ejection fraction, face challenges in simulating all the pathological aspects of Chagas disease.

[…]

Read Full Article

ABC

Editorial

Diagnostic and Prognostic Importance of Functional Capacity in the Different Evolutionary Forms of Chagas Disease

João Marcos Barbosa-Ferreira et al. Charles Mady Fábio Fernandes

The manuscript published by Silva et al. in this issue brings us an important reflection on the evolution of the different forms of Chagas disease (CD), by demonstrating that patients with the indeterminate form (IF) have similar functional capacity, measured through peak oxygen uptake (VO₂peak), to healthy individuals without CD. On the other hand, patients with Chagas’ heart disease without ventricular dysfunction had similar functional capacity to patients with ventricular dysfunction.

The IF of CD has been studied under different aspects for several years. Some studies in asymptomatic patients that are included in the definition of IF for not presenting electrocardiographic and chest X-ray alterations, demonstrated incipient alterations in complementary exams that may suggest the possibility of evolution to the more severe forms of CD over the years. Evaluations made through echocardiography showed alterations in variables such as tissue Doppler and study of myocardial deformity through two-dimensional strain.^, There has also been demonstration of changes in the Autonomic Nervous System, especially in the parasympathetic branch, which can be potential pathways for worsening in the stage disease over the years.^, Studies performed with magnetic resonance have demonstrated the presence of myocardial fibrosis in 12% of patients with IF of the disease. However, despite these small changes, the long-term evolution of these patients has been shown favorable and similar to that of healthy individuals without CD. Ianni et al. studied patients with the IF based on ECG findings for 8 years and concluded that the IF of CD represents a benign condition with a favorable long-term prognosis. However, in a small group of patients, there may be evolution for chronic Chagas cardiopathy (CCC) or digestive tract disease in about 10 to 20 years after acute infection. Sabino et al., in a 10-year retrospective cohort study, suggested a rate of progression to cardiomyopathy of 1.85% per year in patients with FI of the disease. Therefore, studies that identify markers that can predict the possibility of this evolution are needed and the evaluation of the functional capacity of these patients is important in this aspect.

[…]

Read Full Article

ABC

Original Article

Determinants of Functional Capacity in Patients with Chagas Disease

Whesley Tanor Silva et al. Henrique Silveira Costa Pedro Henrique Scheidt Figueiredo Márcia Maria Oliveira Lima … Vanessa Pereira Lima Fábio Silva Martins da Costa Matheus Ribeiro Ávila Vanessa Amaral Mendonça Ana Cristina Rodrigues Lacerda Maria Carmo Pereira Nunes Manoel Otávio Costa Rocha

Abstract

Background:

Chagas disease leads to reduced functional capacity. However, the stage at which functional impairment is detectable remains unclear.

Objectives:

The present study was addressed to compare the functional capacity of patients at different stages of Chagas disease and healthy individuals and to verify the determinants of peak oxygen uptake (VO2peak).

Methods:

In a cross-sectional study, 160 individuals were selected, 35 healthy and 125 with Chagas disease. In the Chagasic group, 61 (49%) were in the indeterminate form of the disease, 45 (36%) with Chagas cardiomyopathy (ChC) and preserved cardiac function and 19 (15%) with cardiac dysfunction and dilated ChC. The data were analyzed using univariate and multivariate regression analysis. Statistical significance was set at 5%.

Results:

Patients in the indeterminate form of disease showed similar functional capacity to healthy individuals (p>0.05). Patients with ChC and preserved cardiac function had lower VO2peak than patients in the indeterminate form (p<0.05), but showed similar VO2peak values than dilated ChC (p=0.46). The age, male sex, NYHA functional class, diastolic blood pressure, ratio of the early diastolic transmitral flow velocity to early diastolic mitral annular velocity, left ventricular ejection fraction (LVEF) and left ventricular end-diastolic diameter were associated with functional capacity. However, only age, male sex, LVEF and NYHA functional class, remained associated with VO2peak in the final model (adjusted R2=0.60).

Conclusion:

Patients with ChC had lower functional capacity than patients in the indeterminate form. LVEF, age, male sex and NYHA functional class were determinants with VO2peak in patients with Chagas disease.

Read Full Article

ABC

Special Article

Chagas Disease: Are Kissing Bugs the Only Culprit?

Abilio Augusto Fragata Filho

Preface

Chagas disease, first described by Carlos Chagas in 1909, is caused by a single-celled parasite (Trypanosoma cruzi). Throughout history, the main mechanism of transmission has been via contact with the feces of an insect infected with the parasite. This insect, known as the “kissing bug” in English, is popularly known as “barbeiro,” “chupão,” or “chupança” in Brazil. The “kissing bugs” are not born with the parasite in their intestine; rather, they acquire it by feeding on the blood of infected mammals. (This disease only affects mammals). When taking a blood meal, the insects eliminate feces, where the parasites are present, and the parasites can contaminate the bite, allowing the parasite to enter the organism. In this manner, the disease begins. The kissing bugs mainly make their nests in cracks in clay walls of houses made in a style known as “pau-a-pique” in Brazil. These houses are very common in diverse regions of Brazil, especially throughout the sertão of the Northeast Region. Other mechanisms of transmission can occur, for example, via blood transfusion, organ donation, mother-to-child transmission, ingestion of contaminated foods, etc.

During the acute phase of the disease, complaints may be mild or even non-existent. They may include general manifestations, such as low fever, malaise or more severe ones, such as shortness of breath and swelling. As bites from kissing bugs usually occur on the face, swelling of the eyebrows, known as the Romaña sign, may occur. As the years pass, generally after 10 years or more, cardiac complaints appear in one third of patients, such as fatigue, shortness of breath, and swelling in the body (heart failure). In some cases, the electrical system of the heart may be compromised, with alterations in cardiac rhythm, fainting, and even sudden death. Dilatation of the esophagus and the colon can also occur, with progressive difficulty in swallowing food and defecating.

[…]

Read Full Article

ABC

Original Article

Prevalence of Trypanosoma Cruzi Infection in Blood Donors

Alanna Carla da Costa et al. Eduardo Arrais Rocha José Damião da Silva Filho Arduina Sofia Ortet de Barros Vasconcelos Fidalgo … Francisca Mylena Melgaço Nunes Carlos Eduardo Menezes Viana Vânia Barreto Aguiar F. Gomes Maria de Fátima Oliveira

Abstract

Background

Chagas disease (CD) is considered a public health problem in Latin America. The northeastern region, especially the state of Ceará, still represents a major concern in terms of the risk of transmission of CD.

Objective

To estimate the prevalence of T. cruzi in blood donors from the state of Ceará.

Methods

This is a retrospective descriptive study that was performed in the period from 2010 to 2015 from data recorded in the computerized system of the Hematology and Hemotherapy Center of Ceará (HEMOCE in Portuguese).

Results

Of the 763,731 potential blood donors, 14,159 were serologically ineligible; 1,982 (0.33%) were serologically ineligible due to positive / inconclusive diagnosis for CD. A total of 425 individuals came to the HEMOCE to repeat the test, with 28.2% (120/425) declared ineligible for donations due to CD.

Conclusion

No significant reduction of positive / inconclusive serology was observed in the period between 2010 and 2015, but a reduction was observed when compared to 1996/1997 in the state. The determination of the prevalence of CD in blood banks may be relevant as an indicator of the risk of CD transmission through blood transfusions in a given region. New serological tests for triage with better accuracy in screening are needed, in an attempt to reduce the unnecessary disposal of blood bags, reduce costs for the Brazilian Unified Health System, and diminish insecurity for the patient and family members. (Arq Bras Cardiol. 2020; 115(6):1082-1091)

Read Full Article

IJCS

Review Article

Heart Transplantation for Chagas Cardiomyopathy

Maria da Consolação Moreira et al. Fabio Morato Castilho Renato Braulio Guilherme Ferraz Messina de Pádua Andrade José Renan da Cunha Melo

Abstract

Heart transplantation (HT) is an established treatment for patients with advanced heart failure (HF). Chagas disease (CD), caused by the Trypanosoma cruzi (T.cruzi) is an important cause of HF in Latin America. Considering CD is a chronic infectious disease, the use of immunosuppressive therapy after HT can reactivate T. cruzi infection and compromise outcomes. Early diagnosis and treatment of this complication is extremely important, which requires knowledge, experience, and a high degree of suspicion by transplant physicians. Furthermore, with the international immigration of people, CD is no longer exclusive to Latin America, since a large number of immigrants with T. cruzi infection are living in non-endemic countries. This phenomenon represents not only a new global epidemiological problem, but also a challenge for transplant teams. This review aims to discuss the peculiarities of HT in the context of CD, with a focus on reactivation of the infection, clinical manifestations, etiological treatment of T. cruzi and differential diagnosis with allograft rejection, among HT recipients.

Read Full Article

IJCS

Case Report

Complete Resolution of Electrocardiographic Changes Induced by Acute Chagas Myocarditis

Joseane Elza Tonussi Mendes Rossette do Valle et al. Luiz Carlos de Abreu Raimundo Barbosa Barros Rodrigo Daminello Raimundo … Andrés Ricardo Pérez Riera Isabel Sorpreso

Abstract

We present a case of a female adolescent with severe acute Chagas myocarditis, acquired by oral transmission in an endemic area in the Brazilian western Amazon, who had electrocardiographic changes normalized after empirical treatment with the antiparasitic drug benznidazole combined with conventional treatment for severe heart failure.

Read Full Article

ABC

Editorial

An Approach to The Acute Phase of Chagas' Disease: The Continuing Challenge it Presents in the 21(st) Century

Dário C. Sobral Filho

Chagas disease, in addition to being widespread on the American continent with around six million persons infected, is currently present in various regions of the world as a result of the migration of individuals with the disease.^,

The statistics show that the incidence of acute cases has fallen from 700,000 new cases in 1990 to the current estimate of 29,000 – 30,000 per year by vector-borne transmission, plus 8,000 other cases by other modes such as transfusion and the digestive tract, owing to ingestion of food contaminated by Trypanosoma cruzi, as described by Ortiz et al. in their publication in this journal, in which they report 63 cases of cases of the acute form of Chagas disease in the state of Amazonas over a period of eight years, with oral transmission in 75% of the patients.

[…]

Read Full Article

ABC

Original Article

Cardiac Evaluation in the Acute Phase of Chagas’ Disease with Post-Treatment Evolution in Patients Attended in the State of Amazonas, Brazil

Jessica Vanina Ortiz et al. Bruna Valessa Moutinho Pereira Katia do Nascimento Couceiro Monica Regina Hosannah da Silva e Silva … Susan Smith Doria Paula Rita Leite da Silva Edson da Fonseca de Lira Maria das Graças Vale Barbosa Guerra Jorge Augusto de Oliveira Guerra João Marcos Bemfica Barbosa Ferreira

Abstract

Background:

In the past two decades, a new epidemiological profile of Chagas’ disease (CD) has been registered in the Brazilian Amazon where oral transmission has been indicated as responsible for the increase of acute cases. In the Amazonas state, five outbreaks of acute CD have been registered since 2004. The cardiac manifestations in these cases may be characterized by diffuse myocarditis, with alteration in the electrocardiogram (ECG) and transthoracic echocardiogram (TTE).

Objective:

To perform a cardiac evaluation in autochthonous patients in the acute phase and at least one year after submitted to treatment for acute CD and evaluate the demographic variables associated with the presence of cardiac alterations.

Methods:

We evaluated patients diagnosed with acute CD through direct parasitological or serological (IgM) methods from 2007 to 2015. These patients were treated with benznidazole and underwent ECG and TTE before and after treatment. We assumed a confidence interval of 95% (CI 95%, p < 0.05) for all variables analyzed.

Results:

We observed 63 cases of an acute CD in which oral transmission corresponded to 75%. Cardiac alterations were found in 33% of the cases, with a greater frequency of ventricular repolarization alteration (13%), followed by pericardial effusion (10%) and right bundle branch block and left anterior fascicular block (2%). The follow-up occurred in 48 patients with ECG and 25 with TTE for a mean period of 15.5 ± 4.1 months after treatment. Of these, 8% presented normalization of the cardiac alterations in ECG, 62.5% remained with the normal exams. All of the patients presented normal results in TTE in the post-treatment period. As for the demographic variables, isolated cases presented more cardiac alterations than outbreaks (p = 0.044) as well as cases from Central Amazonas mesoregion (p = 0.020).

Conclusions:

Although cardiac alterations have not been frequent in most of the studied population, a continuous evaluation of the clinical-epidemiological dynamics of the disease in the region is necessary in order to establish preventive measures.

Read Full Article

ABC

Editorial

Obstructive Sleep Apnea: A Marker of Cardiac Remodeling in Patients with Chronic Chagas Disease

Reinaldo B. Bestetti

Chronic Chagas disease (CCD) continues to be a major scourge for people living in South America and an emergent medical problem outside the American Continent because of world globalization. Chronic Chagas heart disease (CCHD) affects about 30% of patients with CCD, appearing 20-30 years after infection with Trypanosoma cruzi. Prognosis of CCD patients is relentless, with a 5-year mortality approaching 35%. CCHD patients have an outcome even worse, particularly those with ventricular and atrial remodeling, which manifests by chronic systolic heart failure and atrial fibrillation.^,

It is, therefore, important to recognize predictors of ventricular and atrial remodeling in patients with CCHD to offer the proper available treatment for patients with this condition. Systolic blood pressure, male sex, and New York Heart Association Functional Class appear to predict ventricular remodeling in patients with CCD. Conversely, as far as I know, predictors of atrial remodeling have not yet been established for patients with this condition.

[…]

Read Full Article

IJCS

Review Article

Chagas Disease Cardiomyopathy

Marcus Vinicius Simões et al. Minna Moreira Dias Romano André Schmidt Káryta Suely Macedo Martins José Antonio Marin-Neto

Abstract

Chronic Chagas disease cardiomyopathy (CCC) is a result of low-intensity, but incessant, focal fibrosing myocarditis, caused by persistent T. cruzi infection associated with inflammation, mediated by adverse immune mechanisms. About 30 percent of infected individuals have developed throughout life the chronic cardiac form of Chagas’ disease with protean clinical manifestations, such as sudden death, signs and symptoms of heart failure, cardioembolic events, arrhythmia and angioid symptoms. Sudden death and the progression of heart failure (HF) are the most common mechanisms of death in this condition. The most relevant prognostic aspects are symptoms of advanced HF (NYHA Fc III-IV), cardiomegaly, LV systolic dysfunction and nonsustained ventricular tachycardia. Preventing cardioembolic events is an important aspect in the management of patients with CCC. Oral anticoagulant agents must be prescribed for high-risk patients according to the presence of a set of risk factors: LV systolic dysfunction, apical aneurysm, altered ventricular repolarization by ECG and advanced age. The treatment of HF in patients with CCC follows the same principles applied to HF secondary to dilated cardiomyopathy of other etiologies.

Read Full Article

ABC

Case Report

Chronic Heart Disease after Treatment of Oral Acute Chagas Disease

Andrei Fornanciari Antunes et al. Simão Gonçalves Maduro Bruna Valessa Moutinho Pereira Maria das Graças Vale Barbosa … Jorge Augusto de Oliveira Guerra João Marcos Bemfica Barbosa Ferreira

Abstract

We describe the recurrence of cardiac abnormalities in a patient treated during the acute phase of Chagas disease after outpatient follow-up of 5 years.

Read Full Article

ABC

Case Report

Anatomopathological Aspects of Acute Chagas Myocarditis by Oral Transmission

Dilma do Socorro Moraes de Souza et al. Marialva TF Araujo Paulo Roberto Silva Garcez dos Santos Julio Cesar Branco Furtado … Maria Tereza Sanches Figueiredo Rui M.S. Povoa

Introduction

Vector transmission of Trypanosoma cruzi has declined in Latin America, which has been attributed to better epidemiological control of this form of transmission, estimated at 8 to 10 million chronic cases, in addition to reducing the number of new cases.^, However, there has been an increase in the incidence of acute cases, predominantly by oral transmission due to the ingestion of food contaminated with feces of triatomids, both in isolated cases and in family micro-outbreaks.

Necropsy studies that describe myocarditis in the acute phase of Chagas’ disease are scarce and the existing reports in the literature are of studies carried out in the past decades and involve vector transmission in endemic areas.

[…]

Read Full Article