Precordial chest pain in patients with chronic Chagas disease

Precordial chest pain affects about 15% to 33% of patients with chronic Chagas disease. In the absence of megaesophagus, it should be ascribed to chronic Chagas heart disease. Precordial chest pain is atypical because it can usually neither be associated to physical exercise nor be alleviated by nitroglycerin. However, in certain circumstances, precordial chest pain can masquerade as acute coronary syndrome. Although obstructive coronary artery disease can occasionally be found, microvascular angina seems to be the mechanism behind such phenomenon. Precordial chest pain not always has a benign clinical course; sometimes, it can herald a dismal prognosis. On the basis of cases previously reported, it seems that nitrates, betablockers and/or calcium channel blockers can be of value in the treatment of this condition.     

Western blotting method (TESAcruzi) as a supplemental test for confirming the presence of anti-Trypanosoma cruzi antibodies in finger prick blood samples from children aged 0–5 years in Brazil

Some Latin American countries have plans for total control and/or eradication of Chagas disease by the main vector (Triatoma infestans) and by blood transfusion. To achieve this, patients with Chagas disease must be identified. A Western blotting test, TESAcruzi, is described as a supplemental test for diagnosis of Chagas disease using samples collected from children <5 years living in different states of Brazil. Blood samples collected by finger prick on filter paper were sent to the test laboratory by a central laboratory to confirm results obtained previously. Ten percent of negative samples, all doubtful and all positive samples were received. Commercial reagents, IgG indirect immunofluorescence, enzyme immunoassay, and a recently introduced TESAcruzi test were used. From 8788 samples, 163 (1.85%) were reactive by IgG-ELISA and 312 (3.55%) by IgG IIF. From these, 77 (0.87%) were reactive in the TESAcruzi test. The results had high clinical value to identify those truly infected.     

Prevalence of Trypanosoma cruzi/HIV coinfection in southern Brazil

Chagas disease reactivation has been a defining condition for acquired immune deficiency syndrome in Brazil for individuals coinfected with Trypanosoma cruzi and HIV since 2004. Although the first coinfection case was reported in the 1980s, its prevalence has not been firmly established. In order to know coinfection prevalence, a cross-sectional study of 200 HIV patients was performed between January and July 2013 in the city of Pelotas, in southern Rio Grande do Sul, an endemic area for Chagas disease. Ten subjects were found positive for T. cruzi infection by chemiluminescence microparticle immunoassay and indirect immunofluorescence. The survey showed 5% coinfection prevalence among HIV patients (95% CI: 2.0–8.0), which was 3.8 times as high as that estimated by the Ministry of Health of Brazil. Six individuals had a viral load higher than 100,000 copies per μL, a statistically significant difference for T. cruzi presence. These findings highlight the importance of screening HIV patients from Chagas disease endemic areas.     

Echocardiographic Parameters and Survival in Chagas Heart Disease with Severe Systolic Dysfunction

Background

Echocardiography provides important information on the cardiac evaluation of patients with heart failure. The identification of echocardiographic parameters in severe Chagas heart disease would help implement treatment and assess prognosis.

Objective

To correlate echocardiographic parameters with the endpoint cardiovascular mortality in patients with ejection fraction < 35%.

Methods

Study with retrospective analysis of pre-specified echocardiographic parameters prospectively collected from 60 patients included in the Multicenter Randomized Trial of Cell Therapy in Patients with Heart Diseases (Estudo Multicêntrico Randomizado de Terapia Celular em Cardiopatias) - Chagas heart disease arm. The following parameters were collected: left ventricular systolic and diastolic diameters and volumes; ejection fraction; left atrial diameter; left atrial volume; indexed left atrial volume; systolic pulmonary artery pressure; integral of the aortic flow velocity; myocardial performance index; rate of increase of left ventricular pressure; isovolumic relaxation time; E, A, Em, Am and Sm wave velocities; E wave deceleration time; E/A and E/Em ratios; and mitral regurgitation.

Results

In the mean 24.18-month follow-up, 27 patients died. The mean ejection fraction was 26.6 ± 5.34%. In the multivariate analysis, the parameters ejection fraction (HR = 1.114; p = 0.3704), indexed left atrial volume (HR = 1.033; p < 0.0001) and E/Em ratio (HR = 0.95; p = 0.1261) were excluded. The indexed left atrial volume was an independent predictor in relation to the endpoint, and values > 70.71 mL/m² were associated with a significant increase in mortality (log rank p < 0.0001).

Conclusion

The indexed left atrial volume was the only independent predictor of mortality in this population of Chagasic patients with severe systolic dysfunction.     

NK and LAK functions in human chronic Chagas disease

Natural killer (NK) and lymphokine activated killer (LAK) functions were measured in 40 patients with chronic Chagas disease divided into asymptomatic/indeterminate (18) and symptomatic forms (22) and in 24 healthy controls. A chromium release assay was used employing K562 or P815 cell lines as targets. There was no difference in either NK or LAK activity between the three groups. A small number of patients in each group showed results above or below the normal range for controls. However, there was no correlation between NK and LAK values in the same individual. In conclusion, NK and LAK functions do not seem to be involved in the immunosuppression associated with human chronic Chagas disease.     

Reactivation of Chagas disease in a bone marrow transplant patient: case report and review of screening and management

We report a patient with an autologous stem cell transplant and history of residence in a Chagas disease (CD) endemic area who developed Chagas reactivation after induction for transplantation. We recommend that patients at risk for CD be screened before transplantation, and patients found to have chronic infection be monitored for reactivation post transplant.     

Emerging and under-recognized Chagas cardiomyopathy in non-endemic countries

Due to recent population emigration movements,an epidemic of Chagas disease is currently menacing most developed countries.The authors report the case of a 53-year-old Brazilian woman living in Europe for the last 10 years who developed heart failure symptoms,having a previous symptomatic sinus node disease with a pacemaker implant at age of 40 years.The diagnosis was based on serology and myocardial biopsy and the patient was treated with nifurtimox.The authors emphasize the need of a high level of suspicion in patients with suggestive epidemiology and the needof populational screening of specific high risk groups.New treatment options are also discussed.     

Assessment of Galectin-3 Polymorphism in Subjects with Chronic Chagas Disease

Background

Galectin-3, a β-galactoside binding lectin, has been described as a mediator of cardiac fibrosis in experimental studies and as a risk factor associated with cardiovascular events in subjects with heart failure. Previous studies have evaluated the genetic susceptibility to Chagas disease in humans, including the polymorphisms of cytokine genes, demonstrating correlations between the genetic polymorphism and cardiomyopathy development in the chronic phase. However, the relationship between the galectin-3 single nucleotide polymorphism (SNP) and phenotypic variations in Chagas disease has not been evaluated.

Objective

The present study aimed to determine whether genetic polymorphisms of galectin-3 may predispose to the development of cardiac forms of Chagas disease.

Methods

Fifty-five subjects with Chagas disease were enrolled in this observational study. Real-time polymerase chain reaction (PCR) was used for genotyping the variants rs4644 and rs4652 of the galectin-3 gene.

Results

For the SNP rs4644, the relative risk for the cardiac form was not associated with the genotypes AA (OR = 0.79, p = 0.759), AC (OR = 4.38, p = 0.058), or CC (OR = 0.39, p = 0.127). Similarly, for the SNP rs4652, no association was found between the genotypes AA (OR = 0.64, p = 0.571), AC (OR = 2.85, p = 0.105), or CC (OR = 0.49, p = 0.227) and the cardiac form of the disease.

Conclusion

Our results showed no association between the different genotypes for both SNPs of the galectin-3 gene and the cardiac form of Chagas disease.     

N-terminal proBNP levels in patients with Chagas disease: a marker of systolic and diastolic dysfunction of the left ventricle.

AIMS: NT-proBNP levels are known to be elevated in systolic and diastolic dysfunction. Doppler indices of diastolic dysfunction (DD) have been shown to have prognostic value in patients with Chagas' cardiomyopathy (CC). However, the additional value of NT-proBNP levels in further stratifying these patients according to DD has not been established. This study analyzed the correlation of N-terminal proBNP (NT-proBNP) levels with systolic and diastolic function in patients with CC. METHODS AND RESULTS: NT-proBNP levels were measured in 59 patients with dilated cardiomyopathy due to Chagas disease without other systemic illness that were studied by Doppler echocardiography, including left atrial volume (LAV) calculation and tissue Doppler evaluation of LV longitudinal function. Univariate analysis showed a strong correlation of NT-proBNP values with LVEF (r=-0.733, p<0.001) and a weak correlation with most Doppler echocardiographic parameters of diastolic function. On a multivariate analysis, LVEF and LAV volume emerged as correlating with elevated levels of the NT-proBNP. Patients with restrictive filling pattern (n=10), when compared to other patterns of DD, (n=49), showed a lower LVEF (25.4+/-6.4% vs. 39.8+/-9.4, p<0.001), a larger LAV (50.1+/-17.2 vs. 37.7+/-15.6 ml/m(2), p=0.004) and higher NT-proBNP levels (median+/-IQR: 3488+/-3056 vs. 492+/-700 pg/dl, p<0.001). A marked elevated concentration of NT-proBNP (> or =800 pg/ml) had a sensitivity of 90.0%, specificity of 70.5%, positive predictive value of 40.9% and negative predictive value of 96.9% for detecting a restrictive filling pattern. CONCLUSION: In patients with CC, NT-proBNP augmentation is a marker of LV dysfunction, with higher levels correlating with the more severe forms of both systolic and diastolic dysfunction.     

Chagas心脏病研究现状

<正>Chagas病即查加斯病,是一个古老的热带寄生虫病。该病由克氏锥虫感染引起,可累及皮肤、心脏和消化道等全身多个系统,因其广泛流行于墨西哥及拉丁美洲国家的贫穷地区也被称为美洲锥虫病(American trypanosomiasis)。但1909     

ECG Manifestations of the Biggest Outbreak of Chagas Disease due to Oral Infection in Latin-America

Background

Chagas disease affects more than 15 million people worldwide. Although vector-borne transmission has decreased, oral transmission has become important. Recently, our group published the clinical and epidemiological characteristics of the largest outbreak of orally transmitted Chagas disease reported till date. Objective: To describe electrocardiographic changes occurring in the study population during the outbreak caused by ingestion of contaminated guava juice.

Methods

We evaluated 103 positive cases, of which 76 (74%) were aged ≤ 18 years (average age: 9.1 ± 3.1 years) and 27 (26%) were aged > 18 years (average age: 46 ± 11.8 years). All patients underwent clinical evaluations and ECG. If the patients had palpitations or evident alterations of rhythm at baseline, ambulatory ECG monitoring was performed.

Results

A total of 68 cases (66%; 53 children and 15 adults) had ECG abnormalities. Further, 69.7% (53/76) of those aged ≤ 18 years and 56% (15/27) of those aged >18 years showed some ECG alteration (p = ns). ST-T abnormalities were observed in 37.86% cases (39/103) and arrhythmias were evident in 28.16% cases (29/103). ST alterations occurred in 72% of those aged ≤18 years compared with 19% of th ose aged >18 years (p < 0.0001).

Conclusion

This study reports the largest number of cases in the same outbreak of acute Chagas disease caused by oral contamination, with recorded ECGs. ECG changes suggestive of acute myocarditis and arrhythmias were the most frequent abnormalities found.