Screening of at-risk blood donors for Chagas disease in non-endemic countries: Lessons from a 2-year experience in Tuscany, Italy.

BACKGROUND: Chagas disease (CD) is caused by the protozoan parasite Trypanosoma cruzi and is transmitted by blood-sucking triatomine insects in endemic areas of Latin America. Transmission can also occur via blood transfusion and is a major cause of CD in non-endemic areas. OBJECTIVES: The aim of the study was to assess the prevalence of anti-T. cruzi antibodies in blood donors at risk of infection in Tuscany, Italy, following the introduction of blood safety Italian legislation. MATERIAL AND METHODS: Donors (N = 1985) were tested in 2016 to 2018 for anti-T. cruzi IgG using an immunochromatographic test (ICT). Chemiluminescent immunoassay (CLIA) was performed on ICT-positive donors to exclude CD, whereas enzyme-linked immunosorbent assay and western blot were performed in case of discordant results. All assays were performed on CD patients (N = 10) for validation. RESULTS: Ten blood donors had a positive ICT result, with a resulting T. cruzi seroprevalence of 0.5% but demonstrated negative results to CLIA, as well as to the other serological assays. The comparison of serological assays suggested a lower relative sensitivity of ICT. CONCLUSION: The results of this study confirm the significance of serological testing in the screening strategy for CD. However, they provide evidence for discontinuing the use of ICT as a screening test and suggest that a sensitive, specific and multi-sample format assay should be used at the national level for uniformity of results.

Molecular identification and genotyping of Trypanosoma cruzi DNA in autochthonous Chagas disease patients from Texas, USA.

The parasitic protozoan Trypanosoma cruzi, the causative agent of Chagas disease, is widely distributed throughout the Americas, from the southern United States (US) to northern Argentina, and infects at least 6 million people in endemic areas. Much remains unknown about the dynamics of T. cruzi transmission among mammals and triatomine vectors in sylvatic and peridomestic eco-epidemiological cycles, as well as of the risk of transmission to humans in the US. Identification of T. cruzi DTUs among locally-acquired cases is necessary for enhancing our diagnostic and clinical prognostic capacities, as well as to understand parasite transmission cycles. Blood samples from a cohort of 15 confirmed locally-acquired Chagas disease patients from Texas were used for genotyping T. cruzi. Conventional PCR using primers specific for the minicircle variable region of the kinetoplastid DNA (kDNA) and the highly repetitive genomic satellite DNA (satDNA) confirmed the presence of T. cruzi in 12/15 patients. Genotyping was based on the amplification of the intergenic region of the miniexon gene of T. cruzi and sequencing. Sequences were analyzed by BLAST and phylogenetic analysis by Maximum Likelihood method allowed the identification of non-TcI DTUs infection in six patients, which corresponded to DTUs TcII, TcV or TcVI, but not to TcIII or TcIV. Two of these six patients were also infected with a TcI DTU, indicating mixed infections in those individuals. Electrocardiographic abnormalities were seen among patients with single non-TcI and mixed infections of non-TcI and TcI DTUs. Our results indicate a greater diversity of T. cruzi DTUs circulating among autochthonous human Chagas disease cases in the southern US, including for the first time DTUs from the TcII-TcV-TcVI group. Furthermore, the DTUs infecting human patients in the US are capable of causing Chagasic cardiac disease, highlighting the importance of parasite detection in the population.

Chagas disease as a cause of heart failure and ventricular arrhythmias in patients long removed from endemic areas: an emerging problem in Europe.

Chagas disease is a parasitic disease caused by the protozoan Trypanosoma cruzi. In endemic areas (South and Central America), Chagas disease represents a relevant public health issue, and is the most frequent cause of cardiomyopathy. In nonendemic areas, such as Europe, Chagas disease represents an emerging problem following the establishment of sizeable communities from Brazil and Bolivia. Chagas cardiomyopathy represents the most frequent and serious complication of chronic Chagas disease, affecting about 20-30% of patients, potentially leading to heart failure, arrhythmias, thromboembolism, stroke and sudden death. Because late complications of Chagas disease may develop several years or even decades after the acute infection, it may be extremely challenging to reach the correct diagnosis in patients long removed from the countries of origin. We report two examples of Chagas cardiomyopathy in South American women permanently residing in Italy for more than 20 years, presenting with cardiac manifestations ranging from left ventricular dysfunction and heart failure to isolated ventricular arrhythmias. The present review emphasizes that Chagas disease should be considered as a potential diagnosis in patients from endemic areas presenting with 'idiopathic' cardiac manifestations, even when long removed from their country of origin, with potential implications for treatment and control of Chagas disease transmission.

Chagas disease in 2 geriatric rhesus macaques (Macaca mulatta) housed in the Pacific Northwest.

Chagas disease (American trypanosomiasis) is caused by the protozoan parasite Trypanosoma cruzi. It is endemic in Latin America but also is found in the southern United States, particularly Texas and along the Gulf Coast. Typical clinical manifestations of Chagas disease are not well-characterized in rhesus macaques, but conduction abnormalities, myocarditis, and encephalitis and megaesophagus have been described. Here we report 2 cases of Chagas disease in rhesus macaques housed in the northwestern United States. The first case involved a geriatric male macaque with cardiomegaly, diagnosed as dilated cardiomyopathy on ultrasonographic examination. Postmortem findings included myocarditis as well as ganglioneuritis in the esophagus, stomach, and colon. The second case affected a geriatric female macaque experimentally infected with SIV. She was euthanized for a protocol-related time point. Microscopic examination revealed chronic myocarditis with amastigotes present in the cardiomyocytes, ganglioneuritis, and opportunistic infections attributed to her immunocompromised status. Banked serum samples from both macaques had positive titers for T. cruzi. T. cruzi DNA was amplified by conventional PCR from multiple tissues from both animals. Review of their histories revealed that both animals had been obtained from facilities in South Texas more than 12 y earlier. Given the long period of clinical latency, Chagas disease may be more prevalent in rhesus macaques than typically has been reported. T. cruzi infection should be considered for animals with unexplained cardiac or gastrointestinal pathology and that originated from areas known to have a high risk for disease transmission.

Epidemiology of Chagas disease in Europe: many calculations, little knowledge.

Chagas disease and its causative agent Trypanosoma cruzi are endemic in almost all countries in South and Middle America. Currently, there are more than 10 million affected people. It is the most common reason for heart failure and a frequent cause of intestinal problems in Latin America. The phenotype of the Chagas cardiomyopathy is varying. Dilative cardiomyopathy, often accompanied by an apical aneurysm is the most common finding in the end stage heart failure, but rhythm disorders like conduction blocks, ventricular or supraventricular forms of tachycardia or repolarization changes occur as well, mainly in the early stages. Migration of infected people leads to a distribution from the endemic countries to North America and Europe. Although more than 500,000 people of Latin American origin are currently living in Europe, Chagas disease is not considered as a public health problem, yet. Cases of transmission via blood donation, organ transplantation or from mother-to-child are reported for several European countries but there is no database for Germany. Current epidemiological data are mostly available from regional surveys from other countries or are extrapolated. Hence, there is a large variation in the estimated numbers on the incidence of Chagas. Robust and reliable data are lacking. This review gives an overview on the currently available data and calls for a German Chagas surveillance.

Alteraciones electrocardiográficas en pacientes con enfermedad de chagas. Hospital José Rangel de Villa de Cura. 1998 - 2008 / Electrocardiographic abnormalities in patients with. chagas disease. Hospital José Rangel of Villa de Cura. 1998 - 2008

Objetivo: Analizar las principales alteraciones electrocardiográficas en pacientes con Enfermedad de Chagas que asistieron al Hospital José Rangel de Villa de Cura Edo. Aragua, entre los años 1998 -2008. Se realizó una revisión de historias clínicas y electrocardiogramas de la Unidad de Archivos del Hospital José Rangel de Villa de Cura. La población estuvo conformada por 85 pacientes con enfermedad de Chagas que asistieron al Hospital José Rangel de Villa de Cura entre los años 1998 - 2008. De ellos, 64 % de los pacientes tuvo edades comprendidas entre los 60 a 84 años, a predominio del sexo masculino en 55%. El trastorno de conducción más frecuente fue el bloqueo de rama (52,9%), principalmente bloqueo de rama derecha; El trastorno del ritmo más frecuente fue fibrilación auricular (55.3%), principalmente fibrilación auricular con respuesta ventricular rápida. También se observó extrasístole ventricular, bradicardia sinusal, arritmia ventricular, y otras alteraciones electrocardiográficas, principalmente alteraciones del segmento ST, alteraciones de la onda P y bajo voltaje. Las principales patologías cardiovasculares fueron: hipertensión arterial (49,4 %), insuficiencia cardíaca (57,6) enfermedad cerebrovascular (22,4%). Los medicamentos más utilizados fueron Ácido acetilsalicílico (60%), (55,3%), Digoxina (35,6%), Amiodarona (29,4%), Furosemida (57,3%), Espironolactona (31,8%), Captopril (44,7%), Enalapril (22,4%) y Clonidina (20%). solo 4,7% ameritó el uso de marcapasos. Metodología: La investigación se enmarca como un estudio epidemiológico descriptivo de corte transversal. Conclusiones: Se concluye que en estos pacientes la presencia de fibrilación auricular fue levemente más frecuente que el bloqueo de rama, con alta frecuencia de hipertensión arterial e insuficiencia cardíaca, indicando grave compromiso cardíaco y mal pronóstico.

Objective: To analyze the electrocardiographic changes in patients with Chagas disease who attended the Hospital José Rangel de Villa de Cura Edo. Aragua, between the years 1998 -2008. Clinical records and electrocardiograms in the archives unit were reviewed. The population consisted of 85 patients with Chagas disease who attended the Hospital José Rangel of Villa de Cura between the years 1998 to 2008. Of these, 64% of patients were aged 60-84 years, 55% of patients were male. Branch block disorder was the most frequent (52,9%), with predominance of right bundle branch block (31,7%), Atrial fibrillation was the most common rhythm disorder (55,3%), with predominance of atrial fibrillation with rapid ventricular response. (3,7%) was also observed ventricular extrasystole, sinus bradycardia, ventricular arrhythmia and other ECG abnormalities, particularly ST-segment abnormalities, alterations in the P wave and low voltage. The major cardiovascular diseases were: hypertension (49,4%), heart failure (57,6) cerebrovascular disease (22,4%). Acetylsalicylic acid was the drug most used (60%), and also Isosorbide (55,3%), Digoxin (35.6%), Amiodarone (29,4%), Furosemide (57,3%), Spironolactone (31,8%), Captopril (44,7%), Enalapril (22,4%) and Clonidine (20%). just 4,7% required the use of pacemakers. Methodology: The research was framed as cross sectional a descriptive epidemiological study. Conclusions: We conclude that in these patients the presence of atrial fibrillation was slightly more common than bundle branch block, with a high frequency of hypertension and heart failure, indicating severe heart failure and poor prognosis.

[Migration flow and imported diseases: chronic chagasic cardiomyopathy]. / Flussi migratori e nuove patologie di importazione: la cardiomiopatia chagasica cronica.

Chagas disease, caused by the parasite Trypanosoma cruzi, is transmitted by triatomine bugs in endemic regions of the American continent and less frequently by blood transfusion and congenital transmission. Immigration rates explain why the disease can be found worldwide. Non-endemic countries that receive a significant amount of Latin American immigrants should be familiarized with the disease to allow prevention, diagnosis and early treatment. In Italy, where no serologic screening is routinely performed to detect Trypanosoma cruzi in blood donations, a special consideration must be held. Accordingly, attention to congenital transmissions of the disease should be drawn considering the lack of newborn screening. Though commonly unrecognized, chronic chagasic cardiomyopathy is the most common type of chronic myocarditis in the world.

Prognostic impact of Chagas disease in the United States.

A prior publication from our group reported the fact that Chagas disease is underdiagnosed. This review will summarize several aspects of Chagas disease in the United States including modes of transmission, which will demonstrate that clinicians should be more aware of the disease and its consequences. Trypanosoma cruzi is present in many animal species spread throughout most of the United States. Chagas disease also reaches the North American continent through immigration, making it more frequent than expected. Apart from immigration, non-endemic countries should be aware of transmissions through blood transfusions, organ transplantations, or mother-to-child infections. In conclusion, it is possible that many chagasic cardiomyopathies are being misdiagnosed as "primary dilated idiopathic cardiomyopathies." Recognizing that there is an evident threat of Chagas disease present in the United States will allow an increase of clinician's awareness and hence will permit to correctly diagnose and treat this cardiomyopathy. Health authorities should guarantee a generalized screening of T cruzi of blood donors, before organ donations, and of pregnant women who were born or have lived in endemic areas.

Diagnóstico, manejo y tratamiento de la cardiopatía chagásica crónica en áreas donde la infección por Trypanosoma cruzi no es endémica / Diagnosis, management and treatment of chronic Chagas' heart disease in areas where Trypanosoma cruzi infection is not endemic

La enfermedad de Chagas o tripanosomiasis americana es una parasitosis originaria del continente americano. En la naturaleza, Trypanosoma cruzi se transmite vectorialmente a través de diversas especies de chinches triatominos. No obstante, se han descrito otros mecanismos de transmisión no vectorial, como la transmisión a través de productos sanguíneos o mediante el trasplante de órganos infectados, y la transmisión vertical. Actualmente, la enfermedad de Chagas afecta a unos 10-12 millones de personas en el mundo y el proceso de urbanización en América Latina y los movimientos migratorios desde los países endémicos han posibilitado que la enfermedad de Chagas sea diagnosticada en zonas donde la infección no es endémica. Se considera que un 20-30% de las personas infectadas por T. cruzi desarrollarán a lo largo de su vida alteraciones cardiacas. Las características diferenciales de la cardiopatía chagásica, el escaso conocimiento que se tiene de ella en nuestro medio y la elevada frecuencia de arritmias y muerte súbita como primeras manifestaciones potenciales de esta enfermedad hacen prioritarias la elaboración y divulgación de protocolos diagnósticos y terapéuticos para la atención de estos pacientes a fin de mejorar el conocimiento de esta patología por los profesionales sanitarios potencialmente implicados en su detección y manejo

Chagas' disease, or American trypanosomiasis, is a parasitic zoonosis found only in the Americas. Under natural conditions, Trypanosoma cruzi is transmitted by insects belonging to different species of Triatoma. However, several routes of transmission that do not involve insect vectors have also been described, such as transmission via blood products or transplantation of infected organs, and vertical transmission. At present, the number of people infected with Chagas' disease worldwide is estimated to be about 10-12 million. The process of urbanization in Latin America and migratory population movements from endemic countries have led to the disease being diagnosed in non-endemic areas. It is estimated that 20-30% of individuals infected with T. cruzi will develop symptomatic heart disease at some point during their lives. The specific differential characteristics of chronic chagasic cardiopathy, lack of knowledge of the disease among many healthcare workers, and the fact that arrhythmia or sudden death is frequently the first manifestation of disease all make it essential that diagnostic and therapeutic protocols for the disease are developed and disseminated. The aim should be to improve patient care by increasing understanding of the condition by physicians and other healthcare professionals who may be involved in its detection and treatment

Chagas disease in a domestic transmission cycle, southern Texas, USA.

After three dogs died from acute Chagas cardiomyopathy at one location, an investigation was conducted of the home, garage, and grounds of the owner. A serologic study was conducted on stray dogs, and an ecologic niche model was developed to predict areas where the vector Triatoma gerstaeckeri might be expected.

[Chagasic cardiopathy in endemic area versus sporadically infected patients]. / Cardiopatía chagásica en pacientes de área endémica versus contagiados en forma ocasional.

The aim of the study was to compare the degree of cardiac compromise between two patient groups infected with Chagas' disease, A) those permanently residing in endemic areas and B) those sporadically exposed to the parasite and indirectly (non-vector) infected (transfusion, mother-to-child transmission, etc.). The results show that patients sporadically infected presented a lower prevalence of cardiopathy, and when they do present cardiopathy, there is a lower prevalence of dilation when compared to infected patients residing in endemic areas. Also, the role of the parasite, number of reinfections, immunopathogenic mechanisms, quality of life and occupation are considered in the study of disease progression in each patient.

Enfermedad de Chagas en el grupo familiar de un caso crónico de curso fatal en un área sin triatominos del departamento de Ica Perú / Chagas disease in the familial group of a chronic case with fatal course in an area free of triatomines at Ica department, Peru

El propósito de esta comunicación es presentar dos casos de enfermedad de Chagas en el grupo familiar de un caso índice, procedente de Arequipa región sudoccidental del Perú, el cual es una área endémica. El caso índice sufrió una muerte súbita por cardiomiopatía chagásica en una localidad sin triatominos del departamento de Ica. Su hermana y su sobrino mostraron anticuerpos IgG específicos contra Trypanosoma cruzi por Inmunoensayo Enzimático (ELISA) e Inmunofluorescencia Indirecta (IFI), ambos familiares tenían antecedentes de haber vivido en el valle endémico de Vítor (Arequipa). Nuestros resultados enfatizan la importancia de la investigación epidemiológica en el grupo familiar de un caso crónico en áreas de bajo riesgo

Evidence of Trypanosoma cruzi infection (Chagas' disease) among patients undergoing cardiac surgery.

BACKGROUND: Trypanosoma cruzi, the agent of Chagas' heart disease, is transmitted by triatomine insects and by blood transfusion. The emigration of several million people from T cruzi-endemic countries to the United States has raised concerns regarding a possible increase in cases of Chagas' heart disease here, as well as an increased risk of transfusion-transmitted T cruzi. To investigate these 2 possible outcomes, we tested a repository of blood specimens from multiply transfused cardiac surgery patients for antibodies to T cruzi. METHODS AND RESULTS: Postoperative blood specimens from 11 430 cardiac surgery patients were tested by enzyme immunoassay, and if repeat-reactive, were confirmed by radioimmunoprecipitation. Six postoperative specimens (0.05%) were confirmed positive. Corresponding preoperative specimens, available for 4 of these patients, were also positive. The other 2 patients had undergone heart transplantations. Tissue samples from their excised hearts were tested for T cruzi by polymerase chain reaction and were positive. Despite the fact that several of these 6 patients had histories and clinical findings suggestive of Chagas' disease, none of them were diagnosed with or tested for it. Patient demographics showed that 5 of 6 positive patients were Hispanic, and overall, 2. 7% of Hispanic patients in the repository were positive. CONCLUSIONS: No evidence for transfusion-transmitted T cruzi was found. All 6 seropositive patients apparently were infected with T cruzi before surgery; however, a diagnosis of Chagas' disease was not known or even considered in any of these patients. Indeed, Chagas' disease may be an underdiagnosed cause of cardiac disease in the United States, particularly among patients born in countries in which T cruzi is endemic.

[Regression of acute Chagas cardiopathy in an infant with a suspected transfusion infection]. / Regresión de la cardiopatía chagásica aguda en un lactante menor con sospecha de infección transfusional. Nueve años de seguimiento.

Chagas disease was described in Mexico by Mazzotti in 1940. Post-transfusional cases have not been described. We report proved case of acute chagasic cardiopathy in a nine months old infant with suspected transfusional infection during neonatal period. She was treated with nifurtimox with disappearance of parasites and regression of cardiopathy. She is asymptomatic nine years afterwards with normal growth and negative parasitology and serology.