Doença de Chagas congênita com manifestações pleomórficas: relato de caso / Congenital Chagas disease in adolescent with pleomorphic manifestations: case report

JUSTIFICATIVA E OBJETIVOS: A doença de Chagas é uma infecção parasitária, endêmica, em várias regiões do Brasil. Nas últimas décadas, a via de transmissão predominante foi modificada de vetorial para congênita, devido ao êxodo rural e aos métodos mais eficazes de combate aos vetores. Alguns pacientes jovens apresentam manifestações crônicas e intensas, consequentes da transmissão congênita. O objetivo deste estudo foi relatar um caso de uma paciente com doença de Chagas de transmissão vertical com manifestações variadas da doença. Ressalta-se a importância de se conhecer diversas formas de transmissão e, ademais, enfatiza-se a importância de realizar adequado pré-natal em áreas endêmicas para possível diagnóstico, tratamento precoce e acompanhamento clínico. RELATO DO CASO: Paciente do sexo feminino, 20 anos, solteira, apresentando há 8 meses dispneia aos mínimos esforços, precordialgia, epigastralgia e tosse seca, evoluindo com disfagia, confirmando-se o diagnóstico de insuficiência cardíaca com exames complementares. A investigação prosseguiu com provas sorológicas, eletrocardiograma, radiografia do coração e vasos da base (RCVB), Ecodopplercardiograma, confirmando-se: IgG positivo para Chagas em dois testes sorológicos (hemaglutinação indireta e imunofluorescência para T. Cruzi), alterações eletrocardiográficas difusas, megaesôfago grau II, cardiomegalia grau III. Foi realizado tratamento etiológico com benzonidazol (Rochagan®) para doença de Chagas crônica de início recente. Apesar da dificuldade na obtenção dos exames complementares,objetivando maior acurácia no diagnóstico e melhor acompanhamento do tratamento, concluiu-se que era um caso de doença de Chagas congênita, uma vez que a história familiar era positiva e a paciente não teve contato com triatomídeos (morou sempre na área urbana) e a transmissão vetorial está diminuindo devido às campanhas de erradicação dos vetores...

BACKGROUND AND OBJECTIVES: Chagas disease is a parasitic infection, endemic in several regions of Brazil. In recent decades the predominant route of transmission changed from vectorial to congenital, due to rural exodus and more effective methods for fighting the vectors. Some young patients have chronic and severe manifestations due to congenital transmission. The aim of this study was to report a case of a young adult patient with Chagas disease vertical transmission, with varied clinical manifestations of the disease. The importance of knowing the various forms of transmission was emphasized and also of the importance of prenatal assistance in endemic areas for possible early diagnosis, treatment and clinical follow up. CASE REPORT: Female patient, 20 years old, single, has presented experiencing, for the previous 8 months, dyspnea on exertion, constrictive chest pain, epigastric pain, and dry cough associated with progressive dysphagia; the diagnosis of heart failure was confirmed by complementary tests. The investigation progressed with serological tests, electrocardiogram, chest teleradiograph, echodopplercardiogram, confirming: IgG positive for Chagas disease, in two different serological tests (indirect hemagglutination assay and immunofluorescence for T cruzi), diffuse electrocardiographic changes, grade II megaesophagus, grade III cardiomegaly. Etiological treatment was conducted with benzonidazol (Rochagan®) for chronic Chagas disease of recent onset. Despite the difficulty in obtaining additional tests, aiming greater accuracy in the diagnosis and better monitoring of the treatment, it was concluded that it was a case of congenital Chagas disease, since family history is positive and the patient denied having contact with triatomids (hematophagus bugs) as she has always lived in urban areas, and because vectorial transmission is declining due to campaigns for eradication of the vectors...

Chagas en gestantes y transmisión vertical / Chagas in pregnant women and vertical transmission

La enfermedad de Chagas o tripanosomiasis sudamericana, es una parasitosis crónica causada por el protozoario flagelado Tripanosoma cruzi. Este agente puede ser transmitido de la madre al hijo por vía transplacentaria durante la fase aguda y/o crónica de la infección materna. Objetivo: Evaluar la seroprevalencia de la enfermedad de Chagas en gestantes y en niños de madres seropositivas a T. cruzi y su relación con algunos factores condicionantes en el Municipio Roscio del estado Guárico. Métodos: Se realizó un estudio de tipo transversal, estudiando la enfermedad de Chagas en gestantes y en niños (as) nacidos de madres reactivas al T. cruzi. La muestra estuvo conformado por una población representada por todas las gestantes (925) que acudieron al primer control de embarazo en la red primaria de atención, y otra, por los hijos (as) (2) nacidos de madres seropositivas a T. cruzi. Resultados: Se detectaron dos gestantes reactivas utilizando Anticuerpos IgG, obteniéndose una seroprevalencia de 0,22 por ciento. Los dos hijos nacidos de estas madres reactivas resultaron No Reactivos mediante la técnica parasitológica directa (Microhematocrito), confirmando el diagnóstico con ELISA y Hemaglutinación Indirecta.

Usefulness of PCR-based assays to assess drug efficacy in Chagas disease chemotherapy: value and limitations

One major goal of research on Chagas disease is the development of effective chemotherapy to eliminate the infection from individuals who have not yet developed cardiac and/or digestive disease manifestations. Cure evaluation is the more complex aspect of its treatment, often leading to diverse and controversial results. The absence of reliable methods or a diagnostic gold standard to assess etiologic treatment efficacy still constitutes a major challenge. In an effort to develop more sensitive tools, polymerase chain reaction (PCR)-based assays were introduced to detect low amounts of Trypanosoma cruzi DNA in blood samples from chagasic patients, thus improving the diagnosis and follow-up evaluation after chemotherapy. In this article, I review the main problems concerning drug efficacy and criteria used for cure estimation in treated chagasic patients, and the work conducted by different groups on developing PCR methodologies to monitor treatment outcome of congenital infections as well as recent and late chronic T. cruzi infections.

Guías clínicas de la enfermedad de Chagas: Parte II. Enfermedad de Chagas en el adulto, la infancia y adolescencia / Guidelines for the Chagas disease: Part II. Chagas disease in adults, infancy and adolescence

Se describen las distintas etapas de la enfermedad en el adulto: aguda, indeterminada o latente y crónica. Se menciona cómo se realiza el diagnóstico etiológico y la indicación de tratamiento. En la etapa crónica, cuando existe compromiso cardíaco así como también digestivo (esófago o colon), se mencionan los síntomas y signos, la evolución, los exámenes de apoyo diagnóstico y el tratamiento. Se analiza la enfermedad de Chagas congénita desde su prevalencia en la embarazada, la etapa de la enfermedad en la madre, las repercusiones de la transmisión del parásito sobre el producto de la concepción, la frecuencia de la transmisión, cómo se produce la infección del feto, la situación en embarazos sucesivos, hasta las consecuencias sobre el recién nacido, incluyendo la sintomatología cuando éste nace enfermo. Se comenta la concomitancia con la infección por virus de inmunodeficiencia humana. Las formas de presentación no vertical en la infancia y adolescencia no difieren de la enfermedad de Chagas en el adulto. Se menciona el diagnóstico directo e indirecto de la infección y se presenta un algoritmo del diagnóstico y seguimiento de la infección vertical por Tripanosoma cruzi.

The different stages of Chagas disease in adults: acute, undetermined or latent and chronic phases are described. This document contains guidelines for etiological diagnosis of Chagas disease and its treatment. In chronic phase, as cardiac and digestive system (esophagus and colon) are affected, symptoms and signs, evolution of the disease, laboratory analysis and treatment are described. The following topics in congenital Chagas disease are boarded: its prevalence in pregnant women, the importance of mother phase of disease, repercussions of the parasite transmission to the fetus, the frequency of transmission, how the infection to the fetus is produced, the importance of chronic infection in consecutive pregnancies, and clinical consequences to the newborn infant including symptoms of congenital disease. Concomitance with human immunodeficiency virus is commented. No vertically transmitted Chagas disease in infancy and adolescents has similar clinical manifestations as in adults. Direct and indirect laboratory tests of infection are described and an algorithm for diagnosis and follow up of vertical transmission of Trypccnosoma cruzi is presented.

Chagas disease: what is known and what is needed - A background article

Chagas disease began millions of years ago as an enzootic disease of wild animals and started to be transmitted to man accidentally in the form of an anthropozoonosis when man invaded wild ecotopes. Endemic Chagas disease became established as a zoonosis over the last 200-300 years through forest clearance for agriculture and livestock rearing and adaptation of triatomines to domestic environments and to man and domestic animals as a food source. It is estimated that 15 to 16 million people are infected with Trypanosoma cruzi in Latin America and 75 to 90 million people are exposed to infection. When T. cruzi is transmitted to man through the feces of triatomines, at bite sites or in mucosa, through blood transfusion or orally through contaminated food, it invades the bloodstream and lymphatic system and becomes established in the muscle and cardiac tissue, the digestive system and phagocytic cells. This causes inflammatory lesions and immune responses, particularly mediated by CD4+, CD8+, interleukin-2 (IL) and IL-4, with cell and neuron destruction and fibrosis, and leads to blockage of the cardiac conduction system, arrhythmia, cardiac insufficiency, aperistalsis, and dilatation of hollow viscera, particularly the esophagus and colon. T. cruzi may also be transmitted from mother to child across the placenta and through the birth canal, thus causing abortion, prematurity, and organic lesions in the fetus. In immunosuppressed individuals, T. cruzi infection may become reactivated such that it spreads as a severe disease causing diffuse myocarditis and lesions of the central nervous system. Chagas disease is characterized by an acute phase with or without symptoms, and with entry point signs (inoculation chagoma or Romaña's sign), fever, adenomegaly, hepatosplenomegaly, and evident parasitemia, and an indeterminate chronic phase (asymptomatic, with normal results from electrocardiogram and x-ray of the heart, esophagus, and colon) or...

Tratamiento integral de la enfermedad de Chagas congenita: la experiencia boliviana / Integral treatment of congenital Chagas disease: the Bolivian experience

We have analyzed the response to the treatment with benznidazol in newborns and nurslings in the Hospital Materno Infantil Germán Urquidi of Cochabamba, Bolivia, between 1999 and 2002. It is important an integral treatment of the nursling with a subsequent information directed to the family. The response was close to 100% when the treatment was correctly administrated. They were not adverse effects and the detected biochemical alterations did not present clinical significance.

Nivel de endemia de la infección por Trypanosoma cruzi en el lugar de residencia de la madre y desarrollo de la enfermedad de Chagas congénita en Bolivia / Endemic level of congenital Trypanosoma cruzi infection in the areas of maternal residence and the development of congenital Chagas disease in Bolivia

In Bolivia, the prevalence of infection by T. cruzi in women in fertile age can vary between 20 and 60%. The present study made in the Maternity Germin Urquidi of Cochabamba - Bolivia, it has demonstrated, that 19.9% of the mothers who go to this hospitable center to be taken care of in the childbirth, they are carrying of the infection and that 4,6% of them, they are going to transmit, by transplacentaria route, the infection to its babies. Of the 71 children born with congenital Chagas, only 47,8 % present/display some type of alteration or of development(Apgar to 1 minute low, BPN, prematuridad, pathological dismadurez) or signs (SDR, hepatomegalia, esplenomegalia, neurological signs, cardiomegalia, anasarca, petequias). When investigating the effect of the differences in the vectorial density (low, medium and high) of the zone of maternal residence, on the transmission of the infection of the mother infected to the fetus, we concluded that the rate of transmission of the congenital infection of T. cruzi is not modified by the level of endemicidad of the zone of maternal residence. By another infected new born sides whose mothers reside in zones of high endemicidad present/display, most frequently and of significant way, Apgar to 1 minute < to 7, low weight when being born and prematuridad or an association of these alterations with respiratory syndrome of distress or anasarca, when one compares them with new born of resident mothers in the zones of loss or medium endemicidad, mortality in this group is greater. These results suggest calls to account it of the mothers, in areas of high endemicidad, she is associate with a serious increase in the risk of Disease of newborn severe and mortal congenital Chagas in.

Tratamiento de la enfermedad de Chagas / Treatment of Chagas disease

En la actualidad se acepta que la enfermedad de Chagas humana debe ser tratada en cualquier período de su evolución con la única excepción del período crónico terminal. En el período agudo clínico, infección de menos de 2 meses así como en el biológico: pesquisa de parásitos al fresco, frotis, gota gruesa y con serología convencional positiva e IgM(+). El ideal de tratamiento es con nifurtimox (NF) 8-10 mg/kg día en adultos y 15 mg/kg día en niños por 60-90 días. La dosis se reparte en tres tomas. La curación clínica y serológica es de un 60 por ciento. En Brasil donde se utiliza este fármaco se trata con benznidazol (BNZ) 5 mg/kg día (adultos) y 5-10 mg/kg día en niños por 60 días. En las infecciones congénitas la terapia debe ser precoz en cuanto se realice el diagnóstico por clínica y pesquisa del parásito al fresco, frotis, microstraut etc. Muchas veces el diagnóstico se efectúa por persistenica de la serología por más de 6 meses y el recién nacido ya esta en etapa crónica de la infección. Es necesario efectuar seguimiento clínico serológico y parasitológico de los casos. Las infecciones accidentales deben ser tratadas por 10 días. En los trasplantes de órganos en que el receptor o dador es chagásico se debe indicar terapia con NF o BNZ a igual dosis y tiempo que la señalada anteriormente. Las reactivaciones en los casos crónicos ejem: que adquieren un SIDA o que presentan depresiones del sistema inmunidad celular como leucemias, Hodgkin, etc se deben tratar como cuadros agudos con NF ó NBZ por períodos prolongados de 5 ó más meses. En estos casos obviamente la prevención es lo ideal: hacer serología para Chagas a los pacientes con SIDA, etc

Poblaciones de trypanosoma cruzi altamente homogéneas en una región de baja endemia chagásica: relevancia en la patogenia de la enfermedad de Chagas en Chile / Highly homogeneous trypanosoma cruzi populations in a low endemic region for Chagas disease: importance in the pathogenesis of Chagas disease in Chile

Trypanosoma cruzi from 23 chronic and acute cases of Chagas dosease were isolated and further characterized. They displayed a remarkable similarity, after typification by schizodeme analysis using restriction endonuclease Eco Ri. All trypanosoma cruzi isolates belonged to the isoenzymatic Zymodeme 2 Bol. These findings were corroborated analyzing cases from families with demonstrated congenital transmission. The acute cases were newborns or offspring of infected mothers or patients with AIDS. All trypanosoma cruzi strains isolated in theses cases were very similar with almost identical schizodemes. Patients with AIDS had severe clinical manifestations whereas children with congenital infections had a great variety of clinical symptoms. In chronic cases, little clinical differences were observated for the different trypanosoma cruzi strains. It is concluded that there is a low correlation between the trypanosoma cruzi strain and the clinical prognosis of Chagas disease, being of greater relevance the host's genetic background and inmune response

Leiomiócitos parasitados pelo Trypanosoma Cruzi nas formas congênita e crônica adquirida da doença de Chagas / Smooth muscle cells infected by Trypanosoma Cruzi in congenital and chronic acquired forms of Chagas disease

Os leiomiócitos parassitados pelo T. cruzi, de vasos umbilicais e placentários de casos congênitos da doença de Chagas, foram comparados com células semelhantes da veia suprarrenálica de chagásicos crônicos. Observou-se que algumas destas células, em ambos os grupos, apresentavam envoltório visto à microscopia de fase, nas preparaçöes näo coradas, e à microscopia de luz comum, quando coradas pelo PAS e pela HE. A prata-metenamina cora apenas o envoltório das células parasitadas dos casos de doença de Chagas congênita. A técnica do picro-sirius, associada à microscopia de luz polarizada, mostra que ambos os grupos de leiomiócitos parasitados podem apresentar delicada membrana com birrefrigência discreta "verde limäo", enquanto que un envoltório espesso com forte birrefrigência amarelada ou brancacente é visto apenas nos leiomiócitos fetais. A técnica da peroxidase anti-peroxidase cpara T. cruzi mostra acúmulo de material PAP-positivo formando uma faixa interrompida que se coloca mais internamente à faixa PAS-positivo, em ambas as formas da doença. As modificaçöes nucleares e citoplasmáticas das células fetais parasitadas (Chagas congênito) e dos adultos (chagásicos crônicos) säo muito semelhantes, destacando-se o gigantismo nuclear, o aparecimento de grânulos algumas vezes PAP-positivo, e a desproporçäo entre o aumento do volume celular e o número de parasitas. É possível que o estado de imunodeficiência, localizado na glândula suprarrenal do adulto e o tecido fetal tenham algum papel na gênese dessa peculiaridade das células parasitadas, comuns na doença de Chagas congênita e na forma crônica adquirida

Epidemiologia da transmissäo congênita da Doença de Chagas: subsídios para a formulaçäo de um projeto de investigaçäo / Epidemiology of the congenital Chagas disease transmission: subsidies for the formulation of a research project

Este trabalho objetiva o fornecimento de subsídios a projetos de investigaçäo sobre a doença de Chagas congênita. Inicialmente, apresenta um histórico dos estudos sobre a transmissäo congênita da doença de Chagas, desde a data de suspeiçäo de sua ocorrência em 1911, até o ano de 1985. Em seguida, expöe o quadro epidemiológico da doença de Chagas, no Estado de Säo Paulo, mostrando a interrupçäo da transmissäo natural, no intuito de apontar o interesse dos estudos, para se conhecer a freqüência de ocorrência da transmissäo intra-uterina dessa enfermidade nesta área. Baseando-se nos conhecimentos referidos, delineia as várias etapas de um projeto de pesquisa a respeito do tema.

Normas para atención médica del infectado chagásico / Standards of medical attention to the chagasic infected

Un grupo de expertos e investigadores del Programa Nacional de Investigación elaboraron normas de atención médica para el infectado chagásico, formulando recomendaciones para la anámnesis, el examen físico, de laboratorio (inmunodiagnóstico y de análisis clínicos), electrocardiográficos y radiográficos; para el control del recién nacido hijo de madre chagásica; el tratamiento etiológico con nifurtimox y benznidazol (administración, dosificación, precauciones, signos de intolerancia a estas drogas, y contraindicaciones); y otros exámenes complementarios para pacientes con enfermedad de Chagas aguda, crónico, congénito, o con cardiomiopatía chagásica o que presentan trastornos cardiovasculares. También se dan normas para el control de doadores de sangre, a seguir en bancos de sangre, para la detección de Chagas transfusional. Finalmente, se da la orientación laboral para el paciente, según sea el grado de infección en que se encuentre

Enfermedad de Chagas: aportes del Programa Nacional de Investigación en Enfermedades Endemicas 1979-1983 / Chagas' disease: contributions of the Programa Nacional de Investigación en Enfermedades Endemicas 1979-1983

Revisa los resultados obtenidos, entre 1979 y 1983, por investigadores del Programa Nacional de Investigación en Enfermedades Endémicas (PNIEE) de la Secretaría de Estado de Ciencia Y Tecnología (Argentina), sobre siversos aspectos de la enfermedad de Chagas: respuesta inmune; aspectos clínicos en la enfermedad agúda y crónica; miocarditis crónica chagásica; enfermedad de Chagas congénita; bióquímica del Trypanosoma cruzi; quimioterapia; aspctos entomológicos y control integrado. Incluye los resúmenes presentados a la 6a. Reunión de Investigadores de la Enfermedad de Chagas