Chagas disease: Management of acute disease, early chronic disease, and disease in immunocompromised hosts
- Caryn Bern, MD, MPH
Caryn Bern, MD, MPH
- Professor, Global Health Sciences
- University of California, San Francisco
Chagas disease is caused by infection with the protozoan parasite Trypanosoma cruzi. Issues related to management of acute Chagas, congenital Chagas, chronic Chagas, and Chagas in the setting of immunosuppression are reviewed here. The approach to antitrypanosomal therapy for Chagas disease varies by phase and form of disease (table 1 and table 2).
Management of cardiac and gastrointestinal manifestations of chronic Chagas disease is discussed separately (see "Chagas gastrointestinal disease" and "Chagas heart disease: Treatment and prognosis", section on 'Management'). Dosing and adverse effects for antitrypanosomal drugs are discussed in detail separately. (See "Chagas disease: Antitrypanosomal drug therapy".)
ACUTE CHAGAS DISEASE
The natural history and diagnosis of acute and congenital Chagas disease are discussed in detail separately. (See "Chagas disease: Natural history and diagnosis", section on 'Acute phase'.)
Antitrypanosomal therapy with benznidazole or nifurtimox can reduce the severity of symptoms, shorten the clinical course, and reduce the duration of detectable parasitemia in acute and early congenital Chagas disease [1-4]. In the acute phase, parasitological cure (as well as clinical cure) is thought to occur in 60 to 85 percent of patients treated [1-4].
Among congenitally infected infants treated in the first year of life, parasitological cure is thought to occur in >90 percent of cases [1,4-6]. Treatment of infected infants should be initiated as soon as the diagnosis is made; the drugs are well tolerated in infancy [1,7,8]. Successful treatment is assumed to decrease or eliminate risk of later complications, although longitudinal data are lacking [9,10].
- Wegner DH, Rohwedder RW. The effect of nifurtimox in acute Chagas' infection. Arzneimittelforschung 1972; 22:1624.
- Lopez-Velez R, Norman FF, Bern C. American Trypanosomiasis (Chagas Disease). In: Hunter's Tropical Medicine and Emerging Infectious Desease, 9th ed, Magill AJ, Ryan ET, Solomon T, Hill DR (Eds), Saunders, Philadelphia 2013. p.725.
- Kirchhoff LV. Chagas disease. American trypanosomiasis. Infect Dis Clin North Am 1993; 7:487.
- Cancado JR, Brener Z. Terapeutica. In: Trypanosoma cruzi e doença de Chagas, 1st ed, Guanabara Koogan, Rio de Janeiro, Brazil 1979. p.362.
- Rodriques Coura J, de Castro SL. A critical review on Chagas disease chemotherapy. Mem Inst Oswaldo Cruz 2002; 97:3.
- Altcheh J, Biancardi M, Lapeña A, et al. [Congenital Chagas disease: experience in the Hospital de Niños, Ricardo Gutiérrez, Buenos Aires, Argentina]. Rev Soc Bras Med Trop 2005; 38 Suppl 2:41.
- Russomando G, de Tomassone MM, de Guillen I, et al. Treatment of congenital Chagas' disease diagnosed and followed up by the polymerase chain reaction. Am J Trop Med Hyg 1998; 59:487.
- Centers for Disease Control and Prevention (CDC). Congenital transmission of Chagas disease - Virginia, 2010. MMWR Morb Mortal Wkly Rep 2012; 61:477.
- Schijman AG. Congenital Chagas Disease. In: Congenital and Other Related Infectious Diseases of the Newborn, Mushahwar IK (Ed), Elsevier, Amsterdam, Netherlands 2006. Vol 13, p.223.
- Freilij H, Altcheh J. Congenital Chagas' disease: diagnostic and clinical aspects. Clin Infect Dis 1995; 21:551.
- Drugs for Neglected Disease Initiative. Chagas disease: DNDi Strategy, 2010.
- Diez M, Favaloro L, Bertolotti A, et al. Usefulness of PCR strategies for early diagnosis of Chagas' disease reactivation and treatment follow-up in heart transplantation. Am J Transplant 2007; 7:1633.
- Norman FF, López-Vélez R. Chagas disease and breast-feeding. Emerg Infect Dis 2013; 19:1561.
- Bern C. Antitrypanosomal therapy for chronic Chagas' disease. N Engl J Med 2011; 364:2527.
- Bern C, Montgomery SP, Herwaldt BL, et al. Evaluation and treatment of chagas disease in the United States: a systematic review. JAMA 2007; 298:2171.
- Lázzari JO, Pereira M, Antunes CM, et al. Diagnostic electrocardiography in epidemiological studies of Chagas' disease: multicenter evaluation of a standardized method. Rev Panam Salud Publica 1998; 4:317.
- Rassi A Jr, Rassi A, Marin-Neto JA. Chagas disease. Lancet 2010; 375:1388.
- WHO Expert Committee. Control of Chagas Disease. World Health Organization, Brasilia, Brazil 2002. p. 1.
- Ministério da Saúde. Secretaria de Vigilância em Saúde. [Brazilian Consensus on Chagas disease]. Rev Soc Bras Med Trop 2005; 38 Suppl 3:7.
- Viotti R, Vigliano C, Lococo B, et al. Long-term cardiac outcomes of treating chronic Chagas disease with benznidazole versus no treatment: a nonrandomized trial. Ann Intern Med 2006; 144:724.
- Sosa-Estani S, Segura EL. Etiological treatment in patients infected by Trypanosoma cruzi: experiences in Argentina. Curr Opin Infect Dis 2006; 19:583.
- Morillo CA, Marin-Neto JA, Avezum A, et al. Randomized Trial of Benznidazole for Chronic Chagas' Cardiomyopathy. N Engl J Med 2015; 373:1295.
- Wegner DH, Rohwedder RW. Experience with nifurtimox in chronic Chagas' infection. Preliminary report. Arzneimittelforschung 1972; 22:1635.
- Sosa-Estani S, Cura E, Velazquez E, et al. Etiological treatment of young women infected with Trypanosoma cruzi, and prevention of congenital transmission. Rev Soc Bras Med Trop 2009; 42:484.
- Fabbro DL, Danesi E, Olivera V, et al. Trypanocide treatment of women infected with Trypanosoma cruzi and its effect on preventing congenital Chagas. PLoS Negl Trop Dis 2014; 8:e3312.
- Sosa Estani S, Segura EL, Ruiz AM, et al. Efficacy of chemotherapy with benznidazole in children in the indeterminate phase of Chagas' disease. Am J Trop Med Hyg 1998; 59:526.
- de Andrade AL, Zicker F, de Oliveira RM, et al. Randomised trial of efficacy of benznidazole in treatment of early Trypanosoma cruzi infection. Lancet 1996; 348:1407.
- Pérez-Molina JA, Pérez-Ayala A, Moreno S, et al. Use of benznidazole to treat chronic Chagas' disease: a systematic review with a meta-analysis. J Antimicrob Chemother 2009; 64:1139.
- Reyes PA, Vallejo M. Trypanocidal drugs for late stage, symptomatic Chagas disease (Trypanosoma cruzi infection). Cochrane Database Syst Rev 2005; :CD004102.
- Villar JC, Marin-Neto JA, Ebrahim S, Yusuf S. Trypanocidal drugs for chronic asymptomatic Trypanosoma cruzi infection. Cochrane Database Syst Rev 2002; :CD003463.
- Rassi A, Luquetti AO. Specific treatment for Trypanosoma cruzi infection (Chagas disease).. In: American Trypanosomiasis, Miles MA, Tyler KM (Eds), Kluwer Academic Publishers, Boston 2003. p.117.
- Riarte A, Luna C, Sabatiello R, et al. Chagas' disease in patients with kidney transplants: 7 years of experience 1989-1996. Clin Infect Dis 1999; 29:561.
- Fontes Rezende RE, Lescano MA, Zambelli Ramalho LN, et al. Reactivation of Chagas' disease in a patient with non-Hodgkin's lymphoma: gastric, oesophageal and laryngeal involvement. Trans R Soc Trop Med Hyg 2006; 100:74.
- Kohl S, Pickering LK, Frankel LS, Yaeger RG. Reactivation of Chagas' disease during therapy of acute lymphocytic leukemia. Cancer 1982; 50:827.
- Metze K, Lorand-Metze I, De Almeida EA, De Moraes SL. Reactivation of Chagas' myocarditis during therapy of Hodgkin's disease. Trop Geogr Med 1991; 43:228.
- Altclas J, Sinagra A, Dictar M, et al. Chagas disease in bone marrow transplantation: an approach to preemptive therapy. Bone Marrow Transplant 2005; 36:123.
- Bacal F, Silva CP, Bocchi EA, et al. Mychophenolate mofetil increased chagas disease reactivation in heart transplanted patients: comparison between two different protocols. Am J Transplant 2005; 5:2017.
- Bocchi EA, Bellotti G, Mocelin AO, et al. Heart transplantation for chronic Chagas' heart disease. Ann Thorac Surg 1996; 61:1727.
- Campos SV, Strabelli TM, Amato Neto V, et al. Risk factors for Chagas' disease reactivation after heart transplantation. J Heart Lung Transplant 2008; 27:597.
- Fiorelli AI, Stolf NA, Honorato R, et al. Later evolution after cardiac transplantation in Chagas' disease. Transplant Proc 2005; 37:2793.
- Marchiori PE, Alexandre PL, Britto N, et al. Late reactivation of Chagas' disease presenting in a recipient as an expansive mass lesion in the brain after heart transplantation of chagasic myocardiopathy. J Heart Lung Transplant 2007; 26:1091.
- 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; 101:31.
- Gallerano V, Consigli J, Pereyra S, et al. Chagas' disease reactivation with skin symptoms in a patient with kidney transplant. Int J Dermatol 2007; 46:607.
- Duffy T, Bisio M, Altcheh J, et al. Accurate real-time PCR strategy for monitoring bloodstream parasitic loads in chagas disease patients. PLoS Negl Trop Dis 2009; 3:e419.
- Sartori AM, Neto JE, Nunes EV, et al. Trypanosoma cruzi parasitemia in chronic Chagas disease: comparison between human immunodeficiency virus (HIV)-positive and HIV-negative patients. J Infect Dis 2002; 186:872.
- Cordova E, Boschi A, Ambrosioni J, et al. Reactivation of Chagas disease with central nervous system involvement in HIV-infected patients in Argentina, 1992-2007. Int J Infect Dis 2008; 12:587.
- Diazgranados CA, Saavedra-Trujillo CH, Mantilla M, et al. Chagasic encephalitis in HIV patients: common presentation of an evolving epidemiological and clinical association. Lancet Infect Dis 2009; 9:324.
- Vaidian AK, Weiss LM, Tanowitz HB. Chagas' disease and AIDS. Kinetoplastid Biol Dis 2004; 3:2.
- Ferreira MS, Nishioka Sde A, Silvestre MT, et al. Reactivation of Chagas' disease in patients with AIDS: report of three new cases and review of the literature. Clin Infect Dis 1997; 25:1397.
- Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: Recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. http://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdf (Accessed on September 21, 2016).
- Maldonado C, Albano S, Vettorazzi L, et al. Using polymerase chain reaction in early diagnosis of re-activated Trypanosoma cruzi infection after heart transplantation. J Heart Lung Transplant 2004; 23:1345.
- Centers for Disease Control and Prevention (CDC). Chagas disease after organ transplantation--United States, 2001. MMWR Morb Mortal Wkly Rep 2002; 51:210.
- Kun H, Moore A, Mascola L, et al. Transmission of Trypanosoma cruzi by heart transplantation. Clin Infect Dis 2009; 48:1534.
- Chocair PR, Sabbaga E, Amato Neto V, et al. [Kidney transplantation: a new way of transmitting chagas disease]. Rev Inst Med Trop Sao Paulo 1981; 23:280.
- de Arteaga J, Massari PU, Galli B, et al. Renal transplantation and Chagas' disease. Transplant Proc 1992; 24:1900.
- de Faria JB, Alves G. Transmission of Chagas' disease through cadaveric renal transplantation. Transplantation 1993; 56:1583.
- Ferraz AS, Figueiredo JF. Transmission of Chagas' disease through transplanted kidney: occurrence of the acute form of the disease in two recipients from the same donor. Rev Inst Med Trop Sao Paulo 1993; 35:461.
- Figueiredo JF, Martinez R, da Costa JC, et al. Transmission of Chagas disease through renal transplantation: report of a case. Trans R Soc Trop Med Hyg 1990; 84:61.
- Barcán L, Luna C, Clara L, et al. Transmission of T. cruzi infection via liver transplantation to a nonreactive recipient for Chagas' disease. Liver Transpl 2005; 11:1112.
- Souza FF, Castro-E-Silva O, Marin Neto JA, et al. Acute chagasic myocardiopathy after orthotopic liver transplantation with donor and recipient serologically negative for Trypanosoma cruzi: a case report. Transplant Proc 2008; 40:875.
- Bocchi EA, Fiorelli A. The paradox of survival results after heart transplantation for cardiomyopathy caused by Trypanosoma cruzi. First Guidelines Group for Heart Transplantation of the Brazilian Society of Cardiology. Ann Thorac Surg 2001; 71:1833.
- Bocchi EA, Fiorelli A, First Guideline Group for Heart Transplantation of the Brazilian Society of Cardiology. The Brazilian experience with heart transplantation: a multicenter report. J Heart Lung Transplant 2001; 20:637.
- Bestetti RB, Theodoropoulos TA. A systematic review of studies on heart transplantation for patients with end-stage Chagas' heart disease. J Card Fail 2009; 15:249.
- de Carvalho VB, Sousa EF, Vila JH, et al. Heart transplantation in Chagas' disease. 10 years after the initial experience. Circulation 1996; 94:1815.
- Bocchi EA, Bellotti G, Uip D, et al. Long-term follow-up after heart transplantation in Chagas' disease. Transplant Proc 1993; 25:1329.
- ACUTE CHAGAS DISEASE
- CHRONIC CHAGAS DISEASE
- Initial evaluation
- Antitrypanosomal therapy
- Chagas reactivation
- - HIV/AIDS
- - Treatment and prevention
- Organ transplant
- - Donor transmission in organ transplant recipients
- - Heart transplantation for Chagas cardiomyopathy
- Monitoring for reactivation
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS