Snapshot A 58-year-old man presents to the clinic with a 2 month history of cough, dyspnea on exertion, palpitations, and orthopnea. He immigrated from rural Bolivia when he was 25 years of age and visits Bolivia regularly. Past medical history is unremarkable. Physical exam reveals an anxious-looking man in respiratory distress. Cardiovascular exam reveals an elevated JVD, S3 gallop, and pitting edema of both ankles. There are bibasilar crackles on chest exam and a chest radiograph shows cardiomegaly. Echocardiogram revealed biventricular dilatation with an EF of 25%. Serological testing was positive for Trypanosoma cruzi. Introduction Definition a disease caused by Trypanosoma cruzi, a protozoan parasite, that is characterized by cardiomyopathy gastrointestinal disease Epidemiology Incidence occurs predominantly in South America ETIOLOGY Pathogenesis reduviid bug (also known as the "kissing bug") defectates during its blood meal on humans the feces contain the parasite and it infect the host through the bite wound Presentation Acute phase (lasts 8-12 weeks) symptoms malaise fever anorexia can even be asymptomatic physical exam inflammation and swelling at the site of the bite wound (Chagoma) typically occur in the face or extremities Romaña sign inoculation at the conjunctiva leads to swelling of the upper and lower eyelid Chronic phase indeterminate form asymptomatic patients have T. cruzi positive serologies but no signs or symptoms of cardiac or gastrointestinal abnormalities normal physical exam normal 12-lead electrocardiogram (ECG) determinate form cardiac manifestations include acute myopericarditis chronic fibrosing myocarditis dilated cardiomyopathy symptoms of heart failure paroxysmal nocturnal dyspnea orthopnea jugular venous distension arrhythmias (e.g., palpitations, weakness, and syncope) symptoms of stroke focal neurological deficit occurs secondary to thromboembolism formation in dilated cardiac chambers gastrointestinal megaesophagus progressive dysphagia and regurgitation of food megacolon progressive constipation, colicky abdominal pain, and bloating Studies Blood smear trypomastigote (motile, flagellated form) in blood smear Polyermase chain reaction (PCR) Serology enzyme-linked immunosorbent assay (ELISA) Differential Alcohol-induced dilated caridiomyopathy differentiating factor patients will have a history of alcohol use disorder Treatment Medical antitrypanosomal therapy indication first-line treatment for Chagas disease medications benznidazole nifurtimox Complications Dilated cardiomyopathy Cardiac arrest Thromboembolic events (e.g., stroke) Bowel ischemia Malnutrition