Updated: 12/18/2018

Chagas Disease

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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
  • 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
  • Symptoms/Physical exam
    • acute phase (lasts 8-12 weeks)
      • 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
      • nonspecific symptoms
        • malaise
        • fever
        • anorexia
        • can even be asymptomatic
    • chronic phase
      • indeterminate form
        • patients have T. cruzi positive serologies but no signs or symptoms of cardiac or gastrointestinal abnormalities
        • patients have a normal 12-lead electrocardiogram (ECG)
      • determinate form
        • cardiac
          • acute myopericarditis
          • chronic fibrosing myocarditis
          • dilated cardiomyopathy
          • symptoms of heart failure (e.g., paroxysmal nocturnal dyspnea, orthopnea, and jugular venous distension), arrhythmias (e.g., palpitations, weakness, and syncope), stroke (e.g., focal neurological deficit 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
 

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(M2.ID.16.4691) A 45-year-old woman presents to clinic for an employment physical. She has no current complaints. She has no significant past medical history, does not smoke or drink alcohol, and leads an active lifestyle. Upon further questioning, you discover that she is a second generation immigrant from Brazil and frequently returns to South America to visit family. Vital signs are as follows: T 37 C, BP 110/70 mmHg, HR 70, and RR 14. On physical exam, you note a widely-split S2 heart sound. An EKG is performed (Figure A). What is the likely etiology of this patient's cardiac manifestations? Tested Concept

QID: 107609
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Hypothryoid cardiomyopathy

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Myocarditis

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Chagas disease

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Hypertension

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Myocardial infarction

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