Reactivation of Chagas disease with central nervous system involvement: peripheral blood smear evidence

Cerebral Trypanosomiasis in an Immunocompromised Patient: Case Report and Review of the Literature

BACKGROUND

We document a case of central nervous system infection with Trypanosoma cruzi.

CASE DESCRIPTION

An 88-year-old woman presented with altered mental status, right-sided weakness, and slurred speech. Her medical history was significant for methotrexate intake for rheumatoid arthritis, and she tested negative for human immunodeficiency virus. Magnetic resonance imaging of the brain showed bilateral thick and peripherally enhancing white matter lesions in the frontoparietal region with extensive surrounding vasogenic edema. A lumbar puncture revealed increased protein and lymphocytic pleocytosis, and needle biopsy highlighted brain necrosis, chronic inflammation, and numerous intracellular organisms suggestive of T. cruzi amastigotes. Despite treatment with benznidazole, the patient expired soon after presentation.

CONCLUSION

Chagas disease should be included in the differential diagnosis of an immunocompromised patient presenting with a central nervous system mass, meningoencephalitis, or focal neurologic signs.

Chagas disease in Europe: A review for the internist in the globalized world

Chagas disease (CD) or American trypanosomiasis identified in 1909 by Carlos Chagas, has become over the last 40years a global health concern due to the huge migration flows from Latin America to Europe, United States, Canada and Japan. In Europe, most migrants from CD-endemic areas are concentrated in Spain, Italy, France, United Kingdom and Switzerland. Pooled seroprevalence studies conducted in Europe show an overall 4.2% prevalence, with the highest infection rates observed among individuals from Bolivia (18.1%). However, in most European countries the disease is neglected with absence of screening programmes and low access to diagnosis and treatment. Physicians working in Europe should also be aware of the risk of autochthonous transmission of Trypanosoma cruzi to newborns by their infected mothers and to recipients of blood or transplanted organs from infected donors. Finally, physicians should be able to recognize and treat the most frequent and serious complications of chronic Chagas disease, namely cardiomyopathy, megacolon and megaesophagus. This review aims to highlights the problem of CD in Europe by reviewing papers published by European researchers on this argument, in order to raise the awareness of internists who are bound to increasingly encounter patients with the disease in their routine daily activities.

Serological diagnosis of Chagas disease in HIV-infected patients

INTRODUCTION

This study assessed the rate of request for the serological diagnosis of Chagas disease among human immunodeficiency virus (HIV)-infected patients treated at the Specialized Care Service of Pelotas, Rio Grande do Sul, Brazil.

METHODS

This cross-sectional study used secondary data obtained from the medical records of 252 patients aged between 18 and 75 years.

RESULTS

The serological diagnosis of Chagas disease was requested only in 3.2% of cases.

CONCLUSIONS

The results demonstrate poor adherence to protocols on the part of healthcare professionals, indicating the need to reevaluate the procedures applied to HIV-infected patients from endemic regions for both diseases.

Rickettsiae, protozoa, and opisthokonta/metazoa

Rhizobiales (formerly named Rickettsiales) cause in rare instances meningitis and meningovasculitis, respectively. In case of history of exposure, infection by Rhizobiales needs to be considered since both diagnosis and therapy may be extremely difficult and pathogen-specific. The same applies to protozoa; in this chapter, Babesia species, free-living amoebae and Entamoeba histolytica infection, including severe meningitis and brain abscess, infection by Trypanosoma species (South American and African trypanosomiasis) are discussed with respect to history, epidemiology, clinical signs, and symptoms as well as differential diagnosis and therapy. Parasitic flatworms and roundworms, potentially able to invade the central nervous system, trematodes (flukes), cestodes (in particular, Cysticercus cellulosae), but also nematodes (in particular, Strongyloides spp. in the immunocompromised) are of worldwide importance. In contrast, filarial worms, Toxocara spp., Trichinella spp., Gnathostoma and Angiostrongylus spp. are seen only in certain geographically confined areas. Even more regionally confined are infestations of the central nervous system by metazoa, in particular, tongue worms (=arthropods) or larvae of flies (=maggots). The aim of this chapter is (1) to alert the neurologist to these infections, and (2) to enable the attending emergency neurologist to take a knowledgeable history, with an emphasis on epidemiology, clinical signs, and symptoms as well as therapeutic management possibilities.

Co-infection Trypanosoma cruzi/HIV: systematic review (1980-2010)

INTRODUCTION

The co-infection Trypanosoma cruzi/HIV has been described as a clinical event of great relevance. The objective of this study was to describe clinical and epidemiological aspects published in literature.

METHODS

It is a systematic review of a descriptive nature from the databases Medline, Lilacs, SciELO, Scopus, from 1980 to 2010.

RESULTS

There were 83 articles (2.8 articles/year) with a total of 291 cases. The co-infection was described in 1980 and this situation has become the defining AIDS clinical event in Brazil. This is the country with the highest number of publication (51.8%) followed by Argentina (27.7%). The majority of cases are amongst adult men (65.3%) native or from endemic regions with serological diagnosis in the chronic stage (97.9%) and indeterminate form (50.8%). Both diseases follow the normal course, but in 41% the reactivation of the Chagas disease occurs. The most severe form is the meningoencephalitis, with 100% of mortality without specific and early treatment of the T. cruzi. The medication of choice was the benznidazole on doses and duration normally used for the acute phase. The high parasitemia detected by direct or indirect quantitative methods indicated reactivation and its elevation is the most important predictive factor. The lower survival rate was related to the reactivation of the Chagas disease and the natural complications of both diseases. The role of the antiretroviral treatment on the co-infection cannot yet be defined by the knowledge currently existent.

CONCLUSIONS

Despite the relevance of this clinical event there are still gaps to be filled.

Guidelines on the treatment of chronic coinfection by Trypanosoma cruzi and HIV outside endemic areas

As a result of population migration, Chagas disease is no longer limited to the North and South American continents. In HIV-infected patients, chronic infection by Trypanosoma cruzi behaves as an opportunistic infection in severely immunosuppressed patients and is responsible for high morbidity and mortality. Unlike other opportunistic infections, information on the natural history, diagnosis, treatment, and prevention of Chagas disease is scarce. Spain has the highest number of cases of Chagas disease outside the North and South American continents, and coinfection with HIV is increasingly prevalent. In this article, the Spanish Society for Tropical Medicine and International Health (Sociedad Española de Medicina Tropical y Salud Internacional) reviews the current situation of coinfection with HIV and T. cruzi infection and provides guidelines on the diagnosis, treatment, and prevention in areas where Chagas disease is not endemic. It also identifies areas of uncertainty where additional research is necessary.