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Clark EH, Bern C. Chagas disease in the immunocompromised host. Curr Opin Infect Dis 2024; 37:333-341. [PMID: 38963802 DOI: 10.1097/qco.0000000000001035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2024]
Abstract
PURPOSE OF REVIEW To highlight recent advances in our understanding of Trypanosoma cruzi infection in immunocompromised individuals, a condition that is increasingly recognized as populations shift and use of immunosuppressive medications becomes more commonplace. RECENT FINDINGS Chagas disease screening programs should include people at risk for both Chagas disease and immunocompromise, e.g. people who have resided for ≥6 months in endemic Latin America who have an immunocompromising condition such as HIV or who are planned to start an immunosuppressive medication regimen. The goal of identifying such individuals is to allow management strategies that will reduce their risk of T. cruzi reactivation disease. For people with HIV- T. cruzi coinfection, strict adherence to antiretroviral therapy is important and antitrypanosomal treatment is urgent in the setting of symptomatic reactivation. People at risk for T. cruzi reactivation due to immunosuppression caused by advanced hematologic conditions or postsolid organ transplantation should be monitored via T. cruzi qPCR and treated with preemptive antitrypanosomal therapy if rising parasite load on serial specimens indicates reactivation. Reduction of the immunosuppressive regimen, if possible, is important. SUMMARY Chronic Chagas disease can lead to severe disease in immunocompromised individuals, particularly those with advanced HIV (CD4 + < 200 cells/mm 3 ) or peri-transplantation.
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Affiliation(s)
- Eva H Clark
- Departments of Medicine, Section of Infectious Diseases, and Pediatrics, Division of Tropical Medicine, Baylor College of Medicine, Houston, Texas
| | - Caryn Bern
- Department of Epidemiology and Biostatistics, University of California San Francisco School of Medicine, San Francisco, California, USA
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Clark EH, Messenger LA, Whitman JD, Bern C. Chagas disease in immunocompromised patients. Clin Microbiol Rev 2024; 37:e0009923. [PMID: 38546225 PMCID: PMC11237761 DOI: 10.1128/cmr.00099-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024] Open
Abstract
SUMMARYAs Chagas disease remains prevalent in the Americas, it is important that healthcare professionals and researchers are aware of the screening, diagnosis, monitoring, and treatment recommendations for the populations of patients they care for and study. Management of Trypanosoma cruzi infection in immunocompromised hosts is challenging, particularly because, regardless of antitrypanosomal treatment status, immunocompromised patients with Chagas disease are at risk for T. cruzi reactivation, which can be lethal. Evidence-based practices to prevent and manage T. cruzi reactivation vary depending on the type of immunocompromise. Here, we review available data describing Chagas disease epidemiology, testing, and management practices for various populations of immunocompromised individuals, including people with HIV and patients undergoing solid organ and hematopoietic stem cell transplantation.
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Affiliation(s)
- Eva H Clark
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Division of Tropical Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Louisa A Messenger
- Department of Environmental and Occupational Health, University of Nevada Las Vegas, Las Vegas, Nevada, USA
| | - Jeffrey D Whitman
- Department of Laboratory Medicine, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Caryn Bern
- Department of Epidemiology and Biostatistics, University of California San Francisco School of Medicine, San Francisco, California, USA
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Gonzaga BMDS, Ferreira RR, Coelho LL, Carvalho ACC, Garzoni LR, Araujo-Jorge TC. Clinical trials for Chagas disease: etiological and pathophysiological treatment. Front Microbiol 2023; 14:1295017. [PMID: 38188583 PMCID: PMC10768561 DOI: 10.3389/fmicb.2023.1295017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 11/27/2023] [Indexed: 01/09/2024] Open
Abstract
Chagas disease (CD) is caused by the flagellate protozoan Trypanosoma cruzi. It is endemic in Latin America. Nowadays around 6 million people are affected worldwide, and 75 million are still at risk. CD has two evolutive phases, acute and chronic. The acute phase is mostly asymptomatic, or presenting unspecific symptoms which makes it hard to diagnose. At the chronic phase, patients can stay in the indeterminate form or develop cardiac and/or digestive manifestations. The two trypanocide drugs available for the treatment of CD are benznidazole (BZ) and nifurtimox (NFX), introduced in the clinic more than five decades ago. WHO recommends treatment for patients at the acute phase, at risk of congenital infection, for immunosuppressed patients and children with chronic infection. A high cure rate is seen at the CD acute phase but better treatment schemes still need to be investigated for the chronic phase. There are some limitations within the use of the trypanocide drugs, with side effects occurring in about 40% of the patients, that can lead patients to interrupt treatment. In addition, patients with advanced heart problems should not be treated with BZ. This is a neglected disease, discovered 114 years ago that still has no drug effective for their chronic phase. Multiple social economic and cultural barriers influence CD research. The high cost of the development of new drugs, in addition to the low economical return, results in the lack of investment. More economic support is required from governments and pharmaceutical companies on the development of more research for CD treatment. Two approaches stand out: repositioning and combination of drugs, witch drastically decrease the cost of this process, when compared to the development of a new drug. Here we discuss the progress of the clinical trials for the etiological and pathophysiological treatment for CD. In summary, more studies are needed to propose a new drug for CD. Therefore, BZ is still the best option for CD. The trials in course should clarify more about new treatment regimens, but it is already possible to indicate that dosage and time of treatment need to be adjusted.
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Affiliation(s)
| | | | | | | | | | - Tania C. Araujo-Jorge
- Laboratório de Inovações em Terapias, Ensino e Bioprodutos - Instituto Oswaldo Cruz, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
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Furquim SR, Galbiati LC, Avila MS, Marcondes-Braga FG, Fukushima J, Mangini S, Seguro LFBDC, Campos IWD, Strabelli TMV, Barone F, Paulo ARDSAD, Ohe LA, Galante MC, Gaiotto FA, Bacal F. Survival of Heart Transplant Patients with Chagas' Disease Under Different Antiproliferative Immunosuppressive Regimens. Arq Bras Cardiol 2023; 120:e20230133. [PMID: 37909604 PMCID: PMC10586812 DOI: 10.36660/abc.20230133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 07/06/2023] [Accepted: 08/16/2023] [Indexed: 11/03/2023] Open
Abstract
Chagas' disease (CD) is an important cause of heart transplantation (HT). The main obstacle is Chagas' disease reactivation (CDR), usually associated to high doses of immunosuppressants. Previous studies have suggested an association of mycophenolate mofetil with increased CDR. However, mortality predictors are unknown. To identify mortality risk factors in heart transplant patients with CD and the impact of antiproliferative regimen on survival. Retrospective study with CD patients who underwent HT between January 2004 and September 2020, under immunosuppression protocol that prioritized azathioprine and change to mycophenolate mofetil in case of rejection. We performed univariate regression to identify mortality predictors; and compared survival, rejection and evidence of CDR between who received azathioprine, mycophenolate mofetil and those who changed from azathioprine to mycophenolate mofetil after discharge ("Change" group). A p-value < 0.05 was considered statistically significant. Eighty-five patients were included, 54.1% men, median age 49 (39-57) years, and 91.8% were given priority in waiting list. Nineteen (22.4%) used azathioprine, 37 (43.5%) mycophenolate mofetil and 29 (34.1%) switched therapy; survival was not different between groups, 2.9 (1.6-5.0) x 2.9 (1.8-4.8) x 4.2 (2.0-5.0) years, respectively; p=0.4. There was no difference in rejection (42%, 73% and 59% respectively; p=0.08) or in CDR (T. cruzi positive by endomyocardial biopsy 5% x 11% x 7%; p=0.7; benznidazole use 58% x 65% x 69%; p=0.8; positive PCR for T. cruzi 20% x 68% x 42% respectively; p=0.1) rates. This retrospective study did not show difference in survival in heart transplant patients with CD receiving different antiproliferative regimens. Mycophenolate mofetil was not associated with statistically higher rates of CDR or graft rejection in this cohort. New randomized clinical trials are necessary to address this issue.
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Affiliation(s)
- Silas Ramos Furquim
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Luana Campoli Galbiati
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Monica S Avila
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Fabiana G Marcondes-Braga
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Julia Fukushima
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Sandrigo Mangini
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | | | - Iascara Wozniak de Campos
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Tania Mara Varejão Strabelli
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Fernanda Barone
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | | | - Luciana Akutsu Ohe
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Mariana Cappelletti Galante
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Fabio Antonio Gaiotto
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Fernando Bacal
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
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Marin-Neto JA, Rassi A, Oliveira GMM, Correia LCL, Ramos Júnior AN, Luquetti AO, Hasslocher-Moreno AM, Sousa ASD, Paola AAVD, Sousa ACS, Ribeiro ALP, Correia Filho D, Souza DDSMD, Cunha-Neto E, Ramires FJA, Bacal F, Nunes MDCP, Martinelli Filho M, Scanavacca MI, Saraiva RM, Oliveira Júnior WAD, Lorga-Filho AM, Guimarães ADJBDA, Braga ALL, Oliveira ASD, Sarabanda AVL, Pinto AYDN, Carmo AALD, Schmidt A, Costa ARD, Ianni BM, Markman Filho B, Rochitte CE, Macêdo CT, Mady C, Chevillard C, Virgens CMBD, Castro CND, Britto CFDPDC, Pisani C, Rassi DDC, Sobral Filho DC, Almeida DRD, Bocchi EA, Mesquita ET, Mendes FDSNS, Gondim FTP, Silva GMSD, Peixoto GDL, Lima GGD, Veloso HH, Moreira HT, Lopes HB, Pinto IMF, Ferreira JMBB, Nunes JPS, Barreto-Filho JAS, Saraiva JFK, Lannes-Vieira J, Oliveira JLM, Armaganijan LV, Martins LC, Sangenis LHC, Barbosa MPT, Almeida-Santos MA, Simões MV, Yasuda MAS, Moreira MDCV, Higuchi MDL, Monteiro MRDCC, Mediano MFF, Lima MM, Oliveira MTD, Romano MMD, Araujo NNSLD, Medeiros PDTJ, Alves RV, Teixeira RA, Pedrosa RC, Aras Junior R, Torres RM, Povoa RMDS, Rassi SG, Alves SMM, Tavares SBDN, Palmeira SL, Silva Júnior TLD, Rodrigues TDR, Madrini Junior V, Brant VMDC, Dutra WO, Dias JCP. SBC Guideline on the Diagnosis and Treatment of Patients with Cardiomyopathy of Chagas Disease - 2023. Arq Bras Cardiol 2023; 120:e20230269. [PMID: 37377258 PMCID: PMC10344417 DOI: 10.36660/abc.20230269] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2023] Open
Affiliation(s)
- José Antonio Marin-Neto
- Universidade de São Paulo , Faculdade de Medicina de Ribeirão Preto , Ribeirão Preto , SP - Brasil
| | - Anis Rassi
- Hospital do Coração Anis Rassi , Goiânia , GO - Brasil
| | | | | | | | - Alejandro Ostermayer Luquetti
- Centro de Estudos da Doença de Chagas , Hospital das Clínicas da Universidade Federal de Goiás , Goiânia , GO - Brasil
| | | | - Andréa Silvestre de Sousa
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz , Rio de Janeiro , RJ - Brasil
| | | | - Antônio Carlos Sobral Sousa
- Universidade Federal de Sergipe , São Cristóvão , SE - Brasil
- Hospital São Lucas , Rede D`Or São Luiz , Aracaju , SE - Brasil
| | | | | | | | - Edecio Cunha-Neto
- Universidade de São Paulo , Faculdade de Medicina da Universidade, São Paulo , SP - Brasil
| | - Felix Jose Alvarez Ramires
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP - Brasil
| | - Fernando Bacal
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP - Brasil
| | | | - Martino Martinelli Filho
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP - Brasil
| | - Maurício Ibrahim Scanavacca
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP - Brasil
| | - Roberto Magalhães Saraiva
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz , Rio de Janeiro , RJ - Brasil
| | | | - Adalberto Menezes Lorga-Filho
- Instituto de Moléstias Cardiovasculares , São José do Rio Preto , SP - Brasil
- Hospital de Base de Rio Preto , São José do Rio Preto , SP - Brasil
| | | | | | - Adriana Sarmento de Oliveira
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP - Brasil
| | | | - Ana Yecê das Neves Pinto
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz , Rio de Janeiro , RJ - Brasil
| | | | - Andre Schmidt
- Universidade de São Paulo , Faculdade de Medicina de Ribeirão Preto , Ribeirão Preto , SP - Brasil
| | - Andréa Rodrigues da Costa
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz , Rio de Janeiro , RJ - Brasil
| | - Barbara Maria Ianni
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP - Brasil
| | | | - Carlos Eduardo Rochitte
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP - Brasil
- Hcor , Associação Beneficente Síria , São Paulo , SP - Brasil
| | | | - Charles Mady
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP - Brasil
| | - Christophe Chevillard
- Institut National de la Santé Et de la Recherche Médicale (INSERM), Marselha - França
| | | | | | | | - Cristiano Pisani
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP - Brasil
| | | | | | | | - Edimar Alcides Bocchi
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP - Brasil
| | - Evandro Tinoco Mesquita
- Hospital Universitário Antônio Pedro da Faculdade Federal Fluminense , Niterói , RJ - Brasil
| | | | | | | | | | | | - Henrique Horta Veloso
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz , Rio de Janeiro , RJ - Brasil
| | - Henrique Turin Moreira
- Hospital das Clínicas , Faculdade de Medicina de Ribeirão Preto , Universidade de São Paulo , Ribeirão Preto , SP - Brasil
| | | | | | | | - João Paulo Silva Nunes
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP - Brasil
- Fundação Zerbini, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP - Brasil
| | | | | | | | | | | | - Luiz Cláudio Martins
- Universidade Estadual de Campinas , Faculdade de Ciências Médicas , Campinas , SP - Brasil
| | | | | | | | - Marcos Vinicius Simões
- Universidade de São Paulo , Faculdade de Medicina de Ribeirão Preto , Ribeirão Preto , SP - Brasil
| | | | | | - Maria de Lourdes Higuchi
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP - Brasil
| | | | - Mauro Felippe Felix Mediano
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz , Rio de Janeiro , RJ - Brasil
- Instituto Nacional de Cardiologia (INC), Rio de Janeiro, RJ - Brasil
| | - Mayara Maia Lima
- Secretaria de Vigilância em Saúde , Ministério da Saúde , Brasília , DF - Brasil
| | | | | | | | | | - Renato Vieira Alves
- Instituto René Rachou , Fundação Oswaldo Cruz , Belo Horizonte , MG - Brasil
| | - Ricardo Alkmim Teixeira
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP - Brasil
| | - Roberto Coury Pedrosa
- Hospital Universitário Clementino Fraga Filho , Instituto do Coração Edson Saad - Universidade Federal do Rio de Janeiro , RJ - Brasil
| | | | | | | | | | - Silvia Marinho Martins Alves
- Ambulatório de Doença de Chagas e Insuficiência Cardíaca do Pronto Socorro Cardiológico Universitário da Universidade de Pernambuco (PROCAPE/UPE), Recife , PE - Brasil
| | | | - Swamy Lima Palmeira
- Secretaria de Vigilância em Saúde , Ministério da Saúde , Brasília , DF - Brasil
| | | | | | - Vagner Madrini Junior
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP - Brasil
| | | | | | - João Carlos Pinto Dias
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz , Rio de Janeiro , RJ - Brasil
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van der Bijl P, Bax JJ. Myocardial sympathetic denervation in Chagas' cardiomyopathy: A predictor of deterioration of left ventricular systolic function. J Nucl Cardiol 2022; 29:3177-3178. [PMID: 34888827 DOI: 10.1007/s12350-021-02854-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 10/19/2021] [Indexed: 01/18/2023]
Affiliation(s)
- Pieter van der Bijl
- Department of Cardiology, Heart Lung Center, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands.
| | - Jeroen J Bax
- Department of Cardiology, Heart Lung Center, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
- Heart Center, University of Turku and Turku University Hospital, Kiinamyllynkatu 4-8, 20520, Turku, Finland
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Abstract
PURPOSE OF THE REVIEW This review examines the most recent literature on the epidemiology and treatment of Chagas Disease and the risk of Chagas Disease Reactivation and donor-derived disease in solid organ transplant recipients. RECENT FINDINGS Chagas disease is caused by infection with the parasite Trypansoma cruzi . In nonendemic countries the disease is seen primarily in immigrants from Mexico, Central America and South America where the disease is endemic. Benznidazole or nifurtimox can be used for treatment. Posaconazole and fosravuconazole did not provide any additional benefit compared to benznidazole alone or in combination. A phase 2 randomized controlled trial suggests that shorter or reduced dosed regimes of benznidazole could be used. Based on a large randomized controlled trial, benznidazole is unlikely to have a significant preventive effect for established Chagas cardiomyopathy. Transplantation has become the treatment of choice for individuals with refractory Chagas cardiomyopathy. Cohort studies show similar posttransplant outcomes for these patients compared to other indications. Transplant candidates and donors with chronic T. cruzi infection are at risk for Chagas disease reactivation and transmitting infection. Screening them via serology is the first line of prevention. Recipients with chronic infection and those receiving organs from infected donors should undergo sequential monitoring with polymerase chain reaction for early detection of reactivation and preemptive treatment with antitrypanosomal therapy. SUMMARY Patients with chronic T. cruzi infection can be safely transplanted and be noncardiac organ donors.
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Long-term Survival Following Heart Transplantation for Chagas Versus Non-Chagas Cardiomyopathy: A Single-center Experience in Northeastern Brazil Over 2 Decades. Transplant Direct 2022; 8:e1349. [PMID: 35774419 PMCID: PMC9236606 DOI: 10.1097/txd.0000000000001349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 05/06/2022] [Indexed: 11/25/2022] Open
Abstract
Data on post–heart transplant (HT) survival of patients with Chagas cardiomyopathy (CC) are scarce. We sought to evaluate post-HT survival in patients with CC as compared with other causes of heart failure across different eras of HT.
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Irish A, Whitman JD, Clark EH, Marcus R, Bern C. Updated Estimates and Mapping for Prevalence of Chagas Disease among Adults, United States. Emerg Infect Dis 2022; 28:1313-1320. [PMID: 35731040 PMCID: PMC9239882 DOI: 10.3201/eid2807.212221] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Geographic scale estimates of disease in older Latin America–born US residents may be useful for prevention and early recognition of chronic sequelae. We combined American Community Survey data with age-specific Trypanosoma cruzi prevalence derived from US surveys and World Health Organization reports to yield estimates of Chagas disease in the United States, which we mapped at the local level. In addition, we used blood donor data to estimate the relative prevalence of autochthonous T. cruzi infection. Our estimates indicate that 288,000 infected persons, including 57,000 Chagas cardiomyopathy patients and 43,000 infected reproductive-age women, currently live in the United States; 22–108 congenital infections occur annually. We estimated ≈10,000 prevalent cases of locally acquired T. cruzi infection. Mapping shows marked geographic heterogeneity of T. cruzi prevalence and illness. Reliable demographic and geographic data are key to guiding prevention and management of Chagas disease. Population-based surveys in high prevalence areas could improve the evidence base for future estimates. Knowledge of the demographics and geographic distribution of affected persons may aid practitioners in recognizing Chagas disease.
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Macedo CT, Larocca TF, Noya-Rabelo M, Aras R, Macedo CRB, Moreira MI, Caldas AC, Torreão JA, Monsão VMA, Souza CLM, Vasconcelos JF, Bezerra MR, Petri DP, Souza BSF, Pacheco AGF, Daher A, Ribeiro-dos-Santos R, Soares MBP. Efficacy and Safety of Granulocyte-Colony Stimulating Factor Therapy in Chagas Cardiomyopathy: A Phase II Double-Blind, Randomized, Placebo-Controlled Clinical Trial. Front Cardiovasc Med 2022; 9:864837. [PMID: 35757326 PMCID: PMC9222127 DOI: 10.3389/fcvm.2022.864837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 04/26/2022] [Indexed: 11/25/2022] Open
Abstract
Aim Previous studies showed that granulocyte-colony stimulating factor (G-CSF) improved heart function in a mice model of Chronic Chagas Cardiomyopathy (CCC). Herein, we report the interim results of the safety and efficacy of G-CSF therapy vs. placebo in adults with Chagas cardiomyopathy. Methods Patients with CCC, New York Heart Association (NYHA) functional class II to IV and left ventricular ejection fraction (LVEF) 50% or below were included. A randomization list using blocks of 2 and 4 and an allocation rate of 1:1 was generated by R software which was stratified by functional class. Double blinding was done to both arms and assessors were masked to allocations. All patients received standard heart failure treatment for 2 months before 1:1 randomization to either the G-CSF (10 mcg/kg/day subcutaneously) or placebo group (1 mL of 0.9% saline subcutaneously). The primary endpoint was either maintenance or improvement of NYHA class from baseline to 6-12 months after treatment, and intention-to-treat analysis was used. Results We screened 535 patients with CCC in Salvador, Brazil, of whom 37 were randomized. Overall, baseline characteristics were well-balanced between groups. Most patients had NYHA class II heart failure (86.4%); low mean LVEF was 32 ± 7% in the G-CSF group and 33 ± 10% in the placebo group. Frequency of primary endpoint was 78% (95% CI 0.60-0.97) vs. 66% (95% CI 0.40-0.86), p = 0.47, at 6 months and 68% (95% CI 0.43-0.87) vs. 72% (95% CI 0.46-0.90), p = 0.80, at 12 months in placebo and G-CSF groups, respectively. G-CSF treatment was safe, without any related serious adverse events. There was no difference in mortality between both arms, with five deaths (18.5%) in treatment vs. four (12.5%) in the placebo arm. Exploratory analysis demonstrated that the maximum rate of oxygen consumption during exercise (VO2 max) showed an improving trend in the G-CSF group. Conclusion G-CSF therapy was safe and well-tolerated in 12 months of follow-up. Although prevention of symptom progression could not be demonstrated in the present study, our results support further investigation of G-CSF therapy in Chagas cardiomyopathy patients. Clinical Trial Registration [www.ClinicalTrials.gov], identifier [NCT02154269].
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Affiliation(s)
- Carolina T. Macedo
- Department of Cardiology, Hospital São Rafael, Salvador, Brazil
- Gonçalo Moniz Institute, Oswaldo Cruz Foundation, Salvador, Brazil
- Senai Institute on Innovation in Advanced Health Systems, SENAI CIMATEC, Salvador, Brazil
| | | | - Márcia Noya-Rabelo
- Department of Cardiology, Hospital São Rafael, Salvador, Brazil
- Escola Bahiana de Medicina e Saúde Pública, Salvador, Brazil
| | - Roque Aras
- University Hospital Professor Edgard Santos, Federal University of Bahia, Salvador, Brazil
| | - Cristiano R. B. Macedo
- University Hospital Professor Edgard Santos, Federal University of Bahia, Salvador, Brazil
| | | | | | | | | | - Clarissa L. M. Souza
- University Hospital Professor Edgard Santos, Federal University of Bahia, Salvador, Brazil
| | - Juliana F. Vasconcelos
- Gonçalo Moniz Institute, Oswaldo Cruz Foundation, Salvador, Brazil
- Escola Bahiana de Medicina e Saúde Pública, Salvador, Brazil
| | - Milena R. Bezerra
- Senai Institute on Innovation in Advanced Health Systems, SENAI CIMATEC, Salvador, Brazil
| | - Daniela P. Petri
- Center for Biotechnology and Cell Therapy, Hospital São Rafael, Salvador, Brazil
| | - Bruno S. F. Souza
- Gonçalo Moniz Institute, Oswaldo Cruz Foundation, Salvador, Brazil
- Center for Biotechnology and Cell Therapy, Hospital São Rafael, Salvador, Brazil
- D’Or Institute for Research and Education, Rio de Janeiro, Brazil
| | | | - André Daher
- Vice-Presidency of Research and Reference Laboratories, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Ricardo Ribeiro-dos-Santos
- Gonçalo Moniz Institute, Oswaldo Cruz Foundation, Salvador, Brazil
- Senai Institute on Innovation in Advanced Health Systems, SENAI CIMATEC, Salvador, Brazil
| | - Milena B. P. Soares
- Gonçalo Moniz Institute, Oswaldo Cruz Foundation, Salvador, Brazil
- Senai Institute on Innovation in Advanced Health Systems, SENAI CIMATEC, Salvador, Brazil
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11
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Torres RM, Correia D, Nunes MDCP, Dutra WO, Talvani A, Sousa AS, Mendes FDSNS, Scanavacca MI, Pisani C, Moreira MDCV, de Souza DDSM, de W, Martins SM, Dias JCP. Prognosis of chronic Chagas heart disease and other pending clinical challenges. Mem Inst Oswaldo Cruz 2022; 117:e210172. [PMID: 35674528 PMCID: PMC9172891 DOI: 10.1590/0074-02760210172] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 06/17/2021] [Indexed: 01/24/2023] Open
Abstract
In this chapter, the main prognostic markers of Chagas heart disease are addressed, with an emphasis on the most recent findings and questions, establishing the basis for a broad discussion of recommendations and new approaches to managing Chagas cardiopathy. The main biological and genetic markers and the contribution of the electrocardiogram, echocardiogram and cardiac magnetic resonance are presented. We also discuss the most recent therapeutic proposals for heart failure, thromboembolism and arrhythmias, as well as current experience in heart transplantation in patients suffering from severe Chagas cardiomyopathy. The clinical and epidemiological challenges introduced by acute Chagas disease due to oral contamination are discussed. In addition, we highlight the importance of ageing and comorbidities in influencing the outcome of chronic Chagas heart disease. Finally, we discuss the importance of public policies, the vital role of funding agencies, universities, the scientific community and health professionals, and the application of new technologies in finding solutions for better management of Chagas heart disease.
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Affiliation(s)
| | - Dalmo Correia
- Universidade Federal do Triângulo Mineiro, Uberaba, MG, Brasil
| | | | - Walderez O Dutra
- Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil
| | - André Talvani
- Universidade Federal de Ouro Preto, Ouro Preto, MG, Brasil
| | - Andréa Silvestre Sousa
- Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
- Fundação Oswaldo Cruz-Fiocruz, Instituto Nacional de Infectologia Evandro Chagas, Rio de Janeiro, RJ, Brasil
| | | | | | - Cristiano Pisani
- Universidade de São Paulo, Instituto do Coração, São Paulo, SP, Brasil
| | | | | | - Wilson de
- Universidade de Pernambuco, Recife, PE, Brasil
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12
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Neves EGA, Koh CC, Souza-Silva TG, Passos LSA, Silva ACC, Velikkakam T, Villani F, Coelho JS, Brodskyn CI, Teixeira A, Gollob KJ, Nunes MDCP, Dutra WO. T-Cell Subpopulations Exhibit Distinct Recruitment Potential, Immunoregulatory Profile and Functional Characteristics in Chagas versus Idiopathic Dilated Cardiomyopathies. Front Cardiovasc Med 2022; 9:787423. [PMID: 35187122 PMCID: PMC8847602 DOI: 10.3389/fcvm.2022.787423] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 01/10/2022] [Indexed: 11/13/2022] Open
Abstract
Chronic Chagas cardiomyopathy (CCC) is one of the deadliest cardiomyopathies known and the most severe manifestation of Chagas disease, which is caused by infection with the parasite Trypanosoma cruzi. Idiopathic dilated cardiomyopathies (IDC) are a diverse group of inflammatory heart diseases that affect the myocardium and are clinically similar to CCC, often causing heart failure and death. While T-cells are critical for mediating cardiac pathology in CCC and IDC, the mechanisms underlying T-cell function in these cardiomyopathies are not well-defined. In this study, we sought to investigate the phenotypic and functional characteristics of T-cell subpopulations in CCC and IDC, aiming to clarify whether the inflammatory response is similar or distinct in these cardiomyopathies. We evaluated the expression of systemic cytokines, determined the sources of the different cytokines, the expression of their receptors, of cytotoxic molecules, and of molecules associated with recruitment to the heart by circulating CD4+, CD8+, and CD4-CD8- T-cells from CCC and IDC patients, using multiparameter flow cytometry combined with conventional and unsupervised machine-learning strategies. We also used an in silico approach to identify the expression of genes that code for key molecules related to T-cell function in hearts of patient with CCC and IDC. Our data demonstrated that CCC patients displayed a more robust systemic inflammatory cytokine production as compared to IDC. While CD8+ T-cells were highly activated in CCC as compared to IDC, CD4+ T-cells were more activated in IDC. In addition to differential expression of functional molecules, these cells also displayed distinct expression of molecules associated with recruitment to the heart. In silico analysis of gene transcripts in the cardiac tissue demonstrated a significant correlation between CD8 and inflammatory, cytotoxic and cardiotropic molecules in CCC transcripts, while no correlation with CD4 was observed. A positive correlation was observed between CD4 and perforin transcripts in hearts from IDC but not CCC, as compared to normal tissue. These data show a clearly distinct systemic and local cellular response in CCC and IDC, despite their similar cardiac impairment, which may contribute to identifying specific immunotherapeutic targets in these diseases.
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Affiliation(s)
- Eula G. A. Neves
- Department of Morphology, Cell-Cell Interactions Laboratory, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Carolina C. Koh
- Department of Morphology, Cell-Cell Interactions Laboratory, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Thaiany G. Souza-Silva
- Department of Morphology, Cell-Cell Interactions Laboratory, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Lívia Silva Araújo Passos
- Department of Morphology, Cell-Cell Interactions Laboratory, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte, Brazil
- Brigham and Womens Hospital, Harvard University, Boston, MA, United States
| | - Ana Carolina C. Silva
- Department of Morphology, Cell-Cell Interactions Laboratory, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Teresiama Velikkakam
- Department of Morphology, Cell-Cell Interactions Laboratory, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Fernanda Villani
- Department of Morphology, Cell-Cell Interactions Laboratory, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte, Brazil
- Minas Gerais State University, Divinópolis, Brazil
| | - Janete Soares Coelho
- Department of Morphology, Cell-Cell Interactions Laboratory, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte, Brazil
- Ezequiel Dias Foundation, Belo Horizonte, Brazil
| | - Claudia Ida Brodskyn
- Gonçalo Moniz Research Center, Fundação Oswaldo Cruz (FIOCRUZ), Salvador, Brazil
| | - Andrea Teixeira
- Rene Rachou Institute, Fundação Oswaldo Cruz (FIOCRUZ), Belo Horizonte, Brazil
| | - Kenneth J. Gollob
- Hospital Israelita Albert Einstein, São Paulo, Brazil
- Instituto Nacional de Ciência e Tecnologia em Doenças Tropicais, INCT-DT, Salvador, Brazil
| | - Maria do Carmo P. Nunes
- Graduate Program in Infectology and Tropical Medicine, School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Walderez O. Dutra
- Department of Morphology, Cell-Cell Interactions Laboratory, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte, Brazil
- Instituto Nacional de Ciência e Tecnologia em Doenças Tropicais, INCT-DT, Salvador, Brazil
- Graduate Program in Infectology and Tropical Medicine, School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil
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13
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Bacal F, Murad CM, dos Santos Aragão CA, de Campos IW, da Costa Seguro LFB, Avila MS, Mangini S, Gaiotto FA, Strabelli TV, Marcondes-Braga FG. Transplantation for Chagas Heart Disease: a Comprehensive Review. CURRENT TRANSPLANTATION REPORTS 2021. [DOI: 10.1007/s40472-021-00348-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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14
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Romero J, Velasco A, Pisani CF, Alviz I, Briceno D, Díaz JC, Della Rocca DG, Natale A, de Lourdes Higuchi M, Scanavacca M, Di Biase L. Advanced Therapies for Ventricular Arrhythmias in Patients With Chagasic Cardiomyopathy: JACC State-of-the-Art Review. J Am Coll Cardiol 2021; 77:1225-1242. [PMID: 33663741 DOI: 10.1016/j.jacc.2020.12.056] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 11/30/2020] [Accepted: 12/07/2020] [Indexed: 11/24/2022]
Abstract
Chagas disease is caused by infection from the protozoan parasite Trypanosoma cruzi. Although it is endemic to Latin America, global migration has led to an increased incidence of Chagas in Europe, Asia, Australia, and North America. Following acute infection, up to 30% of patients will develop chronic Chagas disease, with most patients developing Chagasic cardiomyopathy. Chronic Chagas cardiomyopathy is highly arrhythmogenic, with estimated annual rates of appropriate implantable cardioverter-defibrillator therapies and electrical storm of 25% and 9.1%, respectively. Managing arrhythmias in patients with Chagasic cardiomyopathy is a major challenge for the clinical electrophysiologist, requiring intimate knowledge of cardiac anatomy, advanced training, and expertise. Endocardial-epicardial mapping and ablation strategy is needed to treat arrhythmias in this patient population, owing to the suboptimal long-term success rate of endocardial mapping and ablation alone. We also describe innovative approaches to improve acute and long-term clinical outcomes in patients with refractory ventricular arrhythmias following catheter ablation, such as bilateral cervicothoracic sympathectomy and bilateral renal denervation, among others.
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Affiliation(s)
- Jorge Romero
- Cardiac Arrhythmia Center, Montefiore-Einstein Center for Heart and Vascular Care, Division of Cardiology, Department of Medicine, Albert Einstein College of Medicine, New York, New York, USA
| | - Alejandro Velasco
- Cardiac Arrhythmia Center, Montefiore-Einstein Center for Heart and Vascular Care, Division of Cardiology, Department of Medicine, Albert Einstein College of Medicine, New York, New York, USA
| | - Cristiano F Pisani
- Arrhythmia Unit, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
| | - Isabella Alviz
- Cardiac Arrhythmia Center, Montefiore-Einstein Center for Heart and Vascular Care, Division of Cardiology, Department of Medicine, Albert Einstein College of Medicine, New York, New York, USA
| | - David Briceno
- Cardiac Arrhythmia Center, Montefiore-Einstein Center for Heart and Vascular Care, Division of Cardiology, Department of Medicine, Albert Einstein College of Medicine, New York, New York, USA
| | - Juan Carlos Díaz
- Cardiac Arrhythmia Center, Montefiore-Einstein Center for Heart and Vascular Care, Division of Cardiology, Department of Medicine, Albert Einstein College of Medicine, New York, New York, USA
| | | | - Andrea Natale
- Cardiac Arrhythmia Center, Montefiore-Einstein Center for Heart and Vascular Care, Division of Cardiology, Department of Medicine, Albert Einstein College of Medicine, New York, New York, USA; Texas Cardiac Arrhythmia Institute at St David's Medical Center, Austin, Texas, USA
| | - Maria de Lourdes Higuchi
- Arrhythmia Unit, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
| | - Mauricio Scanavacca
- Arrhythmia Unit, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
| | - Luigi Di Biase
- Cardiac Arrhythmia Center, Montefiore-Einstein Center for Heart and Vascular Care, Division of Cardiology, Department of Medicine, Albert Einstein College of Medicine, New York, New York, USA; Texas Cardiac Arrhythmia Institute at St David's Medical Center, Austin, Texas, USA.
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15
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Radisic MV, Repetto SA. American trypanosomiasis (Chagas disease) in solid organ transplantation. Transpl Infect Dis 2020; 22:e13429. [DOI: 10.1111/tid.13429] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 06/30/2020] [Accepted: 07/16/2020] [Indexed: 12/22/2022]
Affiliation(s)
- Marcelo V. Radisic
- d. Institute. Instituto de Trasplante y Alta Complejidad (ITAC) Ciudad Autónoma de Buenos Aires Argentina
| | - Silvia A. Repetto
- Instituto de Investigaciones en Microbiologia y Parasitologia Medica (IMPaM) Facultad de Medicina Universidad de Buenos AiresConsejo Nacional de Investigaciones Cientificas y Tecnicas Ciudad Autónoma de Buenos Aires Argentina
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16
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Moreira MDCV, Renan Cunha-Melo J. Chagas Disease Infection Reactivation after Heart Transplant. Trop Med Infect Dis 2020; 5:tropicalmed5030106. [PMID: 32610473 PMCID: PMC7558140 DOI: 10.3390/tropicalmed5030106] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 06/08/2020] [Accepted: 06/10/2020] [Indexed: 11/20/2022] Open
Abstract
Chagas disease, caused by a Trypanosona cruzi infection, is one of the main causes of heart failure in Latin America. It was originally a health problem endemic to South America, predominantly affecting residents of poor rural areas. With globalization and increasing migratory flows from these areas to large cities, the immigration of T. cruzi chronically-infected people to developed, non-endemic countries has occurred. This issue has emerged as an important consideration for heart transplant professionals. Currently, Chagas patients with end-stage heart failure may need a heart transplantation (HTx). This implies that in post-transplant immunosuppression therapy to avoid rejection in the recipient, there is the possibility of T. cruzi infection reactivation, increasing the morbidity and mortality rates. The management of heart transplant recipients due to Chagas disease requires awareness for early recognition and parasitic treatment of T. cruzi infection reactivation. This issue poses challenges for heart transplant professionals, especially regarding the differential diagnosis between rejection and reactivation episodes. The aim of this review is to discuss the complexity of the Chagas disease reactivation phenomenon in patients submitted to HTx for end-stage chagasic cardiomyopathy.
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Affiliation(s)
| | - José Renan Cunha-Melo
- Department of Surgery, School of Medicine, Federal University of Minas Gerais (UFMG), Av. Alfredo Balena 190, Belo Horizonte CEP 30130-110, MG, Brazil
- Correspondence:
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17
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Altamura F, Rajesh R, Catta-Preta CMC, Moretti NS, Cestari I. The current drug discovery landscape for trypanosomiasis and leishmaniasis: Challenges and strategies to identify drug targets. Drug Dev Res 2020; 83:225-252. [PMID: 32249457 DOI: 10.1002/ddr.21664] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 02/05/2020] [Accepted: 03/13/2020] [Indexed: 12/11/2022]
Abstract
Human trypanosomiasis and leishmaniasis are vector-borne neglected tropical diseases caused by infection with the protozoan parasites Trypanosoma spp. and Leishmania spp., respectively. Once restricted to endemic areas, these diseases are now distributed worldwide due to human migration, climate change, and anthropogenic disturbance, causing significant health and economic burden globally. The current chemotherapy used to treat these diseases has limited efficacy, and drug resistance is spreading. Hence, new drugs are urgently needed. Phenotypic compound screenings have prevailed as the leading method to discover new drug candidates against these diseases. However, the publication of the complete genome sequences of multiple strains, advances in the application of CRISPR/Cas9 technology, and in vivo bioluminescence-based imaging have set the stage for advancing target-based drug discovery. This review analyses the limitations of the narrow pool of available drugs presently used for treating these diseases. It describes the current drug-based clinical trials highlighting the most promising leads. Furthermore, the review presents a focused discussion on the most important biological and pharmacological challenges that target-based drug discovery programs must overcome to advance drug candidates. Finally, it examines the advantages and limitations of modern research tools designed to identify and validate essential genes as drug targets, including genomic editing applications and in vivo imaging.
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Affiliation(s)
- Fernando Altamura
- Institute of Parasitology, McGill University, Ste Anne de Bellevue, Quebec, Canada
| | - Rishi Rajesh
- Institute of Parasitology, McGill University, Ste Anne de Bellevue, Quebec, Canada
| | | | - Nilmar S Moretti
- Departamento de Microbiologia, Imunologia e Parasitologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Igor Cestari
- Institute of Parasitology, McGill University, Ste Anne de Bellevue, Quebec, Canada
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18
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Bern C, Messenger LA, Whitman JD, Maguire JH. Chagas Disease in the United States: a Public Health Approach. Clin Microbiol Rev 2019; 33:e00023-19. [PMID: 31776135 PMCID: PMC6927308 DOI: 10.1128/cmr.00023-19] [Citation(s) in RCA: 137] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Trypanosoma cruzi is the etiological agent of Chagas disease, usually transmitted by triatomine vectors. An estimated 20 to 30% of infected individuals develop potentially lethal cardiac or gastrointestinal disease. Sylvatic transmission cycles exist in the southern United States, involving 11 triatomine vector species and infected mammals such as rodents, opossums, and dogs. Nevertheless, imported chronic T. cruzi infections in migrants from Latin America vastly outnumber locally acquired human cases. Benznidazole is now FDA approved, and clinical and public health efforts are under way by researchers and health departments in a number of states. Making progress will require efforts to improve awareness among providers and patients, data on diagnostic test performance and expanded availability of confirmatory testing, and evidence-based strategies to improve access to appropriate management of Chagas disease in the United States.
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Affiliation(s)
- Caryn Bern
- University of California San Francisco School of Medicine, San Francisco, California, USA
| | | | - Jeffrey D Whitman
- University of California San Francisco School of Medicine, San Francisco, California, USA
| | - James H Maguire
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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19
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Inga LAC, Olivera MJ. Reactivation of Chagas disease in a heart transplant patient infected by sylvatic Trypanosoma cruzi discrete typing unit I. Rev Soc Bras Med Trop 2019; 52:e20180512. [PMID: 31340357 DOI: 10.1590/0037-8682-0512-2018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 04/15/2019] [Indexed: 11/22/2022] Open
Abstract
Heart transplantation is an effective treatment for Chagas disease patients with severe cardiomyopathy. However, Trypanosoma cruzi reactivation is of great concern. The T. cruzi parasite is classified into six discrete typing units (DTUs identified as TcI-TcVI). It is unknown whether there is an association between T. cruzi genetic lineages and the different clinical manifestations of the disease. We report the case of a 51-year-old man who received a heart transplantation and presented with a reactivation of the disease. The molecular characterization of the parasite showed that the reactivation was related to specific infection by a DTU I (TcISYL) parasite.
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20
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21
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Gosling AF, Gelape CL. Chagas Disease and the Kissing Bug: An Invisible Giant. J Cardiothorac Vasc Anesth 2019; 33:2349-2350. [PMID: 30704830 DOI: 10.1053/j.jvca.2019.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Andre F Gosling
- Department of Anesthesiology, Tufts Medical Center, Boston, MA
| | - Claudio L Gelape
- Department of Cardiovascular Surgery of the Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
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22
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23
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Gray EB, La Hoz RM, Green JS, Vikram HR, Benedict T, Rivera H, Montgomery SP. Reactivation of Chagas disease among heart transplant recipients in the United States, 2012-2016. Transpl Infect Dis 2018; 20:e12996. [PMID: 30204269 DOI: 10.1111/tid.12996] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 08/24/2018] [Accepted: 08/29/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Heart transplantation has been shown to be a safe and effective intervention for progressive cardiomyopathy from chronic Chagas disease. However, in the presence of the immunosuppression required for heart transplantation, the likelihood of Chagas disease reactivation is significant. Reactivation may cause myocarditis resulting in allograft dysfunction and the rapid onset of congestive heart failure. Reactivation rates have been well documented in Latin America; however, there is a paucity of data regarding the risk in non-endemic countries. METHODS We present our experience with 31 patients with chronic Chagas disease who underwent orthotopic heart transplantation in the United States from 2012 to 2016. Patients were monitored following a standard schedule. RESULTS Of the 31 patients, 19 (61%) developed evidence of reactivation. Among the 19 patients, a majority (95%) were identified by laboratory monitoring using polymerase chain reaction testing. One patient was identified after the onset of clinical symptoms of reactivation. All subjects with evidence of reactivation were alive at follow-up (median: 60 weeks). CONCLUSIONS Transplant programs in the United States are encouraged to implement a monitoring program for heart transplant recipients with Chagas disease. Our experience using a preemptive approach of monitoring for Chagas disease reactivation was effective at identifying reactivation before symptoms developed.
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Affiliation(s)
- Elizabeth B Gray
- Parasitic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ricardo M La Hoz
- Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jaime S Green
- Division of Infectious Disease and International Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota
| | | | - Theresa Benedict
- Parasitic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Hilda Rivera
- Parasitic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Susan P Montgomery
- Parasitic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
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24
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Magarakis M, Macias AE, Tompkins BA, Reis V, Loebe M, Batista R, Salerno TA. Cardiac surgery for Chagas disease. J Card Surg 2018; 33:597-602. [DOI: 10.1111/jocs.13795] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Michael Magarakis
- Jackson Memorial Hospital-University of Miami Miller School of Medicine; Department of Surgery, Division of Cardiothoracic Surgery, Cardiac Surgery section; Miami Florida
| | - Alejandro E. Macias
- Department of Surgery; University of Medicine and Health Sciences; Miami Florida
| | - Bryon A. Tompkins
- Department of Surgery; Jackson Memorial Hospital-University of Miami Miller School of Medicine; Miami Florida
| | - Victor Reis
- Jackson Memorial Hospital-University of Miami Miller School of Medicine; Department of Surgery, Division of Cardiothoracic Surgery, Cardiac Surgery section; Miami Florida
| | - Matthias Loebe
- Jackson Memorial Hospital-University of Miami Miller School of Medicine; Department of Surgery, Division of Transplant Surgery; Miami Florida
| | | | - Tomas A. Salerno
- Jackson Memorial Hospital-University of Miami Miller School of Medicine; Department of Surgery, Division of Cardiothoracic Surgery; Miami Florida
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25
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Atik FA, Cunha CR, Chaves RB, Ulhoa MB, Barzilai VS. Left Ventricular Assist Device as a Bridge to Candidacy in End-stage Chagas Cardiomyopathy. Arq Bras Cardiol 2018; 111:112-114. [PMID: 30110054 PMCID: PMC6078366 DOI: 10.5935/abc.20180095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 09/25/2017] [Indexed: 11/20/2022] Open
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26
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Fabiani S, Fortunato S, Bruschi F. Solid Organ Transplant and Parasitic Diseases: A Review of the Clinical Cases in the Last Two Decades. Pathogens 2018; 7:pathogens7030065. [PMID: 30065220 PMCID: PMC6160964 DOI: 10.3390/pathogens7030065] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 07/17/2018] [Accepted: 07/18/2018] [Indexed: 12/18/2022] Open
Abstract
The aim of this study was to evaluate the occurrence of parasitic infections in solid organ transplant (SOT) recipients. We conducted a systematic review of literature records on post-transplant parasitic infections, published from 1996 to 2016 and available on PubMed database, focusing only on parasitic infections acquired after SOT. The methods and findings of the present review have been presented based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist. From data published in the literature, the real burden of parasitic infections among SOT recipients cannot really be estimated. Nevertheless, publications on the matter are on the increase, probably due to more than one reason: (i) the increasing number of patients transplanted and then treated with immunosuppressive agents; (ii) the “population shift” resulting from immigration and travels to endemic areas, and (iii) the increased attention directed to diagnosis/notification/publication of cases. Considering parasitic infections as emerging and potentially serious in their evolution, additional strategies for the prevention, careful screening and follow-up, with a high level of awareness, identification, and pre-emptive therapy are needed in transplant recipients.
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Affiliation(s)
- Silvia Fabiani
- Infectious Disease Department, Azienda Ospedaliera Pisana, 56124 Pisa, Italy.
- School of Infectious Diseases, Università di Pisa, 56124 Pisa, Italy.
| | - Simona Fortunato
- School of Infectious Diseases, Università di Pisa, 56124 Pisa, Italy.
| | - Fabrizio Bruschi
- School of Infectious Diseases, Università di Pisa, 56124 Pisa, Italy.
- Department of Translational Research, N.T.M.S., Università di Pisa, 56124 Pisa, Italy.
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27
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Nogueira SS, Felizardo AA, Caldas IS, Gonçalves RV, Novaes RD. Challenges of immunosuppressive and antitrypanosomal drug therapy after heart transplantation in patients with chronic Chagas disease: A systematic review of clinical recommendations. Transplant Rev (Orlando) 2018; 32:157-167. [DOI: 10.1016/j.trre.2018.04.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 04/12/2018] [Accepted: 04/13/2018] [Indexed: 02/02/2023]
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28
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Benatti RD, Al-Kindi SG, Bacal F, Oliveira GH. Heart transplant outcomes in patients with Chagas cardiomyopathy in the United States. Clin Transplant 2018; 32:e13279. [PMID: 29744939 DOI: 10.1111/ctr.13279] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2018] [Indexed: 01/03/2023]
Abstract
BACKGROUND Chagas cardiomyopathy (CC) is one of the chronic manifestations of Trypanosoma cruzi (T. cruzi) infection and is among the leading reasons for heart transplantation (HT) in Latin America. Chagas disease is also present in areas with large Hispanic communities in the United States. Our objective is to evaluate the outcomes of cardiac allograft recipients with the diagnosis of CC in the United States. METHODS AND RESULTS We identified 25 adult patients with CC and 15 930 with idiopathic dilated cardiomyopathy (IDCMP) who underwent HT between 1987 and 2015. CC patients were mostly Hispanics, had lower mean pulmonary artery pressure (23 vs 29 mm Hg, P = .035) and lower BMI (24 vs 26, P = .007). Patients with CC were more likely to be supported with a total artificial heart (TAH) as bridge to transplant (P = .009). There were no statistical differences for overall mortality and graft survival between CC and IDCMP cardiac allograft recipients. Induction therapy and mycophenolate mofetil (MMF) use were associated with higher rate of infection in Chagas patients. CONCLUSIONS Heart transplantation recipients with CC diagnosis appear to have similar outcomes to IDCMP patients. Induction therapy and MMF use may be associated with higher risk of infection in CC patients who underwent transplantation.
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Affiliation(s)
- Rodolfo D Benatti
- Advanced Heart Failure and Transplant Center, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Sadeer G Al-Kindi
- Advanced Heart Failure and Transplant Center, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Fernando Bacal
- Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
| | - Guilherme H Oliveira
- Advanced Heart Failure and Transplant Center, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
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Roscoe A, Tomey MI, Torregrossa G, Galhardo C, Parhar K, Zochios V. Chagas Cardiomyopathy: A Comprehensive Perioperative Review. J Cardiothorac Vasc Anesth 2018; 32:2780-2788. [PMID: 29803311 DOI: 10.1053/j.jvca.2018.04.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Indexed: 12/28/2022]
Affiliation(s)
- Andrew Roscoe
- Department of Cardiothoracic Anesthesia and Critical Care Medicine, Papworth Hospital, Cambridge, United Kingdom
| | - Matthew I Tomey
- Cardiovascular Institute and Institute for Critical Care Medicine, The Icahn School of Medicine at Mount Sinai, New York, NY
| | - Gianluca Torregrossa
- Department of Cardiothoracic Surgery, Mount Sinai Saint Luke, Mount Sinai Health System, New York, NY
| | - Carlos Galhardo
- Department of Anesthesia, National Institute of Cardiology, Rio de Janeiro, Brazil
| | - Ken Parhar
- Department of Critical Care Medicine, University of Calgary, Calgary, Canada
| | - Vasileios Zochios
- University Hospitals Birmingham NHS Foundation Trust, Department of Critical Care Medicine, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, United Kingdom; Perioperative Critical Care and Trauma Trials Group, Institute of Inflammation and Ageing, Centre of Translational Inflammation Research, University of Birmingham, Birmingham, United Kingdom.
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Alba AC, Foroutan F, Ng Fat Hing NKV, Fan CPS, Manlhiot C, Ross HJ. Incidence and predictors of sudden cardiac death after heart transplantation: A systematic review and meta-analysis. Clin Transplant 2018; 32:e13206. [DOI: 10.1111/ctr.13206] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Ana C. Alba
- Heart Failure and Transplantation Program; Toronto General Hospital; University Health Network; Toronto ON Canada
| | - Farid Foroutan
- Heart Failure and Transplantation Program; Toronto General Hospital; University Health Network; Toronto ON Canada
| | | | - Chun-Po S. Fan
- The Hospital for Sick Children; University of Toronto; Toronto ON Canada
| | - Cedric Manlhiot
- The Hospital for Sick Children; University of Toronto; Toronto ON Canada
| | - Heather J. Ross
- Heart Failure and Transplantation Program; Toronto General Hospital; University Health Network; Toronto ON Canada
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Traina M, Meymandi S, Bradfield JS. Heart Failure Secondary to Chagas Disease: an Emerging Problem in Non-endemic Areas. Curr Heart Fail Rep 2017; 13:295-301. [PMID: 27807757 DOI: 10.1007/s11897-016-0305-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Chagas disease affects millions of people worldwide. Though the majority of infected individuals remain asymptomatic, approximately 30 % of patients progress to develop cardiac manifestations and eventual heart failure. While vectorial transmission occurs predominantly in South America, Central America, and Mexico, millions of people originally from these endemic regions immigrate to non-endemic countries in North America, Europe, and Asia. Outside of rare specialized centers, health-care providers lack experience diagnosing and treating this disease. This lack of experience likely leads to far fewer Chagas disease patients being diagnosed than what actually exist in non-endemic countries, with subsequent adverse effect on patient outcomes and health-care expenses. Underdiagnosis increases the risk of developing cardiomyopathy, associated heart failure, and life-threatening ventricular arrhythmias as the disease progresses.
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Affiliation(s)
- Mahmoud Traina
- Center of Excellence for Chagas Disease, Olive View-UCLA Medical Center, 14445 Olive View Dr., Sylmar, CA, 91342, USA
- Cleveland Clinic Abu Dhabi, Heart and Vascular Institute, PO Box 112412, Al Maryah Island, Abu Dhabi, UAE
| | - Sheba Meymandi
- Center of Excellence for Chagas Disease, Olive View-UCLA Medical Center, 14445 Olive View Dr., Sylmar, CA, 91342, USA
| | - Jason S Bradfield
- Center of Excellence for Chagas Disease, Olive View-UCLA Medical Center, 14445 Olive View Dr., Sylmar, CA, 91342, USA.
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, 100 Medical Plaza, Suite 660, Los Angeles, CA, 90095, USA.
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32
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Heart transplantation for Chagas cardiomyopathy. Rev Port Cardiol 2017; 36:871.e1-871.e4. [PMID: 29162358 DOI: 10.1016/j.repc.2016.08.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 08/01/2016] [Indexed: 11/22/2022] Open
Abstract
Chagas disease is an endemic disease in Latin America that is increasingly found in non-endemic areas all over the world due to the flow of migrants from Central and South America. We present the case of a Brazilian immigrant in Portugal who underwent orthotopic heart transplantation for end-stage Chagas cardiomyopathy. Immunosuppressive therapy included prednisone, mycophenolate mofetil and tacrolimus. Twelve months after the procedure she is asymptomatic, with good graft function, and with no evidence of complications such as graft rejection, opportunistic infections, neoplasms or reactivation of Trypanosoma cruzi infection. By reporting the first case in Portugal of heart transplantation for Chagas cardiomyopathy, we aim to increase awareness of Chagas disease as an emerging global problem and of Chagas cardiomyopathy as a serious complication for which heart transplantation is a valuable therapeutic option.
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Heart transplantation for Chagas cardiomyopathy. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2017. [DOI: 10.1016/j.repce.2017.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Bocchi EA, Bestetti RB, Scanavacca MI, Cunha Neto E, Issa VS. Chronic Chagas Heart Disease Management: From Etiology to Cardiomyopathy Treatment. J Am Coll Cardiol 2017; 70:1510-1524. [PMID: 28911515 DOI: 10.1016/j.jacc.2017.08.004] [Citation(s) in RCA: 118] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 08/01/2017] [Accepted: 08/02/2017] [Indexed: 12/17/2022]
Abstract
Trypanosoma cruzi (T. cruzi) infection is endemic in Latin America and is becoming a worldwide health burden. It may lead to heterogeneous phenotypes. Early diagnosis of T. cruzi infection is crucial. Several biomarkers have been reported in Chagas heart disease (ChHD), but most are nonspecific for T. cruzi infection. Prognosis of ChHD patients is worse compared with other etiologies, with sudden cardiac death as an important mode of death. Most ChHD patients display diffuse myocarditis with fibrosis and hypertrophy. The remodeling process seems to be associated with etiopathogenic mechanisms and neurohormonal activation. Pharmacological treatment and antiarrhythmic therapy for ChHD is mostly based on results for other etiologies. Heart transplantation is an established, valuable therapeutic option in refractory ChHD. Implantable cardioverter-defibrillators are indicated for prevention of secondary sudden cardiac death. Specific etiological treatments should be revisited and reserved for select patients. Understanding and management of ChHD need improvement, including development of randomized trials.
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Affiliation(s)
- Edimar Alcides Bocchi
- Heart Institute (Incor) of São Paulo, University Medical School São Paulo, São Paulo, Brazil.
| | | | | | - Edecio Cunha Neto
- Heart Institute (Incor) of São Paulo, University Medical School São Paulo, São Paulo, Brazil
| | - Victor Sarli Issa
- Heart Institute (Incor) of São Paulo, University Medical School São Paulo, São Paulo, Brazil
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Benatti RD, Oliveira GH, Bacal F. Heart Transplantation for Chagas Cardiomyopathy. J Heart Lung Transplant 2017; 36:597-603. [DOI: 10.1016/j.healun.2017.02.006] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 12/23/2016] [Accepted: 02/01/2017] [Indexed: 01/27/2023] Open
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da Costa PA, Segatto M, Durso DF, de Carvalho Moreira WJ, Junqueira LL, de Castilho FM, de Andrade SA, Gelape CL, Chiari E, Teixeira-Carvalho A, Junho Pena SD, Machado CR, Franco GR, Filho GB, Vieira Moreira MDC, Mara Macedo A. Early polymerase chain reaction detection of Chagas disease reactivation in heart transplant patients. J Heart Lung Transplant 2017; 36:797-805. [PMID: 28320630 DOI: 10.1016/j.healun.2017.02.018] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 02/15/2017] [Accepted: 02/17/2017] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Heart transplantation is a valuable therapeutic option for Chagas disease patients with severe cardiomyopathy. During patient follow-up, the differential diagnosis between cardiac transplant rejection and Chagas disease infection reactivation remains a challenging task, which hinders rapid implementation of the appropriate treatment. Herein we investigate whether polymerase chain reaction (PCR) strategies could facilitate early detection of Trypanosoma cruzi (T cruzi) in transplanted endomyocardial biopsies (EMBs). METHODS In this study we analyzed 500 EMB specimens obtained from 58 chagasic cardiac transplant patients, using PCR approaches targeted to nuclear (rDNA 24Sα) and kinetoplastid (kDNA) markers, and compared the efficiency of these approaches with that of other tests routinely used. RESULTS T cruzi DNA was detected in 112 EMB specimens derived from 39 patients (67.2%). The first positive result occurred at a median 1.0 month post-transplant. Conventional histopathologic, blood smear and hemoculture analyses showed lower sensitivity and higher median time to the first positive result. Patient follow-up revealed that 31 of 39 PCR-positive cases presented clinical reactivation of Chagas disease at different time-points after transplantation. PCR techniques showed considerable sensitivity (0.82) and specificity (0.60), with area under the receiver operating characteristic (ROC) curves of 0.708 (p = 0.001). Moreover, PCR techniques anticipated the clinical signs of Chagas disease reactivation by up to 36 months, with a median time of 6 months and an average of 9.1 months. CONCLUSIONS We found a good association between the PCR diagnosis and the clinical signs of the disease, indicating that the PCR approaches used herein are suitable for early diagnosis of Chagas disease reactivation, with high potential to assist physicians in treatment decisions. For this purpose, an algorithm is proposed for surveillance based on the molecular tests.
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Affiliation(s)
- Priscilla Almeida da Costa
- Departamento de Bioquímica e Imunologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
| | - Marcela Segatto
- Departamento de Genética, Instituto de Biociências, Universidade Estadual Paulista, Botucatu, São Paulo, Brazil
| | - Danielle Fernandes Durso
- Departamento de Bioquímica e Imunologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Wagson José de Carvalho Moreira
- Departamento de Bioquímica e Imunologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Lucas Lodi Junqueira
- Hospital das Clinicas, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Fábio Morato de Castilho
- Hospital das Clinicas, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Silvio Amadeu de Andrade
- Hospital das Clinicas, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Cláudio Léo Gelape
- Departamento de Cirurgia, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Egler Chiari
- Departamento de Parasitologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Andréa Teixeira-Carvalho
- Centro de Pesquisas René Rachou, Fiocruz-Minas, Grupo Integrado de Pesquisas em Biomarcadores, Belo Horizonte, Minas Gerais, Brazil
| | - Sergio Danilo Junho Pena
- Departamento de Bioquímica e Imunologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Carlos Renato Machado
- Departamento de Bioquímica e Imunologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Gloria Regina Franco
- Departamento de Bioquímica e Imunologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Geraldo Brasileiro Filho
- Departamento de Patologia da Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | | | - Andréa Mara Macedo
- Departamento de Bioquímica e Imunologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
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38
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Klahr JI, Uribe AM, Roa N, González JM. Inmunidad celular en la patogénesis de la cardiopatía chagásica crónica. REVISTA COLOMBIANA DE CARDIOLOGÍA 2016. [DOI: 10.1016/j.rccar.2016.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Abstract
Physicians working in Europe and the United States should suspect Chagas heart failure in every patient coming from Latin America with chronic heart failure. Diagnosis should be confirmed by positive serology. Right bundle branch block and left anterior fascicular block on 12-lead electrocardiogram, enlarged cardiac silhouette with no pulmonary congestion on chest X-ray and left ventricular apical aneurysm on echocardiography are the distinctive features of this condition. The clinical course is poorer than that of non-Chagas heart failure; however, medical treatment is similar. Implantable cardioverter-defibrillators are useful in the primary and secondary prevention of sudden cardiac death. Cardiac resynchronisation therapy can be given to patients on optimal medical therapy and with lengthened QRS complex. Heart transplantation is the treatment of choice for patients with end-stage Chagas heart failure.
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Bezerra CG, Adam EL, Baptista ML, Ciambelli GS, Kopel L, Bernoche C, Lopes LNGD, Macatrão-Costa MF, Falcão BDAA, Lage SG. Aortic Counterpulsation Therapy in Patients with Advanced Heart Failure: Analysis of the TBRIDGE Registry. Arq Bras Cardiol 2015; 106:26-32. [PMID: 26690691 PMCID: PMC4728592 DOI: 10.5935/abc.20150147] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2015] [Accepted: 10/14/2015] [Indexed: 11/24/2022] Open
Abstract
Background The use of aortic counterpulsation therapy in advanced heart failure is
controversial. Objectives To evaluate the hemodynamic and metabolic effects of intra-aortic
balloon pump (IABP) and its impact on 30-day mortality in patients
with heart failure. Methods Historical prospective, unicentric study to evaluate all patients
treated with IABP betwen August/2008 and July/2013, included in an
institutional registry named TBRIDGE (The Brazilian Registry of
Intra-aortic balloon pump in Decompensated heart failure - Global
Evaluation). We analyzed changes in oxygen central venous saturation
(ScvO2), arterial lactate, and use of vasoactive drugs
at 48 hours after IABP insertion. The 30-day mortality was estimated
by the Kaplan-Meier method and diferences in subgroups were evaluated
by the Log-rank test. Results A total of 223 patients (mean age 49 ± 14 years) were included.
Mean left ventricle ejection fraction was 24 ± 10%, and 30% of
patients had Chagas disease. Compared with pre-IABP insertion, we
observed an increase in ScvO2 (50.5% vs. 65.5%, p <
0.001) and use of nitroprusside (33.6% vs. 47.5%, p < 0.001), and a
decrease in lactate levels (31.4 vs. 16.7 mg/dL, p < 0.001) and use
of vasopressors (36.3% vs. 25.6%, p = 0.003) after IABP insertion.
Thirty-day survival was 69%, with lower mortality in Chagas disease
patients compared without the disease (p = 0.008). Conclusion After 48 hours of use, IABP promoted changes in the use of vasoactive
drugs, improved tissue perfusion. Chagas etiology was associated with
lower 30-day mortality. Aortic counterpulsation therapy is an
effective method of circulatory support for patients waiting for heart
transplantation.
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Affiliation(s)
| | - Eduardo Leal Adam
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Mariana Lins Baptista
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | - Liliane Kopel
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Claudia Bernoche
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | | | | | - Silvia Gelas Lage
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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Mangini S, Alves BR, Silvestre OM, Pires PV, Pires LJT, Curiati MNC, Bacal F. Heart transplantation: review. EINSTEIN-SAO PAULO 2015; 13:310-8. [PMID: 26154552 PMCID: PMC4943829 DOI: 10.1590/s1679-45082015rw3154] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 02/08/2015] [Indexed: 12/20/2022] Open
Abstract
Heart transplantation is currently the definitive gold standard surgical approach in the treatment of refractory heart failure. However, the shortage of donors limits the achievement of a greater number of heart transplants, in which the use of mechanical circulatory support devices is increasing. With well-established indications and contraindications, as well as diagnosis and treatment of rejection through defined protocols of immunosuppression, the outcomes of heart transplantation are very favorable. Among early complications that can impact survival are primary graft failure, right ventricular dysfunction, rejection, and infections, whereas late complications include cardiac allograft vasculopathy and neoplasms. Despite the difficulties for heart transplantation, in particular, the shortage of donors and high mortality while on the waiting list, in Brazil, there is a great potential for both increasing effective donors and using circulatory assist devices, which can positively impact the number and outcomes of heart transplants.
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Affiliation(s)
| | | | - Odílson Marcos Silvestre
- Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | | | | | - Fernando Bacal
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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43
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Pierrotti LC, Kotton CN. Transplantation in the tropics: lessons on prevention and management of tropical infectious diseases. Curr Infect Dis Rep 2015; 17:492. [PMID: 26031964 DOI: 10.1007/s11908-015-0492-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Tropical infectious diseases (IDs) remain a rare complication in transplant recipients even in tropical settings, but this topic has become increasingly important during the last decade due to multiple factors. Interestingly, non-tropical countries report most of the experiences with tropical diseases. The reported experience from non-endemic regions, however, does not always reflect the experience of endemic areas. Most of the guidelines and recommendations in the literature may not be applicable in tropical settings due to logistical difficulties, cost, and lack of proven benefit. In addition, certain post-transplant prevention measures, as prophylaxis and reducing exposure risk, are not feasible. Nonetheless, risk assessment and post-transplant management of tropical IDs in tropical areas should not be neglected, and clinicians need to have a higher clinical awareness for tropical ID occurring in this population. Herein, we review the more significant tropical ID in transplant patients, focusing on relevant experience reported by tropical settings.
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Affiliation(s)
- Ligia C Pierrotti
- Infectious Diseases Division, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Eneas de Carvalho Aguiar 255, 4° andar, São Paulo, 05403-900, SP, Brazil,
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Bocchi EA, Tanigawa RY, Brandão SMG, Cruz F, Issa V, Ayub-Ferreira S, Chizzola P, Souza G, Fiorelli AI, Bacal F, Pomerantzeff PMA, Honorato R, Lourenço-Filho D, Guimarães G, Benvenuti LA. Immunohistochemical quantification of inflammatory cells in endomyocardial biopsy fragments after heart transplantation: a new potential method to improve the diagnosis of rejection after heart transplantation. Transplant Proc 2015; 46:1489-96. [PMID: 24935318 DOI: 10.1016/j.transproceed.2013.12.062] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Revised: 10/09/2013] [Accepted: 12/16/2013] [Indexed: 11/30/2022]
Abstract
Inconsistencies in cardiac rejection grading systems corroborate the concept that the evaluation of inflammatory intensity and myocyte damage seems to be subjective. We studied in 36 patients the potential role of the immunohistochemical (IHC) counting of inflammatory cells in endomyocardial biopsy (EMB) as an objective tool, testing the hypothesis of correlation between the International Society for Heart and Lung Transplantation 2004 rejection and IHC counting of inflammatory cells. We observed a progressive increment in CD68+ cells/mm(2) (P = .000) and CD3+ cells/mm(2) (P = .000) with higher rejection grade. A strong correlation between the grade of cellular rejection and both CD68+ cells/mm(2) and CD3+ cells/mm(2) was obtained (P = .000). One patient with CD3+ and CD68+ cells/mm(2) above the upper limit of the 95% confidence interval for cells/mm(2) found in rejection grade 1R evolved to rejection grade 2R without treatment. In patients with 2R that did not respond to treatment the values of CD68+ or CD3+ cells were higher than the overall median values for rejection grade 2R. For diagnosis of rejection needing treatment, the CD68+ and CD3+ cells/mm(2) areas under the receiver operating characteristic curves were 0.956 and 0.934, respectively. IHC counting of mononuclear inflammatory infiltrate in EMB seems to have additive potential role in evaluation of EMB for the diagnosis and prognosis of rejection episodes.
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Affiliation(s)
- E A Bocchi
- Heart Institute (Incor), University of São Paulo Medical School, São Paulo, Brazil.
| | - R Y Tanigawa
- Heart Institute (Incor), University of São Paulo Medical School, São Paulo, Brazil
| | - S M G Brandão
- Heart Institute (Incor), University of São Paulo Medical School, São Paulo, Brazil
| | - F Cruz
- Heart Institute (Incor), University of São Paulo Medical School, São Paulo, Brazil
| | - V Issa
- Heart Institute (Incor), University of São Paulo Medical School, São Paulo, Brazil
| | - S Ayub-Ferreira
- Heart Institute (Incor), University of São Paulo Medical School, São Paulo, Brazil
| | - P Chizzola
- Heart Institute (Incor), University of São Paulo Medical School, São Paulo, Brazil
| | - G Souza
- Heart Institute (Incor), University of São Paulo Medical School, São Paulo, Brazil
| | - A I Fiorelli
- Heart Institute (Incor), University of São Paulo Medical School, São Paulo, Brazil
| | - F Bacal
- Heart Institute (Incor), University of São Paulo Medical School, São Paulo, Brazil
| | - P M A Pomerantzeff
- Heart Institute (Incor), University of São Paulo Medical School, São Paulo, Brazil
| | - R Honorato
- Heart Institute (Incor), University of São Paulo Medical School, São Paulo, Brazil
| | - D Lourenço-Filho
- Heart Institute (Incor), University of São Paulo Medical School, São Paulo, Brazil
| | - G Guimarães
- Heart Institute (Incor), University of São Paulo Medical School, São Paulo, Brazil
| | - L A Benvenuti
- Heart Institute (Incor), University of São Paulo Medical School, São Paulo, Brazil
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Abstract
This review addresses relevant aspects of Chagas disease in the immunocompromised host. Chagas disease--one of the world's most neglected diseases-has become a global public health concern. Novel transmission modalities, such as organ transplantation, evidence of parasite persistence in chronically infected individuals--with the potential for reactivation under immunosuppression--and the prolonged survival of immunosuppressed patients call for an appraisal of the disease in this particular setting. The management and outcome of solid organ transplantation in the infected recipient with special focus on heart transplantation is addressed. The guidelines for management and the outcome of the recipients of organs from infected donors are discussed, and comments on haematopoietic stem cell transplantation are included. Finally, Chagas disease in other situations of impairment of the immune system, such as HIV/AIDS and autoimmune diseases, are considered. Immunosuppression has become an increasingly frequent condition that might modify the natural history of Trypanosoma cruzi infection. A number of strategies are available for Chagas disease management in the immunosuppressed patient. First, according to recent recommendations from the health authorities in Argentina, most infected patients would benefit from being treated at diagnosis. This has not been validated for patients with different immunosuppressive disorders. A different strategy would involve treating only patients with documented reactivation (either parasitaemia or clinical manifestations). These different approaches are discussed. To reach a diagnosis of parasitaemia, monitoring is essential, either with conventional methods or with molecular techniques that are not yet available in all centres. Collaborative studies are needed to improve the level of evidence, which will allow for better guidelines.
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Affiliation(s)
- R Lattes
- Transplant infectious Disease, Department of Transplantation, Instituto de Nefrología/Nephrology, Buenos Aires, Argentina
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Trypanosoma cruzi persistence in the native heart is associated with high-grade myocarditis, but not with Chagas’ disease reactivation after heart transplantation. J Heart Lung Transplant 2014; 33:698-703. [DOI: 10.1016/j.healun.2014.01.920] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Revised: 12/23/2013] [Accepted: 01/30/2014] [Indexed: 11/20/2022] Open
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Martinez-Perez A, Norman FF, Monge-Maillo B, Perez-Molina JA, Lopez-Velez R. An approach to the management of Trypanosoma cruzi infection (Chagas' disease) in immunocompromised patients. Expert Rev Anti Infect Ther 2014; 12:357-73. [PMID: 24484076 DOI: 10.1586/14787210.2014.880652] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The epidemiology of Chagas disease has changed in the last decades due to migration movements, population ageing and the emergence of new transmission routes. In endemic countries, health facilities and access to healthcare are improving and T. cruzi infected patients are also benefiting from medical advances. The HIV epidemic has spread to both endemic and non-endemic areas for T. cruzi, organ transplant rates have increased recently, especially in Latin America, and other medical conditions affecting the immune system are increasing their global burden. The natural course of Chagas disease is mainly determined by the host's cellular immune response. These conditions may therefore overlap with T. cruzi infection and alter the disease's natural history which may present with atypical clinical forms and a higher associated morbidity and mortality in immunocompromised patients. The present review aims to contribute to the management of immunosuppressed patients with T. cruzi infection.
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Affiliation(s)
- Angela Martinez-Perez
- Tropical Medicine and Clinical Parasitology, Infectious Diseases Department, Ramon y Cajal Hospital, Carretera Comenar 9.100 Km, 28034 Madrid, Spain
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Bocchi EA. Exercise training in Chagas' cardiomyopathy: trials are welcome for this neglected heart disease. Eur J Heart Fail 2014; 12:782-4. [DOI: 10.1093/eurjhf/hfq124] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Edimar Alcides Bocchi
- Rua Dr. Melo Alves 690 apto 41, Bairro Cerqueira César; São Paulo Brazil CEP 01417-010
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Mattu UK, Singh GD, Southard JA, Amsterdam EA. The assassin: Chagas cardiomyopathy. Am J Med 2013; 126:864-7. [PMID: 23870790 DOI: 10.1016/j.amjmed.2013.05.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2012] [Revised: 05/16/2013] [Accepted: 05/16/2013] [Indexed: 11/16/2022]
Affiliation(s)
- Uppinder K Mattu
- Department of Internal Medicine, University of California Davis Medical Center, Sacramento
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Bocchi EA, Arias A, Verdejo H, Diez M, Gómez E, Castro P. The Reality of Heart Failure in Latin America. J Am Coll Cardiol 2013; 62:949-58. [DOI: 10.1016/j.jacc.2013.06.013] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2013] [Revised: 06/07/2013] [Accepted: 06/13/2013] [Indexed: 11/26/2022]
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