Human African trypanosomiasis & heart

Original algorithms for the detection of cardiovascular involvement of neglected tropical diseases

INTRODUCTION

Neglected tropical diseases (NTDs) introduce considerable morbidity and mortality on a global scale, directly impacting over 1 billion individuals as well as their families and communities. Afflicted individuals may have limited access to resources and care in these regions, contributing to a high proportion of chronic, progressive, and systemic disease. The cardiovascular system is at particular risk of demise for several NTDs, yet remains largely unstudied due in part to the lack of robust data collection mechanisms in the most impacted regions.

AREAS COVERED

The present review is a part of the Neglected Tropical Diseases and other Infectious Diseases affecting the Heart (NET-Heart) Project, aiming at summarizing the current knowledge on cardiovascular implications of NTDs and providing diagnostic as well as management recommendations which can be tailored to low-resource settings. The diagnostic and management algorithms of 13 unique NTDs are presented and summarized.

EXPERT OPINION

Recognizing cardiac manifestations of NTDs can significantly alter disease trajectory and all physicians benefit from improved knowledge about NTDs. Great potential exists to advance patient care by improving data collection, communication, and international collaboration.

Human African Trypanosomiasis (Sleeping Sickness)-Epidemiology, Clinical Manifestations, Diagnosis, Treatment, and Prevention

Purpose of Review

Human African Trypanosomiasis (HAT), also known as sleeping sickness, is a vector-borne parasitic neglected tropical disease (NTD) endemic in sub-Saharan Africa. This review aims to enhance our understanding of HAT and provide valuable insights to combat this significant public health issue by synthesizing the latest research and evidence.

Recent Findings

HAT has reached a historical < 1000 cases in 2018. In patients without neurologic symptoms and signs, the likelihood of a severe meningoencephalitic stage is deemed low, obviating the need for a lumbar puncture to guide treatment decisions using fexinidazole.

Summary

Both forms of the disease, gambiense HAT (gHAT) and rhodesiense HAT (rHAT), have specific epidemiology, risk factors, diagnosis, and treatment. Disease management still requires a high index of suspicion, infectious disease expertise, and specialized medical care. Essential stakeholders in health policy are critical to accomplishing the elimination goals of the NTD roadmap for 2021-2030.

Pericardial Disease in the Developing World

Pericardial disease in the developing world is dominated primarily by effusive and constrictive syndromes and contributes to the acute and chronic heart failure burden in many regions. The confluence of geography (location in the tropics), a significant burden of diseases of poverty and neglect, and a significant contribution of communicable diseases to the general burden of disease is reflected in the wide etiological spectrum of causes of pericardial disease. The prevalence of Mycobacterium tuberculosis in particular, is high throughout much of the developing world where it is the most frequent and important cause of pericarditis and is associated with significant morbidity and mortality. Acute viral/idiopathic pericarditis, which is the primary manifestation of pericardial disease in the developed world is believed to occur significantly less frequently in the developing world. Although diagnostic approaches and criteria to establish the diagnosis of pericardial disease are similar throughout the globe, resource constraints such as access to multimodality imaging and hemodynamic assessment are a major limitation in much of the developing world. These important considerations significantly influence the diagnostic and treatment approaches, and outcomes related to pericardial disease.

Infections and Cardiovascular Disease: JACC Focus Seminar 1/4

The burden of cardiovascular diseases is sharply rising in low- and middle-income countries (LMICs). Along with the increasing rates of cardiovascular risk factors in these regions, there is a growing recognition of the contribution of neglected tropical diseases and other infections. Several cardiac implications of these infections have been reported but have not yet been validated by robust population data. This is in part due to limited access to health care and insufficient data collection infrastructure in many LMICs. Therefore, the true impact of these infections on the cardiovascular system may be underestimated, because of both underdiagnosis and underreporting bias. There is an urgent need to thoroughly delineate the cardiac impact of these conditions with elevated prevalence in LMICs and to propose strategies to reduce the negative consequences of these diseases in health systems with limited resources.

Cardiac dysfunction in active pulmonary tuberculosis: Mysterious facts of TB’s pandora

<b>Introduction</b>: Cardiac dysfunction in pulmonary tuberculosis is relatively more common and underestimated due to lack of suspicion. We have studied prevalence of cardiac dysfunction in pulmonary tuberculosis with special emphasis on echocardiography, serum cortisol and its correlation in cases with unstable cardiorespiratory parameters.<br /> <b>Methods:</b> Prospective, observational, complete workup, and one year follow up study conducted during January 2016 to December 2020 included 800 cases of active pulmonary tuberculosis with specified inclusion criteria of disproportionate tachycardia, tachypnea with or without hypoxia and shock. Cases with known risk factor for cardiac disease and taking cardiac medicines, and cases with pericardial effusion were excluded from study. All study cases were undergone protocolized analysis such as chest radiograph, pulse oximetry, ECG, sputum examination, cardiac enzymes (CPK-MB, NT-Pro-BNP, and cardiac troponins), serum cortisol, and echocardiography at entry point, at two and six months of treatment with anti-tuberculosis medicines as per NTEP. Statistical analysis was carried out by Chi-square test.<br /> <b>Observations and analysis: </b>In a study of 800 pulmonary tuberculosis cases, 56.00% (448/800) cases were males, and 44.00% (352/800) cases were females. Cases with BMI&lt;18 was 41.62% (333/800) and BMI&gt;18 was 58.37% (467/800). Radiological patterns as unilateral disease in 33.62% (269/800) &amp; bilateral disease in 66.37% (531/800). Hemoglobin less than 10 gm% were documented in 85.12% (681/800) and above 10 gm% were in 14.87% (119/800) cases. Serum albumin less than 3.5 gm% and more than 3.5 gm% were observed in 48.12% (385/800) and 51.12% (415/800) cases respectively. Hypoxia was documented 26.12% (209/800) cases and normal oxygen saturation in 73.87% (591/800) cases. cases with normal and abnormal serum cortisol were 61.37% (491/800) &amp; 38.62% (309/800) respectively. Sputum examination for AFB observed in 30.00% (240/800) and gene Xpert MTB/RIF documented in 51.37% (411/800) cases respectively. Bronchoscopy guided techniques were used in 149 cases and BAL smear AFB in 44.96% (67/149) cases, gene Xpert MTB/RIF in 97.31% (145/149) cases and MGIT culture in four cases (positive in 100% cases subjected to MGIT culture). We have observed global hypokinesia is predominant cardiac dysfunction documented in 82.21% (171/208) cases, followed by left heart systolic dysfunction in 16.34% (34/208) cases and left heart diastolic dysfunction in 75% (156/208) cases. Right heart dysfunction as dilated right atrium and right ventricle documented in 52.88% (110/208) cases and pulmonary hypertension in 40.38% (84/208) cases. Covariates such as age, gender, hemoglobin, BMI, serum cortisol, serum albumin, oxygen saturation and radiological involvement has significant association with cardiac dysfunction. (p&lt;0.00001) Response to treatment with antituberculosis medicines and steroids has documented as improved in 77.40% cases (161/208) cases, persistent in 13.46% (28/2028) cases and progressive in 9.13% (19/208) cases. Final outcome of cardiac dysfunction in Pulmonary tuberculosis cases has significant association with serum cortisol level (p&lt;0.00086).<br /> <b>Conclusion:</b> Cardiac dysfunction is active pulmonary tuberculosis needs prompt workup in presence of disproportionate tachypnea, tachycardia with or without hypoxia and shock. Echocardiography is basic tool to evaluate these cases and global hypokinesis is most common abnormality. Serum cortisol abnormality documented in fair number of cases and very well correlated with left ventricular dysfunction abnormalities. Steroids with antituberculosis treatment backup is mainstay protocol during management of these cases. Cardiac dysfunction is reversible in majority of cases and proportionate number shown complete improvement in cardiac dysfunction.

Pulmonary tuberculosis with cardiac dysfunction: An ignored combination!

Cardiovascular involvement is rare in tuberculosis &amp; high index of suspicion is must in diagnosing these cases in high burden setting to have successful treatment outcome. In this case report, 26-year male, presented with constitutional symptoms for three months duration with acute deterioration with tachycardia and tachypnea with hypoxia. Radiological investigations documented conglomerated miliary tuberculosis and confirmed by sputum smear microscopy. Cardiac investigations revealed sinus tachycardia in ECG, raised cardiac enzymes, and echocardiography as ‘global left ventricular hypokinesia’ with reduced ejection fraction. Treatment initiated with steroids with anti-tuberculosis and recorded near complete radiological resolution, bacteriological cure and restored cardiac function after six months with good compliance. We recommend cardiac workup in all pulmonary tuberculosis cases with disproportionate tachycardia.

CYSTICERCOSIS & HEART: A systematic review

Cysticercosis is a parasitic tissue infection caused by larval cysts of the tapeworm Taenia solium. These larval cysts infect brain, muscle, or other tissue, and are a major cause of adult-onset seizures in most low-income countries with tropical climate. Prevalence it's around 50 million people. Although cardiovascular system is not the most affected, this disease can also be associated with multiple and randomly distributed cysts in the subpericardium, subendocardium and myocardium in up to 25% of infected patients. Most cardiac cysticercosis' cases are asymptomatic, but it can manifest with ventricular arrhythmias and conduction disorders. Area Covered: The "Neglected Tropical Diseases and other Infectious Diseases affecting the Heart" (NET-Heart project) is an initiative by the Emerging Leaders group of the Interamerican Society of Cardiology to systematically review all these endemic conditions affecting the heart. A systematic review was conducted following PRISMA guidelines and including articles published in MEDLINE, ScienceDirect, PubMed and LILACS databases. A total of 41 papers were included in this review. Expert Opinion: In the areas of greatest prevalence, unhealthiness and poverty favor the development of this disease, which highlights the need to establish global health policies that reduce morbidity and mortality, economic losses of the affected population, and health costs related to hospitalizations for cardiovascular involvement. Authors provide an algorithm to evaluate the possibility of Cysticercosis' cardiovascular complications.

Thinking outside the blood: Perspectives on tissue-resident Trypanosoma brucei

Trypanosoma brucei is a protozoan parasite that causes human and animal African trypanosomiases (HAT and AAT). In the mammalian host, the parasite lives entirely extracellularly, in both the blood and interstitial spaces in tissues. Although most T. brucei research has focused on the biology of blood- and central nervous system (CNS)-resident parasites, a number of recent studies have highlighted parasite reservoirs in the dermis and adipose tissue, leading to a renewed interest in tissue-resident parasite populations. In light of this renewed interest, work describing tissue-resident parasites can serve as a valuable resource to inform future investigations of tissue-resident T. brucei. Here, we review this body of literature, which describes infections in humans, natural hosts, and experimental animal models, providing a wealth of information on the distribution and biology of extravascular parasites, the corresponding immune response in each tissue, and resulting host pathology. We discuss the implications of these studies and future questions in the study of extravascular T. brucei.

Snakebite Envenomation and Heart: Systematic Review

Snakebite envenomation is a neglected tropical disease which can result in morbidity and mortality. Cardiac implications are poorly understood due to the low frequency of cardiotoxicity combined with a lack of robust information, as snakebites commonly occur in remote and rural areas. This review aims to assess cardiovascular implications of snakebite envenoming and proposes an algorithm for screening of cardiovascular manifestations. A systematic review was performed and 29 articles relating to cardiovascular involvement in snakebite envenomation were selected. Cardiovascular involvement seems to be rare and includes a wide spectrum of outcomes, such as myocardial infarction, ventricular dysfunction, hypotension, cardiac arrest, and myocarditis. In a significant proportion of the cases analyzed (24.39%), the cardiovascular manifestations had major consequences (cardiac arrest, myocardial infarction, malignant ventricular arrhythmias, or death). Clinical monitoring, physical examination, and early electrocardiogram should be considered as key measures to detect cardiovascular involvement in patients with evidence of systemic illness.

Rabies and the Heart

As one of the neglected diseases, rabies is as a highly fatal viral infection, most prevalent in low- and middle-income regions, which produces a substantial health and economic burden. It mainly affects the central nervous system causing encephalitis, however extraneuronal involvement has been documented. Cardiac structures may be involved and can play a role in the severity of the disease. Most of the existing literature comes from case reports and case series where cardiac involvement results in myocarditis and cardiac arrhythmias. As part of the "Neglected Tropical Diseases and Other Infectious Diseases Involving the Heart" (NET-HEART Project), the objective of this article is to review all the information available on the cardiac involvement of this disease.

Tuberculosis and the Heart

Acquired tuberculosis continues to be a challenge worldwide. Although tuberculosis has been considered a global public health emergency, it remains poorly controlled in many countries. Despite being primarily a pulmonary disease, tuberculosis could involve the heart. This systematic review is part of the "Neglected Tropical Diseases and Other Infectious Diseases Involving the Heart" (the NET-Heart Project) initiative from the Interamerican Society of Cardiology. This project aims to review the cardiovascular involvement of these heterogeneous diseases, advancing original algorithms to help healthcare providers diagnose and manage cardiovascular complications. In tuberculosis, pericardium involvement is relatively common, especially in AIDS, and tuberculosis is the most common cause of constrictive pericarditis in endemic countries. Myocarditis and aortitis by tuberculosis are rare. Clinical manifestations of cardiovascular involvement by tuberculosis differ from those typically found for bacteria or viruses. Prevailing systemic symptoms and the pericarditis diagnostic index should be taken into account. An echocardiogram is the first step for diagnosing cardiovascular involvement; however, several image modalities can be used, depending on the suspected site of infection. Adenosine deaminase levels, gamma interferon, or polymerase chain reaction testing could be used to confirm tuberculosis infection; each has a high diagnostic performance. Antituberculosis chemotherapy and corticosteroids are treatment mainstays that significantly reduce mortality, constriction, and hospitalizations, especially in patients with HIV. In conclusion, tuberculosis cardiac involvement is frequent and could lead to heart failure, constrictive pericarditis, or death. Early detection of complications should be a cornerstone of overall management.

Vector-borne protozoal infections of the CNS: cerebral malaria, sleeping sickness and Chagas disease

PURPOSE OF REVIEW

Malaria, Chagas Disease and Human African Trypanosomiasis are vector-borne protozoan illnesses, frequently associated with neurological manifestations. Intriguing but ignored, limited mainly to resource-limited, tropical settings, these disorders are now coming to light because of globalisation and improved diagnosis and treatment. Enhanced understanding of these illnesses has prompted this review.

RECENT FINDINGS

Methods of diagnosis have currently transitioned from blood smear examinations to immunological assays and molecular methods. Tools to assess neurological involvement, such as magnetic resonance imaging, are now increasingly available in regions and countries with high infection loads. Sleep and other electrophysiological technologies (electroencephalography, actigraphy) are also promising diagnostic tools but requiring field-validation. Access to treatments was formerly limited, even as limitations of agents used in the treatment are increasingly recognised. Newer agents are now being developed and trialled, encouraged by improved understanding of the disorders' molecular underpinnings.

SUMMARY

Prompt diagnosis and treatment are crucial in ensuring cure from the infections. Attention should also be due to the development of globally applicable treatment guidelines, the burden of neurological sequelae and elimination of the zoonoses from currently endemic regions.

Malaria and the Heart: JACC State-of-the-Art Review

As one of the tropical diseases, malaria is endemic in developing countries. Severe malaria, mainly caused by the Plasmodium falciparum parasite, can result in life-threatening complications. Traditionally, cardiac involvement has not been included as a frequent cause of morbidity and mortality. This could be due to under-reporting or underdiagnosing. Specific cardiovascular (CV) complications include electrocardiogram abnormalities, myocarditis, pericarditis, pericardial effusion, ischemic disease, and heart failure. According to the data analyzed, CV manifestations can lead to severe consequences. Possible theories related to the pathophysiological mechanisms related to CV compromise include an imbalanced pro-inflammatory cytokine response and/or erythrocyte sequestration by increased cytoadherence to endothelium. Although there is a paucity of data regarding cardiac manifestations of malaria, an algorithm for appropriate use of diagnostic tools to assess cardiac involvement has been developed in this paper. Furthermore, it is important to note that typical antimalarial treatment regimens can have fatal cardiac side-effects.

Zika & heart: A systematic review

Zika virus infection affects more than 80 countries in the world, mainly those with a tropical climate. Although the most frequent clinical presentation is characterized by rash, conjunctivitis, myalgia, arthralgia and fever, in some cases it is associated with cardiovascular manifestations, such as myocarditis, pericarditis, heart failure and arrhythmias. Furthermore, maternal transmission of the virus generates congenital Zika syndrome, which is associated with cardiac septal defects. Early recognition and treatment of Zika's cardiovascular complications are essential to reduce morbidity and mortality in these patients. There is no specific antiviral treatment or vaccine in humans, so the development of public health strategies to prevent its transmission is of paramount importance. The "Neglected Tropical Diseases and other Infectious Diseases" (NET-Heart project) is an initiative to systematically review all these devastating endemic conditions affecting the heart to spread knowledge and propose algorithms for early diagnosis and treatment.

Toxoplasmosis and the Heart

Toxoplasmosis is a common disease caused by Toxoplasma gondii, a parasite with high prevalence in tropical regions. Most infections show minimal symptoms, but immunocompromised patients tend to have a poor prognosis. Cardiovascular manifestations in toxoplasmosis are rare and reported in a limited number of patients. As part of the "Neglected Tropical Diseases and Other Infectious Diseases Affecting the Heart" (NET-Heart) project, this paper aims to systematically review all available information regarding the cardiovascular implications of toxoplasmosis. Relevant studies were identified in the MEDLINE and/or PubMed database, and 48 articles were ultimately included. This was completed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Cardiac compromise in toxoplasmosis mainly involves myocarditis, and complications vary widely in severity. Toxoplasmic myocarditis is challenging to diagnose, as endomyocardial biopsy is usually required. This article provides a summary of cardiac toxoplasmosis, including an original algorithm facilitating diagnosis and treatment.