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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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Palacios Gil-Antuñano S, Gold S, Abril M, Segovia Hernández M, Cancelo-Hidalgo MJ, Flores-Chávez M, Pelayo-Delgado I. Mother-to-child Chagas disease transmission: The challenge of detection and prevention in areas without the risk of vectorial transmission. Int J Gynaecol Obstet 2024; 164:835-842. [PMID: 37493222 DOI: 10.1002/ijgo.14994] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 06/14/2023] [Accepted: 06/26/2023] [Indexed: 07/27/2023]
Abstract
Chagas disease (CD) is caused by the parasite Trypanosoma cruzi. Although it is endemic in many Latin American (LA) countries, mother-to-child transmission has caused it to expand to other countries and continents. In places where vector transmission is controlled or absent, the epidemiological importance of T. cruzi transmission of the infected mother to her child during pregnancy or childbirth (i.e., perinatal CD) increases. In countries where CD is not endemic, CD screening should be performed in pregnant or fertile women who are native to LA countries or whose mothers are native to LA countries. Diagnosis is established by detecting anti-T. cruzi IgG antibodies in a serum or plasma sample. Antiparasitic treatment cannot be offered during pregnancy, and since the majority of infected newborns are asymptomatic at birth, a diagnosis is made by direct observation or concentration (microhematocrit) or by using molecular testing techniques. Once the infected child receives a diagnosis, it is essential to offer treatment (benznidazole/nifurtimox) as soon as possible, with good tolerance and effectiveness in the first year of life. Even if the diagnosis is negative at birth, the newborn must be followed up for at least the first 9 months of life.
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Affiliation(s)
| | - Silvia Gold
- Mundo Sano Foundation, Buenos Aires, Argentina
| | | | - Manuel Segovia Hernández
- Microbiology and Parasitology Service, Universitary Hospital Virgen de la Arrixaca, Murcia University, Murcia, Spain
| | - Maria Jesus Cancelo-Hidalgo
- Obstetrics and Gynaecology Service, Universitary Hospital of Guadalajara, Gynaecology and Obstetrics Alcala de Henares Universitiy, Madrid, Spain
| | - Maria Flores-Chávez
- Mundo Sano Foundation - National Centre for Microbiology, Instituto de Salud Carlos III, Madrid, Spain
| | - Irene Pelayo-Delgado
- Department of Obstetrics and Gynecology, Alcala de Henares University, Ramon y Cajal Hospital, Madrid, Spain
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Ojara FW, Kawuma AN, Waitt C. A systematic review on maternal-to-infant transfer of drugs through breast milk during the treatment of malaria, tuberculosis, and neglected tropical diseases. PLoS Negl Trop Dis 2023; 17:e0011449. [PMID: 37440491 DOI: 10.1371/journal.pntd.0011449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND Exclusive breastfeeding of infants under 6 months of age is recommended by the World Health Organization. In 2021, over 300 million combined incident cases of malaria, tuberculosis, and neglected tropical diseases (NTDs) were reported, predominantly in low-income countries. For many of the drugs used as first-line treatments for these conditions, there is limited knowledge on infant exposure through breastfeeding with poorly understood consequences. This review summarized available knowledge on mother-to-infant transfer of these drugs to inform future lactation pharmacokinetic studies. METHODOLOGY A list of first-line drugs was generated from the latest WHO treatment guidelines. Using standard online databases, 2 independent reviewers searched for eligible articles reporting lactation pharmacokinetics studies and extracted information on study design, participant characteristics, and the mathematical approach used for parameter estimation. A third reviewer settled any disagreements between the 2 reviewers. All studies were scored against the standardized "ClinPK" checklist for conformity to best practices for reporting clinical pharmacokinetic studies. Simple proportions were used to summarize different study characteristics. FINDINGS The most remarkable finding was the scarcity of lactation pharmacokinetic data. Only 15 of the 69 drugs we listed had lactation pharmacokinetics fully characterized. Most studies enrolled few mothers, and only one evaluated infant drug concentrations. Up to 66% of the studies used non-compartmental analysis to estimate pharmacokinetic parameters rather than model-based compartmental analysis. Unlike non-compartmental approaches, model-based compartmental analysis provides for dynamic characterization of individual plasma and breast milk concentration-time profiles and adequately characterizes variability within and between individuals, using sparsely sampled data. The "ClinPK" checklist inadequately appraised the studies with variability in the number of relevant criteria across different studies. CONCLUSIONS/SIGNIFICANCE A consensus is required on best practices for conducting and reporting lactation pharmacokinetic studies, especially in neglected diseases such as malaria, tuberculosis, and NTDs, to optimize treatment of mother-infant pairs.
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Affiliation(s)
- Francis Williams Ojara
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
- Department of Pharmacology and Therapeutics, Gulu University, Gulu, Uganda
| | - Aida N Kawuma
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Catriona Waitt
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, United Kingdom
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Lascano F, García Bournissen F, Altcheh J. Review of pharmacological options for the treatment of Chagas disease. Br J Clin Pharmacol 2022; 88:383-402. [PMID: 33314266 DOI: 10.1111/bcp.14700] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 11/09/2020] [Accepted: 12/02/2020] [Indexed: 12/20/2022] Open
Abstract
Chagas disease (CD) is a worldwide problem, with over 8 million people infected in both rural and urban areas. CD was first described over a century ago, but only two drugs are currently available for CD treatment: benznidazole (BZN) and nifurtimox (NF). Treating CD-infected patients, especially children and women of reproductive age, is vital in order to prevent long-term sequelae, such as heart and gastrointestinal dysfunction, but this aim is still far from being accomplished. Currently, the strongest data to support benefit-risk considerations come from trials in children. Treatment response biomarkers need further development as serology is being questioned as the best method to assess treatment response. This article is a narrative review on the pharmacology of drugs for CD, particularly BZN and NF. Data on drug biopharmaceutical characteristics, safety and efficacy of both drugs are summarized from a clinical perspective. Current data on alternative compounds under evaluation for CD treatment, and new possible treatment response biomarkers are also discussed. Early diagnosis and treatment of CD, especially in paediatric patients, is vital for an effective and safe use of the available drugs (i.e. BZN and NF). New biomarkers for CD are urgently needed for the diagnosis and evaluation of treatment efficacy, and to guide efforts from academia and pharmaceutical companies to accelerate the process of new drug development.
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Affiliation(s)
- Fernanda Lascano
- Instituto Multidisciplinario de Investigaciones en Patologías Pediátricas (IMIPP), Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Gobierno de la Ciudad de la Nación Argentina, Buenos Aires, Argentina.,Servicio de Parasitología y Chagas, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Facundo García Bournissen
- Division of Pediatric Clinical Pharmacology, Department of Pediatrics, Schulich School of Medicine & Dentistry, University of Western Ontario, Canada
| | - Jaime Altcheh
- Instituto Multidisciplinario de Investigaciones en Patologías Pediátricas (IMIPP), Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Gobierno de la Ciudad de la Nación Argentina, Buenos Aires, Argentina.,Servicio de Parasitología y Chagas, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
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Livingston EG, Duggal R, Dotters-Katz S. Screening for Chagas Disease during Pregnancy in the United States-A Literature Review. Trop Med Infect Dis 2021; 6:tropicalmed6040202. [PMID: 34941658 PMCID: PMC8704518 DOI: 10.3390/tropicalmed6040202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 11/13/2021] [Accepted: 11/22/2021] [Indexed: 11/16/2022] Open
Abstract
Obstetrician-gynecologists in the United States have little clinical experience with the epidemiology, pathophysiology, diagnosis, and treatment of Chagas disease. The number of US parturients born in Central and South America has continued to increase over the last 20 years, making US obstetricians more and more likely to care for Chagas-infected mothers who may never be identified until dealing with long-term consequences of the disease. A literature search demonstrates that few US obstetric care providers recognize the risk of vertical transmission for the neonate and the missed opportunity of infant treatment to decrease disease prevalence. Most women will be asymptomatic during pregnancy, as will their neonates, making routine laboratory screening a necessity for the identification of at-risk neonates. While the benefits of treating asymptomatic women identified in pregnancy are not as clear as the benefits for the infants, future health screenings for evidence of the progression of Chagas disease may be beneficial to these families. The literature suggests that screening for Chagas in pregnancy in the US can be done in a cost-effective way. When viewed through an equity lens, this condition disproportionately affects families of lower socioeconomic means. Improved education of healthcare providers and appropriate resources for diagnosis and treatment can improve this disparity in health outcomes.
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Pérez-Molina JA, Crespillo-Andújar C, Bosch-Nicolau P, Molina I. Trypanocidal treatment of Chagas disease. ACTA ACUST UNITED AC 2021; 39:458-470. [PMID: 34736749 DOI: 10.1016/j.eimce.2020.04.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 04/18/2020] [Indexed: 11/24/2022]
Abstract
Chagas disease is a neglected parasitosis caused by the protozoan parasite Trypanosoma cruzi. This infection is present in most Latin American countries, although, due to migratory movements, it is a growing cause for concern in non-endemic countries. The only two drugs currently available for its treatment-benznidazole and nifurtimox-were marketed 50 years ago. While they are very effective for acute and recent infection, and for the prevention of maternofoetal transmission, their efficacy declines in people who have chronic infection, especially those older than 18 years of age. In the presence of visceral involvement, parasiticidal treatment is of little or no value. The safety profile of both drugs is far from ideal, with frequent adverse events and high rates of drug discontinuation, mainly in adults. So far, new drugs and new strategies have not been shown to improve the results of the current nitroimidazoles, although the results are promising. In this review, we focus on the aspects that allow clinicians to make the best use of currently available drugs. In addition, we discuss new therapeutic options and ongoing research in the field.
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Affiliation(s)
- Jose A Pérez-Molina
- National Referral Centre for Tropical Diseases, Infectious Diseases Department, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain.
| | - Clara Crespillo-Andújar
- National Referral Centre for Tropical Diseases, Infectious Diseases Department, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain
| | - Pau Bosch-Nicolau
- Tropical Medicine Unit, Department of Infectious Diseases, Vall d'Hebron University Hospital, PROSICS Barcelona, Barcelona, Spain
| | - Israel Molina
- Tropical Medicine Unit, Department of Infectious Diseases, Vall d'Hebron University Hospital, PROSICS Barcelona, Barcelona, Spain; Instituto René Rachou-FIOCRUZ Minas, Chagas Disease Research Group, Belo Horizonte, MG, Brazil
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Llenas-García J, Wikman-Jorgensen P, Gil-Anguita C, Ramos- Sesma V, Torrús-Tendero D, Martínez-Goñi R, Romero-Nieto M, García-Abellán J, Esteban-Giner MJ, Antelo K, Navarro-Cots M, Buñuel F, Amador C, García-García J, Gascón I, Telenti G, Fuentes-Campos E, Torres I, Gimeno-Gascón A, Ruíz-García MM, Navarro M, Ramos-Rincón JM. Chagas disease screening in pregnant Latin American women: Adherence to a systematic screening protocol in a non-endemic country. PLoS Negl Trop Dis 2021; 15:e0009281. [PMID: 33760816 PMCID: PMC8021187 DOI: 10.1371/journal.pntd.0009281] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 04/05/2021] [Accepted: 03/01/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Chagas disease (CD) is a chronic parasitic disease caused by Trypanosoma cruzi and is endemic to continental Latin America. In Spain, the main transmission route is congenital. We aimed to assess adherence to regional recommendations of universal screening for CD during pregnancy in Latin American women in the province of Alicante from 2014 to 2018. METHODOLOGY/PRINCIPAL FINDINGS Retrospective quality study using two data sources: 1) delivery records of Latin American women that gave birth in the 10 public hospitals of Alicante between January 2014 and December 2018; and 2) records of Chagas serologies carried out in those centers between May 2013 and December 2018. There were 3026 deliveries in Latin American women during the study period; 1178 (38.9%) underwent CD serology. Screening adherence ranged from 17.2% to 59.3% in the different health departments and was higher in Bolivian women (48.3%). Twenty-six deliveries (2.2%) had a positive screening; CD was confirmed in 23 (2%) deliveries of 21 women. Bolivians had the highest seroprevalence (21/112; 18.7%), followed by Colombians (1/333; 0.3%) and Ecuadorians (1/348; 0.3%). Of 21 CD-positive women (19 Bolivians, 1 Colombian, 1 Ecuadorian), infection was already known in 12 (57.1%), and 9 (42.9%) had already been treated. Only 1 of the 12 untreated women (8.3%) was treated postpartum. Follow-up started in 20 of the 23 (87.0%) neonates but was completed only in 11 (47.8%); no cases of congenital transmission were detected. Among the 1848 unscreened deliveries, we estimate 43 undiagnosed cases of CD and 1 to 2 undetected cases of congenital transmission. CONCLUSIONS/SIGNIFICANCE Adherence to recommendations of systematic screening for CD in Latin American pregnant women in Alicante can be improved. Strategies to strengthen treatment of postpartum women and monitoring of exposed newborns are needed. Currently, there may be undetected cases of congenital transmission in our province.
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Affiliation(s)
- Jara Llenas-García
- Internal Medicine Department, Hospital Vega Baja, Orihuela, Spain
- Foundation for the Promotion of Health and Biomedical Research of the Valencia Region (FISABIO), Valencia, Spain
- Clinical Medicine Department, University Miguel Hernández, Elche, Spain
- * E-mail:
| | - Philip Wikman-Jorgensen
- Foundation for the Promotion of Health and Biomedical Research of the Valencia Region (FISABIO), Valencia, Spain
- Internal Medicine Department, University Hospital San Juan de Alicante, San Juan de Alicante, Spain
| | | | | | - Diego Torrús-Tendero
- Reference Unit of Imported Diseases and International Health, Alicante General University Hospital, Alicante, Spain
- Biomedical and Health Research Institute of Alicante (ISABIAL), Alicante, Spain
- Parasitology Area, University Miguel Hernández, Elche, Spain
| | | | - Mónica Romero-Nieto
- Foundation for the Promotion of Health and Biomedical Research of the Valencia Region (FISABIO), Valencia, Spain
- Clinical Medicine Department, University Miguel Hernández, Elche, Spain
- Internal Medicine Department, Elda General University Hospital, Elda, Spain
| | - Javier García-Abellán
- Foundation for the Promotion of Health and Biomedical Research of the Valencia Region (FISABIO), Valencia, Spain
- Infectious Diseases Unit. Elche General University Hospital, Elche, Spain
| | | | | | - María Navarro-Cots
- Foundation for the Promotion of Health and Biomedical Research of the Valencia Region (FISABIO), Valencia, Spain
- Microbiology Department, Hospital Vega Baja, Orihuela, Spain
| | - Fernando Buñuel
- Foundation for the Promotion of Health and Biomedical Research of the Valencia Region (FISABIO), Valencia, Spain
- Microbiology Department, University Hospital San Juan de Alicante, San Juan de Alicante, Spain
| | - Concepción Amador
- Internal Medicine Department, Hospital Marina Baixa, Villajoyosa, Spain
| | | | - Isabel Gascón
- Foundation for the Promotion of Health and Biomedical Research of the Valencia Region (FISABIO), Valencia, Spain
- Microbiology Department, Elda General University Hospital, Elda, Spain
| | - Guillermo Telenti
- Foundation for the Promotion of Health and Biomedical Research of the Valencia Region (FISABIO), Valencia, Spain
- Infectious Diseases Unit. Elche General University Hospital, Elche, Spain
| | | | | | - Adelina Gimeno-Gascón
- Biomedical and Health Research Institute of Alicante (ISABIAL), Alicante, Spain
- Microbiology Department, Alicante General University Hospital, Alicante, Spain
| | - María Montserrat Ruíz-García
- Foundation for the Promotion of Health and Biomedical Research of the Valencia Region (FISABIO), Valencia, Spain
- Microbiology Department, Elche General University Hospital, Elche, Spain
| | - Miriam Navarro
- Department of Public Health, Science History and Gynaecology, University Miguel Hernández, Elche, Spain
| | - José-Manuel Ramos-Rincón
- Clinical Medicine Department, University Miguel Hernández, Elche, Spain
- Reference Unit of Imported Diseases and International Health, Alicante General University Hospital, Alicante, Spain
- Biomedical and Health Research Institute of Alicante (ISABIAL), Alicante, Spain
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Benznidazole in Cerebrospinal Fluid: a Case Series of Chagas Disease Meningoencephalitis in HIV-Positive Patients. Antimicrob Agents Chemother 2021; 65:AAC.01922-20. [PMID: 33361290 DOI: 10.1128/aac.01922-20] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 12/08/2020] [Indexed: 11/20/2022] Open
Abstract
Chagas disease reactivation in HIV-positive people is an opportunistic infection with 79 to 100% mortality. It commonly involves the central nervous system (CNS). Early treatment with trypanocidal drugs such as benznidazole (BNZ) is crucial for this severe manifestation of Trypanosoma cruzi infection. However, limited BNZ clinical pharmacology data are available, especially its concentration in the CNS. We report a series of HIV-positive patients undergoing treatment for T. cruzi meningoencephalitis, their clinical response, and cerebrospinal fluid (CSF) and plasma BNZ concentrations. Measurements were carried out using leftover samples originally obtained for routine medical care. A high-performance liquid chromatography/tandem mass spectrometry bioanalytical method designed for BNZ plasma measurements was adapted and validated for CSF samples. Six patients were enrolled in this study from 2015 to 2019. A total of 6 CSF and 19 plasma samples were obtained. Only three of the CSF samples had detectable BNZ levels, all under 1 µg/ml. Fifteen plasma samples had detectable BNZ, and 13 were above 2 µg/ml, which is the putative trypanocidal level. We observed BNZ concentrations in human CSF and plasma. CSF BNZ concentrations were low or not measurable in all patients, suggesting that the usual BNZ doses may be suboptimal in HIV-positive patients with T. cruzi meningoencephalitis. While drug-drug and drug-disease interactions may be in part responsible, the factors leading to low CSF BNZ levels remain to be studied in detail. These findings highlight the potential of therapeutic drug monitoring in BNZ treatment and suggest that the use of higher doses may be useful for Chagas disease CNS reactivations.
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Losada Galván I, Alonso-Padilla J, Cortés-Serra N, Alonso-Vega C, Gascón J, Pinazo MJ. Benznidazole for the treatment of Chagas disease. Expert Rev Anti Infect Ther 2020; 19:547-556. [PMID: 33043726 DOI: 10.1080/14787210.2021.1834849] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Chagas disease affects 6-7 million people, mainly in the Americas, and benznidazole is one of the two therapeutic options available. Trypanocide treatment aims to eliminate the parasite from the body to prevent the establishment or progression of visceral damage, mainly cardiac and/or digestive. Remarkably, it helps interrupt vertical transmission when administered to women of childbearing age. AREAS COVERED We discuss the basic and scarce data regarding chemical, pharmacokinetic, and pharmacodynamic structure. We also collect the most important data from previous phase II and III studies, as well as studies currently underway and upcoming. We reflect on the main indications for treatment and its challenges, such as the profile of adverse effects in adults, the pharmaceutical formulations, the search for reliable biomarkers, as well as regulatory aspects and access barriers. Alternative strategies such as shorter regimens, lower doses, and fixed doses are currently being evaluated to improve access and the safety profile of this treatment. EXPERT OPINION Benznidazole is likely to continue to be the drug of choice for Chagas disease in the coming years. However, it would probably be with a different treatment scheme.
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Affiliation(s)
| | | | | | | | - Joaquim Gascón
- ISGlobal, Hospital Clínic - Universitat De Barcelona, Barcelona, Spain
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10
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Cafferata ML, Toscani MA, Althabe F, Belizán JM, Bergel E, Berrueta M, Capparelli EV, Ciganda Á, Danesi E, Dumonteil E, Gibbons L, Gulayin PE, Herrera C, Momper JD, Rossi S, Shaffer JG, Schijman AG, Sosa-Estani S, Stella CB, Klein K, Buekens P. Short-course Benznidazole treatment to reduce Trypanosoma cruzi parasitic load in women of reproductive age (BETTY): a non-inferiority randomized controlled trial study protocol. Reprod Health 2020; 17:128. [PMID: 32831069 PMCID: PMC7446054 DOI: 10.1186/s12978-020-00972-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 08/03/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Retrospective observational studies suggest that transmission of Trypanosoma cruzi does not occur in treated women when pregnant later in life. The level of parasitemia is a known risk factor for congenital transmission. Benznidazole (BZN) is the drug of choice for preconceptional treatment to reduce parasitic load. The fear of treatment-related side effects limits the implementation of the Argentine guideline recommending BZN 60d/300 mg (or equivalent) treatment of T. cruzi seropositive women during the postpartum period to prevent transmission in a future pregnancy. A short and low dose BZN treatment might reduce major side effects and increase compliance, but its efficacy to reduce T. cruzi parasitic load compared to the standard 60d/300 mg course is not yet established. Clinical trials testing alternative BZN courses among women of reproductive age are urgently needed. METHODS AND DESIGN We are proposing to perform a double-blinded, non-inferiority randomized controlled trial comparing a short low dose 30-day treatment with BZN 150 mg/day (30d/150 mg) vs. BZN 60d/300 mg. We will recruit not previously treated T. cruzi seropositive women with a live birth during the postpartum period in Argentina, randomize them at 6 months postpartum, and follow them up with the following specific aims: Specific aim 1: to measure the effect of BZN 30d/150 mg compared to 60d/300 mg preconceptional treatment on parasitic load measured by the frequency of positive Polymerase Chain Reaction (PCR) (primary outcome) and by real-time quantitative PCR (qPCR), immediately and 10 months after treatment. Specific aim 2: to measure the frequency of serious adverse events and/or any adverse event leading to treatment interruption. TRIAL REGISTRATION ClinicalTrials.gov . Identifier: NCT03672487 . Registered 14 September 2018.
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Affiliation(s)
- María L Cafferata
- Instituto de Efectividad Clinica y Sanitaria (IECS), Buenos Aires, Argentina.
- Unidad de Investigación Clínica y Epidemiológica Montevideo (UNICEM), Montevideo, Uruguay.
| | - María A Toscani
- Instituto de Efectividad Clinica y Sanitaria (IECS), Buenos Aires, Argentina
| | - Fernando Althabe
- Maternal and Perinatal Health. UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research (SRH), World Health Organization, Geneva, Switzerland
| | - Jose M Belizán
- Instituto de Efectividad Clinica y Sanitaria (IECS), Buenos Aires, Argentina
| | - Eduardo Bergel
- Instituto de Efectividad Clinica y Sanitaria (IECS), Buenos Aires, Argentina
| | - Mabel Berrueta
- Instituto de Efectividad Clinica y Sanitaria (IECS), Buenos Aires, Argentina
| | - Edmund V Capparelli
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego (UCSD), San Diego, USA
- Schools of Medicine, University of California, San Diego (UCSD), San Diego, USA
| | - Álvaro Ciganda
- Instituto de Efectividad Clinica y Sanitaria (IECS), Buenos Aires, Argentina
- Unidad de Investigación Clínica y Epidemiológica Montevideo (UNICEM), Montevideo, Uruguay
| | - Emmaria Danesi
- Centro Nacional de Diagnóstico e Investigación en Endemoepidemias (CeNDIE) ANLIS Dr. C. G. Malbrán, Buenos Aires, Argentina
| | - Eric Dumonteil
- School of Public Health and Tropical Medicine, Tulane University, New Orleans, USA
| | - Luz Gibbons
- Instituto de Efectividad Clinica y Sanitaria (IECS), Buenos Aires, Argentina
| | - Pablo E Gulayin
- Instituto de Efectividad Clinica y Sanitaria (IECS), Buenos Aires, Argentina
| | - Claudia Herrera
- School of Public Health and Tropical Medicine, Tulane University, New Orleans, USA
| | - Jeremiah D Momper
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego (UCSD), San Diego, USA
| | - Steven Rossi
- Schools of Medicine, University of California, San Diego (UCSD), San Diego, USA
| | - Jeffrey G Shaffer
- School of Public Health and Tropical Medicine, Tulane University, New Orleans, USA
| | - Alejandro G Schijman
- Laboratorio de Biología Molecular de la Enfermedad de Chagas (LaBMECh), Instituto de Investigaciones en Ingeniería Genética y Biología Molecular "Dr. Héctor Torres" (INGEBI), Buenos Aires, Argentina
| | - Sergio Sosa-Estani
- Drugs for Neglected Diseases initiative - Latin America (DNDi), Rio de Janeiro, Brazil
- Centro de Investigaciones en Epidemiología y Salud Pública (CIESP-IECS), Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Buenos Aires, Argentina
| | - Candela B Stella
- Instituto de Efectividad Clinica y Sanitaria (IECS), Buenos Aires, Argentina
| | - Karen Klein
- Instituto de Efectividad Clinica y Sanitaria (IECS), Buenos Aires, Argentina
| | - Pierre Buekens
- School of Public Health and Tropical Medicine, Tulane University, New Orleans, USA
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Vázquez C, García-Vázquez E, Carrilero B, Simón M, Franco F, Iborra MA, Gil-Gallardo LJ, Segovia M. Pregnancy and Chagas Disease: Benznidazole's Impact on Pregnancy and Newborns: A Report of Four Cases. Am J Trop Med Hyg 2020; 102:1075-1077. [PMID: 32207404 DOI: 10.4269/ajtmh.19-0348] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
In recent decades and because of migration, Chagas disease has become a global public health problem. A significant focus has been placed on pregnant women who can transmit the disease to their offspring. Here, we report four cases of women who did not know that they were pregnant while they were being treated with benznidazole. A diagnosis was established according to serology and Trypanosoma cruzi polymerase chain reaction (PCR)-standardized tests. Treatment was discontinued when pregnancy was confirmed, and a thorough follow-up was carried out. Although each case was different, none of the mothers developed health problems during pregnancy, and their newborns were delivered without any teratogenic effects.
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Affiliation(s)
- Cristina Vázquez
- Unidad de Medicina Tropical, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Elisa García-Vázquez
- Universidad de Murcia, Murcia, Spain.,Unidad de Medicina Tropical, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Bartolomé Carrilero
- Unidad de Medicina Tropical, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Marina Simón
- Unidad de Medicina Tropical, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Fuensanta Franco
- Unidad de Medicina Tropical, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Maria A Iborra
- Universidad de Murcia, Murcia, Spain.,Unidad de Medicina Tropical, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Luis J Gil-Gallardo
- Unidad de Medicina Tropical, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Manuel Segovia
- Universidad de Murcia, Murcia, Spain.,Unidad de Medicina Tropical, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
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12
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Pérez-Molina JA, Crespillo-Andújar C, Bosch-Nicolau P, Molina I. Trypanocidal treatment of Chagas disease. Enferm Infecc Microbiol Clin 2020; 39:S0213-005X(20)30193-2. [PMID: 32527494 DOI: 10.1016/j.eimc.2020.04.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 04/02/2020] [Accepted: 04/18/2020] [Indexed: 01/16/2023]
Abstract
Chagas disease is a neglected parasitosis caused by the protozoan parasite Trypanosoma cruzi. This infection is present in most Latin American countries, although, due to migratory movements, it is a growing cause for concern in non-endemic countries. The only two drugs currently available for its treatment-benznidazole and nifurtimox-were marketed 50 years ago. While they are very effective for acute and recent infection, and for the prevention of maternofoetal transmission, their efficacy declines in people who have chronic infection, especially those older than 18 years of age. In the presence of visceral involvement, parasiticidal treatment is of little or no value. The safety profile of both drugs is far from ideal, with frequent adverse events and high rates of drug discontinuation, mainly in adults. So far, new drugs and new strategies have not been shown to improve the results of the current nitroimidazoles, although the results are promising. In this review, we focus on the aspects that allow clinicians to make the best use of currently available drugs. In addition, we discuss new therapeutic options and ongoing research in the field.
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Affiliation(s)
- Jose A Pérez-Molina
- National Referral Centre for Tropical Diseases, Infectious Diseases Department, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain.
| | - Clara Crespillo-Andújar
- National Referral Centre for Tropical Diseases, Infectious Diseases Department, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain
| | - Pau Bosch-Nicolau
- Tropical Medicine Unit, Department of Infectious Diseases, Vall d'Hebron University Hospital, PROSICS Barcelona, Barcelona, Spain
| | - Israel Molina
- Tropical Medicine Unit, Department of Infectious Diseases, Vall d'Hebron University Hospital, PROSICS Barcelona, Barcelona, Spain; Instituto René Rachou-FIOCRUZ Minas, Chagas Disease Research Group, Belo Horizonte, MG, Brazil
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13
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Echeverría LE, Marcus R, Novick G, Sosa-Estani S, Ralston K, Zaidel EJ, Forsyth C, RIbeiro ALP, Mendoza I, Falconi ML, Mitelman J, Morillo CA, Pereiro AC, Pinazo MJ, Salvatella R, Martinez F, Perel P, Liprandi ÁS, Piñeiro DJ, Molina GR. WHF IASC Roadmap on Chagas Disease. Glob Heart 2020; 15:26. [PMID: 32489799 PMCID: PMC7218776 DOI: 10.5334/gh.484] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 01/17/2020] [Indexed: 02/06/2023] Open
Abstract
Background Chagas Disease is a neglected tropical disease caused by the protozoan Trypanosoma cruzi, with some of the most serious manifestations affecting the cardiovascular system. It is a chronic, stigmatizing condition, closely associated with poverty and affecting close to 6 million people globally. Although historically the disease was limited to endemic areas of Latin America recent years have seen an increasing global spread. In addition to the morbidity and mortality associated with the disease, the social and economic burdens on individuals and society are substantial. Often called the 'silent killer', Chagas disease is characterized by a long, asymptomatic phase in affected individuals. Approximately 30% then go on develop chronic Chagas cardiomyopathy and other serious cardiac complications such as stroke, rhythm disturbances and severe heart failure. Methods In a collaboration of the World Hearth Federation (WHF) and the Inter-American Society of Cardiology (IASC) a writing group consisting of 20 diverse experts on Chagas disease (CD) was convened. The group provided up to date expert knowledge based on their area of expertise. An extensive review of the literature describing obstacles to diagnosis and treatment of CD along with proposed solutions was conducted. A survey was sent to all WHF Members and, using snowball sampling to widen the consultation, to a variety of health care professionals working in the CD global health community. The results were analyzed, open comments were reviewed and consolidated, and the findings were incorporated into this document, thus ensuring a consensus representation. Results The WHF IASC Roadmap on Chagas Disease offers a comprehensive summary of current knowledge on prevention, diagnosis and management of the disease. In providing an analysis of 'roadblocks' in access to comprehensive care for Chagas disease patients, the document serves as a framework from which strategies for implementation such as national plans can be formulated. Several dimensions are considered in the analysis: healthcare system capabilities, governance, financing, community awareness and advocacy. Conclusion The WHF IASC Roadmap proposes strategies and evidence-based solutions for healthcare professionals, health authorities and governments to help overcome the barriers to comprehensive care for Chagas disease patients. This roadmap describes an ideal patient care pathway, and explores the roadblocks along the way, offering potential solutions based on available research and examples in practice. It represents a call to action to decision-makers and health care professionals to step up efforts to eradicate Chagas disease.
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Affiliation(s)
| | - Rachel Marcus
- LASOCHA, Washington DC, US
- Medstar Union Memorial Hospital, Baltimore, MD, US
| | - Gabriel Novick
- Swiss Medical Group, Buenos Aires, AR
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, US
| | - Sergio Sosa-Estani
- Drugs for Neglected Diseases initiative-Latin America, Rio de Janeiro, BR
| | | | - Ezequiel Jose Zaidel
- Sanatorio Güemes, Buenos Aires, AR
- Pharmacology Department, School of Medicine, University of Buenos Aires, Buenos Aires, AR
| | - Colin Forsyth
- Drugs for Neglected Diseases initiative-Latin America, Rio de Janeiro, BR
| | - Antonio Luiz P. RIbeiro
- Internal Medicine Department, School of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, BR
- Hospital das Clínicas, UFMG, Belo Horizonte, BR
| | | | - Mariano Luis Falconi
- Cardiology Division, Italian Hospital of Buenos Aires, Buenos Aires, AR
- University Institute of the Italian Hospital of Buenos Aires, Buenos Aires, AR
| | - Jorge Mitelman
- Faculty of Medicine, University of Buenos Aires, Buenos Aires, AR
- School of Medicine, Barcélo University, Buenos Aires, AR
| | - Carlos A. Morillo
- Department of Cardiac Sciences, Cumming School of Medicine Division of Cardiology, Libin Cardiovascular Institute, University of Calgary, Calgary, CA
- Southeastern Alberta Region, Alberta Health Services, Foothills Medical Centre, CA
| | | | | | | | - Felipe Martinez
- National University of Cordoba, Cordoba, AR
- DAMIC Institute/Rusculleda Foundation, Cordoba, AR
| | - Pablo Perel
- World Heart Federation, Geneva, CH
- Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, London, GB
| | - Álvaro Sosa Liprandi
- Sanatorio Güemes, Buenos Aires, AR
- Medical School of Cardiology, University of Buenos Aires, Buenos Aires, AR
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14
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Abstract
About one-sixth of the world's population is affected by a neglected tropical disease as defined by the World Health Organization and Center for Disease Control. Parasitic diseases comprise most of the neglected tropical disease list and they are causing enormous amounts of disability, morbidity, mortality, and healthcare costs worldwide. The burden of disease of the top five parasitic diseases has been estimated to amount to a total 23 million disability-adjusted life-years. Despite the massive health and economic impact, most drugs currently used for the treatment of parasitic diseases have been developed decades ago and insufficient novel drugs are being developed. The current review provides a compilation of the systemic and target-site pharmacokinetics of established antiparasitic drugs. Knowledge of the pharmacokinetic profile of drugs allows for the examination and possibly optimization of existing dosing schemes. Many symptoms of parasitic diseases are caused by parasites residing in different host tissues. Penetration of the antiparasitic drug into these tissues, the target site of infection, is a prerequisite for a successful treatment of the disease. Therefore, for the examination and improvement of established dosing regimens, not only the plasma but also the tissue pharmacokinetics of the drug have to be considered. For the current paper, almost 7000 scientific articles were identified and screened from which 429 were reviewed in detail and 100 were included in this paper. Systemic pharmacokinetics are available for most antiparasitic drugs but in many cases, not for all the relevant patient populations and only for single- or multiple-dose administration. Systemic pharmacokinetic data in patients with organ impairment and target-site pharmacokinetic data for relevant tissues and body fluids are mostly lacking. To improve the treatment of patients with parasitic diseases, research in these areas is urgently needed.
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Affiliation(s)
- Valentin Al Jalali
- Department of Clinical Pharmacology, Vienna University Hospital, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Vienna University Hospital, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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15
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Edwards MS, Stimpert KK, Bialek SR, Montgomery SP. Evaluation and Management of Congenital Chagas Disease in the United States. J Pediatric Infect Dis Soc 2019; 8:461-469. [PMID: 31016324 PMCID: PMC10186111 DOI: 10.1093/jpids/piz018] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 02/26/2019] [Indexed: 01/18/2023]
Abstract
Chagas disease is underappreciated as a health concern in the United States. Approximately 40 000 women of childbearing age living in the United States have chronic Chagas disease. Most of them are unaware that they have an infection that is transmissible to their offspring. The estimated US maternal-to-infant transmission rate of Trypanosoma cruzi is 1% to 5%. Ten percent to 40% of neonates with congenital T cruzi infection have clinical signs consistent with a congenital infection but no findings are unique to Chagas disease. If left untreated, 20% to 40% of infants with Chagas disease will later develop potentially fatal cardiac manifestations. Molecular testing can confirm the diagnosis in neonates. Treatment is well tolerated in infancy and usually results in cure. Screening of at-risk women during pregnancy can identify maternal infection and allow early assessment and treatment for congenital T cruzi infection.
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Affiliation(s)
- Morven S Edwards
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Kelly K Stimpert
- IHRC, Inc, Atlanta, Georgia.,Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Stephanie R Bialek
- Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Susan P Montgomery
- Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia
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16
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Moroni S, Marson ME, Moscatelli G, Mastrantonio G, Bisio M, Gonzalez N, Ballering G, Altcheh J, García-Bournissen F. Negligible exposure to nifurtimox through breast milk during maternal treatment for Chagas Disease. PLoS Negl Trop Dis 2019; 13:e0007647. [PMID: 31415566 PMCID: PMC6711540 DOI: 10.1371/journal.pntd.0007647] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 08/27/2019] [Accepted: 07/22/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Treatment with nifurtimox (NF) for Chagas disease is discouraged during breast-feeding because no information on NF transfer into breast milk is available. NF is safe and effective for paediatric and adult Chagas disease. We evaluated the degree of NF transfer into breast milk in lactating women with Chagas disease. PATIENTS AND METHODS Prospective study of a cohort of lactating women with Chagas disease. Patients were treated with NF for 1 month. NF was measured in plasma and milk by high performance liquid chromatography (HPLC). Breastfed infants were evaluated at admission, 7th and 30th day of treatment (and monthly thereafter, for 6 months). RESULTS Lactating women with chronic Chagas disease (N = 10) were enrolled (median age 28 years, range 17-36). Median NF dose was 9.75 mg/kg/day three times a day (TID). Six mothers had mild adverse drug reactions (ADRs), but no ADRs were observed in any of the breastfed infants. No interruption of breastfeeding was observed. Median NF concentrations were 2.15 mg/L (Inter quartil range (IQR) 1.32-4.55) in milk and 0.30 mg/L (IQR 0.20-0.95) in plasma. Median NF milk/plasma ratio was 16 (range 8.75-30.25). Median relative infant NF dose (assuming a daily breastmilk intake of 150 mL/kg/day) was 6.7% of the maternal dose/kg/day (IQR 2.35-7.19%). CONCLUSIONS The low concentrations of NF in breast milk and the normal clinical evaluation of the breastfed babies imply that maternal NF treatment for Chagas disease during breastfeeding is unlikely to lead to clinically relevant exposures in the breastfed infants. TRIAL REGISTRATION Clinical trial registry name and registration number: ClinicalTrials.gov NCT01744405.
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Affiliation(s)
- Samanta Moroni
- Parasitology and Chagas Service, Buenos Aires Children´s Hospital “Dr. Ricardo Gutierrez”, Multidisciplinary Institute for Research in Pediatric Diseases (IMIPP), Buenos Aires Argentina
| | - Maria Elena Marson
- Toxicology Area, Biological Sciences Department / PlaPiMu-LaSeISiC, Faculty of Exact Sciences, National University of La Plata, La Plata, Buenos Aires, Argentina
- PlaPiMu–LaSeISiC, Buenos Aires Committee for Scientific Research, La Plata, Buenos Aires, Argentina
| | - Guillermo Moscatelli
- Parasitology and Chagas Service, Buenos Aires Children´s Hospital “Dr. Ricardo Gutierrez”, Multidisciplinary Institute for Research in Pediatric Diseases (IMIPP), Buenos Aires Argentina
- National Research Council of Argentina (CONICET), Buenos Aires Argentina
| | - Guido Mastrantonio
- Toxicology Area, Biological Sciences Department / PlaPiMu-LaSeISiC, Faculty of Exact Sciences, National University of La Plata, La Plata, Buenos Aires, Argentina
- PlaPiMu–LaSeISiC, Buenos Aires Committee for Scientific Research, La Plata, Buenos Aires, Argentina
| | - Margarita Bisio
- Parasitology and Chagas Service, Buenos Aires Children´s Hospital “Dr. Ricardo Gutierrez”, Multidisciplinary Institute for Research in Pediatric Diseases (IMIPP), Buenos Aires Argentina
- National Research Council of Argentina (CONICET), Buenos Aires Argentina
| | - Nicolas Gonzalez
- Parasitology and Chagas Service, Buenos Aires Children´s Hospital “Dr. Ricardo Gutierrez”, Multidisciplinary Institute for Research in Pediatric Diseases (IMIPP), Buenos Aires Argentina
| | - Griselda Ballering
- Parasitology and Chagas Service, Buenos Aires Children´s Hospital “Dr. Ricardo Gutierrez”, Multidisciplinary Institute for Research in Pediatric Diseases (IMIPP), Buenos Aires Argentina
| | - Jaime Altcheh
- Parasitology and Chagas Service, Buenos Aires Children´s Hospital “Dr. Ricardo Gutierrez”, Multidisciplinary Institute for Research in Pediatric Diseases (IMIPP), Buenos Aires Argentina
- National Research Council of Argentina (CONICET), Buenos Aires Argentina
| | - Facundo García-Bournissen
- Parasitology and Chagas Service, Buenos Aires Children´s Hospital “Dr. Ricardo Gutierrez”, Multidisciplinary Institute for Research in Pediatric Diseases (IMIPP), Buenos Aires Argentina
- National Research Council of Argentina (CONICET), Buenos Aires Argentina
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17
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Congenital Chagas disease: current diagnostics, limitations and future perspectives. Curr Opin Infect Dis 2019; 31:415-421. [PMID: 30095485 DOI: 10.1097/qco.0000000000000478] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Congenital transmission is an important route of Trypanosoma cruzi infection, both in Latin America and internationally, with considerable populations of infected women of child-bearing age residing in the United States and Europe. This review examines recent literature on congenital Chagas disease, with a focus on the changing clinical spectrum and potential new diagnostic tools. RECENT FINDINGS Vertical transmission occurs in approximately 5-10% of births from T. cruzi-infected mothers. Historically, congenital Chagas disease was associated with high levels of neonatal morbidity and mortality. Bolivian birth cohort data from the early 1990s to the present indicate that the incidence of symptomatic neonatal disease has declined. Treatment with trypanocides is greater than 90% effective and well tolerated in infants. Current programs face challenges from the multistep screening algorithm, low sensitivity of microscopy and high loss to follow-up. SUMMARY Congenital Chagas disease remains an important contributor to the global disease burden because of T. cruzi. PCR and related molecular techniques represent the most sensitive diagnostic modalities for early detection but require further optimization for resource-limited settings. Several novel diagnostic tests show promise for the future but further validation and adaptation to field settings are needed.
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18
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Müller Kratz J, Garcia Bournissen F, Forsyth CJ, Sosa-Estani S. Clinical and pharmacological profile of benznidazole for treatment of Chagas disease. Expert Rev Clin Pharmacol 2018; 11:943-957. [DOI: 10.1080/17512433.2018.1509704] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Jadel Müller Kratz
- Chagas Clinical Program, Drugs for Neglected Disease initiative (DNDi), Geneva, Switzerland
| | - Facundo Garcia Bournissen
- Parasitology and Chagas Service, Buenos Aires Children Hospital Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Colin J. Forsyth
- Chagas Clinical Program, Drugs for Neglected Disease initiative (DNDi), Geneva, Switzerland
| | - Sergio Sosa-Estani
- Chagas Clinical Program, Drugs for Neglected Disease initiative (DNDi), Geneva, Switzerland
- Epidemiology and Public Health Research Center, CONICET, Buenos Aires, Argentina
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19
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Meymandi S, Hernandez S, Park S, Sanchez DR, Forsyth C. Treatment of Chagas Disease in the United States. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2018; 10:373-388. [PMID: 30220883 PMCID: PMC6132494 DOI: 10.1007/s40506-018-0170-z] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
PURPOSE OF REVIEW Chagas disease (CD) is endemic to much of Latin America, but also present in the United States (U.S.). Following a lengthy asymptomatic period, CD produces serious cardiac or gastrointestinal complications in 30-40% of people. Less than 1% of the estimated six million cases in the Americas, including 326,000-347,000 in the U.S., are diagnosed. Infected persons are typically unaware and the bulk of clinicians are unfamiliar with current treatment guidelines. This review provides U.S. and other clinicians with the latest knowledge of CD treatment. RECENT FINDINGS Chagas cardiomyopathy (CCM) causes severe fibrosis and autonomic damage in the myocardium. Eliminating the parasite through antitrypanosomal therapy with benznidazole, a nitroimidazole derivative or nifurtimox, a nitrofuran compound, potentially prevents heart failure and other sequelae of advanced CCM. Benznidazole, recently approved by the U.S. Food and Drug Administration (FDA) for children 2-12 years old, is the first-line therapy; optimal dosages are currently being studied. Antitrypanosomal therapy prevents congenital transmission; produces high cure rates for acute, congenital, and early chronic cases; and improves clinical outcomes in adult chronic indeterminate cases. However, this benefit was not observed in a large clinical trial that included patients with advanced CCM. SUMMARY Treatment with antitrypanosomal drugs can cure CD in acute, congenital, and early chronic cases and provides improved clinical outcomes for chronic indeterminate cases. This treatment should be offered as early as possible, before advanced CCM develops.
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Affiliation(s)
- Sheba Meymandi
- Center of Excellence for Chagas Disease at Olive View-UCLA Medical Center, 14445 Olive View Drive, Sylmar, CA 91342 USA
| | - Salvador Hernandez
- Center of Excellence for Chagas Disease at Olive View-UCLA Medical Center, 14445 Olive View Drive, Sylmar, CA 91342 USA
| | - Sandy Park
- Center of Excellence for Chagas Disease at Olive View-UCLA Medical Center, 14445 Olive View Drive, Sylmar, CA 91342 USA
| | - Daniel R. Sanchez
- Center of Excellence for Chagas Disease at Olive View-UCLA Medical Center, 14445 Olive View Drive, Sylmar, CA 91342 USA
| | - Colin Forsyth
- Center of Excellence for Chagas Disease at Olive View-UCLA Medical Center, 14445 Olive View Drive, Sylmar, CA 91342 USA
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20
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Abstract
Chagas disease is an anthropozoonosis from the American continent that has spread from its original boundaries through migration. It is caused by the protozoan Trypanosoma cruzi, which was identified in the first decade of the 20th century. Once acute infection resolves, patients can develop chronic disease, which in up to 30-40% of cases is characterised by cardiomyopathy, arrhythmias, megaviscera, and, more rarely, polyneuropathy and stroke. Even after more than a century, many challenges remain unresolved, since epidemiological control and diagnostic, therapeutic, and prognostic methods must be improved. In particular, the efficacy and tolerability profile of therapeutic agents is far from ideal. Furthermore, the population affected is older and more complex (eg, immunosuppressed patients and patients with cancer). Nevertheless, in recent years, our knowledge of Chagas disease has expanded, and the international networking needed to change the course of this deadly disease during the 21st century has begun.
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Affiliation(s)
- José A Pérez-Molina
- National Referral Centre for Tropical Diseases, Infectious Diseases Department, Hospital Universitario Ramón y Cajal, Insituto Ramón y Cajal de Investgación Sanitaria, Madrid, Spain.
| | - Israel Molina
- Infectious Diseases Department, Hospital Universitario Vall d'Hebron, Barcelona, Spain; International Health Program of the Catalan Institute of Health, Barcelona, Spain
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21
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Pennington PM, Juárez JG, Arrivillaga MR, De Urioste-Stone SM, Doktor K, Bryan JP, Escobar CY, Cordón-Rosales C. Towards Chagas disease elimination: Neonatal screening for congenital transmission in rural communities. PLoS Negl Trop Dis 2017; 11:e0005783. [PMID: 28892479 PMCID: PMC5634652 DOI: 10.1371/journal.pntd.0005783] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 10/10/2017] [Accepted: 07/06/2017] [Indexed: 11/18/2022] Open
Abstract
Chagas disease is a neglected tropical disease that continues to affect populations living in extreme poverty in Latin America. After successful vector control programs, congenital transmission remains as a challenge to disease elimination. We used the PRECEDE-PROCEED planning model to develop strategies for neonatal screening of congenital Chagas disease in rural communities of Guatemala. These communities have persistent high triatomine infestations and low access to healthcare. We used mixed methods with multiple stakeholders to identify and address maternal-infant health behaviors through semi-structured interviews, participatory group meetings, archival reviews and a cross-sectional survey in high risk communities. From December 2015 to April 2016, we jointly developed a strategy to illustratively advertise newborn screening at the Health Center. The strategy included socioculturally appropriate promotional and educational material, in collaboration with midwives, nurses and nongovernmental organizations. By March 2016, eight of 228 (3.9%) pregnant women had been diagnosed with T. cruzi at the Health Center. Up to this date, no neonatal screening had been performed. By August 2016, seven of eight newborns born to Chagas seropositive women had been parasitologically screened at the Health Center, according to international standards. Thus, we implemented a successful community-based neonatal screening strategy to promote congenital Chagas disease healthcare in a rural setting. The success of the health promotion strategies developed will depend on local access to maternal-infant services, integration with detection of other congenital diseases and reliance on community participation in problem and solution definition.
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Affiliation(s)
- Pamela Marie Pennington
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
- Center for Biotechnology Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - José Guillermo Juárez
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
- Department of Entomology, Texas A&M University, College Station, Texas, United States of America
| | | | | | - Katherine Doktor
- University of Miami, Jackson Memorial Hospital, Miami, Florida, United States of America
| | - Joe P. Bryan
- Centers for Disease Control and Prevention Central America Regional Office, Guatemala City, Guatemala
- Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Clara Yaseli Escobar
- Distrito de Salud de Comapa, Jutiapa, Ministerio de Salud PuÂblica y Asistencia Social de Guatemala
| | - Celia Cordón-Rosales
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
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