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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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2
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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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3
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Silvestrini MMA, Alessio GD, Frias BED, Sales Júnior PA, Araújo MSS, Silvestrini CMA, Brito Alvim de Melo GE, Martins-Filho OA, Teixeira-Carvalho A, Martins HR. New insights into Trypanosoma cruzi genetic diversity, and its influence on parasite biology and clinical outcomes. Front Immunol 2024; 15:1342431. [PMID: 38655255 PMCID: PMC11035809 DOI: 10.3389/fimmu.2024.1342431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 02/26/2024] [Indexed: 04/26/2024] Open
Abstract
Chagas disease, caused by Trypanosoma cruzi, remains a serious public health problem worldwide. The parasite was subdivided into six distinct genetic groups, called "discrete typing units" (DTUs), from TcI to TcVI. Several studies have indicated that the heterogeneity of T. cruzi species directly affects the diversity of clinical manifestations of Chagas disease, control, diagnosis performance, and susceptibility to treatment. Thus, this review aims to describe how T. cruzi genetic diversity influences the biology of the parasite and/or clinical parameters in humans. Regarding the geographic dispersion of T. cruzi, evident differences were observed in the distribution of DTUs in distinct areas. For example, TcII is the main DTU detected in Brazilian patients from the central and southeastern regions, where there are also registers of TcVI as a secondary T. cruzi DTU. An important aspect observed in previous studies is that the genetic variability of T. cruzi can impact parasite infectivity, reproduction, and differentiation in the vectors. It has been proposed that T. cruzi DTU influences the host immune response and affects disease progression. Genetic aspects of the parasite play an important role in determining which host tissues will be infected, thus heavily influencing Chagas disease's pathogenesis. Several teams have investigated the correlation between T. cruzi DTU and the reactivation of Chagas disease. In agreement with these data, it is reasonable to suppose that the immunological condition of the patient, whether or not associated with the reactivation of the T. cruzi infection and the parasite strain, may have an important role in the pathogenesis of Chagas disease. In this context, understanding the genetics of T. cruzi and its biological and clinical implications will provide new knowledge that may contribute to additional strategies in the diagnosis and clinical outcome follow-up of patients with Chagas disease, in addition to the reactivation of immunocompromised patients infected with T. cruzi.
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Affiliation(s)
| | - Glaucia Diniz Alessio
- Integrated Biomarker Research Group, René Rachou Institute, Fiocruz Minas, Oswaldo Cruz Foundation, Belo Horizonte, Minas Gerais, Brazil
| | - Bruna Estefânia Diniz Frias
- Integrated Biomarker Research Group, René Rachou Institute, Fiocruz Minas, Oswaldo Cruz Foundation, Belo Horizonte, Minas Gerais, Brazil
| | - Policarpo Ademar Sales Júnior
- Integrated Biomarker Research Group, René Rachou Institute, Fiocruz Minas, Oswaldo Cruz Foundation, Belo Horizonte, Minas Gerais, Brazil
| | - Márcio Sobreira Silva Araújo
- Integrated Biomarker Research Group, René Rachou Institute, Fiocruz Minas, Oswaldo Cruz Foundation, Belo Horizonte, Minas Gerais, Brazil
| | | | | | - Olindo Assis Martins-Filho
- Integrated Biomarker Research Group, René Rachou Institute, Fiocruz Minas, Oswaldo Cruz Foundation, Belo Horizonte, Minas Gerais, Brazil
| | - Andréa Teixeira-Carvalho
- Integrated Biomarker Research Group, René Rachou Institute, Fiocruz Minas, Oswaldo Cruz Foundation, Belo Horizonte, Minas Gerais, Brazil
| | - Helen Rodrigues Martins
- Department of Pharmacy, Federal University of the Jequitinhonha and Mucuri Valleys, Diamantina, Minas Gerais, Brazil
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Carvalho NB, de Freitas VLT, Seguro FS, Bezerra RC, Fatobene G, Nakanishi ÉYS, Visnadi H, Martinez G, Batista MV, Rocha V, Dulley FL, Costa SF, Shikanai-Yasuda MA. Multiple myeloma and Chagas disease: qPCR as a marker for preemptive antiparasitic therapy: a case reports series and review. Rev Inst Med Trop Sao Paulo 2024; 66:e10. [PMID: 38324876 PMCID: PMC10846554 DOI: 10.1590/s1678-9946202466010] [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] [Received: 10/03/2023] [Accepted: 12/19/2023] [Indexed: 02/09/2024] Open
Abstract
Multiple myeloma (MM) associated with Chagas disease is rarely described. This disease and its therapy suppress T cell and macrophage functions and increase regulatory T cell function, allowing the increase of parasitemia and the risk of Chagas Disease Reactivation (CDR). We aimed to analyze the role of conventional (cPCR) and quantitative Polymerase Chain Reaction (qPCR) for prospective monitoring of T. cruzi parasitemia, searching for markers of preemptive antiparasitic therapy in MM patients with Chagas disease. Moreover, we investigated the incidence and management of hematological diseases and CDR both inside and outside the transplant setting in the MEDLINE database. We found 293 studies and included 31 of them. Around 1.9-2.0% of patients with Chagas disease were reported in patients undergoing Stem Cell Transplantation. One case of CDR was described in eight cases of MM and Chagas disease. We monitored nine MM and Chagas disease patients, seven under Autologous Stem Cell Transplantation (ASCT), during 44.56±32.10 months (mean±SD) using parasitological methods, cPCR, and qPCR. From these patients, three had parasitemia. In the first, up to 256 par Eq/mL were detected, starting from 28 months after ASCT. The second patient dropped out and died soon after the detection of 161.0 par Eq/mL. The third patient had a positive blood culture. Benznidazole induced fast negativity in two cases; followed by notably lower levels in one of them. Increased T. cruzi parasitemia was related to the severity of the underlying disease. We recommend parasitemia monitoring by qPCR for early introduction of preemptive antiparasitic therapy to avoid CDR.
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Affiliation(s)
- Noemia Barbosa Carvalho
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Divisão de Moléstias Infecciosas e Parasitarias, São Paulo, São Paulo, Brazil
| | - Vera Lúcia Teixeira de Freitas
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Moléstias Infecciosas e Parasitarias, São Paulo, São Paulo, Brazil
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Laboratório de Investigação Médica em Imunologia (LIM-48), São Paulo, São Paulo, Brazil
| | - Fernanda Salles Seguro
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Serviço de Hematologia, Transfusão e Terapia Celular, São Paulo, São Paulo, São Paulo, Brazil
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Laboratorio de Investigação Médica em Patogenese e Terapia Celular Dirigida em Onco-Imuno-Hematologia (LIM-31), São Paulo, São Paulo, Brazil
| | - Rita Cristina Bezerra
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Laboratório de Investigação Médica em Parasitologia (LIM-46), São Paulo, São Paulo, Brazil
| | - Giancarlo Fatobene
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Serviço de Hematologia, Transfusão e Terapia Celular, São Paulo, São Paulo, São Paulo, Brazil
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Laboratorio de Investigação Médica em Patogenese e Terapia Celular Dirigida em Onco-Imuno-Hematologia (LIM-31), São Paulo, São Paulo, Brazil
| | - Érika Yoshie Shimoda Nakanishi
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Laboratório de Investigação Médica em Imunologia (LIM-48), São Paulo, São Paulo, Brazil
| | - Helena Visnadi
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Serviço de Hematologia, Transfusão e Terapia Celular, São Paulo, São Paulo, São Paulo, Brazil
| | - Gracia Martinez
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Serviço de Hematologia, Transfusão e Terapia Celular, São Paulo, São Paulo, São Paulo, Brazil
| | - Marjorie Vieira Batista
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Divisão de Moléstias Infecciosas e Parasitarias, São Paulo, São Paulo, Brazil
- AC Camargo Cancer Center, Departamento de Infectologia, São Paulo, São Paulo, Brazil
| | - Vanderson Rocha
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Serviço de Hematologia, Transfusão e Terapia Celular, São Paulo, São Paulo, São Paulo, Brazil
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Laboratorio de Investigação Médica em Patogenese e Terapia Celular Dirigida em Onco-Imuno-Hematologia (LIM-31), São Paulo, São Paulo, Brazil
| | - Frederico Luis Dulley
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Serviço de Hematologia, Transfusão e Terapia Celular, São Paulo, São Paulo, São Paulo, Brazil
| | - Sílvia Figueiredo Costa
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Moléstias Infecciosas e Parasitarias, São Paulo, São Paulo, Brazil
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Laboratório de Investigação Médica em Protozoologia (LIM-49), São Paulo, São Paulo, Brazil
- Universidade de São Paulo, Faculdade de Medicina, Instituto de Medicina Tropical de São Paulo, São Paulo, São Paulo, Brazil
| | - Maria Aparecida Shikanai-Yasuda
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Moléstias Infecciosas e Parasitarias, São Paulo, São Paulo, Brazil
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Laboratório de Investigação Médica em Imunologia (LIM-48), São Paulo, São Paulo, Brazil
- Universidade de São Paulo, Faculdade de Medicina, Instituto de Medicina Tropical de São Paulo, São Paulo, São Paulo, Brazil
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5
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Freitas VLTD, Novaes CTG, Sartori AMC, Carvalho NB, Silva SCVD, Nakanishi ÉS, Salvador F, Castro CND, Bezerra RC, Westphalen EVN, Oliveira CMRD, Busser FD, Ho YL, Buccheri R, Bonilla C, Shikanai-Yasuda MA. Quantitative PCR as a marker for preemptive therapy and its role in therapeutic control in Trypanosoma cruzi/HIV coinfection. PLoS Negl Trop Dis 2024; 18:e0011961. [PMID: 38408095 PMCID: PMC10896531 DOI: 10.1371/journal.pntd.0011961] [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: 08/16/2023] [Accepted: 02/01/2024] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND Trypanosoma cruzi and HIV coinfection can evolve with depression of cellular immunity and increased parasitemia. We applied quantitative PCR (qPCR) as a marker for preemptive antiparasitic treatment to avoid fatal Chagas disease reactivation and analyzed the outcome of treated cases. METHODOLOGY This mixed cross-sectional and longitudinal study included 171 Chagas disease patients, 60 coinfected with HIV. Of these 60 patients, ten showed Chagas disease reactivation, confirmed by parasites identified in the blood, cerebrospinal fluid, or tissues, 12 exhibited high parasitemia without reactivation, and 38 had low parasitemia and no reactivation. RESULTS We showed, for the first time, the success of the timely introduction of benznidazole in the non-reactivated group with high levels of parasitemia detected by qPCR and the absence of parasites in reactivated cases with at least 58 days of benznidazole. All HIV+ patients with or without reactivation had a 4.0-5.1 higher chance of having parasitemia than HIV seronegative cases. A positive correlation was found between parasites and viral loads. Remarkably, treated T. cruzi/HIV-coinfected patients had 77.3% conversion from positive to negative parasitemia compared to 19.1% of untreated patients. Additionally, untreated patients showed ~13.6 times higher Odds Ratio of having positive parasitemia in the follow-up period compared with treated patients. Treated and untreated patients showed no differences regarding the evolution of Chagas disease. The main factors associated with all-cause mortality were higher parasitemia, lower CD4 counts/μL, higher viral load, and absence of antiretroviral therapy. CONCLUSION We recommend qPCR prospective monitoring of T. cruzi parasitemia in HIV+ coinfected patients and point out the value of pre-emptive therapy for those with high parasitemia. In parallel, early antiretroviral therapy introduction is advisable, aiming at viral load control, immune response restoration, and increasing survival. We also suggest an early antiparasitic treatment for all coinfected patients, followed by effectiveness analysis alongside antiretroviral therapy.
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Affiliation(s)
- Vera Lúcia Teixeira de Freitas
- Departamento de Molestias Infecciosas e Parasitarias, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, São Paulo, Brazil
- Laboratorio de Investigacao Medica em Imunologia (LIM 48), Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Christina Terra Gallafrio Novaes
- Divisao de Molestias Infecciosas e Parasitarias, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Ana Marli Christovam Sartori
- Divisao de Molestias Infecciosas e Parasitarias, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Noemia Barbosa Carvalho
- Divisao de Molestias Infecciosas e Parasitarias, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Sheila Cristina Vicente da Silva
- Departamento de Molestias Infecciosas e Parasitarias, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, São Paulo, Brazil
- Laboratorio de Investigacao Medica em Imunologia (LIM 48), Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Érika Shimoda Nakanishi
- Laboratorio de Investigacao Medica em Imunologia (LIM 48), Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Fernando Salvador
- International Health Unit Vall d'Hebron-Drassanes, Infectious Diseases Department, Vall d'Hebron University Hospital, PROSICS Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Cleudson Nery de Castro
- Centre for Tropical Medicine, School of Medicine, University of Brasilia, Brasília, Distrito Federal, Brazil
| | - Rita Cristina Bezerra
- Laboratorio de Investigacao Medica em Parasitologia (LIM 46), Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | | | - Caroline Medeji Ramos de Oliveira
- Departamento de Molestias Infecciosas e Parasitarias, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, São Paulo, Brazil
- Laboratorio de Investigacao Medica em Imunologia (LIM 48), Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Felipe Delatorre Busser
- Departamento de Molestias Infecciosas e Parasitarias, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, São Paulo, Brazil
- Laboratorio de Investigacao Medica em Imunologia (LIM 48), Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Yeh-Li Ho
- Divisao de Molestias Infecciosas e Parasitarias, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Renata Buccheri
- Instituto de Infectologia Emilio Ribas, São Paulo, Brasil
- Vitalant Research Institute, San Francisco, California, United States of America
| | - Carolina Bonilla
- Departamento de Medicina Preventiva, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Maria Aparecida Shikanai-Yasuda
- Departamento de Molestias Infecciosas e Parasitarias, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, São Paulo, Brazil
- Laboratorio de Investigacao Medica em Imunologia (LIM 48), Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
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Shelton WJ, Gonzalez JM. Outcomes of patients in Chagas disease of the central nervous system: a systematic review. Parasitology 2024; 151:15-23. [PMID: 37987164 PMCID: PMC10941035 DOI: 10.1017/s0031182023001117] [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] [Received: 08/08/2023] [Revised: 11/08/2023] [Accepted: 11/09/2023] [Indexed: 11/22/2023]
Abstract
Chagas disease is a parasitic infection caused by the protozoan Trypanosoma cruzi. One of the complications of the disease is the infection of the central nervous system (CNS), as it can result from either the acute phase or by reactivation during the chronic phase, exhibiting high mortality in immunocompromised patients. This systematic review aimed to determine clinical and paraclinical characteristics of patients with Chagas disease in the CNS. Articles were searched from PubMed, Scopus and LILACS until January 2023. From 2325 articles, 59 case reports and 13 case series of patients with Chagas in the CNS were retrieved from which 138 patients were identified. In this population, 77% of the patients were male, with a median age of 35 years old, from which most of them came from Argentina and Brazil. Most of the individuals were immunocompromised from which 89% were HIV-positive, and 54 patients had an average of 48 cells per mm3 CD4+ T cells. Motor deficits and seizures were the most common manifestation of CNS compromise. Furthermore, 90 patients had a documented CNS lesion by imaging from which 89% were supratentorial and 86% were in the anterior/middle cranial fossa. The overall mortality was of 74%. Among patients who were empirically treated with anti-toxoplasma drugs, 70% died. This review shows how Chagas disease in the CNS is a devastating complication requiring prompt diagnosis and treatment to improve patients’ outcomes.
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Affiliation(s)
- William J. Shelton
- Grupo de Ciencias Básicas Medicas, School of Medicine, Universidad de Los Andes, Bogotá, Colombia
| | - John M. Gonzalez
- Grupo de Ciencias Básicas Medicas, School of Medicine, Universidad de Los Andes, Bogotá, Colombia
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7
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de Almeida EA, Mendes FDSNS, Ramos AN, de Sousa AS, Pavan TBS, Mediano MFF, Ostermayer AL, Hasslocher-Moreno AM, Britto CFDPDC, Novaes CG, Correia D, Santos FLN, da Silva GMS, Fernandez ML, Lima MM, de Carvalho NB, Moreira ODC, Albajar-Viñas P, Leite RM, Palmeira SL, da Costa VM, Yasuda MAS. Guidelines for Trypanosoma cruzi-HIV Co-infection and other Immunosuppressive Conditions: Diagnosis, Treatment, Monitoring, and Implementation from the International Network of Care and Studies - 2023. Rev Soc Bras Med Trop 2023; 56:0549. [PMID: 38088667 PMCID: PMC10706049 DOI: 10.1590/0037-8682-0549-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 11/16/2023] [Indexed: 12/18/2023] Open
Affiliation(s)
- Eros Antonio de Almeida
- Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Grupo de Estudos em doença de Chagas, Campinas, SP, Brasil
| | | | - Alberto Novaes Ramos
- Universidade Federal do Ceará, Faculdade de Medicina, Programa de Pós-Graduação em Saúde Pública, Fortaleza, CE, Brasil
| | - Andréa Silvestre de Sousa
- Fundação Oswaldo Cruz, Instituto Nacional de Infectologia Evandro Chagas, Rio de Janeiro, RJ, Brasil
| | - Tycha Bianca Sabaini Pavan
- Fundação Oswaldo Cruz, Instituto Gonçalo Moniz, Laboratório Avançado de Saúde Pública, Bahia, BA, Brasil
| | | | | | | | | | - Christina Gallafrio Novaes
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Moléstias Infecciosas e Parasitárias, São Paulo, Brasil
| | - Dalmo Correia
- Universidade Federal de Sergipe, São Cristóvão, SE, Brasil
| | - Fred Luciano Neves Santos
- Fundação Oswaldo Cruz, Instituto Gonçalo Moniz, Laboratório Avançado de Saúde Pública, Bahia, BA, Brasil
| | | | - Marisa Liliana Fernandez
- Hospital de Infecciosas FJ Muñiz, Instituto Nacional de Parasitología “Dr. Mario Fatala Chabén”, Administración Nacional de Laboratorios e Institutos de Salud, Buenos Aires, Argentina
| | - Mayara Maia Lima
- Ministério da Saúde, Secretaria de Vigilância em Saúde, Brasília, DF, Brasil
| | - Noêmia Barbosa de Carvalho
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Moléstias Infecciosas e Parasitárias, São Paulo, Brasil
| | - Otacílio da Cruz Moreira
- Fundação Oswaldo Cruz, Instituto Oswaldo Cruz, Laboratório de Virologia e Parasitologia Molecular, Rio de Janeiro, RJ, Brasil
| | - Pedro Albajar-Viñas
- Department of Control of Neglected Tropical Diseases, World Health Organization, Geneva, Switzerland
| | - Ruth Moreira Leite
- Centro de Vigilância Epidemiológica Professor Alexandre Vranjac. Secretaria de Estado da Saúde do estado de São Paulo, São Paulo, SP, Brasil
| | - Swamy Lima Palmeira
- Ministério da Saúde, Secretaria de Vigilância em Saúde, Brasília, DF, Brasil
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8
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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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9
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Aplastic Anemia and Chagas Disease: T. cruzi Parasitemia Monitoring by Quantitative PCR and Preemptive Antiparasitic Therapy. Trop Med Infect Dis 2022; 7:tropicalmed7100268. [PMID: 36288009 PMCID: PMC9609300 DOI: 10.3390/tropicalmed7100268] [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: 08/10/2022] [Revised: 09/09/2022] [Accepted: 09/14/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Aplastic anemia is a rare and life-threatening condition, seldomly witnessed concomitantly with Chagas disease. We aim to discuss the management of these patients under risk of chronic Chagas disease reactivation (CDR), a severe condition with a high morbimortality that occurs in chronic Chagas disease patients under immunosuppression. Case reports: Trypanosoma cruzi (T. cruzi) parasitemia was monitored in three patients for 4−58 months by conventional PCR (cPCR), quantitative PCR (qPCR), microhematocrit/buffy coat, blood culture, and/or xenodiagnosis. One patient received antiparasitic treatment (benznidazole) and the other received allopurinol. Although parasitemia was controlled during and after benznidazole treatment at 300 mg/d for 51 days, in one patient, hematologic parameters worsened continuously before, during, and after treatment. Allopurinol led only to the temporary suppression of T. cruzi parasitemia in the second patient, but after danazol and hematological improvement, parasitemia became undetectable until the end of monitoring. Discussion and Conclusion: Unexpected undetectable or low parasitemia by cPCR/qPCR was reported. We show that the monitoring of parasitemia by qPCR and the use of preemptive therapy when the parasitemia was positive proved to be beneficial to our patients. As a result of the toxicity of more effective antiparasitics, shorter regimens of benznidazole or less toxic drugs in preemptive therapy are options that deserve future studies.
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10
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Suárez C, Nolder D, García-Mingo A, Moore DAJ, Chiodini PL. Diagnosis and Clinical Management of Chagas Disease: An Increasing Challenge in Non-Endemic Areas. Res Rep Trop Med 2022; 13:25-40. [PMID: 35912165 PMCID: PMC9326036 DOI: 10.2147/rrtm.s278135] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 06/16/2022] [Indexed: 11/24/2022] Open
Abstract
Chagas disease (CD) is caused by the parasite Trypanosoma cruzi, and it is endemic in Central, South America, Mexico and the South of the United States. It is an important cause of early mortality and morbidity, and it is associated with poverty and stigma. A third of the cases evolve into chronic cardiomyopathy and gastrointestinal disease. The infection is transmitted vertically and by blood/organ donation and can reactivate with immunosuppression. Case identification requires awareness and screening programmes targeting the population at risk (women in reproductive age, donors, immunocompromised patients). Treatment with benznidazole or nifurtimox is most effective in the acute phase and prevents progression to chronic phase when given to children. Treating women antenatally reduces but does not eliminate vertical transmission. Treatment is poorly tolerated, contraindicated during pregnancy, and has little effect modifying the disease in the chronic phase. Screening is easily performed with serology. Migration has brought the disease outside of the endemic countries, where the transmission continues vertically and via blood and tissue/organ donations. There are more than 32 million migrants from Latin America living in non-endemic countries. However, the infection is massively underdiagnosed in this setting due to the lack of awareness by patients, health authorities and professionals. Blood and tissue donation screening policies have significantly reduced transmission in endemic countries but are not universally established in the non-endemic setting. Antenatal screening is not commonly done. Other challenges include difficulties accessing and retaining patients in the healthcare system and lack of specific funding for the interventions. Any strategy must be accompanied by education and awareness campaigns directed to patients, professionals and policy makers. The involvement of patients and their communities is central and key for success and must be sought early and actively. This review proposes strategies to address challenges faced by non-endemic countries.
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Affiliation(s)
- Cristina Suárez
- UK Chagas Hub, London, UK
- Department of Infection, Barts Health NHS Trust, London, UK
| | - Debbie Nolder
- UK Chagas Hub, London, UK
- Diagnostic Parasitology Laboratory, London School of Hygiene & Tropical Medicine, London, UK
| | - Ana García-Mingo
- UK Chagas Hub, London, UK
- Microbiology Department, Whittington Health NHS Trust, London, UK
| | - David A J Moore
- UK Chagas Hub, London, UK
- Hospital for Tropical Diseases, University College London Hospitals NHS Trust;, London, UK
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Peter L Chiodini
- UK Chagas Hub, London, UK
- Hospital for Tropical Diseases, University College London Hospitals NHS Trust;, London, UK
- London School of Hygiene and Tropical Medicine, London, UK
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11
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Shikanai Yasuda MA. Emerging and reemerging forms of Trypanosoma cruzi transmission. Mem Inst Oswaldo Cruz 2022; 117:e210033. [PMID: 35584508 PMCID: PMC9113729 DOI: 10.1590/0074-02760210033] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 02/08/2021] [Indexed: 01/13/2023] Open
Abstract
This review aims to update and discuss the main challenges in controlling emergent and reemergent forms of Trypanosoma cruzi transmission through organ transplantation, blood products and vertical transmission in endemic and non-endemic areas as well as emergent forms of transmission in endemic countries through contaminated food, currently representing the major cause of acute illness in several countries. As a neglected tropical disease potentially controllable with a major impact on morbimortality and socioeconomic aspects, Chagas disease (CD) was approved at the WHO global plan to interrupt four transmission routes by 2030 (vector/blood transfusion/organ transplant/congenital). Implementation of universal or target screening for CD are highly recommended in blood banks of non-endemic regions; in organ transplants donors in endemic/non-endemic areas as well as in women at risk from endemic areas (reproductive age women/pregnant women-respective babies). Moreover, main challenges for surveillance are the application of molecular methods for identification of infected babies, donor transmitted infection and of live parasites in the food. In addition, the systematic recording of acute/non-acute cases and transmission sources is crucial to establish databases for control and surveillance purposes. Remarkably, antiparasitic treatment of infected reproductive age women and infected babies is essential for the elimination of congenital CD by 2030.
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Affiliation(s)
- Maria Aparecida Shikanai Yasuda
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Moléstias Infecciosas e Ptarasitárias, São Paulo, SP, Brasil,Universidade de São Paulo, Hospital das Clínicas da Faculdade de Medicina, Laboratório de Imunologia, São Paulo, SP, Brasil,WHO Technical Group IVb on Prevention and Control of Transmission and Case Management of Trypanosoma cruzi Infections, WHO, Geneva, Switzerland,+ Corresponding author:
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12
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Rodari P, Tamarozzi F, Tais S, Degani M, Perandin F, Buonfrate D, Nicastri E, Lepore L, Giancola ML, Carrara S, Tavelli A, Cozzi-Lepri A, D'Arminio Monforte A, Silva R, Angheben A. Prevalence of Chagas disease and strongyloidiasis among HIV-infected Latin American immigrants in Italy – The CHILI study. Travel Med Infect Dis 2022; 48:102324. [DOI: 10.1016/j.tmaid.2022.102324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 03/15/2022] [Accepted: 03/29/2022] [Indexed: 10/18/2022]
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13
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Clark EH, Marquez C, Whitman JD, Bern C. Screening for Chagas disease should be included in entry-to-care testing for at-risk people with HIV living in the United States. Clin Infect Dis 2022; 75:901-906. [PMID: 35180299 DOI: 10.1093/cid/ciac154] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Indexed: 11/13/2022] Open
Abstract
Chagas disease screening of at-risk populations is essential to identify infected individuals and facilitate timely treatment before end-organ damage occurs. Co-infected people with HIV (PWH) are at risk for dangerous sequelae, specifically Trypanosoma cruzi reactivation disease. Recently published national recommendations indicate that at-risk PWH, particularly those from endemic areas or born to women from endemic areas, should be screened via a sensitive anti-T. cruzi IgG assay. However, immunocompromised patients with negative serologic results may warrant further investigation. Reactivation should be suspected in at-risk, untreated PWH with low CD4 cell counts presenting with acute neurologic or cardiac symptoms; these patients should be promptly evaluated and treated. One pragmatic solution to improve Chagas disease screening among PWH and thereby reduce T. cruzi -related morbidity and mortality is to incorporate Chagas disease screening into the panel of tests routinely performed during the entry-to-care evaluation for at-risk PWH.
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Affiliation(s)
- Eva H Clark
- Department of Medicine, Section of Infectious Diseases, Baylor College of Medicine, Houston, TX, USA.,Department of Pediatrics, Section of Tropical Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Carina Marquez
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Jeffrey D Whitman
- Department of Clinical Laboratory Medicine, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Caryn Bern
- Department of Epidemiology and Biostatistics, University of California San Francisco School of Medicine, San Francisco, CA, USA
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14
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Martins-Melo FR, Castro MC, Werneck GL, Heukelbach J. Deaths related to Chagas disease and HIV/AIDS coinfection in Brazil: a nationwide population-based analysis. Trans R Soc Trop Med Hyg 2021; 116:579-588. [PMID: 34891173 DOI: 10.1093/trstmh/trab183] [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: 09/09/2021] [Revised: 10/31/2021] [Accepted: 11/16/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Trypanosoma cruzi/HIV coinfection has been described as a relevant clinical event and an emerging public health problem. Here, we describe the epidemiological patterns of deaths related to Chagas disease and HIV/AIDS coinfection in Brazil from 2000 to 2019. METHODS We performed a nationwide population-based study using mortality data obtained from the Brazilian Mortality Information System. We included all deaths recorded in Brazil from 2000 to 2019 in which Chagas disease and HIV/AIDS were mentioned on the same death certificate, either as underlying or as associated causes of death. RESULTS Chagas disease and HIV/AIDS were mentioned on 196/22 663 092 death certificates. HIV/AIDS was the underlying cause in 58.2% (114/196) of deaths and Chagas disease in 33.2% (65/196). The average annual mortality rate was 0.05 deaths/1 000 000 inhabitants (95% CI 0.03 to 0.09). The highest death rates were found among males, those aged 60-69 y, Afro-Brazilians, those with 1-3 y of schooling/study and residents in Chagas disease-endemic regions/states. Respiratory, infectious/parasitic and cardiovascular diseases/disorders were the associated causes of death most commonly mentioned. CONCLUSIONS Mortality due to Chagas disease and HIV/AIDS coinfection may be largely underestimated in Brazil. Our data further reinforce the importance of screening for T. cruzi infection in HIV-infected patients from Chagas disease-endemic areas. Appropriate clinical management should be ensured for Chagas disease and HIV coinfected patients.
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Affiliation(s)
| | - Marcia C Castro
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston 02115, Massachusetts, USA
| | - Guilherme Loureiro Werneck
- Institute of Studies in Public Health, Federal University of Rio de Janeiro, Rio de Janeiro 21941-598, Rio de Janeiro, Brazil.,Department of Epidemiology, Social Medicine Institute, State University of Rio de Janeiro, Rio de Janeiro 20550-013, Rio de Janeiro, Brazil
| | - Jorg Heukelbach
- Postgraduate Program in Public Health, School of Medicine, Federal University of Ceará, Fortaleza 60430-140, Brazil
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15
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Beatty NL, White ZS, Bhosale CR, Wilson K, Cannella AP, Stenn T, Burkett-Cadena N, Wisely SM. Anaphylactic Reactions Due to Triatoma protracta (Hemiptera, Reduviidae, Triatominae) and Invasion into a Home in Northern California, USA. INSECTS 2021; 12:insects12111018. [PMID: 34821818 PMCID: PMC8619147 DOI: 10.3390/insects12111018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 10/28/2021] [Accepted: 11/09/2021] [Indexed: 11/16/2022]
Abstract
Simple Summary Kissing bugs are bloodsucking insects found throughout the Western Hemisphere, including the United States, but also within certain regions of the Western Pacific, India, the Middle East, and Africa. Within the Americas, these insects are known to harbor a parasite known as Trypanosoma cruzi, the causative agent of an infection in humans and other mammals known as Chagas disease. The infection can be spread through the fecal matter of the kissing bug when exposed to the skin or ingested from contaminated food or drink products. Kissing bugs will invade human homes and bite residents and their pets. The bite from a kissing bug can also lead to serious allergic reactions, including anaphylaxis. A potentially life-threatening allergic response typically needs emergency medical attention. We describe a home that was invaded by kissing bugs in northern California where the resident developed serious allergic reactions to the bite. The kissing bugs were identified and a blood meal investigation found the presence of human blood as well as the parasite, Trypanosoma cruzi. The resident was tested extensively for chronic Chagas disease due to his repeated exposure to the kissing bug but was found to not have the disease. Those who live in regions where kissing bugs are found naturally should be aware that their bites can be highly allergenic. Abstract Background: Triatoma protracta is a triatomine found naturally throughout many regions of California and has been shown to invade human dwellings and bite residents. A man living in Mendocino County, California, reported developing anaphylactic reactions due to the bite of an “unusual bug”, which he had found in his home for several years. Methods: We conducted environmental, entomological, and clinical investigations to examine the risk for kissing bug invasion, presence of Trypanosoma cruzi, and concerns for Chagas disease at this human dwelling with triatomine invasion. Results: Home assessment revealed several risk factors for triatomine invasion, which includes pack rat infestation, above-ground wooden plank floor without a concrete foundation, canine living in the home, and lack of residual insecticide use. Triatomines were all identified as Triatoma protracta. Midgut molecular analysis of the collected triatomines revealed the detection of T. cruzi discrete typing unit I among one of the kissing bugs. Blood meal PCR-based analysis showed these triatomines had bitten humans, canine and unidentified snake species. The patient was tested for chronic Chagas disease utilizing rapid diagnostic testing and laboratory serological testing, and all were negative. Conclusions: Triatoma protracta is known to invade human dwellings in the western portions of the United States. This is the first report of T. cruzi-infected triatomines invading homes in Mendocino County, California. Triatoma protracta is a known vector responsible for autochthonous Chagas disease within the United States, and their bites can also trigger serious systemic allergic reactions, such as anaphylaxis.
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Affiliation(s)
- Norman L. Beatty
- Department of Medicine, Division of Infectious Diseases and Global Medicine, University of Florida College of Medicine, Gainesville, FL 32610, USA
- Emerging Pathogens Institute, University of Florida, Gainesville, FL 32610, USA;
- Correspondence:
| | - Zoe S. White
- Department of Wildlife Ecology and Conservation, University of Florida Institute of Food and Agricultural Sciences, Gainesville, FL 32610, USA; (Z.S.W.); (C.R.B.); (K.W.)
| | - Chanakya R. Bhosale
- Department of Wildlife Ecology and Conservation, University of Florida Institute of Food and Agricultural Sciences, Gainesville, FL 32610, USA; (Z.S.W.); (C.R.B.); (K.W.)
| | - Kristen Wilson
- Department of Wildlife Ecology and Conservation, University of Florida Institute of Food and Agricultural Sciences, Gainesville, FL 32610, USA; (Z.S.W.); (C.R.B.); (K.W.)
| | - Anthony P. Cannella
- Department of Medicine, Division of Infectious Diseases and International Medicine, University of South Florida Morsani College of Medicine, Tampa, FL 33610, USA;
| | - Tanise Stenn
- Entomology and Nematology Department, Florida Medical Entomology Laboratory, University of Florida, Vero Beach, FL 32962, USA; (T.S.); (N.B.-C.)
| | - Nathan Burkett-Cadena
- Entomology and Nematology Department, Florida Medical Entomology Laboratory, University of Florida, Vero Beach, FL 32962, USA; (T.S.); (N.B.-C.)
| | - Samantha M. Wisely
- Emerging Pathogens Institute, University of Florida, Gainesville, FL 32610, USA;
- Department of Wildlife Ecology and Conservation, University of Florida Institute of Food and Agricultural Sciences, Gainesville, FL 32610, USA; (Z.S.W.); (C.R.B.); (K.W.)
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16
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Clark EH, Bern C. Chagas Disease in People with HIV: A Narrative Review. Trop Med Infect Dis 2021; 6:tropicalmed6040198. [PMID: 34842854 PMCID: PMC8628961 DOI: 10.3390/tropicalmed6040198] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 11/05/2021] [Accepted: 11/05/2021] [Indexed: 01/18/2023] Open
Abstract
Many questions remain unanswered regarding the epidemiology, pathophysiology, diagnosis, treatment, and monitoring of Trypanosoma cruzi infection in people with HIV (PWH). The reported prevalence of T. cruzi infection in PWH living in endemic countries ranges from 1-28% and is likely similar in at-risk US populations. While classic cardiac and gastrointestinal presentations of chronic Chagas disease occur in PWH, PWH are additionally at risk for a severe and often fatal form of T. cruzi-mediated disease called reactivation disease. T. cruzi reactivation typically occurs in PWH with low CD4 counts and poor virologic control. National HIV guidelines in several endemic South American countries recommend that all PWH be screened for T. cruzi infection at the time of HIV diagnosis; however, this recommendation is not widely implemented. The early detection of T. cruzi infection in PWH is critical as the sequelae of Chagas disease, including T. cruzi reactivation, may be preventable through the restoration of robust cellular immunity via the initiation of antiretroviral therapy and the appropriate use of antitrypanosomal therapy.
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Affiliation(s)
- Eva H. Clark
- Department of Medicine, Section of Infectious Diseases, Baylor College of Medicine, Houston, TX 77030, USA
- Department of Pediatrics, Section of Tropical Medicine, Baylor College of Medicine, Houston, TX 77030, USA
- Correspondence:
| | - Caryn Bern
- Department of Biostatistics and Epidemiology, University of California San Francisco, San Francisco, CA 94158, USA;
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Shikanai-Yasuda MA, Mediano MFF, Novaes CTG, de Sousa AS, Sartori AMC, Santana RC, Correia D, de Castro CN, Severo MMDS, Hasslocher-Moreno AM, Fernandez ML, Salvador F, Pinazo MJ, Bolella VR, Furtado PC, Corti M, Neves Pinto AY, Fica A, Molina I, Gascon J, Viñas PA, Cortez-Escalante J, Ramos AN, de Almeida EA. Clinical profile and mortality in patients with T. cruzi/HIV co-infection from the multicenter data base of the "Network for healthcare and study of Trypanosoma cruzi/HIV co-infection and other immunosuppression conditions". PLoS Negl Trop Dis 2021; 15:e0009809. [PMID: 34591866 PMCID: PMC8483313 DOI: 10.1371/journal.pntd.0009809] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 09/10/2021] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE Chagas disease (CD) globalization facilitated the co-infection with Human Immunodeficiency Virus (HIV) in endemic and non-endemic areas. Considering the underestimation of Trypanosoma cruzi (T. cruzi)-HIV co-infection and the risk of life-threatening Chagas Disease Reactivation (CDR), this study aimed to analyze the major co-infection clinical characteristics and its mortality rates. METHODS This is a cross-sectional retrospective multicenter study of patients with CD confirmed by two serological or one parasitological tests, and HIV infection confirmed by immunoblot. CDR was diagnosed by direct microscopy with detection of trypomastigote forms in the blood or other biological fluids and/or amastigote forms in inflammatory lesions. RESULTS Out of 241 patients with co-infection, 86.7% were from Brazil, 47.5% had <200 CD4+ T cells/μL and median viral load was 17,000 copies/μL. Sixty CDR cases were observed. Death was more frequent in patients with reactivation and was mainly caused by CDR. Other causes of death unrelated to CDR were the manifestation of opportunistic infections in those with Acquired Immunodeficiency Syndrome. The time between the co-infection diagnosis to death was shorter in patients with CDR. Lower CD4+ cells count at co-infection diagnosis was independently associated with reactivation. Similarly, lower CD4+ cells numbers at co-infection diagnosis and male sex were associated with higher lethality in CDR. Additionally, CD4+ cells were lower in meningoencephalitis than in myocarditis and milder forms. CONCLUSION This study showed major features on T. cruzi-HIV co-infection and highlighted the prognostic role of CD4+ cells for reactivation and mortality. Since lethality was high in meningoencephalitis and all untreated patients died shortly after the diagnosis, early diagnosis, immediate antiparasitic treatment, patient follow-up and epidemiological surveillance are essentials in T. cruzi/HIV co-infection and CDR managements.
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Affiliation(s)
- Maria Aparecida Shikanai-Yasuda
- Departament of Infectious and Parasitic, Faculdade de Medicina, University of São Paulo, São Paulo, Brazil
- Laboratory of Immunology, Hospital das Clínicas, Faculdade de Medicina, University of São Paulo, São Paulo, Brazil
- WHO Technical Group IVb on prevention, control and management of non congenital infections of the Global Network for Chagas Disease Elimination, WHO, Geneva, Switzerland
- * E-mail: ,
| | - Mauro Felippe Felix Mediano
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Health Ministry, Rio de Janeiro, Brazil
| | | | - Andréa Silvestre de Sousa
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Health Ministry, Rio de Janeiro, Brazil
| | - Ana Marli Christovam Sartori
- Division of Infectious Diseases, Hospital das Clínicas, Faculdade de Medicina, University of São Paulo, São Paulo, Brazil
| | - Rodrigo Carvalho Santana
- Division of Infectious Diseases, Department of Internal Medicine, Ribeirão Preto Medical School University of São Paulo, Ribeirão Preto, Brazil
| | - Dalmo Correia
- Discipline of Infectious and Parasitic Diseases, Department of Internal Medicine, Federal University of Triângulo Mineiro, Uberaba, Brazil
| | | | | | | | - Marisa Liliana Fernandez
- Hospital de Infecciosas, Buenos Aires, Argentina
- National Institute of Parasitology, Departament of Clinics, Pathology and Treatment, Health Ministry, Buenos Aires, Argentina
| | - Fernando Salvador
- Department of Infectious Diseases, Vall d’Hebron University Hospital, PROSICS, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Valdes Roberto Bolella
- Division of Infectious Diseases, Department of Internal Medicine, Ribeirão Preto Medical School University of São Paulo, Ribeirão Preto, Brazil
| | - Pedro Carvalho Furtado
- Discipline of Infectious and Parasitic Diseases, Department of Internal Medicine, Federal University of Triângulo Mineiro, Uberaba, Brazil
| | - Marcelo Corti
- Hospital de Infecciosas, Buenos Aires, Argentina
- Departamento de Medicina, Asignatura Enfermedades Infecciosas, Facultad de Medicina, Universidad Buenos Aires, Buenos Aires, Argentina
| | - Ana Yecê Neves Pinto
- Evandro Chagas Institute, Health Surveillance Secretary, Health Ministry, Belém, Brazil
| | - Alberto Fica
- Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile
| | - Israel Molina
- Department of Infectious Diseases, Vall d’Hebron University Hospital, PROSICS, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Joaquim Gascon
- ISGlobal, Universitat de Barcelona, Hospital Clínic, Barcelona, Spain
| | - Pedro Albajar Viñas
- WHO Technical Group IVb on prevention, control and management of non congenital infections of the Global Network for Chagas Disease Elimination, WHO, Geneva, Switzerland
- Department of Control of Neglected Tropical Diseases, World Health Organization, WHO, Geneva, Switzerland
| | - Juan Cortez-Escalante
- Pan American Health Organization (PAHO), World Health Organization (WHO), Brasília, Brazil
| | - Alberto Novaes Ramos
- Department of Community Health, School of Medicine, Federal University of Ceará, Fortaleza, Brazil
| | - Eros Antonio de Almeida
- Department of Internal Medicine, Faculty of Medical Sciences, State University of Campinas, Campinas, Brazil
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Bustamante EL, Gorensek MJ, Sennhauser SN, Young-Ramsaran JO, Segota ZE, Valdes CG. Unusual Brain Lesions Diagnosed From a Cerebrospinal Fluid Wet Preparation in a Patient With AIDS. Clin Infect Dis 2021; 70:2450-2453. [PMID: 32445477 DOI: 10.1093/cid/ciz796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Edgar L Bustamante
- Internal Medicine Residency Program, University of Miami at Holy Cross Hospital, Fort Lauderdale, Florida, USA
| | | | - Susie N Sennhauser
- Internal Medicine Residency Program, University of Miami at Holy Cross Hospital, Fort Lauderdale, Florida, USA
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Gomes Dos Santos A, Watanabe EH, Ferreira DT, Oliveira J, Nakanishi ÉS, Oliveira CS, Bocchi E, Novaes CTG, Cruz F, Carvalho NB, Sato PK, Yamashiro-Kanashiro EH, Pontillo A, de Freitas VLT, Onuchic LF, Shikanai-Yasuda MA. A Specific IL6 Polymorphic Genotype Modulates the Risk of Trypanosoma cruzi Parasitemia While IL18, IL17A, and IL1B Variant Profiles and HIV Infection Protect Against Cardiomyopathy in Chagas Disease. Front Immunol 2020; 11:521409. [PMID: 33193300 PMCID: PMC7642879 DOI: 10.3389/fimmu.2020.521409] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 09/24/2020] [Indexed: 12/13/2022] Open
Abstract
Background Chagas disease caused by Trypanosoma cruzi (T. cruzi) affects approximately six million individuals worldwide. Clinical manifestations are expected to occur due to the parasite persistence and host immune response. Herein we investigated potential associations between IL1B, IL6, IL17A, or IL18 polymorphism profiles and cardiomyopathy or T. cruzi parasitemia, as well as the impact of HIV infection on cardiopathy. Methods Two hundred twenty-six patients and 90 control individuals were analyzed. IL1B rs1143627 T>C, IL6 rs1800795 C>G, IL17A rs2275913 G>A, IL18 rs187238 C>G, and IL18 rs1946518 C>A SNVs were analyzed by real-time PCR and T. cruzi parasitemia by PCR. Results Our data revealed association between a cytokine gene polymorphism and parasitemia never previously reported. The IL6 rs1800795 CG genotype lowered the risk of positive parasitemia (OR = 0.45, 95% CI 0.24–0.86, P = 0.015). Original findings included associations between IL17A rs2275913 AA and IL18 s1946518 AA genotypes with decreased risk of developing cardiomyopathy (OR = 0.27, 95% CI 0.07–0.97, P = 0.044; and OR = 0.35, 95% CI 0.14–0.87, P = 0.023, respectively). IL18 rs1946518 AA and IL1B rs1143627 TC were associated with reduced risk for cardiomyopathy severity, including NYHA (New York Heart Association) class ≥ 2 (OR = 0.21, 95% CI 0.06–0.68, P = 0.009; and OR = 0.48, 95% CI 0.24–0.95, P = 0.036, respectively) and LVEF (left ventricular ejection fraction) <45% for IL18 rs1946518 AA (OR = 0.22, 95% CI 0.05–0.89, P = 0.034). A novel, unexpected protective effect of HIV infection against development/progression of cardiomyopathy was identified, based on a lower risk of developing cardiopathy (OR = 0.48, 95% CI 0.23–0.96, P = 0.039), NYHA class ≥ 2 (OR = 0.15, 95% CI 0.06–0.39, P < 0.001), and LVEF < 45% (OR = 0.03, 95% CI 0.00–0.25, P = 0.001). Digestive involvement was negatively associated with NYHA ≥ 2 and LVEF < 45% (OR = 0.20, 95% CI 0.09–0.47, P < 0.001; and OR = 0.24, 95% CI 0.09–0.62, P = 0.004, respectively). Conclusions Our data support a protective role of IL17A AA, IL18 AA, and IL1B TC genotypes against development/progression of cardiomyopathy and a modulatory effect of the IL6 CG genotype on the risk of parasitemia in Chagas disease. Notably, HIV infection was shown to protect against development/progression of cardiopathy, potentially associated with a synergistic effect of HIV and highly active antiretroviral therapy (HAART), attenuating a Th1-mediated response in the myocardium. This proposed hypothesis requires confirmation, however, in larger and more comprehensive future studies.
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Affiliation(s)
- Alexandra Gomes Dos Santos
- Department of Infectious and Parasitic Diseases, Faculdade de Medicina, University of São Paulo, São Paulo, Brazil
| | - Elieser Hitoshi Watanabe
- Department of Medicine, Divisions of Molecular Medicine and Nephrology, Faculdade de Medicina, University of São Paulo, São Paulo, Brazil
| | - Daiane Tomomi Ferreira
- Laboratory of Immunology (LIM 48), Hospital das Clínicas, Faculdade de Medicina, University of São Paulo, São Paulo, Brazil
| | - Jamille Oliveira
- Department of Infectious and Parasitic Diseases, Faculdade de Medicina, University of São Paulo, São Paulo, Brazil
| | - Érika Shimoda Nakanishi
- Laboratory of Immunology (LIM 48), Hospital das Clínicas, Faculdade de Medicina, University of São Paulo, São Paulo, Brazil
| | - Claudia Silva Oliveira
- Department of Infectious and Parasitic Diseases, Faculdade de Medicina, University of São Paulo, São Paulo, Brazil
| | - Edimar Bocchi
- Heart Institute, Hospital das Clínicas, Faculdade de Medicina, University of São Paulo, São Paulo, Brazil
| | | | - Fatima Cruz
- Heart Institute, Hospital das Clínicas, Faculdade de Medicina, University of São Paulo, São Paulo, Brazil
| | - Noemia Barbosa Carvalho
- Division of Infectious Diseases, Hospital das Clinicas, Faculdade de Medicina, University of São Paulo, São Paulo, Brazil
| | - Paula Keiko Sato
- Laboratory of Immunology (LIM 48), Hospital das Clínicas, Faculdade de Medicina, University of São Paulo, São Paulo, Brazil
| | - Edite Hatsumi Yamashiro-Kanashiro
- Laboratory of Immunology (LIM 48), Hospital das Clínicas, Faculdade de Medicina, University of São Paulo, São Paulo, Brazil.,Instituto de Medicina Tropical, University of São Paulo, São Paulo, Brazil
| | - Alessandra Pontillo
- Departament of Immunology, Instituto de Ciências Biomédicas (ICB), University of São Paulo, São Paulo, Brazil
| | - Vera Lucia Teixeira de Freitas
- Department of Infectious and Parasitic Diseases, Faculdade de Medicina, University of São Paulo, São Paulo, Brazil.,Laboratory of Immunology (LIM 48), Hospital das Clínicas, Faculdade de Medicina, University of São Paulo, São Paulo, Brazil
| | - Luiz Fernando Onuchic
- Department of Medicine, Divisions of Molecular Medicine and Nephrology, Faculdade de Medicina, University of São Paulo, São Paulo, Brazil
| | - Maria Aparecida Shikanai-Yasuda
- Department of Infectious and Parasitic Diseases, Faculdade de Medicina, University of São Paulo, São Paulo, Brazil.,Laboratory of Immunology (LIM 48), Hospital das Clínicas, Faculdade de Medicina, University of São Paulo, São Paulo, Brazil
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Abstract
As the global COVID-19 pandemic advances, it increasingly impacts those vulnerable populations who already bear a heavy burden of neglected tropical disease. Chagas disease (CD), a neglected parasitic infection, is of particular concern because of its potential to cause cardiac, gastrointestinal, and other complications which could increase susceptibility to COVID-19. The over one million people worldwide with chronic Chagas cardiomyopathy require special consideration because of COVID-19’s potential impact on the heart, yet the pandemic also affects treatment provision to people with acute or chronic indeterminate CD. In this document, a follow-up to the WHF-IASC Roadmap on CD, we assess the implications of coinfection with SARS-CoV-2 and Trypanosoma cruzi, the etiological agent of CD. Based on the limited evidence available, we provide preliminary guidance for testing, treatment, and management of patients affected by both diseases, while highlighting emerging healthcare access challenges and future research needs.
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Sangenito LS, Menna-Barreto RFS, d'Avila-Levy CM, Branquinha MH, Santos ALS. Repositioning of HIV Aspartyl Peptidase Inhibitors for Combating the Neglected Human Pathogen Trypanosoma cruzi. Curr Med Chem 2019; 26:6590-6613. [PMID: 31187704 DOI: 10.2174/0929867326666190610152934] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 08/11/2018] [Accepted: 08/23/2018] [Indexed: 12/11/2022]
Abstract
Chagas disease, caused by the flagellate parasite Trypanosoma cruzi, is a wellknown neglected tropical disease. This parasitic illness affects 6-7 million people and can lead to severe myocarditis and/or complications of the digestive tract. The changes in its epidemiology facilitate co-infection with the Human Immunodeficiency Virus (HIV), making even more difficult the diagnosis and prognosis. The parasitic infection is reactivated in T. cruzi/HIV co-infection, with the appearance of unusual manifestations in the chronic phase and the exacerbation of classical clinical signs. The therapeutic arsenal to treat Chagas disease, in all its clinical forms, is restricted basically to two drugs, benznidazole and nifurtimox. Both drugs are extremely toxic and the therapeutic efficacy is still unclear, making the clinical treatment a huge issue to be solved. Therefore, it seems obvious the necessity of new tangible approaches to combat this illness. In this sense, the repositioning of approved drugs appears as an interesting and viable strategy. The discovery of Human Immunodeficiency Virus Aspartyl Peptidase Inhibitors (HIV-PIs) represented a milestone in the treatment of Acquired Immune Deficiency Syndrome (AIDS) and, concomitantly, a marked reduction in both the incidence and prevalence of important bacterial, fungal and parasitic co-infections was clearly observed. Taking all these findings into consideration, the present review summarizes the promising and beneficial data concerning the effects of HIV-PIs on all the evolutionary forms of T. cruzi and in important steps of the parasite's life cycle, which highlight their possible application as alternative drugs to treat Chagas disease.
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Affiliation(s)
- Leandro S Sangenito
- Laboratorio de Estudos Avancados de Microrganismos Emergentes e Resistentes (LEAMER), Departamento de Microbiologia Geral, Instituto de Microbiologia Paulo de Goes (IMPG), Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - Rubem F S Menna-Barreto
- Laboratorio de Biologia Celular, Instituto Oswaldo Cruz (IOC), Fundacao Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil
| | - Cláudia M d'Avila-Levy
- Laboratorio de Estudos Integrados em Protozoologia, Instituto Oswaldo Cruz (IOC), Fundacao Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil
| | - Marta H Branquinha
- Laboratorio de Estudos Avancados de Microrganismos Emergentes e Resistentes (LEAMER), Departamento de Microbiologia Geral, Instituto de Microbiologia Paulo de Goes (IMPG), Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - André L S Santos
- Laboratorio de Estudos Avancados de Microrganismos Emergentes e Resistentes (LEAMER), Departamento de Microbiologia Geral, Instituto de Microbiologia Paulo de Goes (IMPG), Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil.,Programa de Pós-Graduação em Bioquímica, Instituto de Química, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
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Multani A, Meer A, Smith DS, Kheraj MN, Plowey ED, Blackburn BG. Diagnosis of Chagasic Encephalitis by Sequencing of 28S rRNA Gene. Emerg Infect Dis 2019; 25:1370-1372. [PMID: 31211674 PMCID: PMC6590746 DOI: 10.3201/eid2507.180285] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
We report a case of chagasic encephalitis diagnosed by 28S rRNA sequencing. The diagnosis of chagasic encephalitis is challenging, given the broad differential diagnosis for central nervous system lesions in immunocompromised patients and low sensitivity of traditional diagnostics. Sequencing should be part of the diagnostic armamentarium for potential chagasic encephalitis.
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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: 135] [Impact Index Per Article: 27.0] [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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Clark EH, Serpa JA. Tissue Parasites in HIV Infection. Curr Infect Dis Rep 2019; 21:49. [PMID: 31734888 DOI: 10.1007/s11908-019-0703-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to discuss the current knowledge of HIV and tissue parasite co-infection in the context of transmission enhancement, clinical characteristics, treatment, relapse, and clinical outcomes. RECENT FINDINGS The pathophysiology and clinical sequelae of tissue parasites in people living with HIV (PLWH) have been well described for only a handful of organisms, primarily protozoa such as malaria and leishmaniasis. Available published data indicate that the interactions between HIV and tissue parasites are highly variable depending on the infecting organism and the degree of host immunosuppression. Some tissue parasites, such as Schistosoma species, are known to facilitate the transmission of HIV. Conversely, uncontrolled HIV infection can lead to the earlier and more severe presentation of a variety of tissue parasites and can make treatment more challenging. Although much investigation remains to be done to better understand the interactions between consequences of HIV and tissue parasite co-infection, it is important to disseminate the current knowledge on this topic to health care providers in order to prevent, treat, and control infections in PLWH.
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Affiliation(s)
- Eva H Clark
- Department of Medicine, Section of Infectious Diseases, Baylor College of Medicine, Houston, TX, USA. .,Houston HSR&D Center for Innovations in Quality, Effectiveness and Safety (IQuEST), Baylor College of Medicine, Michael E. DeBakey VA Medical Center, 2450 Holcombe Blvd., Suite 01Y, Houston, TX, 77021, USA.
| | - Jose A Serpa
- Department of Medicine, Section of Infectious Diseases, Baylor College of Medicine, Houston, TX, USA
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Smith K, Marcos LA. Pathogenesis of Chagas Disease: an Emphasis for Transplant Patient Populations. CURRENT TROPICAL MEDICINE REPORTS 2019. [DOI: 10.1007/s40475-019-0168-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Abbas M, Aloudat T, Bartolomei J, Carballo M, Durieux-Paillard S, Gabus L, Jablonka A, Jackson Y, Kaojaroen K, Koch D, Martinez E, Mendelson M, Petrova-Benedict R, Tsiodras S, Christie D, Saam M, Hargreaves S, Pittet D. Migrant and refugee populations: a public health and policy perspective on a continuing global crisis. Antimicrob Resist Infect Control 2018; 7:113. [PMID: 30250735 PMCID: PMC6146746 DOI: 10.1186/s13756-018-0403-4] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 09/07/2018] [Indexed: 02/01/2023] Open
Abstract
The 2015-2017 global migratory crisis saw unprecedented numbers of people on the move and tremendous diversity in terms of age, gender and medical requirements. This article focuses on key emerging public health issues around migrant populations and their interactions with host populations. Basic needs and rights of migrants and refugees are not always respected in regard to article 25 of the Universal Declaration of Human Rights and article 23 of the Refugee Convention. These are populations with varying degrees of vulnerability and needs in terms of protection, security, rights, and access to healthcare. Their health status, initially conditioned by the situation at the point of origin, is often jeopardised by adverse conditions along migratory paths and in intermediate and final destination countries. Due to their condition, forcibly displaced migrants and refugees face a triple burden of non-communicable diseases, infectious diseases, and mental health issues. There are specific challenges regarding chronic infectious and neglected tropical diseases, for which awareness in host countries is imperative. Health risks in terms of susceptibility to, and dissemination of, infectious diseases are not unidirectional. The response, including the humanitarian effort, whose aim is to guarantee access to basic needs (food, water and sanitation, healthcare), is gripped with numerous challenges. Evaluation of current policy shows insufficiency regarding the provision of basic needs to migrant populations, even in the countries that do the most. Governments around the world need to rise to the occasion and adopt policies that guarantee universal health coverage, for migrants and refugees, as well as host populations, in accordance with the UN Sustainable Development Goals. An expert consultation was carried out in the form of a pre-conference workshop during the 4th International Conference on Prevention and Infection Control (ICPIC) in Geneva, Switzerland, on 20 June 2017, the United Nations World Refugee Day.
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Affiliation(s)
- Mohamed Abbas
- Infection Control Programme and WHO Collaborating Centre on Patient Safety, Faculty of Medicine, University of Geneva Hospitals, Geneva, Switzerland
| | | | - Javier Bartolomei
- CAPPI Servette, Department of Mental Health and Psychiatry, Geneva University Hospitals, Genève, Switzerland
| | - Manuel Carballo
- International Centre for Migration, Health and Development, Geneva, Switzerland
| | - Sophie Durieux-Paillard
- Programme Santé Migrants, Department of Community Medicine, Primary Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | | | - Alexandra Jablonka
- Department of Clinical Immunology and Rheumatology, Hannover Medical School, Hannover, Germany
- German Center for Infection Research (DZIF), PARTNER Site Hannover-Braunschweig, Hannover, Germany
| | - Yves Jackson
- Division of Primary Care Medicine, Geneva University Hospitals, Geneva, Switzerland
- Institute of Global Health, Geneva University, Geneva, Switzerland
| | - Kanokporn Kaojaroen
- Department of Service Delivery & Safety, World Health Organization, Geneva, Switzerland
| | - Daniel Koch
- Division of Communicable Diseases, Federal Office of Public Health, Bern, Switzerland
| | - Esperanza Martinez
- Health Unit, International Committee of the Red Cross (ICRC), Geneva, Switzerland
| | - Marc Mendelson
- Division of Infectious Diseases & HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Roumyana Petrova-Benedict
- International Organization for Migration (IOM), Migration Health Division (MHD), Regional office (RO), Brussels, Belgium
| | - Sotirios Tsiodras
- 4th Department of Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
- Hellenic Centre for Disease Control & Prevention, Athens, Greece
| | - Derek Christie
- Division of environmental health, Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Mirko Saam
- Communication in Science, Geneva, Switzerland
| | - Sally Hargreaves
- Section of Infectious Diseases and Immunity, Department of Medicine, Imperial College London, Hammersmith Hospital, London, W12 0HS UK
- The Institute for Infection and Immunity, St George’s, University of London, London, WC1E 7HU UK
| | - Didier Pittet
- Infection Control Programme and WHO Collaborating Centre on Patient Safety, Faculty of Medicine, University of Geneva Hospitals, Geneva, Switzerland
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Clinical and epidemiological features of chronic Trypanosoma cruzi infection in patients with HIV/AIDS in Buenos Aires, Argentina. Int J Infect Dis 2017; 67:118-121. [PMID: 29196277 DOI: 10.1016/j.ijid.2017.11.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 11/21/2017] [Accepted: 11/23/2017] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVES Trypanosoma cruzi reactivation in HIV patients is considered an opportunistic infection, usually with a fatal outcome. The aim of this study was to describe the epidemiological and clinical features of T. cruzi infection in HIV patients and to compare these findings between patients with and without Chagas disease reactivation. METHODS The medical records of T. cruzi-HIV co-infected patients treated at the Muñiz Infectious Diseases Hospital from January 2005 to December 2014 were reviewed retrospectively. Epidemiological and clinical features were assessed and compared between patients with and without Chagas disease reactivation. RESULTS The medical records of 80 T. cruzi-HIV co-infected patients were reviewed. The most likely route of T. cruzi infection was vector-borne (32/80 patients), followed by intravenous drug use (12/80). Nine of 80 patients had reactivation. Patients without reactivation had a significantly higher CD4 T-cell count at diagnosis of T. cruzi infection (144 cells/μl vs. 30 cells/μl, p=0.026). Chagas disease serology was negative in two of nine patients with reactivation. CONCLUSIONS Serological assays for T. cruzi infection may be negative in severely immunocompromised patients. Direct parasitological techniques should be performed in the diagnosis of patients for whom there is a suspicion of T. cruzi reactivation. HIV patients with a lower CD4 count are at higher risk of reactivation.
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Tozetto-Mendoza TR, de Moraes Vasconcelos D, Ibrahim KY, Sartori AMC, Bezerra RC, de Freitas VLT, Shikanai-Yasuda MA. Role of T. cruzi exposure in the pattern of T cell cytokines among chronically infected HIV and Chagas disease patients. Clinics (Sao Paulo) 2017; 72:652-660. [PMID: 29236910 PMCID: PMC5706062 DOI: 10.6061/clinics/2017(11)02] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 07/19/2017] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES The impact of Chagas disease (CD) in HIV-infected patients is relevant throughout the world. In fact, the characterization of the adaptive immune response in the context of co-infection is important for predicting the need for interventions in areas in which HIV and Chagas disease co-exist. METHODS We described and compared the frequency of cytokine-producing T cells stimulated with soluble antigen of Trypanosoma cruzi (T. cruzi) using a cytometric assay for the following groups: individuals with chronic Chagas disease (CHR, n=10), those with Chagas disease and HIV infection (CO, n=11), those with only HIV (HIV, n=14) and healthy individuals (C, n=15). RESULTS We found 1) a constitutively lower frequency of IL-2+ and IFN-γ+ T cells in the CHR group compared with the HIV, CO and healthy groups; 2) a suppressive activity of soluble T. cruzi antigen, which down-regulated IL-2+CD4+ and IFN-γ+CD4+ phenotypes, notably in the healthy group; 3) a down-regulation of inflammatory cytokines on CD8+ T cells in the indeterminate form of Chagas disease; and 4) a significant increase in IL-10+CD8+ cells distinguishing the indeterminate form from the cardiac/digestive form of Chagas disease, even in the presence of HIV infection. CONCLUSIONS Taken together, our data suggest the presence of an immunoregulatory response in chronic Chagas disease, which seems to be driven by T. cruzi antigens. Our findings provide new insights into immunotherapeutic strategies for people living with HIV/AIDS and Chagas disease.
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Affiliation(s)
- Tania Regina Tozetto-Mendoza
- Laboratorio de Imunologia (LIM 48), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Laboratorio de Virologia (LIM 52), Universidade de Sao Paulo, Instituto de Medicina Tropical, Sao Paulo, SP, BR
- #These authors contributed equally to this work
| | - Dewton de Moraes Vasconcelos
- Laboratorio Dermatologia e Imunodeficiencias (LIM-56), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- #These authors contributed equally to this work
| | - Karim Yaqub Ibrahim
- Divisao de Doencas Infecciosas e Parasitarias, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Ana Marli Christovam Sartori
- Divisao de Doencas Infecciosas e Parasitarias, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Rita C. Bezerra
- Laboratorio de Parasitologia (LIM 46), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Vera Lúcia Teixeira de Freitas
- Laboratorio de Imunologia (LIM 48), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Departamento de Doencas Infecciosas e Parasitarias, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Maria Aparecida Shikanai-Yasuda
- Laboratorio de Imunologia (LIM 48), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Departamento de Doencas Infecciosas e Parasitarias, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
- *Corresponding author. E-mail:
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Urquiza JM, Burgos JM, Ojeda DS, Pascuale CA, Leguizamón MS, Quarleri JF. Astrocyte Apoptosis and HIV Replication Are Modulated in Host Cells Coinfected with Trypanosoma cruzi. Front Cell Infect Microbiol 2017; 7:345. [PMID: 28824880 PMCID: PMC5539089 DOI: 10.3389/fcimb.2017.00345] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 07/17/2017] [Indexed: 12/20/2022] Open
Abstract
The protozoan Trypanosoma cruzi is the etiological agent of Chagas disease. In immunosuppressed individuals, as it occurs in the coinfection with human immunodeficiency virus (HIV), the central nervous system may be affected. In this regard, reactivation of Chagas disease is severe and often lethal, and it accounts for meningoencephalitis. Astrocytes play a crucial role in the environment maintenance of healthy neurons; however, they can host HIV and T. cruzi. In this report, human astrocytes were infected in vitro with both genetically modified-pathogens to express alternative fluorophore. As evidenced by fluorescence microscopy and flow cytometry, HIV and T. cruzi coexist in the same astrocyte, likely favoring reciprocal interactions. In this context, lower rates of cell death were observed in both T. cruzi monoinfected-astrocytes and HIV-T. cruzi coinfection in comparison with those infected only with HIV. The level of HIV replication is significantly diminished under T. cruzi coinfection, but without affecting the infectivity of the HIV progeny. This interference with viral replication appears to be related to the T. cruzi multiplication rate or its increased intracellular presence but does not require their intracellular cohabitation or infected cell-to-cell contact. Among several Th1/Th2/Th17 profile-related cytokines, only IL-6 was overexpressed in HIV-T. cruzi coinfection exhibiting its cytoprotective role. This study demonstrates that T. cruzi and HIV are able to coinfect astrocytes thus altering viral replication and apoptosis.
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Affiliation(s)
- Javier M Urquiza
- Consejo Nacional de Investigaciones Científicas y TécnicasBuenos Aires, Argentina.,Instituto de Investigaciones Biomédicas en Retrovirus y Sida, Universidad de Buenos Aires, Consejo Nacional de Investigaciones Científicas y TécnicasBuenos Aires, Argentina
| | - Juan M Burgos
- Consejo Nacional de Investigaciones Científicas y TécnicasBuenos Aires, Argentina.,Instituto de Investigaciones Biotecnológicas, Universidad Nacional de San Martín, San Martín, Argentina Consejo Nacional de Investigaciones Científicas y TécnicasBuenos Aires, Argentina
| | - Diego S Ojeda
- Consejo Nacional de Investigaciones Científicas y TécnicasBuenos Aires, Argentina.,Instituto de Investigaciones Biomédicas en Retrovirus y Sida, Universidad de Buenos Aires, Consejo Nacional de Investigaciones Científicas y TécnicasBuenos Aires, Argentina
| | - Carla A Pascuale
- Consejo Nacional de Investigaciones Científicas y TécnicasBuenos Aires, Argentina.,Instituto de Investigaciones Biotecnológicas, Universidad Nacional de San Martín, San Martín, Argentina Consejo Nacional de Investigaciones Científicas y TécnicasBuenos Aires, Argentina
| | - M Susana Leguizamón
- Consejo Nacional de Investigaciones Científicas y TécnicasBuenos Aires, Argentina.,Instituto de Investigaciones Biotecnológicas, Universidad Nacional de San Martín, San Martín, Argentina Consejo Nacional de Investigaciones Científicas y TécnicasBuenos Aires, Argentina
| | - Jorge F Quarleri
- Consejo Nacional de Investigaciones Científicas y TécnicasBuenos Aires, Argentina.,Instituto de Investigaciones Biomédicas en Retrovirus y Sida, Universidad de Buenos Aires, Consejo Nacional de Investigaciones Científicas y TécnicasBuenos Aires, Argentina
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Benchetrit A, Andreani G, Avila MM, Rossi D, De Rissio AM, Weissenbacher M, Martinez Peralta L, Dolcini G. High HIV-Trypanosoma cruzi Coinfection Levels in Vulnerable Populations in Buenos Aires, Argentina. AIDS Res Hum Retroviruses 2017; 33:330-331. [PMID: 27875909 DOI: 10.1089/aid.2016.0068] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Andres Benchetrit
- Hospital de Enfermedades Infecciosas “Dr. Francisco J. Muñiz”, Buenos Aires, Argentina
| | - Guadalupe Andreani
- Instituto de Investigaciones Biomédicas en Retrovirus y SIDA (INBIRS, UBA CONICET), Buenos Aires, Argentina
| | - Maria Mercedes Avila
- Instituto de Investigaciones Biomédicas en Retrovirus y SIDA (INBIRS, UBA CONICET), Buenos Aires, Argentina
| | - Diana Rossi
- Intercambios Asociación Civil, Buenos Aires, Argentina
| | - Ana Maria De Rissio
- Instituto Nacional de Parasitología “Dr. Mario Fatala Chaben”, Buenos Aires, Argentina
| | | | - Liliana Martinez Peralta
- Instituto de Microbiología y Parasitología Médica, (IMPaM, UBA CONICET), Buenos Aires, Argentina
| | - Guillermina Dolcini
- Laboratorio de Virología, FCV-UNCPBA, Centro de Investigación Veterinaria de Tandil (CIVETAN)-CONICET, Buenos Aires, Argentina
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32
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Montague BT, Salas CM, Montague TL, Mileno MD. The immunosuppressed patient. Infect Dis (Lond) 2017. [DOI: 10.1002/9781119085751.ch28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Brian T. Montague
- Division of Infectious Diseases; University of Colorado; Aurora Colorado USA
| | | | | | - Maria D. Mileno
- Warren Alpert Medical School; Brown University; Providence Rhode Island USA
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Rassi A, Marin JA, Rassi A. Chronic Chagas cardiomyopathy: a review of the main pathogenic mechanisms and the efficacy of aetiological treatment following the BENznidazole Evaluation for Interrupting Trypanosomiasis (BENEFIT) trial. Mem Inst Oswaldo Cruz 2017; 112:224-235. [PMID: 28225900 PMCID: PMC5319366 DOI: 10.1590/0074-02760160334] [Citation(s) in RCA: 116] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Accepted: 11/22/2016] [Indexed: 11/21/2022] Open
Abstract
Chagas cardiomyopathy is the most frequent and most severe manifestation of chronic Chagas disease, and is one of the leading causes of morbidity and death in Latin America. Although the pathogenesis of Chagas cardiomyopathy is incompletely understood, it may involve several mechanisms, including parasite-dependent myocardial damage, immune-mediated myocardial injury (induced by the parasite itself and by self-antigens), and microvascular and neurogenic disturbances. In the past three decades, a consensus has emerged that parasite persistence is crucial to the development and progression of Chagas cardiomyopathy. In this context, antiparasitic treatment in the chronic phase of Chagas disease could prevent complications related to the disease. However, according to the results of the BENEFIT trial, benznidazole seems to have no benefit for arresting disease progression in patients with chronic Chagas cardiomyopathy. In this review, we give an update on the main pathogenic mechanisms of Chagas disease, and re-examine and discuss the results of the BENEFIT trial, together with its limitations and implications.
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Affiliation(s)
- Anis Rassi
- Hospital do Coração Anis Rassi, Goiânia, GO, Brasil
| | - José Antonio Marin
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Clínica Médica, Divisão de Cardiologia, Ribeirão Preto, SP, Brasil
| | - Anis Rassi
- Hospital do Coração Anis Rassi, Goiânia, GO, Brasil
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Dias JCP, Ramos Jr. AN, Gontijo ED, Luquetti A, Shikanai-Yasuda MA, Coura JR, Torres RM, Melo JRDC, Almeida EAD, Oliveira Jr. WD, Silveira AC, Rezende JMD, Pinto FS, Ferreira AW, Rassi A, Fragata Filho AA, Sousa ASD, Correia D, Jansen AM, Andrade GMQ, Britto CFDPDC, Pinto AYDN, Rassi Jr. A, Campos DE, Abad-Franch F, Santos SE, Chiari E, Hasslocher-Moreno AM, Moreira EF, Marques DSDO, Silva EL, Marin-Neto JA, Galvão LMDC, Xavier SS, Valente SADS, Carvalho NB, Cardoso AV, Silva RAE, Costa VMD, Vivaldini SM, Oliveira SM, Valente VDC, Lima MM, Alves RV. 2 nd Brazilian Consensus on Chagas Disease, 2015. Rev Soc Bras Med Trop 2016; 49Suppl 1:3-60. [DOI: 10.1590/0037-8682-0505-2016] [Citation(s) in RCA: 179] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 12/05/2016] [Indexed: 11/22/2022] Open
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Use of a Chagas Urine Nanoparticle Test (Chunap) to Correlate with Parasitemia Levels in T. cruzi/HIV Co-infected Patients. PLoS Negl Trop Dis 2016; 10:e0004407. [PMID: 26919324 PMCID: PMC4768913 DOI: 10.1371/journal.pntd.0004407] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 01/04/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Early diagnosis of reactivated Chagas disease in HIV patients could be lifesaving. In Latin America, the diagnosis is made by microscopical detection of the T. cruzi parasite in the blood; a diagnostic test that lacks sensitivity. This study evaluates if levels of T. cruzi antigens in urine, determined by Chunap (Chagas urine nanoparticle test), are correlated with parasitemia levels in T. cruzi/HIV co-infected patients. METHODOLOGY/PRINCIPAL FINDINGS T. cruzi antigens in urine of HIV patients (N = 55: 31 T. cruzi infected and 24 T. cruzi serology negative) were concentrated using hydrogel particles and quantified by Western Blot and a calibration curve. Reactivation of Chagas disease was defined by the observation of parasites in blood by microscopy. Parasitemia levels in patients with serology positive for Chagas disease were classified as follows: High parasitemia or reactivation of Chagas disease (detectable parasitemia by microscopy), moderate parasitemia (undetectable by microscopy but detectable by qPCR), and negative parasitemia (undetectable by microscopy and qPCR). The percentage of positive results detected by Chunap was: 100% (7/7) in cases of reactivation, 91.7% (11/12) in cases of moderate parasitemia, and 41.7% (5/12) in cases of negative parasitemia. Chunap specificity was found to be 91.7%. Linear regression analysis demonstrated a direct relationship between parasitemia levels and urine T. cruzi antigen concentrations (p<0.001). A cut-off of > 105 pg was chosen to determine patients with reactivation of Chagas disease (7/7). Antigenuria levels were 36.08 times (95% CI: 7.28 to 64.88) higher in patients with CD4+ lymphocyte counts below 200/mL (p = 0.016). No significant differences were found in HIV loads and CD8+ lymphocyte counts. CONCLUSION Chunap shows potential for early detection of Chagas reactivation. With appropriate adaptation, this diagnostic test can be used to monitor Chagas disease status in T. cruzi/HIV co-infected patients.
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Abstract
The constant migration flows have favored the presence of people with Chagas disease in regions traditionally regarded as non-endemic, such as North America, Europe, Asia and Oceania. This has forced both health authorities and professionals to be updated in order to respond to such a demand for assistance. Recent years have led to significant progress in the field of diagnosis and treatment of Chagas disease, one of the most neglected tropical diseases. Recent clinical trials are providing new evidence that makes the management of these patients, a constant challenge for the professionals involved. Innovative diagnostic tools and therapeutic regimens, allow us to face the future of Chagas disease with optimism.
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Buccheri R, Kassab MJ, Freitas VLTD, Silva SCVD, Bezerra RC, Khoury Z, Shikanai-Yasuda MA, Vidal JE. CHAGASIC MENINGOENCEPHALITIS IN AN HIV INFECTED PATIENT WITH MODERATE IMMUNOSUPPRESSION: PROLONGED SURVIVAL AND CHALLENGES IN THE HAART ERA. Rev Inst Med Trop Sao Paulo 2015; 57:531-5. [PMID: 27049711 PMCID: PMC4727143 DOI: 10.1590/s0036-46652015000600014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Accepted: 06/22/2015] [Indexed: 11/29/2022] Open
Abstract
The reactivation of Chagas disease in HIV infected patients presents high mortality and morbidity. We present the case of a female patient with confirmed Chagasic meningoencephalitis as AIDS-defining illness. Interestingly, her TCD4+ lymphocyte cell count was 318 cells/mm3. After two months of induction therapy, one year of maintenance with benznidazol, and early introduction of highly active antiretroviral therapy (HAART), the patient had good clinical, parasitological and radiological evolution. We used a qualitative polymerase chain reaction for the monitoring of T. cruzi parasitemia during and after the treatment. We emphasize the potential value of molecular techniques along with clinical and radiological parameters in the follow-up of patients with Chagas disease and HIV infection. Early introduction of HAART, prolonged induction and maintenance of antiparasitic therapy, and its discontinuation are feasible, in the current management of reactivation of Chagas disease.
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Affiliation(s)
- Renata Buccheri
- Instituto de Infectologia Emílio Ribas, São Paulo, SP, Brasil
| | | | - Vera Lucia Teixeira de Freitas
- Departamento de Moléstias Infecciosas e Parasitárias, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | | | | | - Zarifa Khoury
- Instituto de Infectologia Emílio Ribas, São Paulo, SP, Brasil
| | - Maria Aparecida Shikanai-Yasuda
- Departamento de Moléstias Infecciosas e Parasitárias, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - José E Vidal
- Instituto de Infectologia Emílio Ribas, São Paulo, SP, Brasil
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40
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Salvador F, Sánchez-Montalvá A, Valerio L, Serre N, Roure S, Treviño B, Pou D, Sulleiro E, Bocanegra C, Molina I. Immunosuppression and Chagas disease; experience from a non-endemic country. Clin Microbiol Infect 2015; 21:854-60. [PMID: 26055418 DOI: 10.1016/j.cmi.2015.05.033] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 05/05/2015] [Accepted: 05/27/2015] [Indexed: 10/23/2022]
Abstract
Reactivation of Chagas disease in the chronic phase may occur when immunosuppression is established, sometimes resulting in high parasitaemia and severe clinical manifestations such as meningitis and meningoencephalitis. Although this situation is being increasingly described, there is still scarce information. This retrospective observational study was performed in three Tropical Medicine Units of Barcelona (Spain) included in the International Health Programme of the Catalan Health Institute (PROSICS). The objective of the study was to describe epidemiological, clinical, microbiological, prognostic and therapeutic data from patients with Chagas disease and any kind of immunosuppressive condition attended in these three institutions from January 2007 to October 2014. From 1823 patients with Chagas disease attending these three centres during the study period, 38 (2%) had some kind of immunosuppressive condition: 12 patients had human immunodeficiency virus infection, 8 patients had neoplasia, 4 patients underwent organ transplantation and 14 patients had an autoimmune disease. Eight (21.1%) patients had cardiac involvement, and six (15.8%) patients had gastrointestinal involvement. Acute Trypanosoma cruzi infection was detected in two Spanish patients. Thirty-one (81.6%) patients received treatment with benznidazole, of whom 17 (54.8%) had some kind of adverse event. No patient had a severe manifestation or reactivation of Chagas disease. Patients with Chagas disease under immunosuppressive conditions are being increasingly described, especially in non-endemic countries. More information about this topic is required and international consensus in the diagnosis, treatment and follow up of these patients must be established to reduce the morbidity and mortality.
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Affiliation(s)
- F Salvador
- Department of Infectious Diseases, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, PROSICS Barcelona, Barcelona, Spain.
| | - A Sánchez-Montalvá
- Department of Infectious Diseases, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, PROSICS Barcelona, Barcelona, Spain
| | - L Valerio
- North Metropolitan International Health Unit, PROSICS Metropolitana Nord, Barcelona, Spain
| | - N Serre
- Special Programme for Infectious Diseases Vall d'Hebron-Drassanes, Barcelona, Spain
| | - S Roure
- North Metropolitan International Health Unit, PROSICS Metropolitana Nord, Barcelona, Spain
| | - B Treviño
- Special Programme for Infectious Diseases Vall d'Hebron-Drassanes, Barcelona, Spain
| | - D Pou
- Special Programme for Infectious Diseases Vall d'Hebron-Drassanes, Barcelona, Spain
| | - E Sulleiro
- Department of Microbiology, Vall d'Hebron University Hospital, PROSICS Barcelona, Barcelona, Spain
| | - C Bocanegra
- Special Programme for Infectious Diseases Vall d'Hebron-Drassanes, Barcelona, Spain
| | - I Molina
- Department of Infectious Diseases, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, PROSICS Barcelona, Barcelona, Spain
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Decoding the anti-Trypanosoma cruzi action of HIV peptidase inhibitors using epimastigotes as a model. PLoS One 2014; 9:e113957. [PMID: 25464510 PMCID: PMC4252066 DOI: 10.1371/journal.pone.0113957] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 11/01/2014] [Indexed: 12/21/2022] Open
Abstract
Background Aspartic peptidase inhibitors have shown antimicrobial action against distinct microorganisms. Due to an increase in the occurrence of Chagas' disease/AIDS co-infection, we decided to explore the effects of HIV aspartic peptidase inhibitors (HIV-PIs) on Trypanosoma cruzi, the etiologic agent of Chagas' disease. Methodology and Principal Findings HIV-PIs presented an anti-proliferative action on epimastigotes of T. cruzi clone Dm28c, with IC50 values ranging from 0.6 to 14 µM. The most effective inhibitors, ritonavir, lopinavir and nelfinavir, also had an anti-proliferative effect against different phylogenetic T. cruzi strains. The HIV-PIs induced some morphological alterations in clone Dm28c epimastigotes, as reduced cell size and swollen of the cellular body. Transmission electron microscopy revealed that the flagellar membrane, mitochondrion and reservosomes are the main targets of HIV-PIs in T. cruzi epimastigotes. Curiously, an increase in the epimastigote-into-trypomastigote differentiation process of clone Dm28c was observed, with many of these parasites presenting morphological alterations including the detachment of flagellum from the cell body. The pre-treatment with the most effective HIV-PIs drastically reduced the interaction process between epimastigotes and the invertebrate vector Rhodnius prolixus. It was also noted that HIV-PIs induced an increase in the expression of gp63-like and calpain-related molecules, and decreased the cruzipain expression in epimastigotes as judged by flow cytometry and immunoblotting assays. The hydrolysis of a cathepsin D fluorogenic substrate was inhibited by all HIV-PIs in a dose-dependent manner, showing that the aspartic peptidase could be a possible target to these drugs. Additionally, we verified that ritonavir, lopinavir and nelfinavir reduced drastically the viability of clone Dm28c trypomastigotes, causing many morphological damages. Conclusions and Significance The results contribute to understand the possible role of aspartic peptidases in T. cruzi physiology, adding new in vitro insights into the possibility of exploiting the use of HIV-PIs in the clinically relevant forms of the parasite.
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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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Abstract
Among the world's most neglected tropical diseases, Chagas disease is vector-borne and caused by Trypanosoma cruzi. T cruzi infection is endemic to South and Central America as well as Mexico. Due to population migration, T cruzi is increasingly becoming a public health problem in nonendemic settings. Success with vector control strategies has led to a relative increase in the burden attributable to congenital transmission of T cruzi. In endemic settings, approximately 5% of infected pregnant women transmit to their offspring. Congenital T cruzi infection is generally asymptomatic and parasitological and serological testing is required for diagnosis. This review highlights research gaps with a focus on (1) improving screening, diagnostic, and treatment options and (2) designing epidemiologic studies to understand risk factors for congenital T cruzi.
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Affiliation(s)
- Hirut T. Gebrekristos
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana
| | - Pierre Buekens
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana
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Abstract
Chagas disease is caused by infection with the protozoan Trypanosoma cruzi, and although over 100 years have passed since the discovery of Chagas disease, it still presents an increasing problem for global public health. A plethora of information concerning the chronic phase of human Chagas disease, particularly the severe cardiac form, is available in the literature. However, information concerning events during the acute phase of the disease is scarce. In this review, we will discuss (1) the current status of acute Chagas disease cases globally, (2) the immunological findings related to the acute phase and their possible influence in disease outcome, and (3) reactivation of Chagas disease in immunocompromised individuals, a key point for transplantation and HIV infection management.
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Affiliation(s)
- Daniela V. Andrade
- Department of Morphology, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Kenneth J. Gollob
- National Institute for Science and Technology in Tropical Diseases, INCT-DT, Belo Horizonte, Minas Gerais, Brazil
- Hospital Santa Casa-BH, Institute for Education and Research, Graduate Program in Biomedicine and Medicine, Belo Horizonte, Minas Gerais, Brazil
| | - Walderez O. Dutra
- Department of Morphology, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
- National Institute for Science and Technology in Tropical Diseases, INCT-DT, Belo Horizonte, Minas Gerais, Brazil
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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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Chagas' disease: pregnancy and congenital transmission. BIOMED RESEARCH INTERNATIONAL 2014; 2014:401864. [PMID: 24949443 PMCID: PMC4052072 DOI: 10.1155/2014/401864] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 04/11/2014] [Accepted: 04/24/2014] [Indexed: 01/15/2023]
Abstract
Chagas disease is a chronic infection that kills approximately 12,000 people a year. Mass migration of chronically infected and asymptomatic persons has caused globalization of Chagas disease and has made nonvectorial infection, including vertical and blood-borne transmission, more of a threat to human communities than vectorial infection. To control transmission, it is essential to test all pregnant women living in endemic countries and all pregnant women having migrated from, or having lived in, endemic countries. All children born to seropositive mothers should be tested not only within the first month of life but also at ~6 months and ~12 months of age. The diagnosis is made by identification of the parasite in blood before the age of 6 months and by identification of the parasite in blood and/or positive serology after 10 months of age. Follow up for a year is essential as a significant proportion of cases are initially negative and are only detected at a later stage. If the condition is diagnosed and treated early, the clinical response is excellent and the majority of cases are cured.
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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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Management of Trypanosoma cruzi coinfection in HIV-positive individuals outside endemic areas. Curr Opin Infect Dis 2014; 27:9-15. [DOI: 10.1097/qco.0000000000000023] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Lepesheva GI. Design or screening of drugs for the treatment of Chagas disease: what shows the most promise? Expert Opin Drug Discov 2013; 8:1479-89. [PMID: 24079515 PMCID: PMC3867292 DOI: 10.1517/17460441.2013.845554] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Endemic in Latin America, Chagas disease is now becoming a serious global health problem, and yet has no financial viability for the pharmaceutical industry and remains incurable. In 2012, two antimycotic drugs inhibitors of fungal sterol 14α-demethylase (CYP51) - posaconazole and ravuconazole - entered clinical trials. Availability of the X-ray structure of the orthologous enzyme from the causative agent of the disease, protozoan parasite Trypanosoma cruzi, determined in complexes with posaconazole as well as with several experimental protozoa-specific CYP51 inhibitors opens an excellent opportunity to improve the situation. AREAS COVERED This article summarizes the information available in PubMed and Google on the outcomes of treatment of the chronic Chagas disease. It also outlines the major features of the T. cruzi CYP51 structure and the possible structure-based strategies for rational design of novel T. cruzi specific drugs. EXPERT OPINION There is no doubt that screenings for alternative drug-like molecules as well as mining the T. cruzi genome for novel drug targets are of great value and might eventually lead to groundbreaking discoveries. However, all newly identified molecules must proceed through the long, expensive and low-yielding drug optimization process, and all novel potential drug targets must be validated in terms of their essentiality and druggability. CYP51 is already a well-validated and highly successful target for clinical and agricultural antifungals. With minimal investments into the final stages of their development/trials, T. cruzi-specific CYP51 inhibitors can provide an immediate treatment for Chagas disease, either on their own or in combination with the currently available drugs.
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Affiliation(s)
- Galina I Lepesheva
- Vanderbilt University, Institute for Global Health, School of Medicine, Center for Structural Biology, Department of Biochemistry , 622 RRB, 23rd at Pierce, Nashville, TN 37232 , USA +1 615 343 1373 ; +1 615 322 4349 ;
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Sales-Campos H, Kappel HB, Andrade CP, Lima TP, Mattos ME, de Castilho A, Correia D, Giraldo LER, Lages-Silva E. A DTU-dependent blood parasitism and a DTU-independent tissue parasitism during mixed infection of Trypanosoma cruzi in immunosuppressed mice. Parasitol Res 2013; 113:375-85. [DOI: 10.1007/s00436-013-3665-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Accepted: 10/18/2013] [Indexed: 01/09/2023]
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