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Abras A. Isothermal Nucleic Acid Amplification as a Promising and Versatile Diagnostic Approach for Point-of-Care Testing of Congenital Chagas Disease. J Mol Diagn 2024:S1525-1578(24)00211-3. [PMID: 39332628 DOI: 10.1016/j.jmoldx.2024.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2024] [Revised: 09/03/2024] [Accepted: 09/09/2024] [Indexed: 09/29/2024] Open
Affiliation(s)
- Alba Abras
- Departament de Biologia, Àrea de Genètica, Universitat de Girona, Girona, Spain.
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Larocca L, Stolowicz FG, Vojnov AA, Cano Suarez F, Salvá L, Meli S, Carbajal-de-la-Fuente AL, Carrillo C. A simplified molecular tool for detecting the Chagas etiological agent using a vector feces sample in field conditions. J Invertebr Pathol 2024; 206:108161. [PMID: 38914370 DOI: 10.1016/j.jip.2024.108161] [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: 03/01/2024] [Revised: 06/17/2024] [Accepted: 06/21/2024] [Indexed: 06/26/2024]
Abstract
Triatomine bugs are vectors of Trypanosoma cruzi, the etiologic agent of Chagas disease in the American continent. Here, we have tested a loop-mediated isothermal amplification (LAMP) test for a direct detection of T. cruzi in feces of Triatoma infestans, the main vector of this parasite in the Southern Cone of America. The analytical evaluation showed positive results with samples of triatomine feces artificially inoculated with DNA from strains of T. cruzi corresponding to each Discrete Typing Units (I-VI), with a sensitivity of up to one parasite per reaction. Conversely, the reaction yielded negative results when tested with DNA from Trypanosoma rangeli and other phylogenetically related and unrelated organisms. In triatomines captured under real field conditions (from urban households), and defined as positive or negative for T. cruzi using the reference microscopy technique, the LAMP test achieved a concordance of 100 %. Our results demonstrate that this LAMP reaction exhibits excellent analytical specificity and sensitivity without interference from the fecal matrix, since all the reactions were conducted without purification steps. This simple molecular diagnostic technique can be easily used by vector control agencies under field conditions.
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Affiliation(s)
- Luciana Larocca
- Instituto de Ciencias y Tecnología Dr. César Milstein CONICET (ICT Milstein, Consejo Nacional de Investigaciones Científicas y Técnicas - Fundación Cassará), Saladillo 2468, C1440FFX Ciudad Autónoma de Buenos Aires, Argentina
| | - Fabiana G Stolowicz
- Instituto de Ciencias y Tecnología Dr. César Milstein CONICET (ICT Milstein, Consejo Nacional de Investigaciones Científicas y Técnicas - Fundación Cassará), Saladillo 2468, C1440FFX Ciudad Autónoma de Buenos Aires, Argentina
| | - Adrian A Vojnov
- Instituto de Ciencias y Tecnología Dr. César Milstein CONICET (ICT Milstein, Consejo Nacional de Investigaciones Científicas y Técnicas - Fundación Cassará), Saladillo 2468, C1440FFX Ciudad Autónoma de Buenos Aires, Argentina
| | - Florencia Cano Suarez
- Ministerio de Salud Pública de San Juan, Programa de Control de Enfermedades Transmitidas por Vectores, Santa Fe Este 950, J5402AAT San Juan, Argentina
| | - Liliana Salvá
- Ministerio de Salud Pública de San Juan, Programa de Control de Enfermedades Transmitidas por Vectores, Santa Fe Este 950, J5402AAT San Juan, Argentina
| | - Sergio Meli
- Ministerio de Salud Pública de San Juan, Programa de Control de Enfermedades Transmitidas por Vectores, Santa Fe Este 950, J5402AAT San Juan, Argentina
| | - Ana Laura Carbajal-de-la-Fuente
- Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Godoy Cruz 2290, C1425FQB Ciudad Autónoma de Buenos Aires, Argentina; Centro Nacional de Diagnóstico e Investigación en Endemo-Epidemias (CeNDIE)-Administración Nacional de Laboratorios e Institutos de Salud "Dr. Carlos Malbrán" (ANLIS), Av. Paseo Colón 568 1er. Piso, C1063 Ciudad Autónoma de Buenos Aires, Argentina.
| | - Carolina Carrillo
- Instituto de Ciencias y Tecnología Dr. César Milstein CONICET (ICT Milstein, Consejo Nacional de Investigaciones Científicas y Técnicas - Fundación Cassará), Saladillo 2468, C1440FFX Ciudad Autónoma de Buenos Aires, Argentina.
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Rojas Panozo L, Rivera Nina S, Wehrendt DP, Casellas A, Pinto L, Mendez S, Kuo CW, Lozano DF, Ortiz L, Pinazo MJ, Picado A, Sanz S, Abril M, Gascon J, Wong S, Schijman AG, Torrico F, Alonso-Padilla J. Evaluation and validation of a PrintrLab-based LAMP assay to identify Trypanosoma cruzi in newborns in Bolivia: a proof-of-concept study. THE LANCET. MICROBE 2024; 5:100887. [PMID: 38971173 DOI: 10.1016/s2666-5247(24)00110-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 04/07/2024] [Accepted: 04/19/2024] [Indexed: 07/08/2024]
Abstract
BACKGROUND Vertical transmission of Trypanosoma cruzi represents approximately 20% of new Chagas disease cases. Early detection and treatment for women of childbearing age and newborns is a public health priority, but the lack of a simple and reliable diagnostic test remains a major barrier. We aimed to evaluate the performance of a point-of-care loop-mediated isothermal amplification (LAMP) assay for the detection of T cruzi. METHODS In this proof-of-concept study, we coupled a low-cost 3D printer repurposed for sample preparation and amplification (PrintrLab) to the Eiken T cruzi-LAMP prototype to detect vertically transmitted T cruzi, which we compared with standardised PCR and with the gold-standard algorithm (microscopy at birth and 2 months and serological study several months later). We screened pregnant women from two hospitals in the Bolivian Gran Chaco province, and those who were seropositive for T cruzi were offered the opportunity for their newborns to be enrolled in the study. Newborns were tested by microscopy, LAMP, and PCR at birth and 2 months, and by serology at 8 months. FINDINGS Between April 23 and Nov 17, 2018, 986 mothers were screened, among whom 276 were seropositive for T cruzi (28·0% prevalence, 95% CI 25·6-31·2). In total, 224 infants born to 221 seropositive mothers completed 8 months of follow-up. Congenital transmission was detected in nine of the 224 newborns (4·0% prevalence, 1·9-7·5) by direct microscopy observation, and 14 more cases were diagnosed serologically (6·3%, 3·6-10·3), accounting for an overall vertical transmission rate of 10·3% (6·6-15·0; 23 of 224). All microscopy-positive newborns were positive by PrintrLab-LAMP and by PCR, while these techniques respectively detected four and five extra positive cases among the remaining 215 microscopy-negative newborns. INTERPRETATION The PrintrLab-LAMP yielded a higher sensitivity than microscopy-based analysis. Considering the simpler use and expected lower cost of LAMP compared with PCR, our findings encourage its evaluation in a larger study over a wider geographical area. FUNDING Inter-American Development Bank.
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Affiliation(s)
- Lizeth Rojas Panozo
- Fundación Ciencias y Estudios Aplicados para el Desarrollo en Salud y Medio Ambiente (CEADES), Cochabamba, Bolivia
| | - Silvia Rivera Nina
- Fundación Ciencias y Estudios Aplicados para el Desarrollo en Salud y Medio Ambiente (CEADES), Cochabamba, Bolivia
| | - Diana P Wehrendt
- Laboratorio de Biología Molecular de La Enfermedad de Chagas, Instituto de Investigaciones en Ingeniería Genética y Biología Molecular "Dr. Héctor N. Torres" (INGEBI), Buenos Aires, Argentina
| | - Aina Casellas
- Barcelona Institute for Global Health (ISGlobal), Hospital Clinic - University of Barcelona, Barcelona, Spain
| | - Lilian Pinto
- Fundación Ciencias y Estudios Aplicados para el Desarrollo en Salud y Medio Ambiente (CEADES), Cochabamba, Bolivia
| | - Susana Mendez
- Barcelona Institute for Global Health (ISGlobal), Hospital Clinic - University of Barcelona, Barcelona, Spain
| | | | - Daniel F Lozano
- Fundación Ciencias y Estudios Aplicados para el Desarrollo en Salud y Medio Ambiente (CEADES), Cochabamba, Bolivia; Universidad Mayor de San Simón, Cochabamba, Bolivia
| | - Lourdes Ortiz
- Plataforma de Chagas Tarija - Universidad Autónoma Juan Misael Saracho, Tarija, Bolivia
| | - Maria-Jesus Pinazo
- Drugs for Neglected Diseases Initiative (DNDi), Rio de Janeiro, Brazil; CIBER de Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
| | - Albert Picado
- Foundation for Innovative Diagnostics (FIND), Geneva, Switzerland
| | - Sergi Sanz
- Barcelona Institute for Global Health (ISGlobal), Hospital Clinic - University of Barcelona, Barcelona, Spain
| | | | - Joaquim Gascon
- Barcelona Institute for Global Health (ISGlobal), Hospital Clinic - University of Barcelona, Barcelona, Spain; CIBER de Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
| | | | - Alejandro G Schijman
- Laboratorio de Biología Molecular de La Enfermedad de Chagas, Instituto de Investigaciones en Ingeniería Genética y Biología Molecular "Dr. Héctor N. Torres" (INGEBI), Buenos Aires, Argentina
| | - Faustino Torrico
- Fundación Ciencias y Estudios Aplicados para el Desarrollo en Salud y Medio Ambiente (CEADES), Cochabamba, Bolivia; Universidad Mayor de San Simón, Cochabamba, Bolivia
| | - Julio Alonso-Padilla
- Barcelona Institute for Global Health (ISGlobal), Hospital Clinic - University of Barcelona, Barcelona, Spain; CIBER de Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain.
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Schijman AG, Alonso-Padilla J, Britto C, Herrera Bernal CP. Retrospect, advances and challenges in Chagas disease diagnosis: a comprehensive review. LANCET REGIONAL HEALTH. AMERICAS 2024; 36:100821. [PMID: 39006126 PMCID: PMC11246061 DOI: 10.1016/j.lana.2024.100821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 05/29/2024] [Accepted: 06/05/2024] [Indexed: 07/16/2024]
Abstract
Chagas disease, caused by Trypanosoma cruzi, affects millions worldwide. The 2030 WHO roadmap aims to eliminate it as a public health concern, emphasising the need for timely diagnosis to enhance treatment access. Current diagnostic algorithms, which rely on multiple tests, have prolonged turnaround times. This proves particularly problematic in resource-limited settings. Addressing this issue necessitates the validation and adoption of innovative tools. We explore recent developments in Chagas disease diagnosis, reviewing historical context and advancements. Despite progress, challenges persist. This article contributes to the understanding of current and future directions in this neglected healthcare area. Parasitological methods are simple but exhibit low sensitivity and require supplementary tests. Molecular methods, with automation potential, allow quantification and higher throughput. Serological tools show good performance but struggle with parasite antigenic diversity. Prioritising point-of-care tests is crucial for widespread accessibility and could offer a strategy to control disease impact. Ultimately, balancing achievements and ongoing obstacles is essential for comprehensive progress.
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Affiliation(s)
- Alejandro Gabriel Schijman
- Laboratorio de Biología Molecular de la Enfermedad de Chagas, Instituto de Investigaciones en Ingeniería Genética y Biología Molecular "Dr Héctor Torres", INGEBI- CONICET, Vuelta de Obligado 2490, Buenos Aires, 1428 ADN, Argentina
| | - Julio Alonso-Padilla
- Barcelona Institute for Global Health (ISGlobal), Hospital Clinic - University of Barcelona, Carrer Rosselló 149, 08036, Barcelona, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
| | - Constança Britto
- Fundação Oswaldo Cruz, Fiocruz, Instituto Oswaldo Cruz, Laboratory of Molecular Biology and Endemic Diseases, Avenida Brasil 4365, Manguinhos, Rio de Janeiro, 21045-900, Brazil
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Durães-Oliveira J, Palma-Marques J, Moreno C, Rodrigues A, Monteiro M, Alexandre-Pires G, da Fonseca IP, Santos-Gomes G. Chagas Disease: A Silent Threat for Dogs and Humans. Int J Mol Sci 2024; 25:3840. [PMID: 38612650 PMCID: PMC11011309 DOI: 10.3390/ijms25073840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/15/2024] [Accepted: 03/22/2024] [Indexed: 04/14/2024] Open
Abstract
Chagas disease (CD) is a vector-borne Neglected Zoonotic Disease (NZD) caused by a flagellate protozoan, Trypanosoma cruzi, that affects various mammalian species across America, including humans and domestic animals. However, due to an increase in population movements and new routes of transmission, T. cruzi infection is presently considered a worldwide health concern, no longer restricted to endemic countries. Dogs play a major role in the domestic cycle by acting very efficiently as reservoirs and allowing the perpetuation of parasite transmission in endemic areas. Despite the significant progress made in recent years, still there is no vaccine against human and animal disease, there are few drugs available for the treatment of human CD, and there is no standard protocol for the treatment of canine CD. In this review, we highlight human and canine Chagas Disease in its different dimensions and interconnections. Dogs, which are considered to be the most important peridomestic reservoir and sentinel for the transmission of T. cruzi infection in a community, develop CD that is clinically similar to human CD. Therefore, an integrative approach, based on the One Health concept, bringing together the advances in genomics, immunology, and epidemiology can lead to the effective development of vaccines, new treatments, and innovative control strategies to tackle CD.
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Affiliation(s)
- João Durães-Oliveira
- Global Health and Tropical Medicine, GHTM, Associate Laboratory in Translation and Innovation Towards Global Health, LA-REAL, Instituto de Higiene e Medicina Tropical, IHMT, Universidade NOVA de Lisboa, UNL, Rua da Junqueira 100, 1349-008 Lisbon, Portugal; (J.D.-O.); (G.S.-G.)
| | - Joana Palma-Marques
- Global Health and Tropical Medicine, GHTM, Associate Laboratory in Translation and Innovation Towards Global Health, LA-REAL, Instituto de Higiene e Medicina Tropical, IHMT, Universidade NOVA de Lisboa, UNL, Rua da Junqueira 100, 1349-008 Lisbon, Portugal; (J.D.-O.); (G.S.-G.)
| | - Cláudia Moreno
- Global Health and Tropical Medicine, GHTM, Associate Laboratory in Translation and Innovation Towards Global Health, LA-REAL, Instituto de Higiene e Medicina Tropical, IHMT, Universidade NOVA de Lisboa, UNL, Rua da Junqueira 100, 1349-008 Lisbon, Portugal; (J.D.-O.); (G.S.-G.)
| | - Armanda Rodrigues
- Global Health and Tropical Medicine, GHTM, Associate Laboratory in Translation and Innovation Towards Global Health, LA-REAL, Instituto de Higiene e Medicina Tropical, IHMT, Universidade NOVA de Lisboa, UNL, Rua da Junqueira 100, 1349-008 Lisbon, Portugal; (J.D.-O.); (G.S.-G.)
| | - Marta Monteiro
- Global Health and Tropical Medicine, GHTM, Associate Laboratory in Translation and Innovation Towards Global Health, LA-REAL, Instituto de Higiene e Medicina Tropical, IHMT, Universidade NOVA de Lisboa, UNL, Rua da Junqueira 100, 1349-008 Lisbon, Portugal; (J.D.-O.); (G.S.-G.)
- Centre for Interdisciplinary Research in Animal Health, CIISA, Faculty of Veterinary Medicine, FMV, University of Lisbon, ULisboa, 1649-004 Lisbon, Portugal; (G.A.-P.); (I.P.d.F.)
- Associate Laboratory for Animal and Veterinary Sciences (AL4AnimalS), 1300-477 Lisbon, Portugal
| | - Graça Alexandre-Pires
- Centre for Interdisciplinary Research in Animal Health, CIISA, Faculty of Veterinary Medicine, FMV, University of Lisbon, ULisboa, 1649-004 Lisbon, Portugal; (G.A.-P.); (I.P.d.F.)
- Associate Laboratory for Animal and Veterinary Sciences (AL4AnimalS), 1300-477 Lisbon, Portugal
| | - Isabel Pereira da Fonseca
- Centre for Interdisciplinary Research in Animal Health, CIISA, Faculty of Veterinary Medicine, FMV, University of Lisbon, ULisboa, 1649-004 Lisbon, Portugal; (G.A.-P.); (I.P.d.F.)
- Associate Laboratory for Animal and Veterinary Sciences (AL4AnimalS), 1300-477 Lisbon, Portugal
| | - Gabriela Santos-Gomes
- Global Health and Tropical Medicine, GHTM, Associate Laboratory in Translation and Innovation Towards Global Health, LA-REAL, Instituto de Higiene e Medicina Tropical, IHMT, Universidade NOVA de Lisboa, UNL, Rua da Junqueira 100, 1349-008 Lisbon, Portugal; (J.D.-O.); (G.S.-G.)
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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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Pascual-Vázquez G, Alonso-Sardón M, Rodríguez-Alonso B, Pardo-Lledías J, Romero Alegría A, Fernández-Soto P, Muñoz Bellido JL, Muro A, Belhassen-García M. Molecular diagnosis of Chagas disease: a systematic review and meta-analysis. Infect Dis Poverty 2023; 12:95. [PMID: 37845734 PMCID: PMC10577976 DOI: 10.1186/s40249-023-01143-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 08/20/2023] [Indexed: 10/18/2023] Open
Abstract
BACKGROUND The complexity of the Chagas disease and its phases is impossible to have a unique test for both phases and a lot of different epidemiological scenarios. Currently, serology is the reference standard technique; occasionally, results are inconclusive, and a different diagnostic technique is needed. Some guidelines recommend molecular testing. A systematic review and meta-analysis of available molecular tools/techniques for the diagnosis of Chagas disease was performed to measure their heterogeneity and efficacy in detecting Trypanosoma cruzi infection in blood samples. METHODS A systematic review was conducted up to July 27, 2022, including studies published in international databases. Inclusion and exclusion criteria were defined to select eligible studies. Data were extracted and presented according to PRISMA 2020 guidelines. Study quality was assessed using Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2). A random-effects model was used to calculate pooled sensitivity, specificity, and diagnostic odds ratio (DOR). Forest plots and a summary of the receiving operating characteristics (SROC) curves displayed the outcomes. Heterogeneity was determined by I2 and Tau2 statistics and P values. Funnel plots and Deek's test were used to assess publication bias. A quantitative meta-analysis of the different outcomes in the two different clinical phases was performed. RESULTS We identified 858 records and selected 32 papers. Studies pertained to endemic countries and nonendemic areas with adult and paediatric populations. The sample sizes ranged from 17 to 708 patients. There were no concerns regarding the risk of bias and applicability of all included studies. A positive and nonsignificant correlation coefficient (S = 0.020; P = 0.992) was obtained in the set of studies that evaluated diagnostic tests in the acute phase population (ACD). A positive and significant correlation coefficient (S = 0.597; P < 0.000) was obtained in the case of studies performed in the chronic phase population (CCD). This resulted in high heterogeneity between studies, with the master mix origin and guanidine addition representing significant sources. INTERPRETATION/CONCLUSIONS AND RELEVANCE The results described in this meta-analysis (qualitative and quantitative analyses) do not allow the selection of the optimal protocol of molecular method for the study of Trypanosoma cruzi infection in any of its phases, among other reasons due to the complexity of this infection. Continuous analysis and optimization of the different molecular techniques is crucial to implement this efficient diagnosis in endemic areas.
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Affiliation(s)
- Guillermo Pascual-Vázquez
- Infectious and Tropical Diseases Group (E-INTRO), Biomedical Research Institute of Salamanca (IBSAL), Tropical Diseases Research Center of the University of Salamanca (CIETUS), Faculty of Pharmacy, University of Salamanca, Salamanca, Spain
| | - Montserrat Alonso-Sardón
- Area of Preventive Medicine, Epidemiology and Public Health, Department of Biomedical and Diagnostic Sciences, Faculty of Medicine, E-INTRO, IBSAL, CIETUS, University of Salamanca, Salamanca, Spain
| | - Beatriz Rodríguez-Alonso
- Internal Medicine Service, University Health Care Complex of Salamanca (CAUSA), E-INTRO, IBSAL, CIETUS, Salamanca, Spain
| | - Javier Pardo-Lledías
- Internal Medicine Department, Hospital Marqués de Valdecilla, University of Cantabria, IDIVAL (Valdecilla Research Institute), Santander, Spain
| | | | - Pedro Fernández-Soto
- Infectious and Tropical Diseases Group (E-INTRO), IBSAL. CIETUS. Faculty of Pharmacy, University of Salamanca, Salamanca, Spain
| | - Juan Luis Muñoz Bellido
- Microbiology and Parasitology Service, CAUSA, IBSAL, CIETUS, CSIC, Department of Biomedical and Diagnostic Sciences, University of Salamanca, Salamanca, Spain
| | - Antonio Muro
- Infectious and Tropical Diseases Group (E-INTRO), IBSAL. CIETUS. Faculty of Pharmacy, University of Salamanca, Salamanca, Spain
| | - Moncef Belhassen-García
- Internal Medicine Service. Infectious Diseases Section, CAUSA, IBSAL, CIETUS, University of Salamanca, Paseo San Vicente 58-182, 37007, Salamanca, Spain.
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8
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Gabaldón-Figueira JC, Skjefte M, Longhi S, Escabia E, García LJ, Ros-Lucas A, Martínez-Peinado N, Muñoz-Calderón A, Gascón J, Schijman AG, Alonso-Padilla J. Practical diagnostic algorithms for Chagas disease: a focus on low resource settings. Expert Rev Anti Infect Ther 2023; 21:1287-1299. [PMID: 37933443 DOI: 10.1080/14787210.2023.2279110] [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] [Accepted: 10/31/2023] [Indexed: 11/08/2023]
Abstract
INTRODUCTION Chagas disease, caused by parasite Trypanosoma cruzi, is the most important neglected tropical disease in the Americas. Two drugs are available for treatment, but access to them is challenging, in part due to complex diagnostic algorithms. These are stage-dependent, involve multiple tests, and are ill-adapted to the reality of vast areas where the disease is endemic. Molecular and serologic tools are used to detect acute and chronic infections, with the performance of the latter showing geographic differences. Breakthroughs in the development of new diagnostic tools include the validation of a loop-mediated isothermal amplification assay for acute infections (T. cruzi-LAMP), and the regional validation of several rapid diagnostic tests (RDTs) for chronic infection, which simplify testing in resource-limited settings. The literature search was carried out in the MEDLINE database until 1 August 2023. AREAS COVERED This review outlines existing algorithms, and proposes new ones focused on point-of-care testing. EXPERT OPINION Integrating point-of-care testing into existing diagnostic algorithms in certain endemic areas will increase access to timely diagnosis and treatment. However, additional research is needed to validate the use of these techniques across a wider geography, and to better understand the cost-effectiveness of their large-scale implementation.
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Affiliation(s)
| | - Malia Skjefte
- Population Services International (PSI), Washington, MA, USA
| | - Silvia Longhi
- Laboratorio de Biología Molecular de la Enfermedad de Chagas, Instituto de Investigaciones en Ingeniería Genética y Biología Molecular "Dr Héctor Torres", INGEBI-CONICET, Buenos Aires, Argentina
| | - Elisa Escabia
- Barcelona Institute for Global Health (ISGlobal), Hospital Clinic-University of Barcelona, Barcelona, Spain
| | - Lady Juliette García
- Laboratorio de Biología Molecular de la Enfermedad de Chagas, Instituto de Investigaciones en Ingeniería Genética y Biología Molecular "Dr Héctor Torres", INGEBI-CONICET, Buenos Aires, Argentina
| | - Albert Ros-Lucas
- Barcelona Institute for Global Health (ISGlobal), Hospital Clinic-University of Barcelona, Barcelona, Spain
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III (CIBERINFEC, ISCIII), Madrid, Spain
| | - Nieves Martínez-Peinado
- Barcelona Institute for Global Health (ISGlobal), Hospital Clinic-University of Barcelona, Barcelona, Spain
| | - Arturo Muñoz-Calderón
- Laboratorio de Biología Molecular de la Enfermedad de Chagas, Instituto de Investigaciones en Ingeniería Genética y Biología Molecular "Dr Héctor Torres", INGEBI-CONICET, Buenos Aires, Argentina
| | - Joaquim Gascón
- Barcelona Institute for Global Health (ISGlobal), Hospital Clinic-University of Barcelona, Barcelona, Spain
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III (CIBERINFEC, ISCIII), Madrid, Spain
| | - Alejandro Gabriel Schijman
- Laboratorio de Biología Molecular de la Enfermedad de Chagas, Instituto de Investigaciones en Ingeniería Genética y Biología Molecular "Dr Héctor Torres", INGEBI-CONICET, Buenos Aires, Argentina
| | - Julio Alonso-Padilla
- Barcelona Institute for Global Health (ISGlobal), Hospital Clinic-University of Barcelona, Barcelona, Spain
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III (CIBERINFEC, ISCIII), Madrid, Spain
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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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Sereno D, Oury B, Geiger A, Vela A, Karmaoui A, Desquesnes M. Isothermal Nucleic Acid Amplification to Detect Infection Caused by Parasites of the Trypanosomatidae Family: A Literature Review and Opinion on the Laboratory to Field Applicability. Int J Mol Sci 2022; 23:7543. [PMID: 35886895 PMCID: PMC9322063 DOI: 10.3390/ijms23147543] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/03/2022] [Accepted: 07/04/2022] [Indexed: 12/13/2022] Open
Abstract
Isothermal amplification of nucleic acids has the potential to be applied in resource-limited areas for the detection of infectious agents, as it does not require complex nucleic purification steps or specific and expensive equipment and reagents to perform the reaction and read the result. Since human and animal infections by pathogens of the Tryponasomatidae family occur mainly in resource-limited areas with scant health infrastructures and personnel, detecting infections by these methodologies would hold great promise. Here, we conduct a narrative review of the literature on the application of isothermal nucleic acid amplification for Trypanosoma and Leishmania infections, which are a scourge for human health and food security. We highlight gaps and propose ways to improve them to translate these powerful technologies into real-world field applications for neglected human and animal diseases caused by Trypanosomatidae.
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Affiliation(s)
- Denis Sereno
- Institut de Recherche pour le Développement, Université de Montpellier, UMR INTERTRYP IRD, CIRAD, Parasite Infectiology and Public Health Group, 34032 Montpellier, France
| | - Bruno Oury
- Institut de Recherche pour le Développement, Université de Montpellier, UMR INTERTRYP IRD, CIRAD, Parasite Infectiology and Public Health Group, 34032 Montpellier, France
| | - Anne Geiger
- Centre International de Recherche en Agronomie pour le Développement, Institut de Recherche pour le Développement, Université de Montpellier, UMR INTERTRYP IRD, 34032 Montpellier, France
| | - Andrea Vela
- One Health Research Group, Facultad de Ciencias de la Salud, Universidad de las Américas-Quito, Calle de los Colimes y Avenida De los Granados, Quito 170513, Ecuador
| | - Ahmed Karmaoui
- Bioactives (Health and Environmental, Epigenetics Team), Faculty of Sciences and Techniques, Errachidia (UMI), Moroccan Center for Culture and Sciences, University Moulay Ismail, Meknes 50000, Morocco
| | - Marc Desquesnes
- CIRAD, UMR INTERTRYP, 31076 Toulouse, France
- INTERTRYP, Université de Montpellier, CIRAD, IRD, 34032 Montpellier, France
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Britto CC. Revisiting Chagas' disease diagnostic strategies in light of different scenarios of Trypanosoma cruzi infection. Mem Inst Oswaldo Cruz 2022; 117:e210444chgsb. [PMID: 35613158 PMCID: PMC9164940 DOI: 10.1590/0074-02760210444chgsb] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 12/17/2021] [Indexed: 11/22/2022] Open
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Schijman AG, Alonso-Padilla J, Longhi SA, Picado A. Parasitological, serological and molecular diagnosis of acute and chronic Chagas disease: from field to laboratory. Mem Inst Oswaldo Cruz 2022; 117:e200444. [PMID: 35613155 PMCID: PMC9164950 DOI: 10.1590/0074-02760200444] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 01/13/2021] [Indexed: 01/05/2023] Open
Abstract
There is no consensus on the diagnostic algorithms for many scenarios of Trypanosoma cruzi infection, which hinders the establishment of governmental guidelines in endemic and non-endemic countries. In the acute phase, parasitological methods are currently employed, and standardised surrogate molecular tests are being introduced to provide higher sensitivity and less operator-dependence. In the chronic phase, IgG-based serological assays are currently used, but if a single assay does not reach the required accuracy, PAHO/WHO recommends at least two immunological tests with different technical principles. Specific algorithms are applied to diagnose congenital infection, screen blood and organ donors or conduct epidemiological surveys. Detecting Chagas disease reactivation in immunosuppressed individuals is an area of increasing interest. Due to its neglect, enhancing access to diagnosis of patients at risk of suffering T. cruzi infection should be a priority at national and regional levels.
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Affiliation(s)
- Alejandro Gabriel Schijman
- Instituto de Investigaciones en Ingeniería Genética y Biología Molecular Dr Hector Torres, CONICET, Laboratorio de Biología Molecular de la Enfermedad de Chagas, Ciudad de Buenos Aires, Argentina
| | - Julio Alonso-Padilla
- Barcelona Institute for Global Health, University of Barcelona, Hospital Clinic, Barcelona, Spain
| | - Silvia Andrea Longhi
- Instituto de Investigaciones en Ingeniería Genética y Biología Molecular Dr Hector Torres, CONICET, Laboratorio de Biología Molecular de la Enfermedad de Chagas, Ciudad de Buenos Aires, Argentina
| | - Albert Picado
- Foundation for Innovative New Diagnostics, Geneva, Switzerland
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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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Muñoz-Calderón AA, Besuschio SA, Wong S, Fernández M, García Cáceres LJ, Giorgio P, Barcan LA, Markham C, Liu YE, de Noya BA, Longhi SA, Schijman AG. Loop-Mediated Isothermal Amplification of Trypanosoma cruzi DNA for Point-of-Care Follow-Up of Anti-Parasitic Treatment of Chagas Disease. Microorganisms 2022; 10:microorganisms10050909. [PMID: 35630354 PMCID: PMC9142941 DOI: 10.3390/microorganisms10050909] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 04/06/2022] [Accepted: 04/11/2022] [Indexed: 02/05/2023] Open
Abstract
A loop-mediated isothermal amplification assay was evaluated as a surrogate marker of treatment failure in Chagas disease (CD). A convenience series of 18 acute or reactivated CD patients who received anti-parasitic treatment with benznidazole was selected-namely, nine orally infected patients: three people living with HIV and CD reactivation, five chronic CD recipients with reactivation after organ transplantation and one seronegative recipient of a kidney and liver transplant from a CD donor. Fifty-four archival samples (venous blood treated with EDTA or guanidinium hydrochloride-EDTA buffer and cerebrospinal fluid) were extracted using a Spin-column manual kit and tested by T. cruzi Loopamp kit (Tc-LAMP, index test) and standardized real-time PCR (qPCR, comparator test). Of them, 23 samples were also extracted using a novel repurposed 3D printer designed for point-of-care DNA extraction (PrintrLab). The agreement between methods was estimated by Cohen's kappa index and Bland-Altman plot analysis. The T. cruzi Loopamp kit was as sensitive as qPCR for detecting parasite DNA in samples with parasite loads higher than 0.5 parasite equivalents/mL and infected with different discrete typing units. The agreement between qPCR and Tc-LAMP (Spin-column) or Tc-LAMP (PrintrLab) was excellent, with a mean difference of 0.02 [CI = -0.58-0.62] and -0.04 [CI = -0.45-0.37] and a Cohen's kappa coefficient of 0.78 [CI = 0.60-0.96] and 0.90 [CI = 0.71 to 1.00], respectively. These findings encourage prospective field studies to validate the use of LAMP as a surrogate marker of treatment failure in CD.
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Affiliation(s)
- Arturo A Muñoz-Calderón
- Laboratorio de Biología Molecular de la Enfermedad de Chagas, Instituto de Investigaciones en Ingeniería Genética y Biología Molecular (INGEBI-CONICET), Buenos Aires 1428, Argentina
| | - Susana A Besuschio
- Laboratorio de Biología Molecular de la Enfermedad de Chagas, Instituto de Investigaciones en Ingeniería Genética y Biología Molecular (INGEBI-CONICET), Buenos Aires 1428, Argentina
| | - Season Wong
- AI Biosciences, Inc., College Station, TX 77845, USA
| | - Marisa Fernández
- Hospital de Enfermedades Infecciosas "Dr. Francisco J. Muñiz", Buenos Aires 1282, Argentina
| | - Lady J García Cáceres
- Laboratorio de Biología Molecular de la Enfermedad de Chagas, Instituto de Investigaciones en Ingeniería Genética y Biología Molecular (INGEBI-CONICET), Buenos Aires 1428, Argentina
| | - Patricia Giorgio
- Servicio de Infectología, Hospital Británico de Buenos Aires, Buenos Aires 1280, Argentina
| | - Laura A Barcan
- Sección Infectología, Departamento de Medicina, Hospital Italiano, Buenos Aires 1199, Argentina
| | - Cole Markham
- AI Biosciences, Inc., College Station, TX 77845, USA
| | - Yanwen E Liu
- AI Biosciences, Inc., College Station, TX 77845, USA
| | | | - Silvia A Longhi
- Laboratorio de Biología Molecular de la Enfermedad de Chagas, Instituto de Investigaciones en Ingeniería Genética y Biología Molecular (INGEBI-CONICET), Buenos Aires 1428, Argentina
| | - Alejandro G Schijman
- Laboratorio de Biología Molecular de la Enfermedad de Chagas, Instituto de Investigaciones en Ingeniería Genética y Biología Molecular (INGEBI-CONICET), Buenos Aires 1428, Argentina
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Worldwide Control and Management of Chagas Disease in a New Era of Globalization: a Close Look at Congenital Trypanosoma cruzi Infection. Clin Microbiol Rev 2022; 35:e0015221. [PMID: 35239422 PMCID: PMC9020358 DOI: 10.1128/cmr.00152-21] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Population movements have turned Chagas disease (CD) into a global public health problem. Despite the successful implementation of subregional initiatives to control vectorial and transfusional Trypanosoma cruzi transmission in Latin American settings where the disease is endemic, congenital CD (cCD) remains a significant challenge. In countries where the disease is not endemic, vertical transmission plays a key role in CD expansion and is the main focus of its control. Although several health organizations provide general protocols for cCD control, its management in each geopolitical region depends on local authorities, which has resulted in a multitude of approaches. The aims of this review are to (i) describe the current global situation in CD management, with emphasis on congenital infection, and (ii) summarize the spectrum of available strategies, both official and unofficial, for cCD prevention and control in countries of endemicity and nonendemicity. From an economic point of view, the early detection and treatment of cCD are cost-effective. However, in countries where the disease is not endemic, national health policies for cCD control are nonexistent, and official regional protocols are scarce and restricted to Europe. Countries of endemicity have more protocols in place, but the implementation of diagnostic methods is hampered by economic constraints. Moreover, most protocols in both countries where the disease is endemic and those where it is not endemic have yet to incorporate recently developed technologies. The wide methodological diversity in cCD diagnostic algorithms reflects the lack of a consensus. This review may represent a first step toward the development of a common strategy, which will require the collaboration of health organizations, governments, and experts in the field.
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Ozturk EA, Caner A. Liquid Biopsy for Promising Non-invasive Diagnostic Biomarkers in Parasitic Infections. Acta Parasitol 2022; 67:1-17. [PMID: 34176040 DOI: 10.1007/s11686-021-00444-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 06/16/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Liquid biopsy refers to the sampling and molecular analysis of body fluids such as blood, saliva, and urine in contrast to conventional tissue biopsies. Liquid biopsy approach can offer powerful non-invasive biomarkers (circulating markers) for diagnosis and monitoring treatment response of a variety of diseases, including parasitic infections. METHODS In this review, we concentrate on cell-free DNA (cfDNA), microRNA (miRNA), and exosomes in the published literature. RESULTS Considering the high prevalence and severity of parasitic infections worldwide, circulating biomarkers can provide a new insight into the diagnosis and prognosis of parasites in the near future. Moreover, identifying and characterizing parasite- or host-derived circulating markers are important for a better understanding of the pathogenesis of parasite infection and host-parasite relationship at the molecular level. Profiling of biomarkers for parasitic diseases is a promising potential field, though further studies and optimization strategies are required, both in vitro and in vivo. CONCLUSION In this review, we discuss three approaches in the liquid biopsy including circulating cfDNA, miRNAs, and exosomes for diagnosis and evaluation of parasites and summarize circulating biomarkers in non-invasive samples during parasitic infections.
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Affiliation(s)
- Eylem Akdur Ozturk
- Department of Parasitology, Çukurova University Faculty of Medicine, Adana, Turkey
| | - Ayse Caner
- Department of Parasitology, Ege University Faculty of Medicine, 35100, Izmir, Turkey.
- Cancer Research Center, Ege University, Izmir, Turkey.
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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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Edwards MS, Montgomery SP. Congenital Chagas disease: progress toward implementation of pregnancy-based screening. Curr Opin Infect Dis 2021; 34:538-545. [PMID: 34292173 PMCID: PMC10203783 DOI: 10.1097/qco.0000000000000769] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Lack of recognition of congenital Chagas disease in infants of mothers from endemic regions who are living in countries nonendemic for Trypanosoma cruzi infection suggests a high rate of underdiagnosis. Pregnancy is the optimal access point for identifying Chagas disease in at-risk mothers and their infants. In this review, we update progress toward implementation of pregnancy-based screening for congenital Chagas disease in nonendemic settings. RECENT FINDINGS International organizations have updated recommendations for diagnosis, treatment and prevention of congenital Chagas disease. Reports of successful implementation of pregnancy-based screening at some centers provide a model for optimizing diagnosis of congenital Chagas disease. Screening family members of index patients may identify additional T. cruzi-infected persons. Promising tests to augment current diagnostic modalities for maternal and congenital Chagas disease are in development. Universal or risk-based screening would be cost-effective. More healthcare providers are now aware that treatment of congenital Chagas disease is curative and are promoting efforts to make pregnancy-based screening for congenital Chagas disease a standard of care. SUMMARY Ongoing efforts to implement routine pregnancy-based screening for congenital Chagas disease in nonendemic regions will mutually benefit infants, their mothers and family members and can prevent potentially fatal Chagas cardiomyopathy.
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Affiliation(s)
- Morven S. Edwards
- Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas and
| | - Susan P. Montgomery
- Parasitic Diseases Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, 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: 12] [Impact Index Per Article: 4.0] [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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20
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Bisio MMC, Rivero R, Gonzalez N, Ballering G, D'Amico I, Kessler C, Moroni S, Moscatelli G, Ruiz AM, Altcheh J. Diagnostic Accuracy of Two Molecular Tools for Diagnosis of Congenital Chagas Disease. Mol Diagn Ther 2021; 25:791-801. [PMID: 34426953 PMCID: PMC8382099 DOI: 10.1007/s40291-021-00553-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVE The real prevalence of congenital Chagas disease is undefined because of difficulties in the detection of Trypanosoma cruzi by microscopic examination. The aim of this study was to determine the diagnostic accuracy of two molecular diagnostic tools, qPCR and LAMP, in the diagnosis of congenital Chagas disease in a clinical setting. METHODS To this end, we conducted a prospective cohort study in a tertiary care center, of infants under 9 months of age, born in Buenos Aires to women with Chagas disease. Blood samples were collected for microscopic examination and molecular diagnosis at baseline. If negative, infants were followed up until 9 months of age to determine a final diagnosis by serology. In-house qPCR and LAMP previously validated were challenged as index tests. RESULTS A total of 154 participants were potentially eligible, 120 of whom were enrolled. Finally, 102 (66.2%) of them fulfilled the follow-up. The diagnosis of congenital Chagas disease was confirmed in 13 infants and excluded in 89. Both the sensitivity and specificity of the qPCR were 100.0% (95% confidence interval 75.3-100.0 and 95% confidence interval 95.9-100.0, respectively), whereas the sensitivity and specificity of LAMP were 69.2% (95% confidence interval 38.6-90.9) and 100% (95% confidence interval 95.9-100.0), respectively. CONCLUSIONS The qPCR agreed with the current diagnostic algorithm, and was a reliable and sensitive tool to detect congenital Chagas disease earlier, providing an appropriate and timely identification of infected infants requiring treatment. LAMP was able to detect congenital Chagas disease in infected infants by naked-eye visualization in accordance with a microscopic examination. The advantages of molecular diagnostic tools should be taken into account by the health system to improve congenital Chagas disease diagnosis.
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Affiliation(s)
- Margarita María Catalina Bisio
- Servicio de Parasitología y Enfermedad de Chagas, Hospital de Niños "Dr. Ricardo Gutiérrez", CP 1425 Gallo 1330, Buenos Aires, Argentina. .,Instituto Multidisciplinario de Investigaciones en Patologías Pediátricas, Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET-GCBA), Buenos Aires, Argentina.
| | - Rocío Rivero
- Instituto Nacional de Parasitología Dr. Mario Fatala Chaben, Buenos Aires, Argentina
| | - Nicolás Gonzalez
- Servicio de Parasitología y Enfermedad de Chagas, Hospital de Niños "Dr. Ricardo Gutiérrez", CP 1425 Gallo 1330, Buenos Aires, Argentina
| | - Griselda Ballering
- Servicio de Parasitología y Enfermedad de Chagas, Hospital de Niños "Dr. Ricardo Gutiérrez", CP 1425 Gallo 1330, Buenos Aires, Argentina
| | - Indira D'Amico
- Servicio de Parasitología y Enfermedad de Chagas, Hospital de Niños "Dr. Ricardo Gutiérrez", CP 1425 Gallo 1330, Buenos Aires, Argentina
| | - Camila Kessler
- Instituto Multidisciplinario de Investigaciones en Patologías Pediátricas, Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET-GCBA), Buenos Aires, Argentina
| | - Samanta Moroni
- Servicio de Parasitología y Enfermedad de Chagas, Hospital de Niños "Dr. Ricardo Gutiérrez", CP 1425 Gallo 1330, Buenos Aires, Argentina
| | - Guillermo Moscatelli
- Servicio de Parasitología y Enfermedad de Chagas, Hospital de Niños "Dr. Ricardo Gutiérrez", CP 1425 Gallo 1330, Buenos Aires, Argentina.,Instituto Multidisciplinario de Investigaciones en Patologías Pediátricas, Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET-GCBA), Buenos Aires, Argentina
| | - Andrés Mariano Ruiz
- Instituto Nacional de Parasitología Dr. Mario Fatala Chaben, Buenos Aires, Argentina.,Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Buenos Aires, Argentina
| | - Jaime Altcheh
- Servicio de Parasitología y Enfermedad de Chagas, Hospital de Niños "Dr. Ricardo Gutiérrez", CP 1425 Gallo 1330, Buenos Aires, Argentina. .,Instituto Multidisciplinario de Investigaciones en Patologías Pediátricas, Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET-GCBA), Buenos Aires, Argentina.
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21
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García-Bernalt Diego J, Fernández-Soto P, Muro A. LAMP in Neglected Tropical Diseases: A Focus on Parasites. Diagnostics (Basel) 2021; 11:diagnostics11030521. [PMID: 33804255 PMCID: PMC8000616 DOI: 10.3390/diagnostics11030521] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 03/10/2021] [Accepted: 03/11/2021] [Indexed: 02/01/2023] Open
Abstract
Neglected Tropical Diseases (NTDs), particularly those caused by parasites, remain a major Public Health problem in tropical and subtropical regions, with 10% of the world population being infected. Their management and control have been traditionally hampered, among other factors, by the difficulty to deploy rapid, specific, and affordable diagnostic tools in low resource settings. This is especially true for complex PCR-based methods. Isothermal nucleic acid amplification techniques, particularly loop-mediated isothermal amplification (LAMP), appeared in the early 21st century as an alternative to PCR, allowing for a much more affordable molecular diagnostic. Here, we present the status of LAMP assays development in parasite-caused NTDs. We address the progress made in different research applications of the technique: xenomonitoring, epidemiological studies, work in animal models and clinical application both for diagnosis and evaluation of treatment success. Finally, we try to shed a light on the improvements needed to achieve a true point-of-care test and the future perspectives in this field.
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22
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Wehrendt DP, Alonso-Padilla J, Liu B, Rojas Panozo L, Rivera Nina S, Pinto L, Lozano D, Picado A, Abril M, Pinazo MJ, Gascon J, Torrico F, Wong S, Schijman AG. Development and Evaluation of a Three-Dimensional Printer-Based DNA Extraction Method Coupled to Loop Mediated Isothermal Amplification for Point-of-Care Diagnosis of Congenital Chagas Disease in Endemic Regions. J Mol Diagn 2020; 23:389-398. [PMID: 33387697 DOI: 10.1016/j.jmoldx.2020.12.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 10/22/2020] [Accepted: 12/16/2020] [Indexed: 12/17/2022] Open
Abstract
Vertical transmission of Trypanosomacruzi is the cause of congenital Chagas disease, a re-emerging infectious disease that affects endemic and nonendemic regions alike. An early diagnosis is crucial because prompt treatment achieves a high cure rate, precluding evolution to symptomatic chronic Chagas disease. However, early diagnosis involves low-sensitive parasitologic assays, making necessary serologic confirmation after 9 months of life. With the aim of implementing early diagnostic strategies suitable for minimally equipped laboratories, a T. cruzi-loop-mediated isothermal amplification (LAMP) prototype was coupled with an automated DNA-extraction device repurposed from a three-dimensional printer (PrintrLab). The whole process takes <3 hours to yield a result, with an analytical sensitivity of 0.1 to 2 parasite equivalents per milliliter, depending on the T. cruzi strain. Twenty-five blood samples from neonates born to seropositive mothers were tested blindly. In comparison to quantitative real-time PCR, the PrintrLab-LAMP dual strategy showed high agreement, while both molecular-based methodologies yielded optimal sensitivity and specificity with respect to microscopy-based diagnosis of congenital Chagas disease. PrintrLab-LAMP detected all 10 congenitally transmitted T. cruzi infections, showing promise for point-of-care early diagnosis of congenital Chagas disease.
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Affiliation(s)
- Diana P Wehrendt
- Laboratorio de Biología Molecular de La Enfermedad de Chagas, Instituto de Investigaciones en Ingeniería Genética y Biología Molecular "Dr. Héctor N. Torres", Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Buenos Aires, Argentina
| | - Julio Alonso-Padilla
- Barcelona Institute for Global Health, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Bo Liu
- AI Biosciences Inc., College Station, Texas
| | - Lizeth Rojas Panozo
- Fundación Cienciasy Estudios Aplicados para el Desarrollo en Saludy Medio Ambiente, Cochabamba, Bolivia
| | - Silvia Rivera Nina
- Fundación Cienciasy Estudios Aplicados para el Desarrollo en Saludy Medio Ambiente, Cochabamba, Bolivia
| | - Lilian Pinto
- Fundación Cienciasy Estudios Aplicados para el Desarrollo en Saludy Medio Ambiente, Cochabamba, Bolivia
| | - Daniel Lozano
- Fundación Cienciasy Estudios Aplicados para el Desarrollo en Saludy Medio Ambiente, Cochabamba, Bolivia
| | - Albert Picado
- Foundation for Innovative Diagnostics, Geneva, Switzerland
| | | | - Maria J Pinazo
- Barcelona Institute for Global Health, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Joaquim Gascon
- Barcelona Institute for Global Health, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Faustino Torrico
- Fundación Cienciasy Estudios Aplicados para el Desarrollo en Saludy Medio Ambiente, Cochabamba, Bolivia
| | - Season Wong
- AI Biosciences Inc., College Station, Texas.
| | - Alejandro G Schijman
- Laboratorio de Biología Molecular de La Enfermedad de Chagas, Instituto de Investigaciones en Ingeniería Genética y Biología Molecular "Dr. Héctor N. Torres", Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Buenos Aires, Argentina.
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