Tropical diseases of the myocardium: a review

Population genetics and genomics of Triatoma brasiliensis (Hemiptera, Reduviidae) in an area of high pressure of domiciliary infestation in Northeastern Brazil

Understanding the population dynamics of vectors is crucial for effective control of vector-borne diseases. In the Northeastern Brazilian semi-arid region, Triatoma brasiliensis persists as the most significant Chagas disease vector, frequently displaying recurrent domiciliary infestations. This situation raises relevant public health concerns in the municipality of Currais Novos in the state of Rio Grande do Norte. This area has experienced a high prevalence of peridomiciliary re-infestations by T. brasiliensis, coupled with elevated rates of Trypanosoma cruzi infection. Therefore, we assessed the distribution of genetic variation via mitochondrial Cytochrome b gene (MT-CYB) sequencing (n = 109) and single nucleotide polymorphisms (SNPs, n = 86) to assess the gene flow among distinct populations distributed in varied geographic spots and environments, mainly sylvatic and peridomiciliary. Insects were collected from rural communities at Currais Novos, enclosed within a 16 km radius. Sampling included 13 populations: one intradomiciliary, eight peridomiciliary, and four sylvatic. Furthermore, an external population located 220 km from Currais Novos was also included in the study. The method employed to obtain SNP information relied on ddRAD-seq genotyping-by-sequencing (GBS), enabling a genome-wide analysis to infer genetic variation. Through AMOVA analysis of MT-CYB gene variation, we identified four distinct population groups with statistical significance (FCT= 0.42; p<0.05). We identified a total of 3,013 SNPs through GBS, with 11 loci showing putative signs of being under selection. The variation based on 3,002 neutral loci evidenced low genetic structuration based on low FST values (p>0.05), indicating local panmixia. However, resampling algorithms pointed out that three samples from the external population were assigned (>98 %) in a cluster contrasting from the ones putatively under local panmixia - validating the newly applied genome-wide marker for studies on the population genetics at finer-scale resolution for T. brasiliensis. The presence of population structuring in some of the sampled points, as suggested by the mitochondrial marker, leads us to assume that infestations were probably initiated by small populations of females - demographic event poses a risk for rapid re-infestations. The local panmictic pattern revealed by the GBS marker poses a challenge for vector control measures, as re-infestation foci may be distributed over a wide geographical and ecological range. In such instances, vectors exhibit reduced susceptibility to conventional insecticide spraying operations since sylvatic populations are beyond the reach of these interventions. The pattern of infestation exhibited by T. brasiliensis necessitates integrating innovative strategies into the existing control framework, holding the potential to create a more resilient and adaptive vector control program. In our dataset, the results demonstrated that the genetic signals from both markers were complementary. Therefore, it is essential to consider the nature and inheritance pattern of each marker when inferring the pattern of re-infestations.

Solitary cardiac cysticercosis

Cardiac cysticercosis is rare in clinical practice and is usually accidentally identified during cardiac surgery or autopsies. Although mostly asymptomatic, cardiac cysticercosis could present with severe clinical conditions such as myocarditis, acute myocardial infarction, and arrhythmia. We present a 51-year-old female patient who accidentally discovered a solitary mass in the myocardium. The cardiac magnetic resonance imaging revealed a nonenhanced cyst in the interventricular septum protruding into the right ventricular chamber. Because of cardiac tamponade presenting during a right ventricular endomyocardial biopsy, an emergency open-heart surgery was performed to suture the ventricular wall perforation and remove the tumor. The histopathologic report demonstrated typical cysticercosis. Cardiac cysticercosis is an uncommon lesion and may present with atypical clinical and laboratory features. Therefore, this diagnosis should be considered single or multiple cardiac cystic lesions.

Nutritional Heart Disease and Cardiomyopathies: JACC Focus Seminar 4/4

This JACC Focus Seminar provides an overview of and highlights recently published research on cardiomyopathies and nutritional heart disease that have a higher prevalence in tropical regions. The development of tropical cardiomyopathies and nutritional cardiovascular disease (CVD) is complicated by high rates of poverty, fragmented health care systems, and suboptimal access to health care because of socioeconomic inequalities, leading to the fact that children, adolescents, and young adults are disproportionally affected. Such tropical cardiomyopathies and nutritional CVD that have not been prevalent in high-income countries in the past decades are now reemerging. When treating migrants or refugees, it is important for attending physicians to consider the burden of endemic diseases in the countries of origin and the likelihood that such patients might be affected. In this review, the authors propose an approach for adequate diagnostic work-up leading to appropriate care for those with suspected or confirmed tropical cardiomyopathies and nutritional CVD.

Protozoan phagotrophy from predators to parasites: An overview of the enigmatic cytostome-cytopharynx complex of Trypanosoma cruzi

Eating is fundamental and from this basic principle, living organisms have evolved innumerable strategies to capture energy and nutrients from their environment. As part of the world's aquatic ecosystems, the expansive family of heterotrophic protozoans uses self-generated currents to funnel prokaryotic prey into an ancient, yet highly enigmatic, oral apparatus known as the cytostome-cytopharynx complex prior to digestion. Despite its near ubiquitous presence in protozoans, little is known mechanistically about how this feeding organelle functions. Intriguingly, one class of these flagellated phagotrophic predators known as the kinetoplastids gave rise to a lineage of obligate parasitic protozoa, the trypanosomatids, that can infect a wide variety of organisms ranging from plants to humans. One parasitic species of humans, Trypanosoma cruzi, has retained this ancestral organelle much like its free-living relatives and continues to use it as its primary mode of endocytosis. In this review, we will highlight foundational observations made regarding the cytostome-cytopharynx complex and examine some of the most pressing questions regarding the mechanistic basis for its function. We propose that T. cruzi has the potential to serve as an excellent model system to dissect the enigmatic process of protozoal phagotrophy and thus enhance our overall understanding of fundamental eukaryotic biology.

CYSTICERCOSIS & HEART: A systematic review

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

Neglected Tropical Diseases and Other Infectious Diseases Affecting the Heart. The NET-Heart Project: Rationale and Design

Introduction

Neglected tropical diseases (NTDs) are a group of infections that are prevalent in many of the tropical and sub-tropical developing countries where poverty is rampant. NTDs have remained largely unnoticed in the global health agenda. There is a substantial gap between the burden of disease for NTDs in cardiovascular diseases (CVD) and research devoted to the affected populations. We created a Latin-American initiative with emerging leaders (EL) from the Interamerican Society of Cardiology (IASC) with the objective to perform multiple systematic reviews of NTDs and other infectious diseases affecting the heart: The NET-Heart Project.

Objective

To describe the rationale and design considerations of the NET-Heart project.

Methods

The NET-Heart Project is a collaborative work of the IASC EL program. The main objective of the NET-Heart project is to systematically evaluate the available evidence of NTDs and other infectious diseases and their cardiovascular involvement. As a secondary objective, this initiative aims to offer recommendations and potential diagnostic and therapeutic algorithms that can aid the management of cardiovascular complications of these infectious diseases. After an expert discussion 17 initial infectious diseases were selected, for each disease we created one working group. The project was structured in different phases: Systematic review, brainstorming workshops, analysis and results, manuscript writing and recommendations and evaluation of clinical implications.

Conclusion

The NET-Heart project is an innovative collaborative initiative created to assess burden and impact of NTDs and other infectious diseases in CVD. NTDs can no longer be ignored and must be prioritised on the health and research agenda. This project aims to review in depth the evidence regarding cardiac compromise of these serious conditions and to propose strategies to overcome barriers for efficient diagnosis and treatment of cardiovascular complications.

The Functional Characterization of TcMyoF Implicates a Family of Cytostome-Cytopharynx Targeted Myosins as Integral to the Endocytic Machinery of Trypanosoma cruzi

The parasite Trypanosoma cruzi is the etiological agent of Chagas disease and chronically infects upwards of 7 million people in the Americas. Current diagnostics and treatments remain grossly inadequate due, in part, to our general lack of understanding of this parasite’s basic biology. One aspect that has resisted detailed scrutiny is the mechanism employed by this parasite to extract nutrient resources from the radically different environments that it encounters as it transitions between its invertebrate and mammalian hosts. These parasites engulf food via a tubular invagination of its membrane, a strategy used by many protozoan species, but how this structure is formed or functions mechanistically remains a complete mystery. The significance of our research is in the identification of the mechanistic underpinnings of this feeding organelle that may bring to light new potential therapeutic targets to impede parasite feeding and thus halt the spread of this deadly human pathogen.

Of the pathogenic trypanosomatids, Trypanosoma cruzi alone retains an ancient feeding apparatus known as the cytostome-cytopharynx complex (SPC) that it uses as its primary mode of endocytosis in a manner akin to its free-living kinetoplastid relatives who capture and eat bacterial prey via this endocytic organelle. In a recent report, we began the process of dissecting how this organelle functions by identifying the first SPC-specific proteins in T. cruzi. Here, we continued these studies and report on the identification of the first enzymatic component of the SPC, a previously identified orphan myosin motor (MyoF) specifically targeted to the SPC. We overexpressed MyoF as a dominant-negative mutant, resulting in parasites that, although viable, were completely deficient in measurable endocytosis in vitro. To our surprise, however, a full deletion of MyoF demonstrated only a decrease in the overall rate of endocytosis, potentially indicative of redundant myosin motors at work. Thereupon, we identified three additional orphan myosin motors, two of which (MyoB and MyoE) were targeted to the preoral ridge region adjacent to the cytostome entrance and another (MyoC) which was targeted to the cytopharynx tubular structure similar to that of MyoF. Additionally, we show that the C-terminal tails of each myosin are sufficient for targeting a fluorescent reporter to SPC subregions. This work highlights a potential mechanism used by the SPC to drive the inward flow of material for digestion and unveils a new level of overlapping complexity in this system with four distinct myosin isoforms targeted to this feeding structure.

IMPORTANCE The parasite Trypanosoma cruzi is the etiological agent of Chagas disease and chronically infects upwards of 7 million people in the Americas. Current diagnostics and treatments remain grossly inadequate due, in part, to our general lack of understanding of this parasite’s basic biology. One aspect that has resisted detailed scrutiny is the mechanism employed by this parasite to extract nutrient resources from the radically different environments that it encounters as it transitions between its invertebrate and mammalian hosts. These parasites engulf food via a tubular invagination of its membrane, a strategy used by many protozoan species, but how this structure is formed or functions mechanistically remains a complete mystery. The significance of our research is in the identification of the mechanistic underpinnings of this feeding organelle that may bring to light new potential therapeutic targets to impede parasite feeding and thus halt the spread of this deadly human pathogen.

Chagas heart disease: A contemporary review

Chagas disease is caused by a parasite infection endemic of the Americas. Traditionally observed in rural areas of Latin America, current migration trends have turned Chagas disease into a global epidemic. Acute infection is rarely severe and once it resolves, some patients can develop cardiomyopathy as part of the chronic form many years later. Multiple factors related with both the host and the parasite determine the susceptibility and progression to cardiomyopathy. Current imaging techniques are able to identify cardiac autonomic denervation, perfusion abnormalities, and myocardial fibrosis at an early of stage before the development of symptoms. The prognosis of patients with Chagasic cardiomyopathy remains poor and life-threatening ventricular arrhythmias can occur at an early stage. Treatment of chronic Chagas cardiomyopathy is challenging with a great need for more studies in the field.

Update on Chagas disease in Venezuela during the period 2003-2018. A review

The present article reviews the status of Chagas disease in Venezuela during the period 2003-2018, based on the detection of Trypanosoma cruzi-infection in 3,343 blood samples of individuals from rural localities and 182 patients referred from health centers to confirm presumptive clinical diagnostic. The study involved samples from 81 rural localities of 17 states located at different regions and ecological life zones of the country. Analysis by parasitological (fresh microscopic observation, hemoculture and Giemsa stained blood smears), serological (DAT, IFAT-polyvalent, IgM, IgG tests) and molecular (PCR) tests, revealed 10.7% seroprevalence and 42.8% T. cruzi-infection, in individuals from rural localities and referred patients, respectively. In both groups T. cruzi-infection was detected at any age, revealing active transmission in children under 10-years-old. Clinical profile detected in referred patients, showed significantly major number of symptoms in orally infected patients than in infected by vectorial route (P<0.01). Genetic characterization of T. cruzi isolates obtained from orally and vectorial transmitted acute Chagas disease in western Venezuela, revealed the circulation of DTUI and DTUIII in the former, and DTUI, DTUII and DTUIII in patients infected by vectorial route. DTUI predominated in both cases, and haplotype Ib was the most frequently found in this genotype. Statistical analysis of clinical profile - T. cruzi DTUs - transmission route relationships did not show association among these variables and, consequently, chagasic patient's clinical condition did not depend of T. cruzi genotype or its route of transmission. In addition, differences in clinical severity may be associated with host susceptibility and/or parasite load received by the human receptor in spite of the T. cruzi genotype itself. The epidemiological implications of the present findings are discussed, and the need for developing efficient tools as well as implementation of urgent and radical changes in the public health policy to control Chagas disease transmission in the Venezuelan territory are suggested.

Identification and Localization of the First Known Proteins of the Trypanosoma cruzi Cytostome Cytopharynx Endocytic Complex

The etiological agent of Chagas disease, Trypanosoma cruzi, is an obligate intracellular parasite that infects an estimated 7 million people in the Americas, with an at-risk population of 70 million. Despite its recognition as the highest impact parasitic infection of the Americas, Chagas disease continues to receive insufficient attention and resources in order to be effectively combatted. Unlike the other parasitic trypanosomatids that infect humans (Trypanosoma brucei and Leishmania spp.), T. cruzi retains an ancestral mode of phagotrophic feeding via an endocytic organelle known as the cytostome-cytopharynx complex (SPC). How this tubular invagination of the plasma membrane functions to bring in nutrients is poorly understood at a mechanistic level, partially due to a lack of knowledge of the protein machinery specifically targeted to this structure. Using a combination of CRISPR/Cas9 mediated endogenous tagging, fluorescently labeled overexpression constructs and endocytic assays, we have identified the first known SPC targeted protein (CP1). The CP1 labeled structure co-localizes with endocytosed protein and undergoes disassembly in infectious forms and reconstitution in replicative forms. Additionally, through the use of immunoprecipitation and mass spectrometry techniques, we have identified two additional CP1-associated proteins (CP2 and CP3) that also target to this endocytic organelle. Our localization studies using fluorescently tagged proteins and surface lectin staining have also allowed us, for the first time, to specifically define the location of the intriguing pre-oral ridge (POR) surface prominence at the SPC entrance through the use of super-resolution light microscopy. This work is a first glimpse into the proteome of the SPC and provides the tools for further characterization of this enigmatic endocytic organelle. A better understanding of how this deadly pathogen acquires nutrients from its host will potentially direct us toward new therapeutic targets to combat infection.

Translating Chagasic dilating cardiomyopathy to surgical therapies: An under published global challenge

Chagas disease is a neglected parasitic anthropozoonosis of the Americas linked to social deprivation with no hope of eradication in the future. Having been the most common non-ischemic cause of dilating cardiomyopathy in Latin America, it now spreads beyond the geographical boundaries of its vector via imported and autochthonous transmission. We review the evidence on surgery in Chagasic heart failure and offer a brief narrative on the main aspects of translational management. There is very limited literature on surgery for Chagasic heart failure, especially assist devices and transplantation. This may be attributed to the often unsurmountable economic burden of this single-system parasymphatholytic heart failure to young sufferers who commonly have very limited access to the aforementioned procedures. Chagasic heart failure offers a so far neglected translational model of parasymphatholytic non-ischemic cardiac failure.

Electrocardiography Abnormalities in Macaques after Infection with Encephalitic Alphaviruses

Eastern (EEEV) and Venezuelan (VEEV) equine encephalitis viruses (EEVs) are related, (+) ssRNA arboviruses that can cause severe, sometimes fatal, encephalitis in humans. EEVs are highly infectious when aerosolized, raising concerns for potential use as biological weapons. No licensed medical countermeasures exist; given the severity/rarity of natural EEV infections, efficacy studies require animal models. Cynomolgus macaques exposed to EEV aerosols develop fever, encephalitis, and other clinical signs similar to humans. Fever is nonspecific for encephalitis in macaques. Electrocardiography (ECG) metrics may predict onset, severity, or outcome of EEV-attributable disease. Macaques were implanted with thermometry/ECG radiotransmitters and exposed to aerosolized EEV. Data was collected continuously, and repeated-measures ANOVA and frequency-spectrum analyses identified differences between courses of illness and between pre-exposure and post-exposure states. EEEV-infected macaques manifested widened QRS-intervals in severely ill subjects post-exposure. Moreover, QT-intervals and RR-intervals decreased during the febrile period. VEEV-infected macaques suffered decreased QT-intervals and RR-intervals with fever onset. Frequency-spectrum analyses revealed differences in the fundamental frequencies of multiple metrics in the post-exposure and febrile periods compared to baseline and confirmed circadian dysfunction. Heart rate variability (HRV) analyses revealed diminished variability post-exposure. These analyses support using ECG data alongside fever and clinical laboratory findings for evaluating medical countermeasure efficacy.

Impact of Trypanosoma cruzi infection on nitric oxide synthase and arginase expression and activity in young and elderly mice

Elderly organisms are more susceptible to infectious diseases. However, the impact of aging on antiparasitic mechanisms, especially the nitric oxide pathway, is poorly understood. Using an integrated in vivo and in vitro model, we compared the severity of Trypanosoma cruzi infection in young and elderly (8 or 72 weeks old) mice. Forty C57BL/6 mice were randomized into four groups: Y-inf, young infected; Yn-inf, young uninfected; A-inf, aged infected; An-inf, aged uninfected. Parasitemia was measured daily, and animals were euthanized after 15 days of infection. Trypanosoma cruzi-induced inflammatory processes were analyzed in blood and heart samples, as well as in bone marrow-derived macrophages (BMDMs) co-cultured with splenocytes isolated from young or elderly mice. Our results indicated upregulated IgG2b and IL-17 production in elderly animals, which was not sufficient to reduce parasitemia, parasitic load and myocarditis to levels observed in young animals. The higher susceptibility of elderly mice to T. cruzi infection was accompanied by reduced cardiac inducible nitric oxide synthase (iNOS) gene expression, nitric oxide (NO) and IFN-γ levels, as well as an antagonistic upregulation of arginase-1 expression and arginase activity. The same responses were observed when BMDMs co-cultured with splenocytes from elderly mice were stimulated with T. cruzi antigens. Our findings indicate that elderly mice were more susceptible to T. cruzi infection, which was potentially related to an attenuated response to antigenic stimulation, inhibition of iNOS gene expression and NO production, and antagonistic upregulation of arginase gene expression and activity, which created favorable conditions for heart parasitism and myocarditis development.

Chronic Chagas cardiomyopathy: a therapeutic challenge and future strategies

Infectious diseases are the main cause of acquired dilated cardiomyopathy. This group of disorders shares in common inflammatory cell infiltrate and myocardial remodeling. As part of its pathophysiology, there is coronary microvascular dysfunction, distinct from that observed in coronary artery disease. Chagas cardiomyopathy presents several vascular characteristics that are similar to those presented in other acquired cardiomyopathies. There is convincing evidence of the microvascular involvement and the inflammatory processes that lead to endothelial activation and ischemic damage. Current therapy for the Chagas disease is limited, and it is proposed to combine it with other pharmacological strategies that modify critical physiopathological aspects beneficial for the clinical course of the Chagas cardiomyopathy.