Trypanosomiasis Clinical Presentation

  • Author: Robert W Tolan Jr, MD; Chief Editor: Russell W Steele, MD   more...
 
Updated: Apr 10, 2012
 

History

The early phase of trypanosomiasis is asymptomatic, and only about one third of patients have symptoms of acute Chagas disease. A small minority of patients have severe clinical disease, including heart failure or meningoencephalitis. As many as 10% of patients die in the early stage of severe myocarditis or meningoencephalitis. The vast majority of those who have clinical symptoms include infants, those who are rather defenseless in warding off the triatomid bite, and children aged 10 years or younger. However, the symptoms of the acute phase disappear within 4-8 weeks in most individuals.

The incubation period for Chagas disease is 1-2 weeks. Chronic manifestations do not appear for years after infection. The incubation period is longer (20-40 d) in transfusion-acquired disease.

Symptoms of parasitic infection and proliferation include the following:

  • The first symptom is a bug bite on the face. After 1-3 weeks, the organism proliferates, producing a red nodule known as a chagoma, which develops at the site of the original inoculation. The chagoma is usually located on the face or arms and can be painful. The surrounding skin becomes indurated and, later, hypopigmented.
  • A few days after proliferation, the parasites can spread throughout the body, infecting many tissues, particularly the heart, skeletal muscles, and nervous system. This spread heralds the acute phase of the illness. During this stage, the infected patient may develop a flulike illness. Initial symptoms include a high temperature, chills, headache, irritability, tiredness, anorexia, malaise, myalgias, lymphadenopathy, and splenomegaly. The fever can be continuous, intermittent, or remitting and may last as long as 5 weeks. Epistaxis is common in young children.
  • Cardiac symptoms are observed in almost all patients shortly after proliferation of the parasite begins.

In chronic disease, involvement of the GI system is common.

Symptoms include dysphagia, regurgitation, hiccups, constipation, and abdominal pain. Disturbances in swallowing are the most common manifestations. Symptoms may develop weeks to years after the initial infection and subsequent progression is typically slow.

Symptoms of esophageal involvement include dysphagia, regurgitation, heartburn, hiccups, odynophagia, and coughing. These symptoms generally develop insidiously. Less common symptoms of megaesophagus are severe malnutrition and aspiration with bronchitis and pneumonia.

Hypertrophy of the salivary glands, especially the parotids, is present in 25% of patients with chagasic megaesophagus. These patients have an excessive response to salivary stimuli and the increased volume of saliva can result in drooling.

Second to the esophagus, the colon is the most frequently affected portion of the GI tract in patients with chronic Chagas disease. The rectum and sigmoid colon are affected most often. The primary symptom is slowly progressive constipation. Most patients with megacolon have a bowel movement every 10 days. Impaction, caused by a firm mass of stool or a true fecaloma, develops in a significant minority of cases. Symptoms range from vague abdominal pain and rectal fullness to symptoms of large bowel distention. Other symptoms include obstipation and meteorism.

Megaduodenum is usually asymptomatic but can lead to nonspecific dyspepsia, prolonged nausea and vomiting, and, rarely, malnutrition.

Neurologic symptoms, with involvement of the central, peripheral, or autonomic nervous systems, are present in few patients. Symptoms include paresis, cerebellar disturbance, convulsions, alterations in the dorsal root ganglia, and polyneuritis.[17]

Next

Physical

If the bite occurs near the eye, unilateral periorbital edema of the eyelids, known as Romaña sign, develops. The edematous skin is violet, with conjunctivitis and enlargement of the ipsilateral preauricular lymph node. Unilateral ocular and facial edema that involves the ipsilateral preauricular lymph node is known as the oculoglandular syndrome. In a small number of infected individuals, the edema may be generalized and mistaken for nephrotic syndrome. The preauricular region can significantly swell, causing an initial impression of parotitis, such as that caused by the mumps virus.

The spleen and liver are palpable but, in general, are not greatly enlarged. The disease is often not recognized at this stage and is accurately diagnosed in only a minority of patients.

The younger the patient, the more severe the clinical manifestations. Occasionally, the illness is fatal, especially in children younger than 2 years. Generalized lymphadenopathy, moderate hepatosplenomegaly, anasarca, vomiting, and diarrhea, as well as signs of meningeal irritation, are common in infants. Skin lesions can vary from a generalized maculopapular or morbilliform rash to urticaria.

Tachycardia is present and may not be related to fever; rather, it may result from destruction of the heart's parasympathetic innervation. As many as 30% of patients have cardiovascular abnormalities, which include cardiac enlargement, functional murmurs, and conduction blocks. Evidence of myocarditis is almost always found. Myocarditis is mild in the vast majority of cases. Biventricular heart failure rarely develops. Death from acute myocarditis occurs in 2-3% of patients. The prognosis is poor with the early development of premature ventricular contractions, atrial fibrillation, heart block, or congestive heart failure.

Occasionally, meningoencephalitis can develop. This is more common in young infants and immunosuppressed patients. Death can occur in as many as 50% of these cases. Clinical manifestations include nuchal rigidity, convulsions, paralysis, and coma. Encephalitis can develop in patients who are immunosuppressed.[18]

The manifestations of the acute phase of Chagas disease generally last 2-4 weeks. In individuals who survive, the disease progresses to the indeterminate, or asymptomatic, phase. A low level of parasitemia is present. This phase can persist for years or even for the rest of the patient's life. As many as 30% of persons with disease in the indeterminate phase have cardiac, GI, or neurologic damage 10-20 years after infection. In other individuals, the illness progresses to the chronic phase.

The most serious aspect of Chagas disease is the delayed damage that it can inflict on the heart and GI system during the chronic phase. Serious sequelae consist of cardiomyopathy, heart failure, megaesophagus, and megacolon. Clinical manifestations can develop years after the initial acute infection.

Cardiac abnormalities are the most frequent manifestations of chronic Chagas disease and are the most serious causes of morbidity and mortality. Chagas cardiomyopathy develops in 30% of patients.

Congestive heart failure is the first sign of chagasic heart disease. Once heart failure occurs, it usually is intractable and difficult to control. Signs of right-sided heart failure are more common than signs of left-sided heart failure. Heart sounds may be distant, and functional murmurs of mitral and tricuspid insufficiency can develop. Other signs and symptoms include dyspnea upon exertion, peripheral edema, ascites, hepatomegaly, chest pain, and palpitations. If left ventricular failure is present, it usually causes mild symptoms.

Patients with cardiac abnormalities usually do not have acute pulmonary edema, and orthopnea is uncommon. The most important complications are systemic and pulmonary embolism and sudden death. Sudden death frequently occurs from a fatal dysrhythmia, such as ventricular fibrillation, or, less frequently, from a third-degree heart block or an embolism. In many advanced cases, the typical aneurysm develops at the apex of the left ventricle.

Predictors for poor prognosis include impaired left ventricular function, New York Heart Association class III/IV, cardiomegaly observed on radiographs, left ventricular systolic dysfunction observed on echocardiographs, nonsustained ventricular tachycardia on 24-hour Holter monitoring findings, low QRS voltage on electrocardiography findings, apical aneurysms, and male sex.

QT interval dispersion, a marker of inhomogeneous myocardial repolarization, has been shown to be an independent predictor of sudden cardiac death in patients with Chagas disease.

Abnormalities in the GI system are the second most common manifestation of chronic Chagas disease. These occur in 8-10% of patients and vary from minor changes in motility to severe dilatation of the esophagus or colon.

Esophageal disease is the most common cause of symptoms in chronic disease. Most patients have symptoms when they are aged 20-40 years, and the rate of progression widely varies.

Less commonly involved organs include the duodenum; stomach; small intestine; and, rarely, the gallbladder and biliary tree. Involvement of the stomach leads to hypotonia; hypoperistalsis; delayed emptying and decreased acid secretion; and, rarely, dilatation. Abdominal examinations reveal abdominal distention and tympanism.

Immunosuppression as a result of organ transplantation or human immunodeficiency virus (HIV) infection can lead to reactivation of the infection. Severe myocarditis and neurologic disease with brain abscesses, meningoencephalitis, and seizures caused by T cruzi have been major findings in patients infected with HIV.

Intrauterine infection can cause spontaneous abortion or premature delivery. In its acute stage, congenital Chagas disease often resembles the acquired disease. The onset might be at birth or a few months later.[19]

The infant has a low birth weight, hepatosplenomegaly, jaundice, anemia, fever, edema, and meningoencephalitis with convulsions, hypotonia, hyporeflexia, and tremors. Some patients have metastatic hemorrhagic chagomas in the skin or mucous membranes. Intracranial calcifications and ocular lesions have been described. Cardiac involvement is rare. GI abnormalities from megaesophagus present as dysphagia and cause death by aspiration.

Death frequently occurs within the first few weeks of life. Those who survive have severe neurologic sequelae with mental deficiency or behavioral and learning disabilities.

The differential diagnosis of intrauterine infection includes erythroblastosis fetalis, congenital toxoplasmosis, cytomegalovirus, parvovirus B19, lymphocytic choriomeningitis virus, and herpes simplex infections. A positive serologic result for specific immunoglobulin G (IgG) at 6-12 months is an indication for treatment.

Transmission of this infection through infected mother's milk has been observed in breastfed babies.

Rare findings ascribed to Chagas disease include bronchiectasia, hemosiderosis, and dilatation of the ureter or urinary bladder.

Previous
Next

Causes

T cruzi, a protozoan hemoflagellate, causes American trypanosomiasis. T cruzi belongs to the order Kinetoplastida, suborder Trypanosomatina, genus Trypanosoma, and subgenus Schizotrypanum.

These organisms undergo an obligatory developmental and reproductive cycle in the alimentary tract of a reduviid or triatomine insect. The reduviid or triatomine insects commonly are called assassins, cone-nose, or kissing bugs because of their predilection for biting the victim's face while he or she is sleeping.

The insects are large (2-3 cm in length), obligate hematophages that hide in crevices in mud walls, windows, door frames, and dark corners of poorly constructed adobe-style huts. These insects come out at night to feed on the blood of sleeping humans. They require blood to grow and mature.

The vector (ie, reduviid or triatomine insect) becomes infected by ingesting trypomastigotes present in the bloodstream of an infected mammal. Infection lasts for the life of the vector, which can be as long as 2 years.

The developmental cycle of T cruzi includes 3 morphologic forms: amastigotes, trypomastigotes, and epimastigotes. The entire cycle takes place in the insect gut lumen over 6-15 days.

Within a few hours after the ingestion of infected blood, short, spindle-shaped forms lacking a free flagellum can be found in the insect's foregut. These develop into small epimastigote forms that divide and elongate, resulting in large (35-40 µm long) epimastigotes. By the third or fourth day, these organisms attach to the rectal epithelium.

By the fifth day, the epimastigotes become rounded, short trypomastigotes, which then elongate.

By the seventh and eighth days, they become infective metacyclic trypomastigotes that are long (17-22 µm), slender, and spindle shaped. They have a large kinetoplast posterior to the nucleus and a flagellum. Each microliter of insect excreta may contain 3000-4000 organisms.

Human transmission occurs through contact with infected insect excreta. These insects defecate while ingesting human blood, thereby excreting the infective trypanosomes. The person who is bitten is inoculated by inadvertently rubbing the insect's feces into the site of the bite. The organism can also enter through abraded skin or intact mucous membranes of the mouth, nose, and conjunctiva.

T cruzi invades cells near the inoculum. Once inside the cell, the infective metacyclic trypomastigote moves from the digestive vacuole to the cytosol. Next, they transform into intracellular amastigote forms and multiply by binary fission.

The amastigotes have a short flagellum and are spherical or oval and 2-4 µm in diameter. After a period of multiplication, amastigotes transform back into trypomastigotes; rupture the cell; enter the bloodstream; and invade other cells, predominantly reticuloendothelial, cardiac, skeletal and smooth muscle, and neuroglial cells.

The parasites are transmitted through the feces of the insects of the triatomid or reduviid families. Natural infection occurs in a wide variety of animals, including guinea pigs, opossums, foxes, squirrels, armadillos, anteaters, porcupines, rats, mice, bats, and monkeys. After humans, birds are the most important blood sources; however, birds are not susceptible to infection. Domestic cats and dogs are the most important domestic reservoirs for human infection.

The parasite can be congenitally transmitted[20, 21] or transmitted through organ transplantation[22] , via infected breast milk, by blood transfusion, or accidentally in the laboratory. As much as 1.9-6.5% of the blood in some blood banks in Latin America is contaminated by T cruzi. In highly endemic areas, this figure can be as high as 20%. Transplacental transmission occurs in 2-10.5% of infected mothers.[23]

The parasite can be transmitted orally.[24, 25, 26, 27]

  • Ingestion of food contaminated by triatomine feces or entire insects
  • Consumption of raw or undercooked blood and/or meat of reservoir hosts
  • Eating food contaminated by the anal gland secretions of the common opossum
Previous
Proceed to Differential Diagnoses
 
 
Contributor Information and Disclosures
Author

Robert W Tolan Jr, MD  Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine

Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility

Disclosure: Novartis Honoraria Speaking and teaching

Coauthor(s)

Antonio Muñiz, MD  Professor of Emergency Medicine and Pediatrics, University of Texas Medical School at Houston; Medical Director of the Pediatric Emergency Department, Children's Memorial Hermann Hospital

Antonio Muñiz, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, American College of Emergency Physicians, American Heart Association, American Medical Association, Society for Academic Emergency Medicine, and Southern Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Ashir Kumar, MD, MBBS, FAAP  Professor Emeritus, Department of Pediatrics and Human Development, Michigan State University College of Human Medicine

Ashir Kumar, MD, MBBS, FAAP is a member of the following medical societies: American Association of Physicians of Indian Origin and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Leslie L Barton, MD  Professor Emerita of Pediatrics, University of Arizona College of Medicine

Leslie L Barton, MD is a member of the following medical societies: American Academy of Pediatrics, Association of Pediatric Program Directors, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Daniel Rauch, MD, FAAP  Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine

Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine

Disclosure: Baxter Honoraria Consulting

Chief Editor

Russell W Steele, MD  Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association

Disclosure: Nothing to disclose.

References

  1. Lescure FX, Le Loup G, Freilij H, Develoux M, Paris L, Brutus L, et al. Chagas disease: changes in knowledge and management. Lancet Infect Dis. Aug 2010;10(8):556-70. [Medline].

  2. Verma A, Manchanda S, Kumar N, Sharma A, Goel M, Banerjee PS. Trypanosoma lewisi or T. lewisi-like Infection in a 37-Day-Old Indian Infant. Am J Trop Med Hyg. Aug 2011;85(2):221-4. [Medline].

  3. Teixeira AR, Hecht MM, Guimaro MC, Sousa AO, Nitz N. Pathogenesis of chagas' disease: parasite persistence and autoimmunity. Clin Microbiol Rev. Jul 2011;24(3):592-630. [Medline].

  4. Hanford EJ, Zhan FB, Lu Y, et al. Chagas disease in Texas: recognizing the significance and implications of evidence in the literature. Social Sci Med. Jul 2007;65(1):60-79. [Medline].

  5. Hwang WS, Zhang G, Maslov D, Weirauch C. Infection rates of Triatoma protracta (Uhler) with Trypanosoma cruzi in Southern California and molecular identification of trypanosomes. Am J Trop Med Hyg. Nov 2010;83(5):1020-2. [Medline].

  6. Dorn PL, Perniciaro L, Yabsley MJ, Roellig DM, Balsamo G, Diaz J. Autochthonous transmission of Trypanosoma cruzi, Louisiana. Emerg Infect Dis. Apr 2007;13(4):605-7. [Medline].

  7. [Best Evidence] Bern C, Kjos S, Yabsley MJ, Montgomery SP. Trypanosoma cruzi and Chagas' Disease in the United States. Clin Microbiol Rev. Oct 2011;24(4):655-81. [Medline].

  8. Bern C, Montgomery SP. An Estimate of the Burden of Chagas Disease in the United States. Clin Infect Dis. Jul 29 2009;49:e52-4. [Medline].

  9. Yadon ZE, Schmunis GA. Congenital Chagas disease: estimating the potential risk in the United States. Am J Trop Med Hyg. Dec 2009;81(6):927-33. [Medline].

  10. Reisenman CE, Lawrence G, Guerenstein PG, Gregory T, Dotson E, Hildebrand JG. Infection of Kissing Bugs with Trypanosoma cruzi, Tucson, Arizona, USA. Emerg Infect Dis. Mar 2010;16(3):400-5. [Medline].

  11. Reisenman CE, Gregory T, Guerenstein PG, Hildebrand JG. Feeding and Defecation Behavior of Triatoma rubida (Uhler, 1894) (Hemiptera: Reduviidae) under Laboratory Conditions, and Its Potential Role as a Vector of Chagas Disease in Arizona, USA. Am J Trop Med Hyg. Oct 2011;85(4):648-56. [Medline].

  12. Stevens L, Dorn PL, Hobson J, de la Rua NM, Lucero DE, Klotz JH, et al. Vector blood meals and chagas disease transmission potential, United States. Emerg Infect Dis. Apr 2012;18(4):646-9. [Medline].

  13. Salazar-Schettino PM, Perera R, Ruiz-Hernandez AL, Bucio Torres MI, Zamora-Gonzalez C, Cabrera-Bravo M. Chagas disease as a cause of symptomatic chronic myocardopathy in mexican children. Pediatr Infect Dis J. Nov 2009;28(11):1011-3. [Medline].

  14. Ramos-Ligonio A, Lopez-Monteon A, Guzman-Gomez D, et al. Identification of a hyperendemic area for Trypanosoma cruzi infection in central Veracruz, Mexico. Am J Trop Med Hyg. Jul 2010;83(1):164-70. [Medline].

  15. del Puerto R, Nishizawa JE, Kikuchi M, et al. Lineage analysis of circulating Trypanosoma cruzi parasites and their association with clinical forms of Chagas disease in Bolivia. PLoS Negl Trop Dis. May 18 2010;4(5):e687. [Medline]. [Full Text].

  16. Anez N, Crisante G, Rojas A. Update on Chagas disease in Venezuela--a review. Mem Inst Oswaldo Cruz. Dec 2004;99(8):781-7. [Medline].

  17. Cordova E, Maiolo E, Corti M, Orduna T. Neurological manifestations of Chagas' disease. Neurol Res. Apr 2010;32(3):238-44. [Medline].

  18. Diazgranados CA, Saavedra-Trujillo CH, Mantilla M, Valderrama SL, Alquichire C, Franco-Paredes C. Chagasic encephalitis in HIV patients: common presentation of an evolving epidemiological and clinical association. Lancet Infect Dis. May 2009;9(5):324-30. [Medline].

  19. Muñoz J, Coll O, Juncosa T, Vergés M, del Pino M, Fumado V. Prevalence and vertical transmission of Trypanosoma cruzi infection among pregnant Latin American women attending 2 maternity clinics in Barcelona, Spain. Clin Infect Dis. Jun 15 2009;48(12):1736-40. [Medline].

  20. Oliveira I, Torrico F, Munoz J, Gascon J. Congenital transmission of Chagas disease: a clinical approach. Expert Rev Anti Infect Ther. Aug 2010;8(8):945-56. [Medline].

  21. De Rissio AM, Riarte AR, García MM, Esteva MI, Quaglino M, Ruiz AM. Congenital Trypanosoma cruzi infection. Efficacy of its monitoring in an urban reference health center in a non-endemic area of Argentina. Am J Trop Med Hyg. May 2010;82(5):838-45. [Medline].

  22. Kun H, Moore A, Mascola L, Steurer F, Lawrence G, Kubak B. Transmission of Trypanosoma cruzi by heart transplantation. Clin Infect Dis. Jun 1 2009;48(11):1534-40. [Medline].

  23. Brutus L, Castillo H, Bernal C, Salas NA, Schneider D, Santalla JA, et al. Detectable Trypanosoma cruzi parasitemia during pregnancy and delivery as a risk factor for congenital Chagas disease. Am J Trop Med Hyg. Nov 2010;83(5):1044-7. [Medline]. [Full Text].

  24. Bastos CJ, Aras R, Mota G, et al. Clinical outcomes of thirteen patients with acute chagas disease acquired through oral transmission from two urban outbreaks in northeastern Brazil. PLoS Negl Trop Dis. Jun 15 2010;4(6):e711. [Medline]. [Full Text].

  25. Miles MA. Orally acquired Chagas disease: lessons from an urban school outbreak. J Infect Dis. May 1 2010;201(9):1282-4. [Medline].

  26. Alarcón de Noya B, Díaz-Bello Z, Colmenares C, Ruiz-Guevara R, Mauriello L, Zavala-Jaspe R, et al. Large urban outbreak of orally acquired acute Chagas disease at a school in Caracas, Venezuela. J Infect Dis. May 1 2010;201(9):1308-15. [Medline].

  27. [Best Evidence] Shikanai-Yasuda MA, Carvalho NB. Oral transmission of chagas disease. Clin Infect Dis. Mar 2012;54(6):845-52. [Medline].

  28. Rosenblatt JE. Laboratory diagnosis of infections due to blood and tissue parasites. Clin Infect Dis. Oct 1 2009;49(7):1103-8. [Medline].

  29. Riera C, Verges M, Iniesta L, Fisa R, Gállego M, Tebar S, et al. Identification of a Western Blot Pattern for the Specific Diagnosis of Trypanosoma cruzi Infection in Human Sera. Am J Trop Med Hyg. Mar 2012;86(3):412-6. [Medline].

  30. Avila HA, Pereira JB, Thiemann O, et al. Detection of Trypanosoma cruzi in blood specimens of chronic chagasic patients by polymerase chain reaction amplification of kinetoplast minicircle DNA: comparison with serology and xenodiagnosis. J Clin Microbiol. Sep 1993;31(9):2421-6. [Medline]. [Full Text].

  31. Avila HA, Sigman DS, Cohen LM, et al. Polymerase chain reaction amplification of Trypanosoma cruzi kinetoplast minicircle DNA isolated from whole blood lysates: diagnosis of chronic Chagas' disease. Mol Biochem Parasitol. Oct 1991;48(2):211-21. [Medline].

  32. Bern C, Verastegui M, Gilman RH, Lafuente C, Galdos-Cardenas G, Calderon M, et al. Congenital Trypanosoma cruzi transmission in Santa Cruz, Bolivia. Clin Infect Dis. Dec 1 2009;49(11):1667-74. [Medline].

  33. Russomando G, Sanchez Z, Meza G, de Guillen Y. Shed acute-phase antigen protein in an ELISA system for unequivocal diagnosis of congenital Chagas disease. Expert Rev Mol Diagn. Sep 2010;10(6):705-7. [Medline].

  34. Mallimaci MC, Sosa-Estani S, Russomando G, Sanchez Z, Sijvarger C, Alvarez IM. Early diagnosis of congenital Trypanosoma cruzi infection, using shed acute phase antigen, in Ushuaia, Tierra del Fuego, Argentina. Am J Trop Med Hyg. Jan 2010;82(1):55-9. [Medline].

  35. Barbosa MM, P. Nunes Mdo Carmo, Ribeiro AL, et al. N-terminal proBNP levels in patients with Chagas disease: a marker of systolic and dyastolic dysfunction of the left ventricle. Eur J Echocardiography. Jun 2007;8(3):204-12. [Medline].

  36. Ndao M, Spithill TW, Caffrey R, et al. Identification of novel diagnostic serum biomarkers for Chagas' disease in asymptomatic subjects by mass spectrometric profiling. J Clin Microbiol. Apr 2010;48(4):1139-49. [Medline]. [Full Text].

  37. Acquatella H. Echocardiography in Chagas heart disease. Circulation. Mar 6 2007;115(9):1124-31. [Medline].

  38. Corbucci HA, Haber DM, Bestetti RB, Cordeiro JA, Fioroni ML. QT interval dispersion in patients with chronic heart failure secondary to Chagas' cardiomyopathy: correlation with clinical variables of prognostic significance. Cardiovasc Pathol. Jan-Feb 2006;15(1):18-23. [Medline].

  39. Bowman NM, Kawai V, Gilman RH, et al. Autonomic Dysfunction and Risk Factors Associated with Trypanosoma cruzi Infection among Children in Arequipa, Peru. Am J Trop Med Hyg. Jan 2011;84(1):85-90. [Medline]. [Full Text].

  40. Altcheh J, Moscatelli G, Moroni S, Garcia-Bournissen F, Freilij H. Adverse Events After the Use of Benznidazole in Infants and Children With Chagas Disease. Pediatrics. Dec 20 2010;[Medline].

  41. Bustamante JM, Lo Presti MS, Rivarola HW, et al. Treatment with benzidazole or thioridazine in the chronic phase of experimental Chagas disease improves cardiopathy. Int J Antimicrob Agents. Jun 2007;29(6):733-737. [Medline].

  42. de Andrade AL, Zicker F, de Oliveira RM, et al. Randomised trial of efficacy of benznidazole in treatment of early Trypanosoma cruzi infection. Lancet. Nov 23 1996;348(9039):1407-13. [Medline].

  43. Laucella SA, Mazliah DP, Bertocchi G, Alvarez MG, Cooley G, Viotti R. Changes in Trypanosoma cruzi-specific immune responses after treatment: surrogate markers of treatment efficacy. Clin Infect Dis. Dec 1 2009;49(11):1675-84. [Medline].

  44. Pinazo MJ, Espinosa G, Gállego M, López-Chejade PL, Urbina JA, Gascón J. Successful treatment with posaconazole of a patient with chronic chagas disease and systemic lupus erythematosus. Am J Trop Med Hyg. Apr 2010;82(4):583-7. [Medline].

  45. Bern C, Montgomery SP, Katz L, Caglioti S, Stramer SL. Chagas disease and the US blood supply. Curr Opin Infect Dis. Oct 2008;21(5):476-82. [Medline].

  46. Le Loup G, Pialoux G, Lescure FX. Update in treatment of Chagas disease. Curr Opin Infect Dis. Oct 2011;24(5):428-34. [Medline].

  47. Guedes PM, Silva GK, Gutierrez FR, Silva JS. Current status of Chagas disease chemotherapy. Expert Rev Anti Infect Ther. May 2011;9(5):609-20. [Medline].

  48. Bern C. Antitrypanosomal therapy for chronic Chagas' disease. N Engl J Med. Jun 30 2011;364(26):2527-34. [Medline].

  49. Murcia L, Carrilero B, Munoz MJ, Iborra MA, Segovia M. Usefulness of PCR for monitoring benznidazole response in patients with chronic Chagas' disease: a prospective study in a non-disease-endemic country. J Antimicrob Chemother. Aug 2010;65(8):1759-64. [Medline].

  50. Gallerano RH, Marr JJ, Sosa RR. Therapeutic efficacy of allopurinol in patients with chronic Chagas' disease. Am J Trop Med Hyg. Aug 1990;43(2):159-66. [Medline].

  51. Apt W, Arribada A, Zulantay I, et al. Itraconazole or allopurinol in the treatment of chronic American trypanosomiasis: the result of clinical and parasitological examinations 11 years post-treatment. Ann Trop Med Parasitol. Dec 2005;99(8):733-41. [Medline].

  52. Lo Presti MS, Rivarola HW, Bustamante JM, et al. Thioridazine treatment prevents cardiomyopathy in Trypanosoma cruzi mice. Int J Antimicrob Agents. Jun 2004;23(6):634-636. [Medline].

  53. Lee BY, Bacon KM, Connor DL, Willig AM, Bailey RR. The potential economic value of a Trypanosoma cruzi (Chagas disease) vaccine in Latin America. PLoS Negl Trop Dis. Dec 14 2010;4(12):e916. [Medline]. [Full Text].

  54. Burgos JM, Diez M, Vigliano C, Bisio M, Risso M, Duffy T. Molecular identification of Trypanosoma cruzi discrete typing units in end-stage chronic Chagas heart disease and reactivation after heart transplantation. Clin Infect Dis. Sep 1 2010;51(5):485-95. [Medline].

  55. Trindade M, Carvalho NB, Belfort EC, Pagliari C, Gakiya E, Sakai-Valente NY. A patient with erythema nodosus leprosum and Chagas cardiopathy: challenges in patient management and review of the literature. Am J Trop Med Hyg. Jun 2011;84(6):973-7. [Medline].

  56. Brutus L, Ernould JC, Postigo J, Romero M, Schneider D, Santalla JA. Influence of pregnancy on Trypanosoma cruzi parasitemia in chronically infected women in a rural Bolivian community. Am J Trop Med Hyg. May 2011;84(5):808-12. [Medline]. [Full Text].

  57. Verani JR, Montgomery SP, Schulkin J, Anderson B, Jones JL. Survey of obstetrician-gynecologists in the United States about Chagas disease. Am J Trop Med Hyg. Oct 2010;83(4):891-5. [Medline]. [Full Text].

  58. Acosta Rodriguez EV, Zuniga EI, Montes CL, et al. Trypanosoma cruzi infection beats the B-cell compartment favouring parasite establishment: can we strike first?. Scand J Immunol. Aug-Sep 2007;66(2-3):137-42. [Medline].

  59. Alter HJ, Stramer SL, Dodd RY. Emerging infectious diseases that threaten the blood supply. Semin Hematol. Jan 2007;44(1):32-41. [Medline].

  60. American Academy of Pediatrics. American Trypanosomiasis (Chagas Disease). In: Red Book: 2009 Report of the Committee on Infectious Diseases. 28th. Elk Grove Village, IL: American Academy of Pediatrics; 2009:678-9.

  61. Araújo CA, Waniek PJ, Jansen AM. An overview of Chagas disease and the role of triatomines on its distribution in Brazil. Vector Borne Zoonotic Dis. Jun 2009;9(3):227-34. [Medline].

  62. Trypanosomiasis, American. In: Spector JM, Gibson TE. Atlas of Pediatrics in the Tropics and Resource-Limited Settings. Elk Grove Village, IL: American Academy of Pediatrics; 2009:277-280.

  63. Barbosa B. Noninvasive prognostic markers for cardiac death and ventricular arrhythmia in long-term follow-up of subjects with chronic Chagas' disease. Braz J Med Biol Res. 40(2);2007 Feb:167-178. [Medline].

  64. Barratt JL, Harkness J, Marriott D, Ellis JT, Stark D. Importance of nonenteric protozoan infections in immunocompromised people. Clin Microbiol Rev. Oct 2010;23(4):795-836. [Medline]. [Full Text].

  65. Barrett MP. Potential new drugs for human African trypanosomiasis: some progress at last. Curr Opin Infect Dis. Dec 2010;23(6):603-8. [Medline].

  66. [Best Evidence] Bern C, Montgomery SP, Herwaldt BL, et al. Evaluation and treatment of chagas disease in the United States: a systematic review. JAMA. Nov 14 2007;298(18):2171-81. [Medline].

  67. Bittencourt AL. Congenital Chagas disease. Am J Dis Child. Jan 1976;130(1):97-103. [Medline].

  68. Black CL, Ocaña-Mayorga S, Riner DK, Costales JA, Lascano MS, Arcos-Terán L, et al. Seroprevalence of Trypanosoma cruzi in rural Ecuador and clustering of seropositivity within households. Am J Trop Med Hyg. Dec 2009;81(6):1035-40. [Medline].

  69. Blood donor screening for chagas disease--United States, 2006-2007. MMWR Morb Mortal Wkly Rep. Feb 23 2007;56(7):141-3. [Medline].

  70. Bocchi EA, Bellotti G, Mocelin AO, et al. Heart transplantation for chronic Chagas' heart disease. Ann Thorac Surg. Jun 1996;61(6):1727-33. [Medline].

  71. Brun R, Balmer O. New developments in human African trypanosomiasis. Curr Opin Infect Dis. Oct 2006;19(5):415-20. [Medline].

  72. Buckner FS, Navabi N. Advances in Chagas disease drug development: 2009-2010. Curr Opin Infect Dis. Dec 2010;23(6):609-16. [Medline].

  73. Burgos JM, Altcheh J, Petrucelli N, Bisio M, Levin MJ, Freilij H, et al. Molecular diagnosis and treatment monitoring of congenital transmission of Trypanosoma cruzi to twins of a triplet delivery. Diagn Microbiol Infect Dis. Sep 2009;65(1):58-61. [Medline].

  74. Caballero ZC, Sousa OE, Marques WP, Saez-Alquezar A, Umezawa ES. Evaluation of serological tests to identify Trypanosoma cruzi infection in humans and determine cross-reactivity with Trypanosoma rangeli and Leishmania spp. Clin Vaccine Immunol. Aug 2007;14(8):1045-9. [Medline].

  75. Calzada JE, Beraún Y, González CI, Martín J. Transforming growth factor beta 1 (TGFbeta1) gene polymorphisms and Chagas disease susceptibility in Peruvian and Colombian patients. Cytokine. Mar 2009;45(3):149-53. [Medline].

  76. Carod-Artal FJ, Horan TA, Vargas AP, Ribeiro LS, Mamare EM. Cardioembolic stroke and ischemic small bowel infarction in a Chagas' disease patient. Eur J Neurol. May 2007;14(5):e8. [Medline].

  77. Castro JA, de Mecca MM, Bartel LC. Toxic side effects of drugs used to treat Chagas' disease (American Trypanosomiasis). Hum Exp Toxicol. Aug 2006;25(8):471-79. [Medline].

  78. Chagas' disease--an epidemic that can no longer be ignored. Lancet. Aug 19 2006;368(9536):619. [Medline].

  79. Crema E, Ribeiro LB, Terra JA Jr, Silva AA. Laparoscopic transhiatal subtotal esophagectomy for the treatment of advanced megaesophagus. Ann Thorac Surg. Oct 2005;80(4):1196-201. [Medline].

  80. Cui M, McCooeye MA, Fraser C, Mester Z. Quantitation of lysergic acid diethylamide in urine using atmospheric pressure matrix-assisted laser desorption/ionization ion trap mass spectrometry. Anal Chem. Dec 1 2004;76(23):7143-8. [Medline].

  81. D'Avila H, Freire-de-Lima CG, Roque NR, Teixeira L, Barja-Fidalgo C, Silva AR, et al. Host Cell Lipid Bodies Triggered by Trypanosoma cruzi Infection and Enhanced by the Uptake of Apoptotic Cells Are Associated With Prostaglandin E2 Generation and Increased Parasite Growth. J Infect Dis. Sep 2011;204(6):951-61. [Medline].

  82. da Silveira AB, Lemos EM, Adad SJ, et al. Megacolon in Chagas disease: a study of inflammatory cells, enteric nerves, and glial cells. Hum Pathol. May 7 2007;[Medline].

  83. de Melo-Jorge M, PereiraPerrin M. The Chagas' disease parasite Trypanosoma cruzi exploits nerve growth factor receptor TrkA to infect mammalian hosts. Cell Host Microbe. Jun 14 2007;1(4):251-61. [Medline].

  84. de Oliveira RB, Troncon LE, Dantas RO, Menghelli UG. Gastrointestinal manifestations of Chagas' disease. Am J Gastroenterol. Jun 1998;93(6):884-9. [Medline].

  85. de Souza W. Chagas' disease: facts and reality. Microbes Infect. Apr 2007;9(4):544-5. [Medline].

  86. Delgado S, Castillo Neyra R, Quispe Machaca VR, Ancca Juárez J, Chou Chu L, Verastegui MR, et al. A history of chagas disease transmission, control, and re-emergence in peri-rural La Joya, Peru. PLoS Negl Trop Dis. Feb 22 2011;5(2):e970. [Medline]. [Full Text].

  87. Docampo R, Moreno SN, Cruz FS. Enhancement of the cytotoxicity of crystal violet against Trypanosoma cruzi in the blood by ascorbate. Mol Biochem Parasitol. Jan 15 1988;27(2-3):241-7. [Medline].

  88. Dutra WO, Rocha MO, Teixeira MM. The clinical immunology of human Chagas disease. Trends Parasitol. Dec 2005;21(12):581-7. [Medline].

  89. Fabbro DL, Olivera V, Bizai ML, Denner S, Diez C, Mancipar I. Humoral immune response against P2ß from Trypanosoma cruzi in persons with chronic Chagas disease: its relationship with treatment against parasites and myocardial damage. Am J Trop Med Hyg. Apr 2011;84(4):575-80. [Medline].

  90. Fabbro DL, Streiger ML, Arias ED, et al. Trypanocide treatment among adults with chronic Chagas disease living in Santa Fe (Argentina), over a mean follow-up of 21 years: parasitological, serological and clinical evaluation. Rev Soc Bras Med Trop. Jan-Feb 2007;40(1):1-10. [Medline].

  91. Ferreira MS, Nishioka Sde A, Rocha A, et al. Acute fatal Trypanosoma cruzi meningoencephalitis in a human immunodeficiency virus-positive hemophiliac patient. Am J Trop Med Hyg. Dec 1991;45(6):723-7. [Medline].

  92. Ferreira MS, Nishioka Sde A, Silvestre MT, et al. Reactivation of Chagas' disease in patients with AIDS: report of three new cases and review of the literature. Clin Infect Dis. Dec 1997;25(6):1397-400. [Medline].

  93. Flores-Chavez M, Bosseno MF, Bastrenta B, et al. Polymerase chain reaction detection and serologic follow-up after treatment with benznidazole in Bolivian children infected with a natural mixture of Trypanosoma cruzi I and II. Am J Trop Med Hyg. Sep 2006;75(3):497-501. [Medline].

  94. Flores-Chavez M, Fernandez B, Puente S, Torres P, Rodríguez M, Monedero C. Transfusional chagas disease: parasitological and serological monitoring of an infected recipient and blood donor. Clin Infect Dis. Mar 1 2008;46(5):e44-7. [Medline].

  95. Fraser B. Controlling Chagas' disease in urban Peru. Lancet. Jul 5 2008;372(9632):16-7. [Medline].

  96. Garg N, Bhatia V. Current status and future prospects for a vaccine against American trypanosomiasis. Expert Rev Vaccines. Dec 2005;4(6):867-80. [Medline].

  97. Gottdenker NL, Calzada JE, Saldana A, Carroll CR. Association of Anthropogenic Land Use Change and Increased Abundance of the Chagas Disease Vector Rhodnius pallescens in a Rural Landscape of Panama. Am J Trop Med Hyg. Jan 2011;84(1):70-7. [Medline].

  98. Grant IH, Gold JW, Wittner M, et al. Transfusion-associated acute Chagas disease acquired in the United States. Ann Intern Med. Nov 15 1989;111(10):849-51. [Medline].

  99. Gurtler RE, Kitron U, Cecere MC, Segura EL, Cohen JE. Sustainable vector control and management of Chagas disease in the Gran Chaco, Argentina. Proc Natl Acad Sci U S A. Oct 9 2007;104(41):16194-9. [Medline].

  100. Gurtler RE, Kitron U, Cecere MC, Segura EL, Cohen JE. Sustainable vector control and management of Chagas disease in the Gran Chaco, Argentina. Proc Natl Acad Sci U S A. Oct 9 2007;104(41):16194-9. [Medline].

  101. Guzman-Bracho C. Epidemiology of Chagas disease in Mexico: an update. Trends Parasitol. Aug 2001;17(8):372-6. [Medline].

  102. Hagar JM, Rahimtoola SH. Chagas' heart disease in the United States. N Engl J Med. Sep 12 1991;325(11):763-8. [Medline].

  103. Heringer-Walther S, Moreira MC, Wessel N, et al. Brain natriuretic peptide predicts survival in Chagas' disease more effectively than atrial natriuretic peptide. Heart. Mar 2005;91(3):385-7. [Medline].

  104. Hermann E, Alonso-Vega C, Berthe A, et al. Human congenital infection with Trypanosoma cruzi induces phenotypic and functional modifications of cord blood NK cells. Pediatr Res. Jul 2006;60(1):38-43. [Medline].

  105. Hidron A, Vogenthaler N, Santos-Preciado JI, Rodriguez-Morales AJ, Franco-Paredes C, Rassi A Jr. Cardiac involvement with parasitic infections. Clin Microbiol Rev. Apr 2010;23(2):324-49. [Medline].

  106. Jardim E, Takayanagui OM. Chagasic meningoencephalitis with detection of Trypanosoma cruzi in the cerebrospinal fluid of an immunodepressed patient. J Trop Med Hyg. Dec 1994;97(6):367-70. [Medline].

  107. Kirchhoff LV. American trypanosomiasis (Chagas' disease)--a tropical disease now in the United States. N Engl J Med. Aug 26 1993;329(9):639-44. [Medline].

  108. Lewis MD, Ma J, Yeo M, Carrasco HJ, Llewellyn MS, Miles MA. Genotyping of Trypanosoma cruzi: systematic selection of assays allowing rapid and accurate discrimination of all known lineages. Am J Trop Med Hyg. Dec 2009;81(6):1041-9. [Medline].

  109. Lopes MF, Guillermo LV, Silva EM. Decoding caspase signaling in host immunity to the protozoan Trypanosoma cruzi. Trends Immunol. Aug 2007;28(8):366-72. [Medline].

  110. Lowichik A, Ruff AJ. Parasitic infections of the central nervous system in children. Part II: Disseminated infections. J Child Neurol. Mar 1995;10(2):77-87. [Medline].

  111. Lowichik A, Siegel JD. Parasitic infections of the central nervous system in children. Part I: Congenital infections and meningoencephalitis. J Child Neurol. Mar 1995;10(1):4-17. [Medline].

  112. Marin-Neto JA, Cunha-Neto E, Maciel BC, Simoes MV. Pathogenesis of chronic Chagas heart disease. Circulation. Mar 6 2007;115(9):1109-23. [Medline].

  113. Medina-Torres I, Vázquez-Chagoyán JC, Rodríguez-Vivas RI, de Oca-Jiménez RM. Risk factors associated with triatomines and its infection with Trypanosoma cruzi in rural communities from the southern region of the State of Mexico, Mexico. Am J Trop Med Hyg. Jan 2010;82(1):49-54. [Medline].

  114. Melo L, Caldas IS, Azevedo MA, Gonçalves KR, da Silva do Nascimento AF, Figueiredo VP. Low Doses of Simvastatin Therapy Ameliorate Cardiac Inflammatory Remodeling in Trypanosoma cruzi-Infected Dogs. Am J Trop Med Hyg. Feb 2011;84(2):325-31. [Medline].

  115. Meneghelli UG. Chagasic enteropathy. Rev Soc Bras Med Trop. May-Jun 2004;37(3):252-60. [Medline].

  116. Miles MA, Feliciangeli MD, de Arias AR. American trypanosomiasis (Chagas' disease) and the role of molecular epidemiology in guiding control strategies. BMJ. Jun 28 2003;326(7404):1444-8. [Medline]. [Full Text].

  117. Moncayo A, Ortiz Yanine MI. An update on Chagas disease (human American trypanosomiasis). Ann Trop Med Parasitol. Dec 2006;100(8):663-77. [Medline].

  118. Moon TD, Oberhelman RA. Antiparasitic therapy in children. Pediatr Clin North Am. Jun 2005;52(3):917-48, viii. [Medline].

  119. Mora MC, Negrette OS, marco D, et al. Early diagnosis of congenital Trypanosoma cruzi infection using PCR, hemoculture, and capillary concentration, as compared with delayed serology. J Parasotol. Dec 2005;91(6):1468-1473. [Medline].

  120. Nagajyothi F, Desruisseaux MS, Machado FS, Upadhya R, Zhao D, Schwartz GJ. Response of Adipose Tissue to Early Infection With Trypanosoma cruzi (Brazil Strain). J Infect Dis. Mar 2012;205(5):830-40. [Medline].

  121. Nahas SC, Habr-Gama A, Nahas CS, et al. Surgical treatment of Chagasic megacolon by abdominal rectosigmoidectomy with immediate posterior end-to-side stapling (Habr-Gama technique). Dis Colon Rectum. Sep 2006;49(9):1371-8. [Medline].

  122. Oliveira-Filho J, Viana LC, Vieira-de-Melo RM, et al. Chagas disease is an independent risk factor for stroke: baseline characteristics of a Chagas Disease cohort. Stroke. Sep 2005;36(9):2015-7. [Medline].

  123. Ortega-Barria E, Pereira ME. Entry of Trypanosoma cruzi into eukaryotic cells. Infect Agents Dis. Jun 1992;1(3):136-45. [Medline].

  124. Paglini-Oliva P, Rivarola HW. Central nervous system agents used as Trypanosoma cruzi infection chemotherapy: phenothiazines and related compounds. Anti-Infect Agents. 2003;2:323-33.

  125. Peralta JM, Teixeira MG, Shreffler WG, et al. Serodiagnosis of Chagas' disease by enzyme-linked immunosorbent assay using two synthetic peptides as antigens. J Clin Microbiol. Apr 1994;32(4):971-4. [Medline]. [Full Text].

  126. Pinto Dias JC. The treatment of Chagas disease (South American Tyrpanosomiasis). Ann Intern Med. May 16 2006;144(10):772-774. [Medline].

  127. Piron M, Fisa R, Casamitjana N, et al. Development of a real-time PCR assay for Trypanosoma cruzi detection in blood samples. Acta Trop. Sep 2007;103(3):195-200. [Medline].

  128. Prata A. Chagas' disease. Infect Dis Clin North Am. Mar 1994;8(1):61-76. [Medline].

  129. Prata A. Clinical and epidemiological aspects of Chagas disease. Lancet Infect Dis. Sep 2001;1(2):92-100. [Medline].

  130. Puerto FD, Sánchez Z, Nara E, Meza G, Paredes B, Ferreira E. Trypanosoma cruzi Lineages Detected in Congenitally Infected Infants and Triatoma infestans from the Same Disease-Endemic Region under Entomologic Surveillance in Paraguay. Am J Trop Med Hyg. Mar 2010;82(3):386-90. [Medline].

  131. Punukollu G, Gowda RM, Khan IA, et al. Clinical aspects of the Chagas' heart disease. Int J cardiol. Feb 14 2007;115(3):279-83. [Medline].

  132. Ramasawmy R, Cunha-Neto E, Fae KC, Borba SC, Teixeira PC, Ferreira SC, et al. Heterozygosity for the S180L Variant of MAL/TIRAP, a Gene Expressing an Adaptor Protein in the Toll-Like Receptor Pathway, Is Associated with Lower Risk of Developing Chronic Chagas Cardiomyopathy. J Infect Dis. Jun 15 2009;199(12):1838-1845. [Medline].

  133. Ramasawmy R, Faé KC, Cunha-Neto E, Borba SC, Ianni B, Mady C, et al. Variants in the promoter region of IKBL/NFKBIL1 gene may mark susceptibility to the development of chronic Chagas' cardiomyopathy among Trypanosoma cruzi-infected individuals. Mol Immunol. Jan 2008;45(1):283-8. [Medline].

  134. Ramirez LE, Lages-Silva E, Pianetti GM, et al. Prevention of transfusion-associated Chagas' disease by sterilization of Trypanosoma cruzi-infected blood with gentian violet, ascorbic acid, and light. Transfusion. Mar 1995;35(3):226-30. [Medline].

  135. Rassi A Jr, Dias JC, Marin-Neto JA, Rassi A. Challenges and opportunities for primary, secondary, and tertiary prevention of Chagas' disease. Heart. Apr 2009;95(7):524-34. [Medline].

  136. [Best Evidence] Rassi A Jr, Rassi A, Little WC, et al. Development and validation of a risk score for predicting death in Chagas' heart disease. N Engl J Med. Aug 24 2006;355(8):799-808. [Medline].

  137. Rassi A Jr, Rassi A, Rassi SG. Predictors of mortality in chronic Chagas disease: a systematic review of observational studies. Circulation. Mar 6 2007;115(9):1101-8. [Medline].

  138. Rassi A, Luquetti AO, Rassi A Jr, et al. Specific treatment for Trypanosoma cruzi: lack of efficacy of allopurinol in the human chronic phase of Chagas disease. Am J Trop Med Hyg. Jan 2007;76(1):58-61. [Medline].

  139. Reddy M, Gill SS, Kalkar SR, et al. Oral drug therapy for multiple neglected tropical diseases: a systematic review. JAMA. Oct 24 2007;298(16):1911-24. [Medline].

  140. Reyes PA, Vallejo M. Trypanocidal drugs for late stage, symptomatic Chagas disease (Trypanosoma cruzi infection). Cochrane Database Syst Rev. 2005;(4):CD004102. [Medline].

  141. Riarte A, Luna C, Sabatiello R, et al. Chagas' disease in patients with kidney transplants: 7 years of experience 1989-1996. Clin Infect Dis. Sep 1999;29(3):561-7. [Medline].

  142. Riera C, Guarro A, El Kassab H, et al. Congenital transmission of Trypanosoma cruzi in Europe (Spain): a case report. Am J Trop Med Hyg. Dec 2006;75(6):1078-1081. [Medline].

  143. Risso MG, Sartor PA, Burgos JM, Briceno L, Rodriguez EM, Guhl F. Immunological Identification of Trypanosoma cruzi Lineages in Human Infection Along the Endemic Area. Am J Trop Med Hyg. Jan 2011;84(1):78-84. [Medline].

  144. Rocha MO, Teixeira MM, Ribeiro AL. An update on the management of Chagas cardiomyopathy. Expert Rev Anti Infect Ther. Aug 2007;5(4):727-43. [Medline].

  145. Rochitte CE, Nacif MS, de Oliveira Junior AC, et al. Cardiac magnetic resonance in Chagas' disease. Artif Organs. Apr 2007;31(4):259-67. [Medline].

  146. Roddy P, Goiri J, Flevaud L, et al. Field evaluation of a rapid immunochromatographic assay for detection of Trypanosoma cruzi infection by use of whole blood. J Clin Microbiol. Jun 2008;46(6):2022-7. [Medline].

  147. Salis GB, Mazzadi SA, Garcia AO, Chiocca JC. Pneumatic dilatation in achalasia of the esophagus: a report from Argentina. Dis Esophagus. 2004;17(2):124-8. [Medline].

  148. Sandler SG, Yu H, Rassai N. Risks of blood transfusion and their prevention. Clin Adv Hematol Oncol. May 2003;1(5):307-13. [Medline].

  149. Sartori AM, Ibrahim KY, Nunes Westphalen EV, et al. Manifestations of Chagas disease (American trypanosomiasis) in patients with HIV/AIDS. Ann Trop Med Parasitol. Jan 2007;101(1):31-50. [Medline].

  150. Scapellato PG, Bottaro EG, Rodríguez-Brieschke MT. Mother-child transmission of Chagas disease: could coinfection with human immunodeficiency virus increase the risk?. Rev Soc Bras Med Trop. Mar-Apr 2009;42(2):107-9. [Medline].

  151. Silva-Grecco RL, Balarin MA, Correia D, Prata A, Rodrigues V Jr. Familial analysis of seropositivity to Trypanosoma cruzi and of clinical forms of Chagas disease. Am J Trop Med Hyg. Jan 2010;82(1):45-8. [Medline].

  152. Siriano Lda R, Luquetti AO, Avelar JB, Marra NL, de Castro AM. Chagas disease: increased parasitemia during pregnancy detected by hemoculture. Am J Trop Med Hyg. Apr 2011;84(4):569-74. [Medline].

  153. Sosa-Estani S, Segura EL. Etiological treatment in patients infected by Trypanosoma cruzi: experiences in Argentina. Curr Opin Infect Dis. Dec 2006;19(6):583-7. [Medline].

  154. Sternick EB, Martinelli M, Sampaio R, et al. Sudden cardiac death in patients with chagas heart disease and preserved left ventricular function. J Cardiovasc Electrophysiol. Jan 2006;17(1):113-6. [Medline].

  155. Tarleton RL. Immune system recognition of Trypanosoma cruzi. Curr Opin Immunol. Aug 2007;19(4):430-4. [Medline].

  156. Teixeira AR, Monteiro PS, Rebelo JM, et al. Emerging Chagas disease: trophic network and cycle of transmission of Trypanosoma cruzi from palm trees in the Amazon. Emerg Infect Dis. Jan-Feb 2001;7(1):100-12. [Medline].

  157. Teixeira ARL, Nitz N, Guimaro MC, Gomes C, Santos-Buch CA. Chagas disease. Postgrad Med. Dec 2006;82(974):788-798. [Medline].

  158. Teixeira PC, Santos RH, Fiorelli AI, Bilate AM, Benvenuti LA, Stolf NA, et al. Selective decrease of components of the creatine kinase system and ATP synthase complex in chronic Chagas disease cardiomyopathy. PLoS Negl Trop Dis. Jun 2011;5(6):e1205. [Medline]. [Full Text].

  159. Tobler LH, Contestable P, Pitina L, et al. Evaluation of a new enzyme-linked immunosorbent assay for detection of Chagas antibody in US blood donors. Transfusion. Jan 2007;47(1):90-6. [Medline].

  160. Torrico F, Vega CA, Suarez E, et al. Are maternal re-infections with Trypanosoma cruzi associated with higher morbidity and mortality of congenital Chagas disease?. Trop Med Int Health. May 2006;11(5):628-35. [Medline].

  161. Urbina JA. New advances in the management of a long-neglected disease. Clin Infect Dis. Dec 1 2009;49(11):1685-7. [Medline].

  162. Valente SA, da Costa Valente V, das Neves Pinto AY, de Jesus Barbosa César M, dos Santos MP, Miranda CO, et al. Analysis of an acute Chagas disease outbreak in the Brazilian Amazon: human cases, triatomines, reservoir mammals and parasites. Trans R Soc Trop Med Hyg. Mar 2009;103(3):291-7. [Medline].

  163. Viotti R, Vigliano C. Etiological treatment of chronic Chagas disease: neglected 'evidence' by evidence-based medicine. Expert Rev Anti Infect Ther. Aug 2007;5(4):717-26. [Medline].

  164. Viotti R, Vigliano C, Armenti H, Segura E. Treatment of chronic Chagas' disease with benznidazole: clinical and serologic evolution of patients with long-term follow-up. Am Heart J. Jan 1994;127(1):151-62. [Medline].

  165. Viotti R, Vigliano C, Lococo B, et al. Exercise stress testing as a predictor of progression of early chronic Chagas heart disease. Heart. Mar 2006;92(3):403-4. [Medline].

  166. Viotti R, Vigliano C, Lococo B, et al. Long-term cardiac outcomes of treating chronic Chagas disease with benznidazole versus no treatment. Ann Intern Med. May 16 2006;144(10):724-34. [Medline].

  167. Viotti RJ, Vigliano C, Laucella S, et al. Value of echocardiography for diagnosis and prognosis of chronic Chagas disease cardiomyopathy without heart failure. Heart. Jun 2004;90(6):655-60. [Medline].

  168. Walker MD, Zunt JR. Neuroparasitic infections: cestodes, trematodes, and protozoans. Semin Neurol. Sep 2005;25(3):262-77. [Medline].

  169. Weber JT, Courvalin P. An emptying quiver: antimicrobial drugs and resistance. Emerg Infect Dis. Jun 2005;11(6):791-3. [Medline].

  170. Weitzel T, Zulantay I, Danquah I, Hamann L, Schumann RR, Apt W, et al. Mannose-binding lectin and Toll-like receptor polymorphisms and Chagas disease in Chile. Am J Trop Med Hyg. Feb 2012;86(2):229-32. [Medline]. [Full Text].

  171. Williams-Blangero S, Magalhaes T, Rainwater E, et al. Electrocardiographic characteristics in a population with high rates of seropositivity for Trypanosoma cruzi infection. Am J Trop Med Hyg. Sep 2007;77(3):495-9. [Medline].

  172. Wincker P, Britto C, Pereira JB, et al. Use of a simplified polymerase chain reaction procedure to detect Trypanosoma cruzi in blood samples from chronic chagasic patients in a rural endemic area. Am J Trop Med Hyg. Dec 1994;51(6):771-7. [Medline].

  173. Young C, Losikoff P, Chawla A, Glasser L, Forman E. Transfusion-acquired Trypanosoma cruzi infection. Transfusion. Mar 2007;47(3):540-4. [Medline].

  174. Zulantay I, Honores P, Solari A, et al. Use of ploymerase chain reaction (PCR) and hybridization assays to detect Trypanosoma cruzi in chronic chagasic patients treated with itraconozole or allopurinol. Diag Microbiol Infect Dis. Apr 2004;48(4):253-7. [Medline].

 
Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.