Trypanosomiasis Clinical Presentation
- Author: Germaine L Defendi, MD, MS, FAAP; Chief Editor: Russell W Steele, MD more...
The early phase of trypanosomiasis is typically asymptomatic, as only about one-third of patients have symptoms of acute Chagas disease. A minority of patients have severe clinical disease. About 10% of patients die in the early stage of the disease due to severe myocarditis or meningoencephalitis. The vast majority of people who have clinical symptoms include the following: infants, those who are defenseless in warding off the triatomid bite, and children aged 10 years or younger. Symptoms of the acute phase disappear within 4-8 weeks in most individuals.
The incubation period for Chagas disease is 7-14 d (1-2 weeks). In transfusion-acquired disease, the incubation period is longer (20-40 d). Chronic manifestations do not appear for years after infection.
Symptoms of parasitic infection and proliferation include the following:
The first symptom is a bug bite by a reduviid or triatomine insect, typically on or near 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 in particular 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. 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 common. These symptoms may develop weeks to years after the initial infection and subsequent progression is typically slow.
Symptoms specifically 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 lead to 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 minority of cases. Symptoms can 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 are present in few patients with chronic disease. Involvement of the central, peripheral, or autonomic nervous systems can occur. Symptoms include paresis, cerebellar disturbance, convulsions, alterations in the dorsal root ganglia, and polyneuritis.
If the bite occurs near the eye, unilateral periorbital edema of the eyelids, known as Romaña sign, develops. This edematous eyelid skin has a violaceous coloring. Conjunctivitis and enlargement of the ipsilateral preauricular lymph node is observed. Unilateral ocular and facial edema that involves the ipsilateral preauricular lymph node is known as oculoglandular syndrome. The preauricular region can markedly swell, causing an initial impression of parotitis, such as that caused by the mumps virus. In a small number of infected individuals, the facial edema may be generalized and mistaken for nephrotic syndrome.
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 old. Generalized lymphadenopathy, moderate hepatosplenomegaly, anasarca, vomiting, and diarrhea are common in infants. Meningoencephalitis is also more common in young infants.  If dermatological findings are seen, they can vary from a generalized maculopapular or morbilliform rash to urticaria.
In the acute phase, 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 majority of cases. Biventricular heart failure rarely develops. Death from acute myocarditis occurs in 2-3% of patients. Prognosis is poor with early development of premature ventricular contractions, atrial fibrillation, heart block, or congestive heart failure.
The manifestations of the acute phase of Chagas disease generally last 2-4 weeks. In those 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.
Clinical manifestations of chronic disease can develop years after the initial acute infection. During the chronic phase, the most serious aspect of Chagas disease is the delayed damage that it can inflict on the heart and GI system. Serious sequelae can be cardiomyopathy, heart failure, megaesophagus, and megacolon.
Cardiac abnormalities are the most frequent manifestations of chronic Chagas disease.
Cardiac disease is the most serious cause 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.
Patients with cardiac abnormalities typically do not have acute pulmonary edema. Orthopnea is also 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 advanced cases of cardiac disease, 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 at age 20-40 years, and the rate of progression widely varies.
Less commonly involved organs include the stomach and duodenum; 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.
Other rare findings ascribed to Chagas disease include bronchiectasia, hemosiderosis, and dilatation of the ureter or urinary bladder.
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.
The affected infant has a low birth weight, hepatosplenomegaly, jaundice, anemia, fever, and edema.
Neurologic involvement includes 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 for Chagas disease is an indication for treatment. Transmission of this infection through infected mother's milk has been observed in breastfed babies.
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. Clinical findings of neurologic involvement are nuchal rigidity, convulsions, paralysis, and coma.
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: epimastigotes, trypomastigotes, amastigotes. 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, the epimastigotes 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.
Human transmission occurs through contact with infected insect excreta. These insects defecate while ingesting human blood, thereby excreting the infective trypanosomes. Each microliter of insect excreta may contain 3000-4000 organisms. 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.
Amastigotes have a short flagellum, 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 parasite can be transmitted congenitally, [24, 25, 26] transmitted through organ transplantation , via infected breast milk, via blood transfusion, or accidentally in the laboratory. As much as 6.5% of blood stored 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.
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 also be transmitted orally.[30, 31, 32, 33]
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
Rassi A Jr, Rassi A, Marcondes de Rezende J. American trypanosomiasis (chagas disease). Infect Dis Clin North Am. 2012 Jun. 26(2):275-91. [Medline].
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. 2010 Aug. 10(8):556-70. [Medline].
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. 2011 Aug. 85(2):221-4. [Medline].
Teixeira AR, Hecht MM, Guimaro MC, Sousa AO, Nitz N. Pathogenesis of chagas' disease: parasite persistence and autoimmunity. Clin Microbiol Rev. 2011 Jul. 24(3):592-630. [Medline].
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. 2007 Jul. 65(1):60-79. [Medline].
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. 2010 Nov. 83(5):1020-2. [Medline].
Bern C, Kjos S, Yabsley MJ, Montgomery SP. Trypanosoma cruzi and Chagas' Disease in the United States. Clin Microbiol Rev. 2011 Oct. 24(4):655-81. [Medline].
Bern C, Montgomery SP. An Estimate of the Burden of Chagas Disease in the United States. Clin Infect Dis. 2009 Jul 29. 49:e52-4. [Medline].
Yadon ZE, Schmunis GA. Congenital Chagas disease: estimating the potential risk in the United States. Am J Trop Med Hyg. 2009 Dec. 81(6):927-33. [Medline].
Centers for Disease Control and Prevention. Congenital transmission of Chagas disease - Virginia, 2010. MMWR Morb Mortal Wkly Rep. 2012 Jul 6. 61(26):477-9. [Medline].
Carter YL, Juliano JJ, Montgomery SP, Qvarnstrom Y. Acute Chagas disease in a returning traveler. Am J Trop Med Hyg. 2012 Dec. 87(6):1038-40. [Medline].
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. 2010 Mar. 16(3):400-5. [Medline].
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. 2011 Oct. 85(4):648-56. [Medline].
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. 2012 Apr. 18(4):646-9. [Medline].
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. 2009 Nov. 28(11):1011-3. [Medline].
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. 2010 Jul. 83(1):164-70. [Medline].
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. 2010 May 18. 4(5):e687. [Medline]. [Full Text].
Anez N, Crisante G, Rojas A. Update on Chagas disease in Venezuela--a review. Mem Inst Oswaldo Cruz. 2004 Dec. 99(8):781-7. [Medline].
Otero S, Sulleiro E, Molina I, Espiau M, Suy A, Martín-Nalda A. Congenital transmission of Trypanosoma cruzi in non-endemic areas: evaluation of a screening program in a tertiary care hospital in Barcelona, Spain. Am J Trop Med Hyg. 2012 Nov. 87(5):832-6. [Medline].
Cordova E, Maiolo E, Corti M, Orduna T. Neurological manifestations of Chagas' disease. Neurol Res. 2010 Apr. 32(3):238-44. [Medline].
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. 2009 May. 9(5):324-30. [Medline].
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. 2009 Jun 15. 48(12):1736-40. [Medline].
Oliveira I, Torrico F, Munoz J, Gascon J. Congenital transmission of Chagas disease: a clinical approach. Expert Rev Anti Infect Ther. 2010 Aug. 8(8):945-56. [Medline].
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. 2010 May. 82(5):838-45. [Medline].
Murcia L, Carrilero B, Munoz-Davila MJ, Thomas MC, López MC, Segovia M. Risk factors and primary prevention of congenital chagas disease in a nonendemic country. Clin Infect Dis. 2013 Feb. 56(4):496-502. [Medline].
Kun H, Moore A, Mascola L, Steurer F, Lawrence G, Kubak B. Transmission of Trypanosoma cruzi by heart transplantation. Clin Infect Dis. 2009 Jun 1. 48(11):1534-40. [Medline].
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. 2010 Nov. 83(5):1044-7. [Medline]. [Full Text].
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. 2010 Jun 15. 4(6):e711. [Medline]. [Full Text].
Miles MA. Orally acquired Chagas disease: lessons from an urban school outbreak. J Infect Dis. 2010 May 1. 201(9):1282-4. [Medline].
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. 2010 May 1. 201(9):1308-15. [Medline].
Shikanai-Yasuda MA, Carvalho NB. Oral transmission of chagas disease. Clin Infect Dis. 2012 Mar. 54(6):845-52. [Medline].
Rosenblatt JE. Laboratory diagnosis of infections due to blood and tissue parasites. Clin Infect Dis. 2009 Oct 1. 49(7):1103-8. [Medline].
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. 2012 Mar. 86(3):412-6. [Medline].
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].
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].
Qvarnstrom Y, Schijman AG, Veron V, Aznar C, Steurer F, da Silva AJ. Sensitive and specific detection of Trypanosoma cruzi DNA in clinical specimens using a multi-target real-time PCR approach. PLoS Negl Trop Dis. 2012. 6(7):e1689. [Medline]. [Full Text].
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. 2009 Dec 1. 49(11):1667-74. [Medline].
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. 2010 Sep. 10(6):705-7. [Medline].
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. 2010 Jan. 82(1):55-9. [Medline]. [Full Text].
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. 2007 Jun. 8(3):204-12. [Medline].
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. 2010 Apr. 48(4):1139-49. [Medline]. [Full Text].
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. 2006 Jan-Feb. 15(1):18-23. [Medline].
Acquatella H. Echocardiography in Chagas heart disease. Circulation. 2007 Mar 6. 115(9):1124-31. [Medline].
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. 2011 Jan. 84(1):85-90. [Medline]. [Full Text].
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. 2010 Dec 20. [Medline].
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. 2007 Jun. 29(6):733-737. [Medline].
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].
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. 2009 Dec 1. 49(11):1675-84. [Medline]. [Full Text].
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. 2010 Apr. 82(4):583-7. [Medline]. [Full Text].
Bern C, Montgomery SP, Katz L, Caglioti S, Stramer SL. Chagas disease and the US blood supply. Curr Opin Infect Dis. 2008 Oct. 21(5):476-82. [Medline].
Mejia AM, Hall BS, Taylor MC, Gómez-Palacio A, Wilkinson SR, Triana-Chávez O. Benznidazole-Resistance in Trypanosoma cruzi Is a Readily Acquired Trait That Can Arise Independently in a Single Population. J Infect Dis. 2012 Jul. 206(2):220-8. [Medline].
Le Loup G, Pialoux G, Lescure FX. Update in treatment of Chagas disease. Curr Opin Infect Dis. 2011 Oct. 24(5):428-34. [Medline].
Guedes PM, Silva GK, Gutierrez FR, Silva JS. Current status of Chagas disease chemotherapy. Expert Rev Anti Infect Ther. 2011 May. 9(5):609-20. [Medline].
Bern C. Antitrypanosomal therapy for chronic Chagas' disease. N Engl J Med. 2011 Jun 30. 364(26):2527-34. [Medline].
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. 2010 Aug. 65(8):1759-64. [Medline].
Gallerano RH, Marr JJ, Sosa RR. Therapeutic efficacy of allopurinol in patients with chronic Chagas' disease. Am J Trop Med Hyg. 1990 Aug. 43(2):159-66. [Medline].
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. 2005 Dec. 99(8):733-41. [Medline].
Lo Presti MS, Rivarola HW, Bustamante JM, et al. Thioridazine treatment prevents cardiomyopathy in Trypanosoma cruzi mice. Int J Antimicrob Agents. 2004 Jun. 23(6):634-636. [Medline].
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. 2010 Dec 14. 4(12):e916. [Medline]. [Full Text].
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. 2010 Sep 1. 51(5):485-95. [Medline].
Trindade MÂ, 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. 2011 Jun. 84(6):973-7. [Medline].
Cucunubá ZM, Flórez AC, Cárdenas A, Pavía P, Montilla M, Aldana R, et al. Prevalence and risk factors for Chagas disease in pregnant women in Casanare, Colombia. Am J Trop Med Hyg. 2012 Nov. 87(5):837-42. [Medline]. [Full Text].
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. 2011 May. 84(5):808-12. [Medline]. [Full Text].
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. 2010 Oct. 83(4):891-5. [Medline]. [Full Text].
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. 2007 Aug-Sep. 66(2-3):137-42. [Medline].
Aiga H, Sasagawa E, Hashimoto K, Nakamura J, Zúniga C, Chévez JE, et al. Chagas Disease: Assessing the Existence of a Threshold for Bug Infestation Rate. Am J Trop Med Hyg. 2012 Jun. 86(6):972-979. [Medline].
Alter HJ, Stramer SL, Dodd RY. Emerging infectious diseases that threaten the blood supply. Semin Hematol. 2007 Jan. 44(1):32-41. [Medline].
American Academy of Pediatrics. American Trypanosomiasis (Chagas Disease). Red Book: 2009 Report of the Committee on Infectious Diseases. 28th. Elk Grove Village, IL: American Academy of Pediatrics; 2009. 678-9.
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. 2009 Jun. 9(3):227-34. [Medline].
Trypanosomiasis, American. 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.
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].
Barrett MP. Potential new drugs for human African trypanosomiasis: some progress at last. Curr Opin Infect Dis. 2010 Dec. 23(6):603-8. [Medline].
Bern C, Montgomery SP, Herwaldt BL, et al. Evaluation and treatment of chagas disease in the United States: a systematic review. JAMA. 2007 Nov 14. 298(18):2171-81. [Medline].
Bittencourt AL. Congenital Chagas disease. Am J Dis Child. Jan 1976. 130(1):97-103. [Medline].
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. 2009 Dec. 81(6):1035-40. [Medline].
Blood donor screening for chagas disease--United States, 2006-2007. MMWR Morb Mortal Wkly Rep. 2007 Feb 23. 56(7):141-3. [Medline].
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].
Brun R, Balmer O. New developments in human African trypanosomiasis. Curr Opin Infect Dis. 2006 Oct. 19(5):415-20. [Medline].
Buckner FS, Navabi N. Advances in Chagas disease drug development: 2009-2010. Curr Opin Infect Dis. 2010 Dec. 23(6):609-16. [Medline].
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. 2009 Sep. 65(1):58-61. [Medline].
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. 2007 Aug. 14(8):1045-9. [Medline].
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. 2009 Mar. 45(3):149-53. [Medline].
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. 2007 May. 14(5):e8. [Medline].
Castro JA, de Mecca MM, Bartel LC. Toxic side effects of drugs used to treat Chagas' disease (American Trypanosomiasis). Hum Exp Toxicol. 2006 Aug. 25(8):471-79. [Medline].
Chagas' disease--an epidemic that can no longer be ignored. Lancet. 2006 Aug 19. 368(9536):619. [Medline].
Crema E, Ribeiro LB, Terra JA Jr, Silva AA. Laparoscopic transhiatal subtotal esophagectomy for the treatment of advanced megaesophagus. Ann Thorac Surg. 2005 Oct. 80(4):1196-201. [Medline].
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. 2004 Dec 1. 76(23):7143-8. [Medline].
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. 2011 Sep. 204(6):951-61. [Medline].
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. 2007 May 7. [Medline].
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. 2007 Jun 14. 1(4):251-61. [Medline].
de Oliveira RB, Troncon LE, Dantas RO, Menghelli UG. Gastrointestinal manifestations of Chagas' disease. Am J Gastroenterol. 1998 Jun. 93(6):884-9. [Medline].
de Souza W. Chagas' disease: facts and reality. Microbes Infect. 2007 Apr. 9(4):544-5. [Medline].
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. 2011 Feb 22. 5(2):e970. [Medline]. [Full Text].
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].
Dutra WO, Rocha MO, Teixeira MM. The clinical immunology of human Chagas disease. Trends Parasitol. 2005 Dec. 21(12):581-7. [Medline].
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. 2011 Apr. 84(4):575-80. [Medline].
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. 2007 Jan-Feb. 40(1):1-10. [Medline].
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. 1991 Dec. 45(6):723-7. [Medline].
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. 1997 Dec. 25(6):1397-400. [Medline].
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].
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. 2008 Mar 1. 46(5):e44-7. [Medline].
Fraser B. Controlling Chagas' disease in urban Peru. Lancet. 2008 Jul 5. 372(9632):16-7. [Medline].
Garg N, Bhatia V. Current status and future prospects for a vaccine against American trypanosomiasis. Expert Rev Vaccines. 2005 Dec. 4(6):867-80. [Medline].
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. 2011 Jan. 84(1):70-7. [Medline].
Grant IH, Gold JW, Wittner M, et al. Transfusion-associated acute Chagas disease acquired in the United States. Ann Intern Med. 1989 Nov 15. 111(10):849-51. [Medline].
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. 2007 Oct 9. 104(41):16194-9. [Medline].
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. 2007 Oct 9. 104(41):16194-9. [Medline].
Guzman-Bracho C. Epidemiology of Chagas disease in Mexico: an update. Trends Parasitol. Aug 2001. 17(8):372-6. [Medline].
Heringer-Walther S, Moreira MC, Wessel N, et al. Brain natriuretic peptide predicts survival in Chagas' disease more effectively than atrial natriuretic peptide. Heart. 2005 Mar. 91(3):385-7. [Medline].
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. 2006 Jul. 60(1):38-43. [Medline].
Hidron A, Vogenthaler N, Santos-Preciado JI, Rodriguez-Morales AJ, Franco-Paredes C, Rassi A Jr. Cardiac involvement with parasitic infections. Clin Microbiol Rev. 2010 Apr. 23(2):324-49. [Medline].
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. 2009 Dec. 81(6):1041-9. [Medline]. [Full Text].
Longhi SA, Brandariz SB, Lafon SO, Niborski LL, Luquetti AO, Schijman AG. Evaluation of in-house ELISA using Trypanosoma cruzi lysate and recombinant antigens for diagnosis of Chagas disease and discrimination of its clinical forms. Am J Trop Med Hyg. 2012 Aug. 87(2):267-71. [Medline].
Lopes MF, Guillermo LV, Silva EM. Decoding caspase signaling in host immunity to the protozoan Trypanosoma cruzi. Trends Immunol. 2007 Aug. 28(8):366-72. [Medline].
Marin-Neto JA, Cunha-Neto E, Maciel BC, Simoes MV. Pathogenesis of chronic Chagas heart disease. Circulation. 2007 Mar 6. 115(9):1109-23. [Medline].
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. 2010 Jan. 82(1):49-54. [Medline]. [Full Text].
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. 2011 Feb. 84(2):325-31. [Medline].
Meneghelli UG. Chagasic enteropathy. Rev Soc Bras Med Trop. 2004 May-Jun. 37(3):252-60. [Medline].
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].
Moncayo A, Ortiz Yanine MI. An update on Chagas disease (human American trypanosomiasis). Ann Trop Med Parasitol. 2006 Dec. 100(8):663-77. [Medline].
Moon TD, Oberhelman RA. Antiparasitic therapy in children. Pediatr Clin North Am. Jun 2005. 52(3):917-48, viii. [Medline].
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. 2005 Dec. 91(6):1468-1473. [Medline].
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. 2012 Mar. 205(5):830-40. [Medline].
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. 2006 Sep. 49(9):1371-8. [Medline].
Navarro M, Norman FF, Pérez-Molina JA, López-Vélez R. Benznidazole shortage makes chagas disease a neglected tropical disease in developed countries: data from Spain. Am J Trop Med Hyg. 2012 Sep. 87(3):489-90. [Medline]. [Full Text].
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. 2005 Sep. 36(9):2015-7. [Medline].
Ortiz S, Zulantay I, Solari A, Bisio M, Schijman A, Carlier Y, et al. Presence of Trypanosoma cruzi in pregnant women and typing of lineages in congenital cases. Acta Trop. 2012 Dec. 124(3):243-6. [Medline].
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.
Pinto Dias JC. The treatment of Chagas disease (South American Tyrpanosomiasis). Ann Intern Med. 2006 May 16. 144(10):772-774. [Medline].
Piron M, Fisa R, Casamitjana N, et al. Development of a real-time PCR assay for Trypanosoma cruzi detection in blood samples. Acta Trop. 2007 Sep. 103(3):195-200. [Medline].
Prata A. Clinical and epidemiological aspects of Chagas disease. Lancet Infect Dis. 2001 Sep. 1(2):92-100. [Medline].
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. 2010 Mar. 82(3):386-90. [Medline]. [Full Text].
Punukollu G, Gowda RM, Khan IA, et al. Clinical aspects of the Chagas' heart disease. Int J cardiol. 2007 Feb 14. 115(3):279-83. [Medline].
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. 2009 Jun 15. 199(12):1838-1845. [Medline].
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. 2008 Jan. 45(1):283-8. [Medline].
Ramírez-Macías I, Marín C, Chahboun R, Messouri I, Olmo F, Rosales MJ. In vitro and in vivo studies of the trypanocidal activity of four terpenoid derivatives against Trypanosoma cruzi. Am J Trop Med Hyg. 2012 Sep. 87(3):481-8. [Medline].
Rassi A Jr, Dias JC, Marin-Neto JA, Rassi A. Challenges and opportunities for primary, secondary, and tertiary prevention of Chagas' disease. Heart. 2009 Apr. 95(7):524-34. [Medline].
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. 2006 Aug 24. 355(8):799-808. [Medline].
Rassi A Jr, Rassi A, Rassi SG. Predictors of mortality in chronic Chagas disease: a systematic review of observational studies. Circulation. 2007 Mar 6. 115(9):1101-8. [Medline].
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. 2007 Jan. 76(1):58-61. [Medline].
Reddy M, Gill SS, Kalkar SR, et al. Oral drug therapy for multiple neglected tropical diseases: a systematic review. JAMA. 2007 Oct 24. 298(16):1911-24. [Medline].
Reyes PA, Vallejo M. Trypanocidal drugs for late stage, symptomatic Chagas disease (Trypanosoma cruzi infection). Cochrane Database Syst Rev. 2005. (4):CD004102. [Medline].
Riarte A, Luna C, Sabatiello R, et al. Chagas' disease in patients with kidney transplants: 7 years of experience 1989-1996. Clin Infect Dis. 1999 Sep. 29(3):561-7. [Medline].
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. 2006 Dec. 75(6):1078-1081. [Medline].
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. 2011 Jan. 84(1):78-84. [Medline].
Rocha MO, Teixeira MM, Ribeiro AL. An update on the management of Chagas cardiomyopathy. Expert Rev Anti Infect Ther. 2007 Aug. 5(4):727-43. [Medline].
Rochitte CE, Nacif MS, de Oliveira Junior AC, et al. Cardiac magnetic resonance in Chagas' disease. Artif Organs. 2007 Apr. 31(4):259-67. [Medline].
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. 2008 Jun. 46(6):2022-7. [Medline].
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].
Sandler SG, Yu H, Rassai N. Risks of blood transfusion and their prevention. Clin Adv Hematol Oncol. May 2003. 1(5):307-13. [Medline].
Sartori AM, Ibrahim KY, Nunes Westphalen EV, et al. Manifestations of Chagas disease (American trypanosomiasis) in patients with HIV/AIDS. Ann Trop Med Parasitol. 2007 Jan. 101(1):31-50. [Medline].
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. 2009 Mar-Apr. 42(2):107-9. [Medline].
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. 2010 Jan. 82(1):45-8. [Medline]. [Full Text].
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. 2011 Apr. 84(4):569-74. [Medline].
Soares RP, Torrecilhas AC, Assis RR, Rocha MN, Moura E Castro FA, Freitas GF, et al. Intraspecies Variation in Trypanosoma cruzi GPI-Mucins: Biological Activities and Differential Expression of a-Galactosyl Residues. Am J Trop Med Hyg. 2012 Jul. 87(1):87-96. [Medline].
Sosa-Estani S, Segura EL. Etiological treatment in patients infected by Trypanosoma cruzi: experiences in Argentina. Curr Opin Infect Dis. 2006 Dec. 19(6):583-7. [Medline].
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. 2006 Jan. 17(1):113-6. [Medline].
Tarleton RL. Immune system recognition of Trypanosoma cruzi. Curr Opin Immunol. 2007 Aug. 19(4):430-4. [Medline].
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. 2001 Jan-Feb. 7(1):100-12. [Medline].
Teixeira ARL, Nitz N, Guimaro MC, Gomes C, Santos-Buch CA. Chagas disease. Postgrad Med. 2006 Dec. 82(974):788-798. [Medline].
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. 2011 Jun. 5(6):e1205. [Medline]. [Full Text].
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. 2007 Jan. 47(1):90-6. [Medline].
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].
Urbina JA. New advances in the management of a long-neglected disease. Clin Infect Dis. 2009 Dec 1. 49(11):1685-7. [Medline].
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. 2009 Mar. 103(3):291-7. [Medline].
Viotti R, Vigliano C. Etiological treatment of chronic Chagas disease: neglected 'evidence' by evidence-based medicine. Expert Rev Anti Infect Ther. 2007 Aug. 5(4):717-26. [Medline].
Viotti R, Vigliano C, Lococo B, et al. Exercise stress testing as a predictor of progression of early chronic Chagas heart disease. Heart. 2006 Mar. 92(3):403-4. [Medline].
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. 2006 May 16. 144(10):724-34. [Medline].
Viotti RJ, Vigliano C, Laucella S, et al. Value of echocardiography for diagnosis and prognosis of chronic Chagas disease cardiomyopathy without heart failure. Heart. 2004 Jun. 90(6):655-60. [Medline].
Walker MD, Zunt JR. Neuroparasitic infections: cestodes, trematodes, and protozoans. Semin Neurol. 2005 Sep. 25(3):262-77. [Medline].
Weber JT, Courvalin P. An emptying quiver: antimicrobial drugs and resistance. Emerg Infect Dis. 2005 Jun. 11(6):791-3. [Medline].
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. 2012 Feb. 86(2):229-32. [Medline]. [Full Text].
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. 2007 Sep. 77(3):495-9. [Medline].
Young C, Losikoff P, Chawla A, Glasser L, Forman E. Transfusion-acquired Trypanosoma cruzi infection. Transfusion. 2007 Mar. 47(3):540-4. [Medline].
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. 2004 Apr. 48(4):253-7. [Medline].