eMedicine Specialties > Pediatrics: General Medicine > Parasitology

Trypanosomiasis: Treatment & Medication

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
Coauthor(s): Antonio Muñiz, MD, Associate 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
Contributor Information and Disclosures

Updated: Jan 27, 2009

Treatment

Medical Care

The acute phase of trypanosomiasis (Chagas disease) is treated with nifurtimox or benznidazole.8,9 Cases of congenital Chagas disease have been successfully treated with either drug.

  • The management of chronic Chagas disease is supportive, although recent studies and some expert opinion suggest that therapy with benznidazole in chronic disease may be appropriate in certain circumstances.10
    • Dysrhythmias usually respond to typical agents. Patients with bradydysrhythmias and atrial fibrillation with a slow ventricular response may require a permanent pacemaker if they are symptomatic. In the management of heart failure, digitalis or vasoactive drugs are not well tolerated and must be cautiously administered. However, diuretics are effective. Transplantation is not without risk, as immunosuppression reactivates the chronic trypanosome infection.
    • Embolism or evidence of thrombosis may necessitate anticoagulant therapy.
  • Treatment of esophageal alterations in patients with Chagas disease is the same as in idiopathic achalasia.
    • The focus is on facilitating the transit of food and liquids through the achalasic lower esophageal sphincter. Dietary measures, such as eating soft foods or administering anticholinergic drugs, are generally of little use. Nifedipine or sublingual isosorbide dinitrate taken prior to meals may provide some relief in patients with a nondilated esophagus.
    • In most patients, symptomatic megaesophagus can benefit from pneumatic dilation of the lower esophageal sphincter. Relapse occurs in as many as 26% of patients, but patients might have good results with second dilations. Surgical approaches for chagasic megaesophagus are reserved for use when repeat dilation fails and for the most severe cases with dolichomegaesophagus.
  • Treatment of patients with colonic dysfunction is as follows:
    • Patients with Chagas disease in the early stages of colonic dysfunction can be treated with a diet that is high in fiber and fluids, as well as laxatives. These patients occasionally require enemas.
    • Fecal impaction might occur as the disease progresses and requires manual disimpaction. Treat fecaloma with multiple mineral oil or saline enemas and colonic lavages with balanced salt solutions or tap water. In the most severe cases, manual emptying under general anesthesia may be necessary. Endoscopic emptying can be performed as the initial treatment in patients in whom no clinical, radiographic, or endoscopic signs of ischemia are present. Complicated cases require surgical decompression. Patients in whom conservative methods fail, as well as those with frequent fecal impaction or sigmoid volvulus, need surgical treatment.

Surgical Care

  • Surgical care for those with esophageal dysfunction
    • Surgical approaches for chagasic megaesophagus are reserved for disease that fails to respond to repeated dilatation and the most severe cases with dolichomegaesophagus. Laparoscopic transhiatal subtotal esophagectomy has been successful with fewer complications than a transthoracic approach.
    • Good results have been evidenced after performing a Thal operation with a wide esophagocardiomyotomy on the anterior gastroesophageal junction combined with a valvuloplasty to reduce reflux. Surgical complications include pleural effusions and fistulas at the site of anastomosis.
    • Future approaches might include laparoscopic myotomy, which is successful in patients with severe idiopathic achalasia.
  • Surgical care for those with colon dysfunction
    • Patients with megacolon in whom conservative methods fail, as well as those with frequent fecal impaction or sigmoid volvulus, need surgical treatment.
    • Various surgical procedures have been used to treat advanced megacolon. These procedures include resection of the sigmoid colon as well as a portion of the rectum.
    • Resection of part of the rectum has been found to be necessary to prevent subsequent recurrences of megacolon in the portion brought down and sutured to the rectum. Resection of the rectum requires an abdominal-perineal approach; the Duhamel procedure, as modified by Haddad, has been used with considerable success; however, it is a 2-stage procedure. Another procedure, the Habr-Gama technique, consists of abdominal rectosigmoidectomy with immediate posterior colorectal end-to-end stapling and also has good success.

Consultations

  • Consultations with an infectious diseases specialist, cardiologist, gastroenterologist, neurologist, and surgeon may be helpful; these specialists should be consulted as indicated by the patient's clinical condition.

Diet

  • Dietary measures are generally not effective, except for high-fiber and increased fluid intake for the treatment of mild colonic dysfunction.

Medication

The acute phase of Chagas disease is treated with nifurtimox or benznidazole. Both agents reduce the duration and severity of acute and congenital Chagas disease. Treatment is also indicated in a patient with HIV who has reactivation trypanosomiasis. Both agents are available in the United States from the drug service of the CDC at the Parasite Drug Service, which can be reached at (770) 488-7775 during business hours and at (770) 488-7100 on evenings, weekends, and holidays.

Nifurtimox has been reported to be 75-90% effective. In some areas, such as Brazil, it is not as effective. Benznidazole has similar efficacy and may be better tolerated than nifurtimox. No evidence suggests that individuals in the indeterminate or chronic phases of the illness benefit from treatment. The drug might be effective for the chronic phase if parasites can be demonstrated in the blood.

A long-term follow-up study of patients with chronic disease treated with benznidazole revealed a significant decrease in the electrocardiographic changes, clinical deterioration, and rate of seropositivity. Allopurinol has been shown to be as effective as nifurtimox and benznidazole in suppressing parasitemia with fewer adverse effects.11 However, the open and nonrandomized study structure and the lack of well-defined criteria for cure make interpretation of these findings difficult. In addition, allopurinol has recently been ineffective in eradicating T cruzi in patients from Brazil. In Chile, the use of itraconazole has been shown to decrease electrocardiographic abnormalities in some patients with chronic Chagas disease.12

Nifurtimox and recombinant interferon alfa were successfully used to treat Chagas disease in a child who acquired the disease through transfusion and in a laboratory worker who accidentally was infected. Interferon-alfa may improve the activation of macrophages that kill the organism.

Thioridazine is a phenothiazine with high antitrypanothionine reductase activity that has been shown to be effective in preventing chagasic myocardiopathy in mice when used in the acute phase of infection.13

Anthelmintics

These are used to treat acute and congenital Chagas disease. Parasite biochemical pathways are different from the human host, thus toxicity is directed to the parasite, egg, or larvae. Mechanism of action varies within the drug class. Antiparasitic actions may include the following:

  • Inhibition of microtubules causes irreversible block of glucose uptake
  • Tubulin polymerization inhibition
  • Depolarizing neuromuscular blockade
  • Cholinesterase inhibition
  • Increased cell membrane permeability, resulting in intracellular calcium loss
  • Vacuolization of the schistosome tegument
  • Increased cell membrane permeability to chloride ions via chloride channels alteration

Nifurtimox (Lampit)

Used to treat acute and congenital Chagas disease. It decreases the period of acute disease and decreases the mortality rate from myocarditis and meningoencephalitis. It interferes with the parasite's carbohydrate metabolism by inhibiting pyruvic acid synthesis. Available in the US via a compassionate IND from the CDC.

Adult

8-10 mg/kg/d PO divided tid/qid pc for 120 days

Pediatric

<10 years: 15-20 mg/kg/d PO divided tid/qid for 90-120 d
11-16 years: 12.5-15 mg/kg/d PO divided tid/qid for 90-120 d

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Most common adverse effects include weakness, anorexia, nausea, vomiting, abdominal pain; less common adverse effects include skin rashes, toxic hepatitis, central and peripheral nervous system symptoms (eg, loss of memory, tremor, insomnia, disorientation, restlessness, twitching, polyneuritis, paresthesia, seizures); hemolysis can occur in patients with G-6-PD deficiency; children tolerate drug better than adults; preliminary findings of chromosomal aberrations need confirmation


Benznidazole (Rochagan)

Imidazole that inhibits nucleic acid synthesis. Used for acute and congenital Chagas disease. More trypanocidal than nifurtimox. Not available in the US.

Adult

5-10 mg/kg/d PO divided bid for 60 days (range, 30-120 d)

Pediatric

Administer as in adults

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Common adverse effects include photosensitive skin rashes, headaches, peripheral neuritis, anorexia, nausea, dizziness, weight loss, asthenia, hematologic alterations (eg, neutropenia, agranulocytosis, thrombocytopenia, bone marrow suppression); several authors have described potential carcinogenic effects

More on Trypanosomiasis

Overview: Trypanosomiasis
Differential Diagnoses & Workup: Trypanosomiasis
Treatment & Medication: Trypanosomiasis
Follow-up: Trypanosomiasis
References
[ CLOSE WINDOW ]

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Further Reading

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Keywords

trypanosomiasis, American trypanosomiasis, Chagas disease, Chagas' disease, chagasic heart disease, chagasic megaesophagus, chagoma, chronic Chagas disease, chronic chagasic cardiopathy, contraction band necrosis, dyspepsia, focal myonecrosis, interstitial fibrosis, Kinetoplastida, lymphocytic infiltration, megacolon, megaduodenum, megaesophagus, parasitemia, parasitic disease, Romaña sign, Romaña's sign, Schizotrypanum, triatomid, Trypanosoma cruzi, T cruzi, Trypanosomatina

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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: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Consulting; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Novartis Honoraria Speaking and teaching; sanofi pasteur Grant/research funds Unrestricted research grant; sanofi pasteur  Consulting; sanofi pasteur Honoraria Speaking and teaching; Tap Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching

Coauthor(s)

Antonio Muñiz, MD, Associate 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.

Medical Editor

Ashir Kumar, MBBS, MD, FAAP, Professor, Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University; Consulting Staff, Department of Pediatrics, EW Sparrow Hospital
Ashir Kumar, MBBS, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics, American Association of Physicians of Indian Origin, American Federation for Clinical Research, American Society for Microbiology, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Leslie L Barton, MD, Professor, Program Director, Department of Pediatrics, University of Arizona School 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.

CME Editor

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; Pfizer 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: None None None

 
 
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