Trypanosomiasis Treatment & Management

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

Medical Care

The acute phase of trypanosomiasis (Chagas disease) is treated with nifurtimox or benznidazole.[37, 38, 39, 40] Cases of congenital Chagas disease have been successfully treated with either drug. A single case of successful treatment of an adult with posaconazole (after failure of therapy with benznidazole) has been reported.[41]

The management of chronic Chagas disease is supportive, although recent studies and some expert opinion suggests that therapy with benznidazole in chronic disease may be appropriate in certain circumstances.[42] Recommendations continue to evolve, as neither of the available drugs is well-tolerated, and alternatives are lacking.[43, 44]

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.

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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.

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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.

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Diet

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

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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: 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.

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