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Chagas Disease (American Trypanosomiasis) Treatment & Management

  • Author: Louis V Kirchhoff, MD, MPH; Chief Editor: Pranatharthi Haran Chandrasekar, MBBS, MD  more...
 
Updated: Nov 10, 2014
 

Medical Care

The goals of therapy in persons with T cruzi infection are to eliminate the parasites with specific drug treatment and to manage the signs and symptoms that result from the largely irreversible lesions associated with the disease. Two drugs, benznidazole and nifurtimox (see Medication), are available through the CDC for specific treatment of T cruzi infection. As noted below, both benznidazole and nifurtimox are limited in their capacity to effect parasitologic cure, especially in chronically infected patients.[112, 113, 114] In fact, the usefulness of treating chronic infection has not been established in properly structured treatment trials; thus, the use of these drugs in such patients is controversial.[115]

Acute Chagas disease

All patients with acute Chagas disease, including those with congenital infection and those with reactivation of chronic infections due to immunosuppression, should be treated with either benznidazole or nifurtimox.

In general, the younger the patient and the closer to acquisition of the infection, the higher the probability of parasitologic cure. Babies with congenital Chagas disease have the greatest chance for cure. Data from Argentina show that the cure rate exceeds 90% if treatment is given within the first year of life.[116] Some sources have stated that the overall parasitologic cure rate in persons with acute Chagas disease is 70%, although the author is unaware of specific data that support this estimate.

The usefulness of corticosteroids or interferon-γ in patients with acute Chagasic myocarditis or meningoencephalitis has not been established.

Indeterminate-phase Chagas disease

All children and adolescents through age 18 years with chronic T cruzi infection should receive either benznidazole or nifurtimox. Good data indicate that a high proportion of these patients will be cured parasitologically.[117]

In contrast, the probability of parasitologic cure with full courses of either drug in adults with long-standing T cruzi infection, most of whom were infected while quite young, is less than 10%.[118, 119, 120] Although such treatment suppresses the infection and reduces the likelihood of isolation of parasites via xenodiagnosis or hemoculture after treatment, the overall effect of this transient suppression is unknown. No properly structured comparative trials have been completed to determine whether treatment imparts a long-term benefit in these patients. A detailed discussion of this issue that resulted from a 2-day meeting of a panel of Latin American and US Chagas experts late in 2006 has been published.[115]

A large, blinded, placebo-controlled trial of benznidazole therapy in persons with T cruzi infection is currently underway in Colombia, Argentina, and Brazil (the BENEFIT trial), but results will not be available until 2015.

Only one small study has been done supporting the concept that treatment of chronic infection in women prior to pregnancy reduces the probability of congenital transmission.[121] Likewise, no information is available on which to base guidance for prophylactic treatment of chronic infection in persons who will undergo immunosuppression (eg, pretransplant) or in persons who are already immunosuppressed (eg, those with HIV infection).

Chronic symptomatic Chagas disease

The consensus among experts is that persons who have already developed cardiac or gastrointestinal symptoms should not be given antiparasitic treatment.

General medical treatment

As with diagnostic procedures, the medical treatment of cardiac and gastrointestinal signs and symptoms attributable to Chagas disease is similar to that instituted for similar problems caused by other etiologies. Such patients should be referred to specialists for appropriate evaluation and management.

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Surgical Care

Cardiopathy

Atrial and ventricular rhythm disturbances may require pacemaker placement. Ablation procedures for tachyarrhythmias, as well as implanted defibrillators, have been used in some patients with Chagas disease.

The usefulness of implantable cardioverter devices in patients with advanced Chagas heart disease is controversial, and randomized clinical trials are needed to resolve this issue.[122, 123, 124, 125] This issue is currently being studied in a randomized controlled trial.

The usefulness of resection of the left ventricular apical aneurysms that develop in some patients with Chagas cardiomyopathy has not been established.

Cardiac transplantation is an option for some patients with end-stage Chagas heart disease. More than 100 such procedures have been performed, mostly in Brazil, but also in the United States. Interestingly, the survival rate among patients with Chagas disease who have undergone cardiac transplantation is better than that in the general group of patients who have undergone cardiac transplantation for other reasons,[126, 127] probably because the pathogenic process that results in cardiomyopathy in Chagas disease is not systemic, as is the case in diabetes mellitus, for example. Reactivation of the underlying T cruzi infection was a severe problem when the first such transplantations were performed in the late 1980s in Brazil; however, this is less of a problem now with the reduced dosing of immunosuppressives.[128, 129, 130]

Megaesophagus

Patients with Chagasic megaesophagus in whom esophageal dilatation is inadequate often undergo wide esophagocardiomyectomy of the anterior gastroesophageal junction, combined with valvuloplasty to reduce reflux. Laparoscopic myotomy is being used increasingly to manage severe megaesophagus.

Partial esophageal resection with reconstruction with esophagogastroplasty has been used in extreme cases.

Megacolon

Patients with chagasic megacolon may benefit from the Duhamel-Haddad operation typically used in the treatment of idiopathic congenital megacolon.[131]

In some cases, patients with sigmoid volvulus awaiting the Duhamel-Haddad procedure have undergone anterior sigmoidostomy with an eventual resection of the necrosed segment.

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Consultations

Depending on the phase of T cruzi infection, the following consultations may be appropriate:

  • Infectious diseases specialist
  • Cardiologist and cardiac surgeon
  • Gastroenterologist and general surgeon
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Diet

A diet appropriate for patients with congestive heart failure should be recommended as appropriate.

Ingestion of warm and pasty food, in small volumes with water, is recommended in patients with megaesophagus. Such patients should not eat in the hours before bedtime to reduce the likelihood of regurgitation and aspiration.

A high-fiber diet is recommended in patients with chagasic megacolon.

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Activity

Activity should be as tolerated.

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Contributor Information and Disclosures
Author

Louis V Kirchhoff, MD, MPH Professor, Departments of Internal Medicine (Infectious Diseases) and Epidemiology, Carver College of Medicine and College of Public Health, University of Iowa; Staff Physician, Medical Service, Iowa City Veterans Affairs Medical Center; Professor of Clinical Medicine, SUNY Upstate Medical Center (2012-2013)

Louis V Kirchhoff, MD, MPH is a member of the following medical societies: American Association of Blood Banks, American Society of Tropical Medicine and Hygiene

Disclosure: Received salary from Goldfinch Diagnostics Inc. for equity owner; Received royalty from Quest Diagnostics Inc. for licensed technology; Received royalty from Abbott Laboratories, Inc. for licensed technology.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

John W King, MD Professor of Medicine, Chief, Section of Infectious Diseases, Director, Viral Therapeutics Clinics for Hepatitis, Louisiana State University Health Sciences Center; Consultant in Infectious Diseases, Overton Brooks Veterans Affairs Medical Center

John W King, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Federation for Medical Research, Association of Subspecialty Professors, American Society for Microbiology, Infectious Diseases Society of America, Sigma Xi

Disclosure: Nothing to disclose.

Chief Editor

Pranatharthi Haran Chandrasekar, MBBS, MD Professor, Chief of Infectious Disease, Program Director of Infectious Disease Fellowship, Department of Internal Medicine, Wayne State University School of Medicine

Pranatharthi Haran Chandrasekar, MBBS, MD is a member of the following medical societies: American College of Physicians, American Society for Microbiology, International Immunocompromised Host Society, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Additional Contributors

Mary D Nettleman, MD, MS MACP, Professor and Chair, Department of Medicine, Michigan State University College of Human Medicine

Mary D Nettleman, MD, MS is a member of the following medical societies: American College of Physicians, Association of Professors of Medicine, Central Society for Clinical and Translational Research, Infectious Diseases Society of America, Society of General Internal Medicine

Disclosure: Nothing to disclose.

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Chagas disease (American trypanosomiasis). The trypomastigote is the infective flagellated form of the parasite found in the blood of the mammalian hosts (blood trypomastigote) and in the hindgut of vectors (metacyclic trypomastigote). Image courtesy of Peter Darben, MD.
Chagas disease (American trypanosomiasis). The epimastigote form of Trypanosoma cruzi is the multiplying stage of the parasite that grows in the gut of the insect vector and also in cell-free culture medium as shown here. Image courtesy of Peter Darben, MD.
Chagas disease (American trypanosomiasis). Megacolon.
Life cycle of triatomines. Courtesy of the CDC.
Trypanosoma cruzi trypomastigotes in a mouse blood smear (Giemsa, x625). Courtesy of Dr. Herbert B Tanowitz, New York, NY.
Rhodnius prolixus, a common vector of Trypanosoma cruzi. Eggs, first- and second-stage nymphs, and adult.
Trypanosoma cruzi in heart muscle of a child who died of acute Chagas disease in Texas. (H&E, x900).
Chest radiograph of a Bolivian patient with chronic Trypanosoma cruzi infection, congestive heart failure, and rhythm disturbances. Pacemaker wires can be seen in the area of the left ventricle.
Barium swallow radiographic study of a Brazilian patient with chronic Trypanosoma cruzi infection and megaesophagus. The markedly increased diameter of the esophagus and its failure to empty are typical findings in patients with megaesophagus caused by Chagas disease. Courtesy of Dr. Franklin A. Neva, Bethesda, MD.
Air-contrast barium enema of a Bolivian patient with chronic Chagas disease and megacolon. The markedly incrased diameters of the ascending, transverse, and sigmoid segments of teh colon are readily apparent.
Natural course of American trypanosomiasis. Courtesy of Dr. Patricia Paredes, Guadalajara, Jal., Mexico.
 
 
 
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