Trypanosomiasis Treatment & Management

Updated: Mar 16, 2016
  • Author: Germaine L Defendi, MD, MS, FAAP; Chief Editor: Russell W Steele, MD  more...
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Treatment

Medical Care

The acute phase of trypanosomiasis (Chagas disease) is treated with nifurtimox or benznidazole. [47, 48, 49, 50] 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. [51]

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. [52] Recommendations continue to evolve, as neither of the available drugs is well-tolerated, treatment failures have been reported , [53] and alternatives are lacking. [54, 55]

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 for those 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 good results have been achieved with second dilations. Surgical approaches for chagasic megaesophagus are reserved for use when repeat dilation fails and for the most severe cases with dolichomegaesophagus.

Patients with Chagas disease in the early stages of colonic dysfunction can be treated employing a high-fiber diet and increased fluid intake, as well as laxatives. These patients occasionally require enemas to evacuate the bowel.

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 colonic 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 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 has positive reports of 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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