Letters to the Editor

Chagas Disease as Secondary Cause of Cardiomyopathy



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Am Fam Physician. 2010 Feb 15;81(4):407-414.

Original Article: Cardiomyopathy: An Overview

Issue Date: May 1, 2009

Available at: http://www.aafp.org/afp/2009/0501/p778.html

to the editor: Chagas disease, caused by infection with Trypanosoma cruzi, should have been included in Table 2 of this article as one of the potential secondary causes of inflammatory cardiomyopathy. T. cruzi is transmitted by various species of bloodsucking “kissing bugs” from the Triatominae subfamily, and is present in many animal species spread throughout most of the United States.1 Chagas disease is a significant public health problem, especially in Central and South America where an estimated 10 million people are still infected with T. cruzi.2 Chagas disease reaches North America through immigration,1 and an estimated 14 million people from countries where Chagas disease is endemic are living in non-endemic areas.3

The heart is the organ most commonly affected in chronic Chagas disease4, and up to 30 percent of affected persons develop a chronic inflammatory cardiomyopathy years or even decades after the initial infection.2 It is possible that many cases of Chagas' cardiomyopathy are being misdiagnosed.

Chronic T. cruzi infection is usually detected through various serologic antibody tests.4 Exposure history can usually be identified, typically attributed to current or previous residence in endemic areas or blood transfusions and solid organ transplantation from infected persons.1

As the article points out, treatment for various cardiomyopathies is directed at treating the underlying disease, reducing symptoms and complications of heart failure, and suppressing arrhythmias. Anti-infectives do not appear to be effective in patients with chronic Chagas cardiomyopathy.5 The heart failure associated with Chagas disease is treated as is cardiomyopathy due to other causes, which includes beta blockers, angiotensin-converting enzyme inhibitors, and diuretics. Treatment of chronic Chagas disease includes monitoring for arrhythmias, as there is a role for pacemaker/defibrillator implantation in the primary and secondary prevention of sudden cardiac death.6

Author disclosure: Nothing to disclose.

REFERENCES

1. Milei J, Guerri-Guttenberg RA, Grana DR, Storino R. Prognostic impact of Chagas disease in the United States. Am Heart J. 2009;157(1):22–29.

2. Bilate AM, Cunha-Neto E. Chagas disease cardiomyopathy: current concepts of an old disease. Rev Inst Med Trop Sao Paulo. 2008;50(2):67–74.

3. Senior K. Chagas disease: moving towards global elimination. Lancet Infect Dis. 2007;7(9):572.

4. Kirchoff LV. Trypanosoma Species (American Trypanosomiasis, Chagas' Disease): Biology of Trypanosomes. In: Mandell GL, Bennett JE, Dolin R. Principles and Practice of Infectious Diseases. 6th ed. Edinburgh: Elsevier Churchill Livingstone, 2004.

5. Weir E. Chagas disease: hidden affliction and visible neglect. CMAJ. 2006;174(8):1096.

6. Bestetti RB, Theodoropoulos TA, Cardinalli-Neto A, Cury PM. Treatment of chronic systolic heart failure secondary to Chagas heart disease in the current era of heart failure therapy. Am Heart J. 2008;156(3):422–430.

IN REPLY: I appreciate Dr. Junnila's commentary regarding Trypanosoma cruzi as a cause of cardiomyopathy. Though an extensive listing of causes of cardiomyopathy was not possible, T. cruzi does warrant special mention.

Transmission of T. cruzi commonly occurs in rural Latin America because of poor housing conditions and close contact with the primary vector, triatomine bugs.1 Most T. cruzi infections in the United States occur in patients who acquired the infection while living in endemic areas, and affects approximately 100,000 persons.2 Because of increased recognition of the T. cruzi infection owing to increased immigration from endemic areas, the U.S. Food and Drug Administration approved an assay for blood donor screening in 2006.3

Most infected persons will remain asymptomatic, but approximately 30 percent will progress clinically to overt disease, which most commonly affects the heart.1,4 Early on, symptoms are mainly related to conduction abnormalities resulting in right bundle branch block, but left ventricular wall motion abnormalities also occur.5 As the disease progresses, sustained ventricular tachycardia, heart block, thromboembolic disease, and dilated cardiomyopathy may occur.1,6 The underlying cause of cardiac dysfunction is believed to be caused by an autoimmune, as well as a parasite-driven immune response, which promotes an increase in cytokine and chemokine activity.4

Increased immigration from endemic areas and screening on the U.S. blood supply makes it increasingly likely that family physicians will encounter such patients in their practice. Patients with newly diagnosed T. cruzi should undergo a complete history and physical examination, and electrocardiogram (ECG) with rhythm strip.1 These patients should be followed with annual ECG to assess for cardiac changes.1 Family physicians should have a high index of suspicion for T. cruzi in cases of idiopathic cardiomyopathy in immigrants and travelers.

Author disclosure: Dr. Wexler has received research grants from CVRx, Inc., and the American Academy of Family Physicians Foundation. He also serves on the Data Safety Monitoring Board for CardioMems.

REFERENCES

1. Bern C, Montgomery SP, Herwaldt BL, et al. Evaluation and treatment of chagas disease in the United States: a systematic review. JAMA. 2007;298(18):2171–2181.

2. Leiby DA, Herron RM Jr, Read EJ, Lenes BA, Stumpf RJ. Trypanosoma cruzi in Los Angeles and Miami blood donors: impact of evolving donor demographics on seroprevalence and implications for transfusion transmission. Transfusion. 2002;42(5):549–555.

3. Centers for Disease Control and Prevention. Blood donor screening for chagas disease—United States, 2006–2007. MMWR Morb Mortal Wkly Rep. 2007;56(7):141–143.

4. Bilate AM, Cunha-Neto E. Chagas disease cardiomyopathy: current concepts of an old disease. Rev Inst Med Trop Sao Paulo. 2008;50(2):67–74.

5. Maguire JH, Hoff R, Sherlock I, et al. Cardiac morbidity and mortality due to Chagas' disease: prospective electrocardiographic study of a Brazilian community. Circulation. 1987;75(6):1140–1145.

6. Hagar JM, Rahimtoola SH. Chagas' heart disease. Curr Probl Cardiol. 1995;20(12):825–924.

Send letters to Kenneth W. Lin, MD, MPH, Associate Deputy Editor for AFP Online, e-mail: afplet@aafp.org, or 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2680.

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