Chagas disease panniculitis in a patient with AIDS

Abstract

Background: Chagas disease is an endemic trypanosomiasis in Latin America. Trypanososma cruzi is the etiological agent of the disease. The acute illness is usually self-limited due to a cell-mediated immune response that controls parasite replication, turning to a chronic phase characterized by lifelong low-grade parasitemia. Reactivation of Chagas Disease has been described in immunocompromised hosts. In HIV-infected patients, has been most commonly associated with meningoencephalitis and myocarditis. The following is a description and analysis of an AIDS patient who presented erythema nodosum associated with a reactivation of Chagas disease. Methods & Materials: A 56-year-old woman born in Santiago del Estero, Argentina was admitted with a history of fever, weight loss, non-productive cough and dyspnea lasting 6 months. She had lesions in her right arm and leg, and her left shoulder consisting in erythematous, indurate, painful plaques and nodules compatible with erythema nodosum. The lesions evolved with central ulceration. Test for antibodies to HIV were positive. Serological tests for Chagas disease resulted positive. Molecular diagnosis was performed from skin biopsy and cerebrospinal fluid samples. The DNA was extracted using QIAGEN Mini kit and tested by T. cruzi specific PCR (Tcz1 and Tcz2 primers). Results: Cytology study from a sample of one subcutaneous nodule performed by fine needle aspiration (FNA) revealed abundant histiocytes with intracytoplasmic amastigotes. A skin biopsy using H&E showed diffuse lympho-histiocytic infiltrate, abundant bluish-gray amastigotes (Giemsa stain positive) with round to oval bodies inside and outside the histocytes cytoplasm distributed along the epidermis. PCR from skin was positive and enabled the detection of T. cruzi in cerebrospinal fluid. The patient was empirically treated with cotrimoxazole and prednisone for Pneumocystis jirovecii. She started benznidazol 5 mg/kg/12 hours and by the 14th day HAART with tenofovir/emtricitabine and darunavir/ritonavir was initiated. The patient experienced a good clinical outcome, with no new skin lesions and no drug-related adverse reactions. Conclusion: The presence of parasites in the skin is unusual for Chagas disease. Finally, immunosuppressed patients, especially in endemic areas, should be investigated for T. cruzi infection and should be closely monitored during the immunosuppression.