High Rate of Reactivation of Chagas Disease after Heart Transplantation in the United States

Abstract

Purpose Chagas cardiomyopathy (CC) is a common indication for heart transplant (HTx) in endemic countries, but uncommon in the U.S. Given the potential for reactivation (react) of the causative agent Trypanosoma cruzi (TC) with immunosuppression, close monitoring for TC react is required.We sought to determine the rate of TC react in patients undergoing HTx for CC at a U.S. transplant center. Methods and Materials Serological testing for TC was performed using a whole epimastigote immunofluorescence assay and Chagatest ELISA recombinante v.3.0 (Wiener Laboratorios). After HTx, clinical surveillance for react comprised of: 1) serial clinical evaluation 2) echocardiography, and 3) heart biopsy to assess for presence of amastigotes. Positivity for any of these features was considered as clinical react of TC. Lab surveillance for react comprised of: 1) microscopy of a buffy coat blood sample for TC and 2) whole blood real-time polymerase chain reaction (PCR) testing for TC at the Reference Diagnostic Laboratory of the Division of Parasitic Diseases and Malaria at the CDC. All clinical reacts were treated. Reacts based on positive PCR results (“PCR reactivation”) were treated, except in 1 patient where repeat testing was negative. Results Between June 2006 and January 2011, 11 patients underwent HTx for CC. Two patients were lost to follow up. Two patients experienced clinical react, occurring 100 days and 216 days post-HTx. Four patients experienced PCR react at an average of 23 days post-HTx. Two patients with clinical react and 3 with PCR react were treated for TC (nifurtimox 1 patient and benznidazole 4 patients). One patient w/clinical react died due to cardiogenic shock, whereas the other 5 patients are alive at a median of 399 days post-HTx. Conclusions React of TC is common after HTx, occurring in 67% of patients, at an average of 68 days post-HTx. React is associated with mortality and therefore close clinical/laboratory monitoring is essential. Antibiotic prophylaxis requires further investigation.