Chagas Reactivation Research Articles

(1141) - An Elusive Chagas Reactivation Mimicking an Acute Cellular Rejection After a Heart Transplant: The Importance of Pursuing the Diagnosis

(1141) - An Elusive Chagas Reactivation Mimicking an Acute Cellular Rejection After a Heart Transplant: The Importance of Pursuing the Diagnosis

HIV and Chagas Disease: An Evaluation of the Use of Real-Time Quantitative Polymerase Chain Reaction to Measure Levels of Trypanosoma cruzi Parasitemia in HIV Patients in Cochabamba, Bolivia.

This cross-sectional study evaluated epidemiologic characteristics of persons living with HIV (PWH) coinfected with Trypanosoma cruzi in Cochabamba, Bolivia, and estimated T. cruzi parasitemia by real-time quantitative polymerase chain reaction (qPCR) in patients with and without evidence of reactivation by direct microscopy. Thirty-two of the 116 HIV patients evaluated had positive serology for T. cruzi indicative of chronic Chagas disease (27.6%). Sixteen of the 32 (50%) patients with positive serology were positive by quantitative polymerase chain reaction (qPCR), and four of the 32 (12.5%) were positive by direct microscopy. The median parasite load by qPCR in those with CD4+ <200 was 168 parasites/mL (73-9951) compared with 28.5 parasites/mL (15-1,528) in those with CD4+ ≥200 (P = 0.89). There was a significant inverse relationship between the degree of parasitemia estimated by qPCR from blood clot and CD4+ count on the logarithmic scale (rsBC= -0.70, P = 0.007). The correlation between T. cruzi estimated by qPCR+ blood clot and HIV viral load was statistically significant with rsBC = 0.61, P = 0.047. Given the significant mortality of PWH and Chagas reactivation and that 57% of our patients with CD4+ counts <200 cells/mm3 showed evidence of reactivation, we propose that screening for chronic Chagas disease be considered in PWH in regions endemic for Chagas disease and in the immigrant populations in nonendemic regions. Additionally, our study showed that PWH with advancing immunosuppression have higher levels of estimated parasitemia measured by qPCR and suggests a role for active surveillance for Chagas reactivation with consideration of treatment with antitrypanosomal therapy until immune reconstitution can be achieved.

Venous Thromboembolism as an Initial Manifestation of COVID-19 in a Heart Transplant Patient

IntroductionThe disease caused by the coronavirus 2019 (COVID-19) is mainly characterized by symptoms related to the upper respiratory tract associated with fever and constitutional symptoms, progressing in the most severe cases to pneumonia and severe acute respiratory syndrome (SARS). However, due to the increasing number of cases, atypical presentations have been found. Among them, thromboembolic manifestations stand out, since the virus itself seems to predispose to changes in the coagulation system.Case ReportA 62-year-old male patient who underwent cardiac transplantation 6 months ago, secondary to chagasic cardiomyopathy, had pain and edema in his left foot for 1 week. Upon admission, he was eupneic, afebrile, heart rate of 96bpm, blood pressure of 120 × 70mmhg, with edema and erythema on his left foot. Chagas reactivation, cellulite or deep vein thrombosis were the diagnostic hypotheses suggested. Soft tissue ultrasound and venous doppler of the left lower limb were compatible with deep venous thrombosis and superficial thrombophlebitis. Skin lesion biopsy confirmed Chagas reactivation. Antibiotic therapy with cefazolin, full anticoagulation with enoxaparin and treatment with benzonidazole were introduced. In the second day of hospitalization, patient presented myalgia and dry cough, in addition to an increased C-reactive protein and multiple ground-glass opacities on computed tomography of the chest, suggestive of COVID-19. This finding was corroborated by a positive result of RT-PCR for SARS-COV2. The patient evolved with SARS, requiring progressive use of vasoactive drugs, mechanical ventilation and pronation.SummaryIt is currently known that COVID-19 increases the risk of thromboembolic events, especially in hospitalized patients, reaching an incidence of 25%, even in the presence of effective prophylaxis. Several mechanisms have been proposed for this association, but not with robust evidence. Despite these increased cases, there are no reports in the literature of initial presentation with a thromboembolic event in a heart transplant patient, emphasizing the importance of clinical suspicion and appropriate investigation.

Long-Term Survival Outcomes after Heart Transplantation in Patients with Chagas Cardiomyopathy

We report the long-term survival of heart transplant (HT) patients with a diagnosis of Chagas cardiomyopathy. The UNOS database was queried for HT candidates with a pre-transplant diagnosis of Chagas cardiomyopathy (1987-2019). Post-HT survival was followed over the ensuing 120 months. Demographics, comorbidities, hemodynamics were compared using standard statistical methods. Multivariate Cox-proportional hazard regression analysis (adjusted for age, sex, diabetes, ethnicity, ischemic time, dialysis, life support and HLA mismatch) was also performed for survival analysis. 38 patients with Chagas cardiomyopathy received HT. The Chagas group tended to be older recipients (Mean 52.6 ± 8.2 vs. 46.7 ± 19.2 years, p=0.053) and have older donors (Mean 28.2 ± 14.0 vs. 32.4 ± 11.2 years, p=0.063). Ethnic composition was significantly different (p<0.001) between the two groups, with Hispanic patients accounting for 92.1% of transplanted Chagas patients. While Chagas patients were more likely to have required VAD support prior to HT (p=0.001), there were no differences in patient waitlist time or ischemic time. Post-HT overall survival through 120 months was significantly higher in Chagas patients (Figure, p=0.0342). Long-term survival after HT in carefully selected patients with a diagnosis of Chagas cardiomyopathy is shown to be favorable as compared to that of non-Chagas patients. The proportion of patients with this disease may be underestimated and their increased recognition is prudent given the adverse consequences to Chagas reactivation post-HT.

Chagas’ Disease Reactivation after Heart Transplant: Update on New Immunosuppression Era

Chagas’ disease is one of the most frequent etiology of heart failure in patients submitted to heart transplant in Latin America. Incidence of Chagas cardiomiopathy is also increasing in developed countries. Reactivation of Chagas' disease may occur after transplantation, leading to higher morbidity and graft dysfunction. There is lack of data in incidence of reactivation in the last decade. The aim of this study is to evaluate the incidence of Chagas' disease reactivation on new immunosuppression era.

Heart Transplantation for Chagas Cardiomyopathy

Chagas cardiomyopathy (CC) is one of the chronic manifestations of Trypanosoma cruzi (T. cruzi) infection and is a major public health disease in Latin America. Since it is a chronic systemic infection, Chagas disease was long considered a potential contraindication for transplantation because of the risk of recurrence with immunosuppression. However, early South American experience in the 1980's established the feasibility of heart transplantation (HT) in patients with Chagas disease. Indeed, the first cardiac transplant for a recipient with CC was performed in 1985 in Brazil. Chagas etiology of heart failure has become the third most common indication for HT in South America. T. cruzi reactivation post-transplant is a common issue that requires prophylactic surveillance but responds well to appropriate therapy. Chagas reactivation has been associated with the potency of the immunosuppressive protocol and occurs more frequently after rejection episodes. Yet, many important questions regarding the management of Chagas HT candidates and recipients remain unanswered. For example, biventricular systolic failure is frequent in end-stage CC, but its impact on the modality of mechanical circulatory bridging has not been described. Also, there is no consensus regarding the most adequate immunosuppressive regimen that balances the risk of graft rejection and disease reactivation. The real efficacy and safety of HT for end-stage CC will only be appreciated when a Latin American transplant registry is established. This review covers the current state of the art of HT for CC.

Trypanozoma cruzi Infection in Patients Undergoing Solid Organ Transplantation

BackgroundIt is estimated that 1.5 million people are infected with T. cruzi in Argentina (4%). Chagas reactivation rate (R) in patients with solid organ transplantation (SOT) is around 33%, being higher in cardiac transplantation (Tx). ObjectiveTo describe the clinical characteristics, evolution, mortality, to evaluate reactivation risk factors and to analyze the usefulness of molecular tests in patients undergoing at SOT with Chagas’ disease risk (ChR) (R or Donor-derived transmission, -DT-), in a hospital in our country.MethodsRetrospective cohort from all the patients who received an SOT in our hospital from January 1988 to March 2017. All patients with ChR: either R or DT were analyzed. Inclusion: survival more 30 days and 6 months of follow-up or until death. We performed post-Tx monitoring with parasitaemia (Strout), and serial whole blood polymerase chain reaction (PCR) testing, weekly until 2 months, every 2 weeks until the sixth month and monthly until the year, later annual. PCR monitoring is done since 2006.ResultsWe performed 1932 SOT in 29 years: 54 SOT in patients with ChR, 46 chagasic recipients (CR) and 8 chagasic donors (CD) to negative recipient 24/46 (52%) presented R, (see Table 1), 4 had more than one episode. Time to first R was 67 days (r = 3–296, median 30 days). At the time of the R Strout was performed in 19 episode 13 were negative, PCR was positive in 10/10 of perfcormed test, 32% vs. 100% (P = 0.001). Clinical R: 5 episode in 4 patients (panniculitis 3, 1 with myocarditis, 1 myocarditis). Strout was negative in 2 of these, in the other episode monitoring had not been performed. Immunosuppression (IS): there were no differences in the IS, (induction and treatment of rejections). Reactivation: 21/24 responded to treatment, 2 spontaneously PCR-negative, 1 died. Mortality: 6/24 (25%) in pt. R and 2/17 (12%) in pt no R (P = ns), not related mortality. DT occurred in 1/ 3 liver and in 0/5 renal recipients.Type of TxAllReactivationClinicLiver (L)7867/26 (27%)1/7 (14%)Heart24113/23 (56%)2/13 (15%)Kidney (K)6132/5 (40%)1/2 (50%)Lung1051/2 (50%)0LK261/1 (100%0Others16100ConclusionPCR was more sensitive than Strout for detection of R or transmission. There was no clinical R in pt monitored by PCR. Also PCR sensitivity allow safe acceptance of Chagasic organs.Disclosures All authors: No reported disclosures.

Multiplex Real-Time PCR Assay Using TaqMan Probes for the Identification of Trypanosoma cruzi DTUs in Biological and Clinical Samples.

Background Trypanosoma cruzi has been classified into six Discrete Typing Units (DTUs), designated as TcI–TcVI. In order to effectively use this standardized nomenclature, a reproducible genotyping strategy is imperative. Several typing schemes have been developed with variable levels of complexity, selectivity and analytical sensitivity. Most of them can be only applied to cultured stocks. In this context, we aimed to develop a multiplex Real-Time PCR method to identify the six T. cruzi DTUs using TaqMan probes (MTq-PCR).Methods/Principal FindingsThe MTq-PCR has been evaluated in 39 cultured stocks and 307 biological samples from vectors, reservoirs and patients from different geographical regions and transmission cycles in comparison with a multi-locus conventional PCR algorithm. The MTq-PCR was inclusive for laboratory stocks and natural isolates and sensitive for direct typing of different biological samples from vectors, reservoirs and patients with acute, congenital infection or Chagas reactivation. The first round SL-IR MTq-PCR detected 1 fg DNA/reaction tube of TcI, TcII and TcIII and 1 pg DNA/reaction tube of TcIV, TcV and TcVI reference strains. The MTq-PCR was able to characterize DTUs in 83% of triatomine and 96% of reservoir samples that had been typed by conventional PCR methods. Regarding clinical samples, 100% of those derived from acute infected patients, 62.5% from congenitally infected children and 50% from patients with clinical reactivation could be genotyped. Sensitivity for direct typing of blood samples from chronic Chagas disease patients (32.8% from asymptomatic and 22.2% from symptomatic patients) and mixed infections was lower than that of the conventional PCR algorithm.Conclusions/SignificanceTyping is resolved after a single or a second round of Real-Time PCR, depending on the DTU. This format reduces carryover contamination and is amenable to quantification, automation and kit production.

Prevalência das Coinfecções em Pacientes Notificados com Aids no Centro de Referência na Paraíba

Objective: To identify the prevalence of co-infections and opportunistic infections, as well as the main clinical signs and symptoms in patients diagnosed with AIDS in the state of Paraiba, Brazil. Material and Methods: This was an epidemiological observational study, with descriptive and retrospective nature, and quantitative approach. We used secondary data from the SINAN-AIDS database of the Reference Center for AIDS of the state of Paraiba. The study population consisted of all the patients notified and diagnosed with AIDS between January 2007 and December 2012. Results: Of the 3,019 patients analyzed, 66.7 % were men and 33.3 % were women. The adapted CDC criterion was the most commonly used for notification of AIDS. Nonspecific manifestations are among the most prevalent clinical conditions, such as cough, fever, cachexy, asthenia and diarrhea. Others diseases with high prevalence were: oral and esophageal candidiasis, pulmonary and extrapulmonary tuberculosis, cerebral toxoplasmosis, herpes zoster and central nervous system disorders. In the six-year period of analysis, there were no detected cases of chronic intestinal cryptosporidiosis, primary lymphoma of the brain and reactivation of Chagas' disease (meningoencephalitis or myocarditis). Conclusion: The knowledge about the prevalence of certain common symptoms and co-infections may support the Reference Center for AIDS, in the state of Paraiba, to develop interventional strategies. By knowing the patients with AIDS and their real needs, we can improve their quality of life and treatment. DESCRIPTORS Acquired Immunodeficiency Syndrome. HIV Infections. Coinfection. Epidemiology.

Reactivation of Chagas’ disease: cutaneous manifestations in two immunosuppressed patients

Chagas' disease is a zoonosis caused by a protozoan agent, Trypanosoma cruzi. Patients undergoing immunosuppressive treatment due to organ transplant, malignancies, infections, or chemotherapy may reactivate a preexisting chronic or indeterminate Trypanosoma cruzi infection. We present two transplant patients who underwent reactivation of Chagas' disease with cutaneous manifestations after an augmentation in their immunosuppressive therapy. A 38-year-old man was hospitalized on day 69 after receiving an allogeneic bone marrow transplant; he developed multiple painful erythematous plaques with diffuse borders, confined to the right cheek, trunk, thigh, elbows, and feet. A 59-year-old woman with a 14-year history of Chagasic cardiomyopathy presented one month after heart transplantation with a painful infiltrated purpuric plaque on the back of her right leg. In both cases, histologic examination of skin biopsies showed dermal infiltration with intrahistiocytic amastigotes. In one of the reported cases, the Strout method detected parasitemia. Treatments with nifurtimox (600 mg/d) in case 1 and benznidazole (400 mg/d) in case 2 were started. Fever and cutaneous lesions resolved immediately after seven days of treatment. Reactivation of Chagas' disease is a serious complication that usually occurs in immunocompromised patients. Clinical manifestations include febrile illness occasionally associated with painful skin lesions. Early diagnosis and proper treatment can significantly improve these patients' outcome.

Heart Transplantation in 107 Cases of Chagas' Disease

Introduction Chagas' disease is endemic in South America. Objective This research reviewed the experience with cardiac transplantation in Chagas' disease, emphasizing reactivation, immunosuppression, and mortality. Methods Over 25 years from March 1985 to March 2010, 107/409 (26.2%) patients with Chagas' disease underwent heart transplantation, patients including 74 (71.1%) men and 72 (67.2%), in functional class IV with 33 (30.8%) on vasopressors and 17 (10.7%) on mechanical circulatory support. Results The diagnosis of disease reactivation was performed by identifying the parasite in the myocardium ( n = 23; 71.8%) in the subcutaneous tissue ( n = 8; 25.0%), in blood ( n = 11; 34.3%), or in central nervous tissue ( n = 1; 3.1%). Hospital mortality was 17.7% ( n = 19) due to infection ( n = 6; 31.5%), graft dysfunction ( n = 6; 31.5%), rejection ( n = 4; 21.1%), or sudden death ( n = 2; 10.5%). Late mortality was 27 (25.2%) cases, which were distributed as: rejection ( n = 6; 22.2%), infection ( n = 6; 22.2%), ( n = lymphoma 4; 14.8%), sarcoma ( n = 2; 7.4%), for constrictive pericarditis ( n = 2; 7.4%) reactivation of Chagas' disease in the central nervous system ( n = 1; 7.1%). Conclusions Transplantation in Chagas' disease has peculiar problems that differ from other etiologies due to the possibility of disease reactivation and the increased possibility of emergence of cancers. However, transplantation is the only treatment able to modify the natural progression of the disease in its terminal phase. Early diagnosis and rapid introduction of benzonidazole reverses the histological patterns. Immunosuppression, especially steroids, predisposes to the development of cancer and disease reactivation.

Molecular Identification ofTrypanosoma cruziDiscrete Typing Units in End‐Stage Chronic Chagas Heart Disease and Reactivation after Heart Transplantation

One hundred years after the discovery of Chagas disease, it remains a major neglected tropical disease. Chronic Chagas heart disease (cChHD) is the most severe manifestation. Heart transplantation is the proper treatment for end-stage heart failure, although reactivation of disease may result after receipt of immunosuppressive therapy. T. cruzi strains cluster into 6 discrete typing units (DTUs; I-VI) associated with different geographical distribution, transmission cycles and varying disease symptoms. In the southern cone of South America, T. cruzi II, V, and VI populations appear to be associated with Chagas disease and T. cruzi I with sylvatic cycles. Molecular characterization of DTUs, T. cruzi I genotypes (on the basis of spliced-leader gene polymorphisms), and minicircle signatures was conducted using cardiac explant specimens and blood samples obtained from a cohort of 16 Argentinean patients with cChHD who underwent heart transplantation and from lesion samples obtained from 6 of these patients who presented with clinical reactivation of Chagas disease. Parasite persistence was associated with myocarditis progression, revealing T. cruzi I (genotype Id) in 3 explant samples and T. cruzi II, V, or VI in 5 explant samples. Post-heart transplantation follow-up examination of bloodstream DTUs identified T. cruzi I in 5 patients (genotypes Ia or Id) and T. cruzi II, V, or VI in 7 patients. T. cruzi I, V, and VI were detected in skin chagoma specimens, and T. cruzi V and VI were detected in samples obtained from patients with myocarditis reactivations. Multiple DTUs or genotypes at diverse body sites and polymorphic minicircle signatures at different cardiac regions revealed parasite histotropism. T. cruzi I infections clustered in northern Argentina (latitude, 23 degrees S-27 degrees S), whereas T. cruzi II, V, or VI DTUs were more ubiquitous. Multiple DTUs coexist in patients with Chagas disease. The frequent finding of T. cruzi I associated with cardiac damage was astounding, revealing its pathogenic role in cChHD at the southern cone.

Chagas’ disease and HIV co-infection in patients without effective antiretroviral therapy: prevalence, clinical presentation and natural history

The objectives of this study were to establish the prevalence of Chagas' disease among HIV seropositive patients and to define the clinical profile of co-infected cases. Cross-sectional study: the prevalence of co-infected subjects was 1.3% and there was no significant difference between co-infected and non co-infected patients relative to race, birthplace, home address and CD4 T cells. The co-infected group comprised predominantly women and mean age and median viral load were higher. Longitudinal study: included 20 patients (12 women) and described the clinical presentation and natural history of concomitant infections. The mean follow-up time was 35.8 months, mean age was 43+/-8.7 years and 60% of patients were white. During the follow-up, a total of 113 serological tests for Chagas' disease were performed: 89 (78.8%) were reactive/positive, 21 (18.6%) were doubtful and three (2.6%) were non-reactive/negative. Positive results for xenodiagnosis were high (81%). At the baseline evaluation, thirteen patients had the indeterminate form of Chagas' disease and seven cardiopathy. One patient developed from indeterminate to digestive form, three had a reactivation of Chagas' disease in the central nervous system, all had parasitological confirmation and received specific treatment. There were 11 deaths. Thus, HIV-infected patients should be tested for Chagas' disease when epidemiologically relevant.

Reativação da doença de Chagas com envolvimento do sistema nervoso central durante tratamento de linfoma não Hodgkin

Estados de imunossupressão têm provocado mudanças na história natural da doença de Chagas com descrição de reativação da doença em pacientes com a Síndrome de Imunodeficiência Adquirida (AIDS), durante transplantes de órgãos e em quimioterapia de malignidades hematológicas. É relatado caso de reativação de doença de Chagas com meningoencefalite durante quimioterapia de linfoma não Hodgkin não relacionado a transplante de células-tronco hematopoéticas com tardia detecção de Trypanosoma cruzi em sangue e líquido cefalorraquidiano. Apesar de tratamento específico com benzonidazol, paciente morreu após oito dias. Alta suspeição clínica com abordagens diagnósticas sensíveis é fundamental para diagnóstico precoce e início de tratamento com objetivo de diminuir mortalidade.

Evaluación de las pruebas de PCR TcH2AF-R y S35-S36 para la detección de Trypanosoma cruzi en tejido cardiaco de ratón

Heart transplant is a therapeutic option in the treatment of chagasic cardiomyopathy. For early detection of Chagas reactivation cases, the use of PCR tests using endomyocardial biopsies has been proposed. Development of an animal model will be the first step in evaluating the applicability of this approach. PCR tests based on the TcH2AF-R and S35-S36 primers were evaluated for the detection of T. cruzi in heart tissue of mice experimentally infected with the parasite. Two groups of ICR mice of 15 and 10 individuals were infected by intraperitoneal injection with 0.3 ml of PBS containing 1 x 10(6) trypomastigotes of the MHOM/CO/2001/D.A. (T. cruzi I) strain or 1 x 10(4) trypomastigotes of MHOM/BR/00/Y (T. cruzi II) strain. Parasitemia and cardiac parasitic infection were determined at 30, 60 (acute model), 100 and 150 (chronic model) days by means of histopathological examination and by PCR, using the TcH2AF-R and S35-S36 primers. The histopathological findings revealed alterations in the heart and the presence of intracellular amastigotes in acute and chronic models. In contrast to parasitemia levels and histopathological analyses, S35-S36 PCR detected infections in mice that were infected with either parasite strain. TcH2AF-R PCR detected T. cruzi I-infected mice earlier and more frequently than inspection for parasitemia or histopathological examination. Applying PCR tests with both primers proved superior for Chagas disease confirmation over currently standard detection methods.

Molecular Identification of Trypanosoma cruzi I Tropism for Central Nervous System in Chagas Reactivation Due to AIDS

Trypanosoma cruzi lineages, microsatellite allelic polymorphism, and mithocondrial gene haplotypes were directly typified from peripheral blood and cerebrospinal fluid specimens of a Bolivian patient with Chagas disease with accompanying AIDS and central nervous system severe involvement. Of note, the patient's blood was infected by a mixture of T. cruzi I and T. cruzi IId/e polyclonal populations while the cerebrospinal fluid showed only a monoclonal T. cruzi I population. Our findings do not corroborate the original assumption of innocuity for T. cruzi I in the southern cone of the Americas and highlight lineage I tropism for central nervous system causing lethal Chagas reactivation.

Late Reactivation of Chagas’ Disease Presenting in a Recipient as an Expansive Mass Lesion in the Brain after Heart Transplantation of Chagasic Myocardiopathy

Chagas' disease is endemic in many Latin American countries. In the last decades, millions of people from these countries have migrated to the United States, changing the scenario of acute Chagas' disease associated with blood transfusion in North America. We report the case of a chagasic patient who developed intracranial hypertension and focal neurologic signs 7 months after heart transplantation. Immunosuppression after transplantation was achieved with prednisone, cyclosporine A, and mycophenolate mofetil. Cranial magnetic resonance imaging revealed a right temporoparietal mass lesion with surrounding edema. Trypanosoma cruzi was observed in the cerebrospinal fluid by Giemsa method, and autopsy disclosed a cerebral chagoma with amastigote forms of T cruzi, with neither associated myocarditis nor systemic infection. In chagasic patients who undergo heart transplantation and immunosuppression, the risk of late reactivation of Chagas' disease by means of an isolated cerebral mass lesion must be considered.

Chagas’ disease reactivation with skin symptoms in a patient with kidney transplant

Immunodepressed patients in the intermediate phase of Chagas' disease may undergo reactivation of the disease together with atypical symptoms. The case of an immunodepressed kidney transplant patient with reactivation of Chagas' disease with skin symptoms is reported. A 65-year-old man presented with infiltrated erythematous lesions on the anterior aspect of the right thigh of 2 weeks' duration. The lesions later extended to the abdomen, thorax, and lower limbs. In the histologic skin examination, amastigotes and Trypanosoma cruzi trypoamastigotes were observed. A fresh smear showed positive parasitemia. Using the Strout hemoconcentration method, multiple Trypanosoma cruzi trypoamastigotes with motility could be seen. Polymerase chain reaction was positive for Trypanosoma cruzi. An immunofluorescence test was positive (1 : 64) and there was hemoagglutination (1 : 32). Treatment was started with benznidazole, 7 mg/kg/day. The patient did not evolve favorably and died 20 days after hospitalization. Skin lesions may be a manifestation of the reactivation of Chagas' disease in immunosuppressed patients. All patients with positive Chagas' serology who require immunosuppressant drugs should receive specific treatment for Chagas' disease.

Usefulness of PCR Strategies For Early Diagnosis of Chagas' Disease Reactivation and Treatment Follow-Up in Heart Transplantation

Heart transplantation (HTx) is a useful therapy for end-stage Chagaś cardiomyopathy; however, Chagas reactivation remains a mayor complication. Parasitological methods offer poor diagnostic sensitivity, and use of more sensitive tools such as the Polymerase chain reaction (PCR) is usually necessary. In the present study, reactivation incidence and PCR usefulness for early reactivation diagnosis, as well as for treatment response evaluation during follow-up, were analyzed using Strout parasite detection test, in 10 of 222 consecutive HTx patients suffering Chagas cardiomyopathy. PCR strategies targeted to minicircle sequences (kDNA, detection limit 1 parasite/ 10 mL blood) and miniexon genes (SL-DNA, 200 parasite/10 mL) were performed to compare parasite burdens between samples. No patients received prophylactic antiprotozoal therapy (benznidazole). Five patients (50%) exhibited clinical reactivation within a mean period of 71.6 days; positive Strout results were observed in most cases presenting clinical manifestations. kDNA-PCR was positive 38-85 days before reactivation, whereas SLDNA-PCR became positive only 7-21 days later, revealing post-HTx parasitic load enhancement present prior to clinical reactivation development. Reactivations were successfully treated with benznidazole and generated negative PCR results. Results observed in this study indicate the value of PCR testing for an early diagnosis of Chagas reactivation as well as for monitoring treatment efficacy.

Chagas disease in a recipient of cord blood transplantation

American trypanosomiasis, or Chagas' disease, is caused by a protozoan, Trypanosoma cruzi. It is endemic in Latin America where it represents a major public health problem. Chagas' disease also occurs in non-endemic areas where it can be acquired by blood transfusion, congenital transmission and organ transplantation. The disease can be fatal in immunosuppressed patients.1 We report a case of reactivation of Chagas' disease (acute form) in a patient who underwent cord blood transplantation in a non-endemic European country.