Chronic Chagasic Cardiomyopathy Research Articles

Cardiac extrinsic neuropathy: Lesions of the mediastinal paraganglia in chronic chagasic cardiomyopathy

The pathology of cardiac innervation, both intrinsic and external to the heart (mediastinal paraganglia included), is scarcely known, yet it can be critical to life-threatening disorders in cardiac performance or to reflexes discharging outside the heart, or both. This article focuses on such a fundamental and ill-understood subject through an anatomoclinical outlook of mediastinal paraganglia lesions in the setting of sudden death in chronic chagasic cardiomyopathy.

Trypanosoma cruzi: Exposure of Murine Cells to Live Parasites in Vitro Leads to Enhanced Surface Class I MHC Expression Which Is Type I Interferon-Dependent

Previous reports indicate that myocardial cells from human patients with chronic Chagasic cardiomyopathy express increased levels of class I MHC molecules on their surfaces. To determine whether parasites can modulate class I expression. we have examined the effect of in vitro exposure to live Trypanosoma cruzi trypomastigotes on class I MHC expression by murine cells. Here we show that co-incubation of various murine cell lines, including 3T3 fibroblasts, J774.A1 macrophage-like cells, and freshly-explanted BALB/c primary embryo fibroblasts, with live trypomastigotes leads to a two- to fourfold increase in their expression of surface class I MHC molecules. Cell-Gee supernatants from T. cruzi-exposed cells, but not from either cells or parasites cultured alone, were also capable of upregulating class I expression, indicating the involvement of a soluble factor. Active supernatants were shown to contain IFN-α/β activity and their ability to upregulate class I was inhibitable by anti-IFN-α/β Abs. This ability of T. cruzi to enhance class I MHC expression on host cells via IFN-α/β induction could be an important factor in the initiation of host immunity and/or immune-mediated pathology.

Ventricular tachycardia during exercise testing as a predictor of sudden death in patients with chronic chagasic cardiomyopathy and ventricular arrhythmias.

To verify the prognostic value of exercise induced ventricular arrhythmias in patients with chagasic cardiomyopathy. 69 consecutive patients (37 male, 32 female; age range 21-67 years) with chronic chagasic cardiomyopathy and ventricular arrhythmias (more than 10 ventricular premature complexes per hour) were evaluated during treadmill exercise testing, using the Bruce protocol. Protocol end points were peak heart rate or presence of sustained ventricular tachycardia. Sudden cardiac death. 44 patients (group I) developed ventricular tachycardia during exercise testing (five sustained and 39 non-sustained), and 25 did not (group II). After a follow up of 24 (SD 15) months sudden cardiac death occurred in seven patients in group I and in none in group II (P < 0.05). Ventricular tachycardia on exercise testing is significantly associated with sudden cardiac death in patients with chronic chagasic cardiomyopathy and ventricular arrhythmias.

Immunohistochemical localization of laminin in the hearts of patients with chronic chagasic cardiomyopathy: Relationship to thickening of basement membranes

Histologic, ultrastructural, immunohistochemical studies were made of endomyocardial biopsy specimens from 10 patients with chronic chagasic cardiomyopathy. Histologic and electron microscopic observation disclosed marked thickening of the basement membranes of the myocytes, endothelial cells, and vascular smooth muscle cells in all patients. Light (peroxidase-labeled antibodies) and electron (gold-conjugated antibody) microscopic immunohistochemical methods revealed a positive reaction for laminin in these thickened basement membranes. This thickening of basement membranes may develop as a consequence of: (1) an immunologic reaction that is triggered by the presence of a laminin-like molecule on the surfaces of Trypanosoma cruzi amastigotes and trypomastigotes; (2) an immunologic response to direct injury of basement membranes causing some of their components to become antigenic; (3) myocardial fibrosis, with synthesis of new connective tissue components; and (4) a combination of the preceding factors. The relationship of these changes to antilaminin antibodies requires clarification.

Expression of major histocompatibility complex antigens and adhesion molecules in hearts of patients with chronic Chagas' disease.

We have previously reported that heart lesions in patients with chronic cardiac Chagas' disease are composed predominantly of granzyme A+, cytolytic CD8+ T lymphocytes. We now pursue this study in the immunopathology of chronic chagasic cardiomyopathy by investigation of the expression of HLA antigens, and adhesion molecules in the hearts of seven chagasic patients with cardiac disease, two asymptomatic chagasic patients, and seven normal controls. Comparative immunohistochemical analyses show that HLA-ABC antigen expression is enhanced on the myocardial cells of chagasic patients with chronic cardiomyopathy, suggesting a possible role for these cells as targets for the CD8+ cytolytic lymphocytes dominant in these lesions. The HLA-DR antigens are not observed on myocardial cells, but are consistently upregulated on the endothelial cells in the hearts of patients with chronic chagasic cardiomyopathy. Intercellular adhesion molecule is expressed by endothelial cells of both chagasic and nonchagasic individuals, but E-selectin was detected only on vessels of hearts from chagasic patients who had chronic cardiomyopathy. Most of the lymphocytes in these lesions express lymphocyte function antigen-1 (LFA-1), CD44, and very late antigen-4, and a few display weak expression of LFA-3. We propose that the expression of these adhesion molecules and major histocompatibility complex antigens by endothelial cells, myocardial cells, and lymphoid cells in these lesions contribute to the pathogenesis of chronic chagasic cardiomyopathy.

Characterization of inflammatory infiltrates in chronic chagasic myocardial lesions: presence of tumor necrosis factor-alpha+ cells and dominance of granzyme A+, CD8+ lymphocytes.

The inflammatory infiltrates in the heart lesions of chronic chagasic cardiomyopathy are composed predominantly of small lymphocytes with admixed macrophages, plasma cells, and segmented leukocytes. The phenotypes of the lymphoid cells in these infiltrates of human Chagas' disease have not been previously detailed. We used a panel of monoclonal and polyclonal antibodies to immunohistochemically characterize the inflammatory cells in frozen and fixed cardiac tissues from autopsied patients with severe chronic chagasic cardiomyopathy. In all cases, the inflammatory lesions were dominated by CD8+ lymphocytes, many of which expressed granzyme A. A few macrophage-like cells that expressed tumor necrosis factor-alpha were observed in each case. Relatively few natural killer cells or B lymphocytes were found in the lesions. These findings in human chagasic lesions are compatible with concepts that involve cytolysis and fibrosis, and new experimental findings that emphasize potential roles for CD8+ T cells in Chagas' disease.

Amplification of a Trypanosoma cruzi DNA sequence from inflammatory lesions in human chagasic cardiomyopathy.

The major cause of morbidity and mortality in Chagas' disease is a chronic inflammatory cardiomyopathy, which presents ten or more years following initial infection. Demonstration of Trypanosoma cruzi in cardiac tissue by routine microscopy or culture is difficult in these patients, which has suggested that persistent organisms are not required for chronic disease. Consequently, studies have focused on elucidating an autoimmune pathogenesis of chronic injury. To further assess the persistence of T. cruzi in host tissue, DNA extracted from formalin-fixed, paraffin-embedded autopsy specimens from seronegative or seropositive patients was amplified by the polymerase chain reaction using T. cruzi-specific primers. Trypanosoma cruzi DNA sequences were not consistently amplified from four seropositive patients who lacked evidence of fatal chronic chagasic cardiomyopathy (CCC) (0 positive of 12 heart samples, 0 positive of four gonadal samples, and 0 positive of four adrenal samples) or nine seronegative patients (0 positive of 27 heart samples, 0 positive of nine gonadal samples and 0 positive of nine adrenal samples). In seven seropositive patients with severe CCC, cardiac tissue adjacent to inflammatory infiltrates yielded amplified T. cruzi DNA sequences in 18 of 21 heart samples. Parallel testing of gonadal and adrenal tissues from these same patients produced detectable T. cruzi DNA in none of the gonadal tissue samples and one of the seven adrenals. Our studies demonstrate that T. cruzi, or a portion of its genome, is present in the inflammatory lesion of chronic cardiac Chagas' disease.

Antibodies to laminin and immunohistochemical localization of laminin in chronic chagasic cardiomyopathy: a review.

Antibodies against laminin were determined by ELISA in forty six patients suffering from Chagas' disease and twenty healthy persons (control group). The patients were divided into three groups according to the severity of clinical, electrocardiographic and echocardiographic studies. Histologic, ultrastructural and immunohistochemical studies were made of endomyocardial biopsy specimens from 10 of these patients with chronic Chagasic cardiomyopathy. Antibodies to laminin were detected in 50% of the patients in each of the three groups. However analysis of the data did not allow us to determine any significant correlation among the severity of the different clinical and non-invasive studies and the level of circulating antibodies to laminin. The highest titers of antilaminin antibodies were detected in the group with severe cardiological alterations (37% of the patients). Histological and electron microscopic observation of myocardial biopsies disclosed marked thickening of the basement membranes of the myocytes, endothelial cells and vascular smooth muscle cells. Light (peroxidase-labeled antibodies) and electron (gold-conjugated antibody) microscopic immunohistochemical methods revealed a positive reaction for laminin in these thickened basement membranes. This thickening may develop as a consequence of: a) an immunologic reaction which is triggered by the presence of a laminin-like molecule on the surfaces of T. cruzi amastigotes and trypomastigotes; b) an immunologic response to direct injury of basement membranes causing some of their components to become antigenic; c) myocardial fibrosis, with synthesis of new connective tissue components, and d) a combination of the preceding factors. The relationship of these changes to antilaminin antibodies remains unclear.(ABSTRACT TRUNCATED AT 250 WORDS)

Characterization of a natural human antibody with anti-galactosyl(alpha 1-2)galactose specificity that is present at high titers in chronic Trypanosoma cruzi infection.

An antibody reactive with the galactosyl(alpha 1-2)galactose [gal(alpha 1-2)gal] epitope was characterized in human sera by enzyme-linked immunosorbent assay, red blood cell (RBC) and laminin absorption, and oligosaccharide inhibition. This antibody was found evenly distributed between the IgG and IgM classes and was present at high titers in the serum of all normal adults studied, but in 75% of children less than three years of age, it was observed at the lower limit of detection, and gradually increased to adult levels by the age of six. Although this antibody bound to gal(alpha 1-3)gal-linked synthetic antigens, it did not bind to the same residues present in rabbit, rat, and guinea pig RBC or in murine laminin or nidogen. These latter results, plus the fact that antigen-antibody binding was strongly blocked by gal(alpha 1-2)gal but not by methyl-alpha-galactopyranoside or melibiose, suggest that this antibody is indeed different from anti-gal(alpha 1-3)gal antibody. Anti-gal(alpha 1-2)gal antibody levels were significantly elevated in 66% of patients with chronic chagasic cardiomyopathy, but were not elevated in patients with different clinical forms of leishmaniasis, Trypanosoma rangeli-infected patients, or in patients with 15 other infectious and inflammatory diseases. Gal(alpha 1-2)gal antibodies did not absorb to intact T. cruzi parasites, but absorbed strongly to trypomastigote and epimastigote sonicates, suggesting some masking of reactive epitopes.(ABSTRACT TRUNCATED AT 250 WORDS)

Endomyocardial biopsies in chronic chagasic cardiomyopathy. Immunohistochemical and ultrastructural findings.

Mononuclear cellular infiltrates and extensive fibrosis, with or without apical ventricular aneurysms, are the usual morphological findings in chronic chagasic cardiomyopathy. These lesions are thought to be mediated by immune phenomena rather than by continuing parasitic invasion of the heart. In the present report, we correlated clinical, immunohistochemical and ultrastructural findings in 30 endomyocardial biopsies from patients with chronic chagasic cardiomyopathy. In 12 of these biopsies, immunocytochemical techniques were used to identify and count leukocytes (common leukocyte antigen, CLA), T lymphocytes (UCHL-1 antibody) and B lymphocytes (L-26 antibody). The biopsy specimens showed variable degrees of myocardial hypertrophy and mononuclear infiltrates. No tissue forms of trypanosomes were found. The endocardium averaged 24 +/- 12.6 microns (mean +/- SD) in thickness. The mean myocyte diameter was 20 +/- 7.33 microns. The hearts were severely fibrotic containing a mean of 24.1 +/- 12.8% of fibrous tissue (range 8.2-49%), mast cells were scarce. Mononuclear cell infiltrates were found in 25 of the 30 biopsies. In 12 biopsies, immunohistochemical studies showed that the majority of the lymphocytes were T lymphocytes and associated with necrotic or degenerating myocytes. 10 of the 12 biopsy samples showed 5 or more CLA-positive mononuclear cells/high power field. In these 10 patients, T and B lymphocytes represented 32 and 13% of the total mononuclear infiltrating cells, respectively. The remaining cells were monocytes and macrophages.

Myocardial beta-adrenergic adenylate cyclase complex in a canine model of chagasic cardiomyopathy.

Infection of beagles with an opossum-derived strain of Trypanosoma cruzi (Tc-O) results in features of early and chronic chagasic cardiomyopathy, that is, increases in PR interval, atrioventricular block, and frequent ventricular premature contractions, ventricular tachycardia, and decreased left ventricular ejection fraction. These signs are not observed in animals infected with a canine strain of T. cruzi (Tc-D). To understand the biochemical basis for these early cardiac effects, we examined the beta-adrenergic adenylate cyclase complex in myocardial membranes prepared from animals infected with either of the two strains. In animals infected with Tc-O (symptomatic), the maximum velocity (Vmax) decreased and concentration of agonist resulting in 50% of Vmax (Kact) increased for isoproterenol-dependent adenylate cyclase activity; in animals infected with Tc-D (asymptomatic), Vmax and Kact for isoproterenol were unchanged from control, uninfected animals. beta-Receptor density decreased by 20% in symptomatic animals with no change in affinity, whereas no differences were observed between uninfected and infected asymptomatic animals. A complex pattern of changes was apparent in the guanine nucleotide binding protein, Gs, in the setting of infection. Alterations in cholera toxin-dependent ADP-ribosylation patterns as well as immunochemical detection with anti-G alpha s antisera suggested a change in the biochemical nature of the Gs species and not necessarily a physical loss of this protein. Reconstitution of adenylate cyclase activity in cyc- membranes demonstrated a decrease in hormone-sensitive Gs activity in membranes prepared from symptomatic animals without a change in activity demonstrable in the presence of Gpp(NH)p. Collectively, the results suggest that the depression in beta-adrenergic adenylate cyclase activity associated with symptomatic infection of beagles with T. cruzi occurs primarily as a result of changes in the Gs protein complex, most likely resulting in an uncoupling of the beta-adrenergic receptor from the Gs protein.

Dynamic cardiomyoplasty in chronic chagas' heart disease: Clinicopathological data

We report a 44-year-old man with chronic chagasic cardiomyopathy who underwent latissimus dorsi dynamic cardiomyoplasty and died 4 months later. The clinicopathological findings are discussed, and the literature is reviewed.

The pattern of myocardial fibrosis in chronic Chagas' heart disease

Observations are described on the fibrillar nature and structural features of the collagenous interstices of the human myocardium in chronic chagasic cardiomyopathy, comparing them with similar observations in normal hearts, using the picrosirius red technique and polarization microscopy. A total of 28 adult hearts obtained at autopsy were used: 5 control without evidence of cardiac disease, and 23 with chronic Chagas' heart disease. The findings in the myocardium of those without Chagas' disease were in keeping with those reported in the literature. In those with Chagas' disease diffuse interstitial fibrosis could be observed in all cases, albeit to varying degree. The pattern was that of a diffuse increase in the amount of thick collagen fibers surrounding bundles of muscle fibers (perimysial matrix), varying in intensity from one area to another, and around the intramyocardial coronary vessels, combined with a less pronounced increase in the matrix of endomysial collagen. The relationship between the observed myocardial fibrosis and cardiac function, and the potential mechanisms for its production, are discussed. Further research is needed into the patterns and pathogenesis of myocardial fibrosis in order possibilities for prevention and development of corrective forms of therapy for the fibrotic process.

Pathophysiological insights into the cardiomyopathy of Chagas' disease.

The evidence gained from both human and animal studies of chronic chagasic cardiomyopathy suggests that the disease occurs as a consequence of several discrete and progressive pathophysiological processes occurring after infection, the ultimate expression of which depends on a host of unidentified factors. Collectively, the infection-associated events compromise microvasculature function and result in hypoperfusion, with consequences indistinguishable from those observed in other, nonparasitological cardiomyopathic diseases secondary to hypoperfusion. Therefore, chronic chagasic cardiomyopathy may share similar pathophysiological abnormalities with other chronic congestive cardiomyopathic states.

Estudo comparativo entre o método convencional e o método da peroxidase anti-peroxidase na pesquisa do parasitismo tissular na cardiopatia chagásica crônica

Na maioria dos chagásicos crônicos o Trypanosoma cruzi não é detectado no tecido ou apresenta se com extrema raridade, mesmo quando é pesquisado exaustivamente. Sendo os métodos utilizados, até então, inespecíficos para a demonstração do T. cruzi, propôs-se no presente trabalho proceder ao estudo comparativo entre o método convencional (HE) e o método imunocitoquímico pela peroxidase anti-peroxidase (PAP), na avaliação quantitativa do parasitismo. Selecionaram-se 3 casos de cardiopatia chagásica crônica e, de um mesmo fragmento de cada caso, obtiveram se cortes que foram corados pelo H.E. (média de 100 cortes por caso) e, consecutivamente, outros que foram corados pelo PAP (média de 70 cortes por caso). O caso n.° 1 foi autopsiado em 1952 e apresentava parasitismo freqüente. Nos demais, o exame rotineiro foi negativo. Obtiveram-se os seguintes resultados expressos em n.° de ninhos/100 cortes, respectivamente, corados pelo H.E. e pelo P.A.P. (HE/PAP). Caso n.° 1 - 80/171; caso n.° 2 = 5/116 e caso n.° 3 = 1/2. Os resultados mostram que o método imunocitoquímico empregado, além de facilitar o diagnóstico do parasitismo, demonstra também pequenos ninhos de amastigotas que dificilmente seriam diagnosticados pelos métodos convencionais; além disso mostrou-se útil mesmo em tecido incluídos em parafina há longo tempo.

Chronic murine myocarditis due to Trypanosoma cruzi--an ultrastructural study and immunochemical characterization of cardiac interstitial matrix.

In an attempt to define the mouse-model for chronic Chagas' disease, a serological, histopathological and ultrastructural study as well as immunotyping of myocardium collagenic matrix were performed on Swiss mice, chronically infected with Trypanosoma cruzi strains: 21 SF and Mambaí (Type II); PMN and Bolivia (Type III), spontaneously surviving after 154 to 468 days of infection. Haemagglutination and indirect immunofluorescence tests showed high titres of specific antibodies. The ultrastructural study disclosed the cellular constitution of the inflammatory infiltrate showing the predominance of monocytes, macrophages with intense phagocytic activity, fibroblasts, myofibroblasts and abundant collagen matrix suggesting the association of the inflammatory process with fibrogenesis in chronic chagasic cardiomyopathy. Arteriolar and blood capillary alterations together with dissociation of cardiac cells from the capillary wall by edema and inflammation were related to ultrastructural lesions of myocardial cells. Rupture of parasitized cardiac myocells contribute to intensify the inflammatory process in focal areas. Collagen immunotyping showed the predominance of Types III and IV collagen. Collagen degradation and phagocytosis were present suggesting a reversibility of the fibrous process. The mouse model seems to be valuable in the study of the pathogenetic mechanisms in Chagas cardiomyopathy, providing that T. cruzi strains of low virulence and high pathogenicity are used.

Lymphocyte subpopulations in chronic Chagas' disease

Monoclonal antibodies of the Orthoclone series were used to identify total T lymphocytes (OKT3) and their helper-inducer (OKT4) and cytotoxic-suppressor (OKT8) subsets in 25 patients with chronic Chagas' disease and 25 healthy controls. No significant difference in the number of total T cells (OKT3 +) circulating in the peripheral blood of patients and controls was found. However, in contrast to normal subjects, chagasic patients show quantitative alterations in both helper (OKT4 +) and suppressor (OKT8 +) T cell subsets. The chagasic patients have abnormal helper/suppressor ratios, with low and high values scattered around the mean. Surprisingly, high ratios were found within females while almost all males have low ratio values. These findings suggest that the putative immunoregulatory disfunctions in patients with chronic chagasic cardiomyopathy may involve both helper and suppressor T cell subsets.

Morte súbita em área endêmica da doença de Chagas

Em área endêmica da doença de Chagas foi realizado estudo da freqüência e da etiologia da morte súbita. Constatou-se que a proporção destes casos na área estudada equipara-se à observada em outros centros do país, onde estudos similares foram feitos; entretanto, é relativamente baixa quando comparada com a de outros países. Quanto às causas da subitaneidade do óbito, verificou-se que a etiologia mais freqüente é representada pelçis doenças cardiovasculares, sendo a doença de Chagas a principal responsável em indivíduos de mais de 15 anos de idade.