Chronic Chagasic Patients Research Articles

Trypanosoma cruzi persistence at oral inflammatory foci in chronic chagasic patients

The persistence of Trypanosoma cruzi in seropositive individuals, previously diagnosed as chronic chagasic patients (CCP), was detected for the first time in biopsies taken from gingival inflammatory foci processed by polymerase chain reaction (PCR). Seven out of 31 (22.5%) gum samples from selected unquestionably CCP showing different degrees of gingival inflammation revealed T. cruzi-DNA using 3 specific PCR assays. All the included CCP had been diagnosed in previous studies carried out over the last 19 years. Samples of inflamed gums were recently taken from the indicated patients at: an outpatient hospital cardiac unit; a village where Chagas disease is endemic; and a specialized diagnostic research center, showing molecular evidence of parasite persistence in 17.6%, 42.8% and 14.3% of them, respectively. The relatively frequent parasite persistence, demonstrated here in oral inflammatory processes of treated and/or untreated patients bearing long term T. cruzi-infection, suggests the establishment of secondary small foci for the maintenance of hidden or inapparent chagasic infection. The easy and low-risk, non-invasive method to get the sample may add the use of gingival biopsy as a potential alternative diagnostic tool to confirm T. cruzi-infection in CCP. The significance of T. cruzi persistence as a primary cause of chronic Chagas disease and the proposal of this mechanism to explain the pathogenesis in CCP are considered.

Histological, biochemical and pharmacologycal characterization of the gastric muscular layer in Chagas disease

To assess in vitro the correlation between the number of neurons and the sensitivity to cholinergic drugs and acetylcholinesterase activity in chagasic patients. A 3 x 1 cm strip of the muscle layer of the anterior part of the stomach, always close to the angular incisure, was removed from 10 chronic chagasic patients (6 men) submitted to megaesophagus or megacolon surgery and from 10 non-chagasic patients (4 men) submitted to other types of surgery (control group), aged on average 52.3 and 50.1 years, respectively, for histological and pharmacological studies. The action of cholinergic drugs was investigated in isolated preparations according to the superfusion method of Ferreira and Costa, and acetylcholinesterase activity was determined by the method of Ellman. For neuron count, the strips were cut into 8 µm sections according to the method standardized by Alcântara. There was a difference in number of neurons between the chagasic (5,6) and control (7,3) groups. Acetylcholinesterase activity, in moles of hydrolyzed substrate per minute per gram tissue, was reduced in chagasic patients (4,32) compared to the controls (7,30). No hypersensitivity of the gastric musculature to cholinergic drugs was detected, with a reduced maximum response to carbachol and betanechol in the chagasic group. The reduction of neurons in the myenteric plexus of the stomach of chronic chagasic patients can be demonstrated even in the absence of clinical chagasic gastropathy. The hypersensitivity of the gastric musculature to cholinergic drugs probably depends on intense denervation. The reduced acetylcholinesterase activity demonstrates the involvement of the cholinergic innervation in the stomach of chronic chagasic patients. There was no correlation between number of neurons, sensitivity to cholinergic drugs and acetylcholinesterase activity in the gastric musculature of chagasic and non-chagasic patients.

Acidente vascular encefálico isquêmico em paciente chagásico crônico autóctone da Amazônia Brasileira

An episode of stroke in a chronic autochthonous chagasic patient from the Brazilian Amazon is reported. This is the first documented case of a predominantly thromboembolic form of chronic Chagasic cardiopathy in the region.

Chagas cardiomyopathy manifestations and Trypanosoma cruzi genotypes circulating in chronic Chagasic patients.

Chagas disease caused by Trypanosoma cruzi is a complex disease that is endemic and an important problem in public health in Latin America. The T. cruzi parasite is classified into six discrete taxonomic units (DTUs) based on the recently proposed nomenclature (TcI, TcII, TcIII, TcIV, TcV and TcVI). The discovery of genetic variability within TcI showed the presence of five genotypes (Ia, Ib, Ic, Id and Ie) related to the transmission cycle of Chagas disease. In Colombia, TcI is more prevalent but TcII has also been reported, as has mixed infection by both TcI and TcII in the same Chagasic patient. The objectives of this study were to determine the T. cruzi DTUs that are circulating in Colombian chronic Chagasic patients and to obtain more information about the molecular epidemiology of Chagas disease in Colombia. We also assessed the presence of electrocardiographic, radiologic and echocardiographic abnormalities with the purpose of correlating T. cruzi genetic variability and cardiac disease. Molecular characterization was performed in Colombian adult chronic Chagasic patients based on the intergenic region of the mini-exon gene, the 24Sα and 18S regions of rDNA and the variable region of satellite DNA, whereby the presence of T.cruzi I, II, III and IV was detected. In our population, mixed infections also occurred, with TcI-TcII, TcI-TcIII and TcI-TcIV, as well as the existence of the TcI genotypes showing the presence of genotypes Ia and Id. Patients infected with TcI demonstrated a higher prevalence of cardiac alterations than those infected with TcII. These results corroborate the predominance of TcI in Colombia and show the first report of TcIII and TcIV in Colombian Chagasic patients. Findings also indicate that Chagas cardiomyopathy manifestations are more correlated with TcI than with TcII in Colombia.

Stroke in Asymptomatic Trypanosoma cruzi-Infected Patients

Background: The knowledge about the natural history of stroke in Chagas disease is incomplete. Methods: Vascular risk factors and stroke subtypes of asymptomatic Trypanosoma cruzi-infected patients with no clinical evidence of heart failure were assessed. They were compared with chronic chagasic cardiomyopathy patients who suffered a stroke and with a control group of 60 T. cruzi-noninfected stroke patients. Eighty-six consecutive chagasic stroke patients (mean age: 57.4 years; 64% females) were studied. Results: 38.4% of chagasic stroke patients had asymptomatic T. cruzi infection. Smoking was more frequent in asymptomatic chagasic stroke patients (21.2 vs. 5.7%; p = 0.04). Prevalence of hypertension, diabetes and prior stroke was similar in both groups. Small-vessel infarction (15.6 vs. 3.8%) and large-vessel atherosclerosis (9.4 vs. 3.8%) were significantly more frequent in asymptomatic than in symptomatic T. cruzi-infected stroke patients (p = 0.001). Nevertheless, their frequency was even higher in T. cruzi-noninfected stroke patients (36.7 and 13.3%, respectively). Apical aneurysm (27.3%), left atrial dilatation (12.1%), left ventricle hypokinesia (9.4%) and right bundle branch block (36.4%) were also detected in asymptomatic T. cruzi-infected stroke patients. Conclusions: Ischemic stroke may be the first manifestation of Chagas disease in asymptomatic patients with mild left ventricle dysfunction. Other noncardioembolic stroke subtypes can occur in asymptomatic T. cruzi-infected patients.

Microsatellite marker analysis shows differentiation among Trypanosoma cruzi populations of peripheral blood and dejections of Triatoma infestans fed on the same chronic chagasic patients

To investigate whether Trypanosoma cruzi populations found in chagasic cardiopathic and non-cardiopathic patients are genetically differentiated, three molecular microsatellite markers were analysed. This analysis was also applied to compare T. cruzi samples from peripheral blood or dejections of Triatoma infestans fed on the blood of the same patients. In order to obtain the first objective, analyses of predominant T. cruzi genotypes were conducted using three approaches: a locus-by-locus analysis; a Fisher method across three loci; and analysis of molecular variance by Genepop and Arlequin programs. Only with one locus and on the blood samples was a significant differentiation detected among non-cardiopathic and cardiopathic groups, which was not confirmed by the other two methods. On the contrary, with the three approaches, it was found that T. cruzi clones present in the blood of patients are genetically differentiated from those detected in dejections of T. infestans fed on the same patients. Our results showed that the most frequent lineage both in blood as well as in triatomine dejection samples was TcI. No significant difference in T. cruzi lineage distribution was observed among chagasic cardiopathic and non-cardiopathic patients. The majority of the samples (50-60%) had only one T. cruzi clone (uniclonal) either in blood or dejection samples.

Células dendríticas y linfocitos T reguladores naturales en pacientes con enfermedad crónica de Chagas

Given the chronicity and persistence of the parasite Trypanosoma cruzi in the Chagas disease victims, the homeostatic control of immune response to prevent tissue damage and limit the duration of the inflammatory process involves cells with regulatory potential as dendritic cells (DC) and regulatory T cells. For this reason, the objective of this study is to evaluate the proportion of total DC, myeloid and plasmacytoid DC subpopulations and natural regulatory T cells in chronic chagasic patients and healthy control subjects. Peripheral blood mononuclear cells (PBMC) from 18 chronic chagasic patients and 16 healthy control subjects were staining to myeloid DC Lin- HLA-DR+ CD11c+, plasmacytoid DC Lin-, HLA-DR+, CD123+ and natural regulatory T lymphocytes CD3+ CD4+ CD25+ Foxp3+ CD127low. Cellular proportions were calculated using the percentage obtained by flow cytometry. It was found that plasmacytoid CD proportion was lower than myeloid CD in both, chronic chagasic patients and healthy control subjects, without significant differences between the two groups. On the contrary, it was found that the proportion of natural regulatory T cells was significantly higher in chronic chagasic patients than in healthy control subjects upon comparing the two. These results suggest that the higher proportion of natural regulatory T cells in chronic chagasic patients might contribute to the disease pathogenesis.

Gap junction reduction in cardiomyocytes following transforming growth factor-β treatment and Trypanosoma cruzi infection

Gap junction connexin-43 (Cx43) molecules are responsible for electrical impulse conduction in the heart and are affected by transforming growth factor-beta (TGF-beta). This cytokine increases during Trypanosoma cruzi infection, modulating fibrosis and the parasite cell cycle. We studied Cx43 expression in cardiomyocytes exposed or not to TGF-beta T. cruzi, or SB-431542, an inhibitor of TGF-beta receptor type I (ALK-5). Cx43 expression was also examined in hearts with dilated cardiopathy from chronic Chagas disease patients, in which TGF-beta signalling had been shown previously to be highly activated. We demonstrated that TGF-beta treatment induced disorganised gap junctions in non-infected cardiomyocytes, leading to a punctate, diffuse and non-uniform Cx43 staining. A similar pattern was detected in T. cruzi-infected cardiomyocytes concomitant with high TGF-beta secretion. Both results were reversed if the cells were incubated with SB-431542. Similar tests were performed using human chronic chagasic patients and we confirmed a down-regulation of Cx43 expression, an altered distribution of plaques in the heart and a significant reduction in the number and length of Cx43 plaques, which correlated negatively with cardiomegaly. We conclude that elevated TGF-beta levels during T. cruzi infection promote heart fibrosis and disorganise gap junctions, possibly contributing to abnormal impulse conduction and arrhythmia that characterise severe cardiopathy in Chagas disease.

Characterising the KMP-11 and HSP-70 recombinant antigens' humoral immune response profile in chagasic patients

BackgroundAntigen specificity and IgG subclass could be significant in the natural history of Chagas' disease. The relationship between the different stages of human Chagas' disease and the profiles of total IgG and its subclasses were thus analysed here; they were directed against a crude T. cruzi extract and three recombinant antigens: the T. cruzi kinetoplastid membrane protein-11 (rKMP-11), an internal fragment of the T. cruzi HSP-70 protein192-433, and the entire Trypanosoma rangeli HSP-70 protein.MethodsSeventeen Brazilian acute chagasic patients, 50 Colombian chronic chagasic patients (21 indeterminate and 29 cardiopathic patients) and 30 healthy individuals were included. Total IgG and its subtypes directed against the above-mentioned recombinant antigens were determined by ELISA tests.ResultsThe T. cruzi KMP-11 and T. rangeli HSP-70 recombinant proteins were able to distinguish both acute from chronic chagasic patients and infected people from healthy individuals. Specific antibodies to T. cruzi crude antigen in acute patients came from IgG3 and IgG4 subclasses whereas IgG1 and IgG3 were the prevalent isotypes in indeterminate and chronic chagasic patients. By contrast, the specific prominent antibodies in all disease stages against T. cruzi KMP-11 and T. rangeli HSP-70 recombinant antigens were the IgG1 subclass.ConclusionT. cruzi KMP-11 and the T. rangeli HSP-70 recombinant proteins may be explored together in the immunodiagnosis of Chagas' disease.Polarising the IgG1 subclass of the IgG response to T. cruzi KMP-11 and T. rangeli HSP-70 recombinant proteins could have important biological effects, taking into account that this is a complement fixing antibody.

Evaluation of Adult Chronic Chagas' Heart Disease Diagnosis by Molecular and Serological Methods

Chagas' disease caused by Trypanosoma cruzi is endemic in Latin America. T. cruzi presents heterogeneous populations and comprises two main genetic lineages, named T. cruzi I and T. cruzi II. Diagnosis in the chronic phase is based on conventional serological tests, including indirect immunofluorescence (IIF) and enzyme-linked immunosorbent assay (ELISA), and diagnosis in the acute phase based on parasitological methods, including hemoculture. The objective of this study was to evaluate the diagnostic procedures of Chagas' disease in adult patients in the chronic phase by using a PCR assay and conventional serological tests, including TESA-blot as the gold standard. Samples were obtained from 240 clinical chronic chagasic patients. The sensitivities, compared to that of TESA-blot, were 70% for PCR using the kinetoplast region, 75% for PCR using the nuclear repetitive region, 99% for IIF, and 95% for ELISA. According to the serological tests results, we recommend that researchers assess the reliability and sensitivity of the commercial kit Chagatest ELISA recombinant, version 3.0 (Chagatest Rec v3.0; Wiener Lab, Rosario, Argentina), due to the lack of sensitivity. Based on our analysis, we concluded that PCR cannot be validated as a conventional diagnostic technique for Chagas' disease. These data have been corroborated by low levels of concordance with serology test results. It is recommended that PCR be used only for alternative diagnostic support. Using the nuclear repetitive region of T. cruzi, PCR could also be applicable for monitoring patients receiving etiologic treatment.

The presence of antiautonomic membrane receptor antibodies do not correlate with brain lesions in Chagas' disease

We previously demonstrated correlation between parasympathetic dysfunction and brain white matter lesions in chronic chagasic patients. To correlate serum functional circulating antibodies with beta adrenergic (Ab-beta), muscarinic (Ab-M) or muscarinic and beta adrenergic (Ab-Mbeta) activity, the autonomic system function and brain lesions in chronic chagasic patients. In fifteen consecutive chagasic patients, the autonomic nervous system was evaluated and brain magnetic resonance imaging (MRI) was performed. The sera of all patients were tested to the presence of circulating functional antibodies. Sera from 11 of 15 chronic chagasic patients had some activity (Ab-beta: 7; Ab-M: 1; Ab-Mbeta: 3); however, there was no significant correlation between the presence of antibodies and the autonomic system function or the presence of hyperintensities in MRI. The mechanism involved in the genesis of hyperintense lesions seen in brain MRI of chronic chagasic patients is still unresolved, although apparently related to parasympathetic dysfunction.

Antioxidant therapy attenuates oxidative insult caused by benzonidazole in chronic Chagas' heart disease

Chronic chagasic cardiac patients are exposed to oxidative stress that apparently contributes to disease progression. Benznidazole (BZN) is the main drug used for the treatment of chagasic patients and its action involves the generation of reactive species. 41 patients with Chagas' heart disease were selected and biomarkers of oxidative stress were measured before and after 2 months of BZN treatment (5 mg/kg/day) and the subsequent antioxidant supplementation with vitamin E (800 UI/day) and C (500 mg/day) during 6 months. Patients were classified according to the modified Los Andes clinical hemodynamic classification in groups IA, IB, II and III, and the activity of superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GPx), glutathione S-transferase (GST) and glutathione reductase (GR), as well as the contents of reduced glutathione (GSH), thiobarbituric acid reactive species (TBARS), protein carbonyl (PC), vitamin E and C and nitric oxide (NO), myeloperoxidase (MPO) and adenosine deaminase (ADA) activities were measured in their blood. Excepting in group III, after BZN treatment SOD, CAT, GPx and GST activities as well as PC levels were enhanced while vitamin E levels were decreased in these groups. After antioxidant supplementation the activities of SOD, GPx and GR were decreased whereas PC, TBARS, NO, and GSH levels were decreased. In conclusion, BZN treatment promoted an oxidative insult in such patients while the antioxidant supplementation was able to attenuate this effect by increasing vitamin E levels, decreasing PC and TBARS levels, inhibiting SOD, GPx and GR activities as well as inflammatory markers, mainly in stages with less cardiac involvement.

Leukoreduction by Centrifugation Does Not EliminateTrypanosoma cruzifrom Infected Blood Units

Current strategies to prevent transfusion-associated Chagas disease include the identification of Trypanosoma cruzi-infected blood donors through questionnaires and serologic tests. There are other procedures such as leukoreduction that prevent the transmission of infectious agents associated to white cells. The objective of the present work was to estimate the seroprevalence, evaluate the efficacy of leukoreduction by centrifugation to eliminate T. cruzi in infected blood units, and the correlation of immunoglobulin G (IgG) subclasses of seropositive blood donors with chronic chagasic cardiopathy. Over a period of 14 months, 33 out of 6600 blood donors (0.5%) at Centro Estatal de la Transfusión Sanguínea in Campeche State, México were seropositive for T. cruzi. Twenty seropositive blood units were submitted through leukoreduction by centrifugation, and in the fractions generated (red cell fraction, platelets, and the buffy-coat), we searched for the presence of T. cruzi using specific polymerase chain reaction. We detected parasite DNA in 50% to 60% of the fractions tested, suggesting that leukoreduction by centrifugation does not eliminate the microorganisms in the infected blood unit. We also observed that the level of IgG2 and IgG4 subclasses specific for T. cruzi in seropositive blood donors was lower than in chronic cardiopathic chagasic patients. In conclusion, leukoreduction by centrifugation has a limited role in eliminating T. cruzi in infected blood supply, and the low level of specific IgG2 and IgG4 could be a marker in the indeterminate phase of infection.

Probing population dynamics of Trypanosoma cruzi during progression of the chronic phase in chagasic patients.

Our research aimed to characterize the genetic profiles of 102 Trypanosoma cruzi isolates recently obtained from 44 chronic chagasic patients from different regions of the states of Minas Gerais and Goiás in Brazil. At least two isolates were obtained from each patient at different times in order to study the parasite population dynamics during disease progression in the chronic phase. The isolates were characterized molecularly by genotyping the 3' region of the 24S alpha rRNA, the mitochondrial cytochrome oxidase subunit 2 (COII) gene, and the intergenic region of the spliced leader intergenic region (SL-IR) gene. Seventy-seven isolates were analyzed for nine microsatellite loci. The data presented here show a strong correlation between the T. cruzi lineage II (T. cruzi II) and human infection in these regions of Brazil. Interestingly, isolates from two patients were initially characterized (by rRNA genotyping) as T. cruzi I and hybrid strains, but subsequent analyses of the COII and SL-IR genes confirmed that those isolates belonged to T. cruzi III and a hybrid group, respectively. Our results confirm the risk of misclassifying T. cruzi isolates on the basis of analysis of a single molecular marker. The microsatellite profiles showed that different isolates obtained from the same patient were genetically identical and monoclonal. Exceptions were observed for T. cruzi isolates from two patients who presented differences for the SCLE11 locus and also from two other patients who showed amplification of three peaks for a microsatellite locus (TcAAAT6), implying that they were multiclonal. On the basis of the findings of the studies described here, we were not able to establish a correlation between the clinical forms of Chagas' disease and the genetic profiles of the T. cruzi isolates.

Efficacy of benznidazol treatment for asymptomatic chagasic patients from state of Rio Grande do Sul evaluated during a three years follow-up

The efficacy of benznidazol on the treatment of chagasic patients from the state of Rio Grande do Sul was evaluated during a three-year follow-up. A cohort of 80 asymptomatic chronic chagasic patients or blood bank donors (49 male and 31 female) was studied. Their ages varied from 17-42 years, with a mean and a median of 30 and 35 years, respectively. The 80 patients presented positive serology, hemoculture and polymerase chain reaction (PCR). They were treated with 5 mg/Kg benznidazol twice a day for 60 days. Serological, parasitological and PCR methods were used to evaluate response. Serology was performed using commercial ELISA and indirect immunofluorescence (IFI) tests, parasitemia was monitored by hemoculture in LIT medium and PCR with primers S35/S36 was used to amplify a Trypanosoma cruzi 330 bp kDNA repetitive sequence. PCR positivity of 240 seropositive individuals was compared using DNA preparations from whole blood/guanidine EDTA (GE), buffy-coat/GE and frozen buffy-coat. Fifty non-chagasic individuals were used as negative controls. PCR positivity was 86.7% for the frozen buffy-coat, 71.7% for the GE/buffy-coat and 69.2% for the GE/whole blood. The hemocultures became negative just after treatment and remained negative during the three years of follow-up. In the third year after treatment, 9/80 (11.3%) patients presented negative PCR and, from those, four also presented negative serological tests. Furthermore, a reduction in three serological titers was observed in 27/80 (33.8%) of the patients treated. Taken together, the results show that four of the 80 (5.0%) chronic chagasic patients from the state of Rio Grande do Sul were cured after treatment with benznidazol.

Natural CD4+ T‐cell responses against Trypanosoma cruzi KMP‐11 protein in chronic chagasic patients

Correction to: Immunology and Cell Biology advance online publication, 28 October 2008; doi:10.1038/icb.2008.76 Due to a typesetting error, Figure 2 in the above paper appeared incorrectly. The correct figure is shown below. The typesetters would like to apologize for this mistake. Response of CD3+ CD4+ CD69+ T-cells non-stimulated (NS) or co-cultured with polyclonal stimulation (Staphylococcus aureus enterotoxin B (SEB)). Dot plot analysis representative of 1 out of 21 studied subjects showing the phenotype distribution (a) and cytokine secretion (b). Comparison of cytokine secretion in healthy donors (empty bars), indeterminate chagasic patients (gray bar) and chronic chagasic patients (black bars) (c). The results are shown as the average of the percentages of positive cells and respective standard error (s.e.m.). *Denotes statistical differences, P=0.03.

Natural CD4+ T‐cell responses against Trypanosoma cruzi KMP‐11 protein in chronic chagasic patients

Trypanosoma cruzi kinetoplastid membrane protein-11 (KMP-11) is able to induce protective immunity in mice. In humans, T-cell immunity during Chagas disease has been documented using parasite antigens allowing the identification of specific CD8(+) T cells. However, little is known about the CD4(+) T-cell response during the evolution of the disease. In this paper, the induction of a natural CD4(+) T-cell response against the KMP-11 protein in T. cruzi infected humans was studied to assess whether this parasite-derived protein could be processed, presented and detected as a major histocompatibility complex class II restricted epitope. The results show that helper T cells from 5 out of 13 chagasic patients specifically produced interferon-gamma after exposure to the KMP-11 antigen, whereas healthy donors and non-chagasic cardiopathic patients did not respond. This is the first description of T. cruzi KMP-11 protein recognition by CD4(+) T cells in chronic chagasic patients.

Glial fibrillary acidic protein and S-100 colocalization in the enteroglial cells in dilated and nondilated portions of colon from chagasic patients

After acute immunoreactive infestation with the Chagas' disease parasite, Trypanosoma cruzi, some patients develop chronic megacolon, whereas others remain asymptomatic. Chronic chagasic patients with gastrointestinal involvement exhibit inflammation and degeneration of enteric neurons. Our hypothesis is that enteric glial cells may be involved in the modulation of enteric inflammatory responses or even control the colon's dilatation. The aims of this study were to characterize the phenotype of enteric glial cells according to the expression of S-100 and glial fibrillary acidic protein and to look for correlation between these data and the neuronal loss in the colon of chagasic patients. We studied both dilated and nondilated portions of chagasic megacolon. We used a pan-enteric glial cell marker (anti-S-100), a subpopulation enteric glial cell marker (anti-glial fibrillary acidic protein), and a pan-neuronal marker (anti-Human protein C and protein D) with double-labeled sheets using a confocal microscope. Our results demonstrate that neuronal loss is similar in dilated and nondilated portions of chagasic megacolon. Moreover, the results indicate that neuronal destruction present in chagasic megacolon is preceded by glial component loss. The nondilated portion of chagasic megacolon exhibited increased expression of glial fibrillary acidic protein comparable with the dilated portion and also to the noninfected group. Our results suggest that glial fibrillary acidic protein enteric glial cells prevent dilatation of the organ and protect the enteric nervous system against the inflammatory process and neuronal destruction, preventing the destruction from expanding to unaffected areas of the colon.

Guías clínicas de la enfermedad de Chagas: Parte IV. Enfermedad de Chagas en pacientes inmunocomprometidos

A summary of different kind of immune suppressed hosts and the importance of Trypanosoma cruzi infection in this group of patients is presented. Then, most relevant aspects of immune compromised host-parasite interaction are analyzed such as the moment of acquiring the infection, immune compromise level, mechanisms of acquisition the infection and geographic region. Clinical features of primary infection and reactivation of infection in chronic Chagasic patients are described making special emphasis in solid organ transplant and BMT. Chagas disease in AIDS patients is discussed including its treatment, follow up, monitoring the immune compromise level and prophylaxis.

Guidelines for chagas disease: Part IV. Chagas disease in immune compromised patients

A summary of different kind of immune suppressed hosts and the importance of Trypanosoma cruzi infection in this group of patients is presented. Then, most relevant aspects of immune compromised host-parasite interaction are analyzed such as the moment of acquiring the infection, immune compromise level, mechanisms of acquisition the infection and geographic region. Clinical features of primary infection and reactivation of infection in chronic Chagasic patients are described making special emphasis in solid organ transplant and BMT. Chagas disease in AIDS patients is discussed including its treatment, follow up, monitoring the immune compromise level and prophylaxis.