BADAOUI, E.

COX, J.

LERCH, R.

PACHE, J. C.

RUTISHAUSER, W.

SZTAJZEL, J.

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European Heart Journal (1996) 17, 1289-1291Letters to theEditorChagas' disease may also beencountered in EuropeAn increasing number of cases ofChagas' disease due to TrypanosomaCruzi (TC) are being detected amongimmigrants to the United States11'.We report the case of a 56-year-oldBolivian woman, visiting relatives inSwitzerland, who consulted the Medi-cal Policlinics, Geneva, because ofchronic constipation.Physical examination revealeda slow and irregular pulse rate, corre-sponding to an atrial flutter, with ven-tricular rate of 30-40 beats. min~'.Her ECG showed right bundle branchblock (RBBB) associated with isolatedventricular ectopic beats. She had nocardiovascular risk factors, but admit-ted having had episodes of dizzinessand breathing difficulties during effort.Doppler-echocardiography (Fig. 1A)revealed a slightly diminished left ven-tricular (LV) ejection fraction, mildmitral regurgitation, and left atrial(LA) dilatation. The right atrium (RA)and the right ventricle (RV) were mod-erately dilated without evidence ofpulmonary hypertension. These find-ings, together with a clinical history ofhaving lived, when younger for severalmonths in a rural area in Brazil,suggested the possibility of Chagas'cardiomyopathy (CCM). Cardiaccatheterisation showed normal press-ures in both cavities, with moderatedilatation and a LV ejection fractionof 55%. Coronary arteries were nor-mal. Left anterior fascicular block(LAFB) became apparent during theprocedure as the patient reverted to aslow sinus rhythm.Right ventricular endomyo-cardial biopsies (Fig. IB) showed dif-fuse interstitial fibrosis, sometimesenglobing small bundles of atrophic ordegenerating cardiomyocytes, contain-ing scattered mononuclear cell aggre-gates, predominantly CD3+ withslightly more CD8+ than CD4+,principally around small vessels. Anindirect immunofluorescent antibodyserological test for TC was markedlypositive (1280 (n<160)). A singlechamber (WIR) pacemaker wasimplanted, without antiarrhythmictherapy, as the patient decided toreturn to Bolivia.Figure 1 (A) Doppler-eehocardio-graphic recording at the four chamberapical view showing slightly dimin-ished left ventricular systolic functionand dilatation of the right cavities,particularly of the right atrium. (B)Endomyocardial biopsy showing dif-fuse interstitial fibrosis englobingbundles of isolated myocardial fibreswith scattered mononuclear cell ag-gregates, principally around vessels.Inset: Strong positive immunohisto-chemical staining of the inflammatorycells by CD3 antibodies, indicatingtheir T-cell nature.The clinical history, the ECGchanges, the echocardiographic,haemodynamic and histopathologicalfindings in this patient are consistentwith a characteristic form of chronicCCM. The chronic form of Chagas'disease is characterized by alterationsin the cardiac and/or digestive systems,due among other factors, to auto-nomical neuronal dysfunction ofthese systems'21. There is a preferen-tial involvement of the right bundlebranch and the anterior fascicles of theleft branch, due to progressive andongoing inflammation and fibrosis131.Our patient had RBBB in combinationwith LAFB, which are ECG altera-tions frequently observed in patients inendemic Chagas' areas'21. Ventriculararrhythmias are a prominent featureof CCM and atrial arrhythmias, in-cluding atrial fibrillation or flutter,may also occur14'51. Patients with apositive serology for TC with RBBB,especially in combination with fascicu-lar block or ventricular extrasystoles,as in this patient, have a significantlyhigher mortality rate than seropositivepersons with a normal ECG. Echo-cardiographic findings include LVdilatation, with reduced systolic func-tion and abnormal diastolic filling,often with enlargement of the LA andright cavities. Our patient had globalmyocardial involvement, but the rightcavities were more markedly involved.Although the histopathological find-ings in our patient are non-specific andparasites were not seen, the lesions areconsistent with the diagnosis of CCMin the clinical context and the strongpositive serology for TC13'4'51.It is now well established thatChagas' disease can also be transmit-ted by transfusion of blood donatedby infected persons, or by transplanta-tion of donated organs, thus making itof vital importance that all Europeanphysicians should be aware of the dis-ease, especially with the increasingnumber of immigrants and touristscoming from or returning from Southand Central America'4'^ 1. Cardiolo-gists, gastroenterologists and patholo-gjsts, in particular, should be morefamiliar with the clinical and patho-logical presentation of Chagas' dis-ease, which may also be discoveredfortuitously in Europe.J. SZTAJZELJ. COX*J. C. PACHE*E. BADAOUIR. LERCHW. RUT1SHAUSERCardiology Centre and'Department of Pathology,University Hospital,Geneva, SwitzerlandReferences[1] Hagar JM, Rahimtoola SH. Chagas'heart disease in the United States.N Engl J Med 1991; 325: 763-8.[2] Morris SA, Tanowitz HB, Winner M,Bilezikian JP. Pathophysiological in-sights into the cardiomyopathy ofChagas' disease. Circulation 1990; 82:1900-9.[3] Higuchi ML, Gutierrez PS, Aiello VDel al. Immunnohistochemical charac-terization of infiltrating cells in humanchronic chagask myocarditis: compari-son with myocardial rejection process.Virchows Archiv A Pathol Anat 1993;423: 157-60.[4] KirchholT LV. American Trypano-somiasis (Chagas' disease) — A tropicaldisease now in the United States.N Engl J Med 1993; 329: 639-44.[5] Lange LG, Schreiner GF. Immunemechanisms of cardiac disease. N EnglJMed 1994; 330: 1129-35Eur Heart J, Vol. 17, August 1996

Chagas' disease may also be encountered in Europe

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