Approximately 8 million people worldwide are infected by the protozoan parasite
Trypanosoma cruzi, the causative agent of Chagas disease. After a latent period that
can last years or decades, 10% to 30% of infected people develop serious complications,
such as cardiomyopathy or gastrointestinal dysfunction. Contrary to popular
belief, Chagas disease is not solely a vector-borne infection of Latin America.
Clinicians in nonendemic regions must be aware of the potential for childhood
T cruzi infections

Bowman, N.M.

Tustin, A.W.

PubMed

Carolina Digital Repository

Chagas DiseaseAaron W. Tustin, MD, MPH,* Natalie M. Bowman, MD, MPH†*Department of Environmental Health Sciences, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.†Department of Medicine, Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC.Approximately 8 million people worldwide are infected by the protozoan parasiteTrypanosoma cruzi, the causative agent of Chagas disease. After a latent period thatcan last years or decades, 10% to 30% of infected people develop serious compli-cations, such as cardiomyopathy or gastrointestinal dysfunction. Contrary to popularbelief, Chagas disease is not solely a vector-borne infection of Latin America.Clinicians in nonendemic regions must be aware of the potential for childhoodT cruzi infections.Humans typically acquire the parasite through contact with the infected fecesof blood-feeding triatomine insects. Vector-mediated transmission occurs inendemic regions that extend from the southern United States to the southerncone of South America. T cruzi can also be transmitted in food and beveragescontaminated with triatomine feces, via infected organ transplants and bloodtransfusions, and vertically from mother to child. In the United States, humancontact with triatomines isminimal, and blood donations are screened for Tcruzi.However, more than 300,000 US residents, mostly immigrants from LatinAmerica, may harbor chronic T cruzi infections. Many of those infected arechildren and reproductive-age women.Vertical transmission is an underrecognized problem. Children born toinfected mothers have an approximately 5% chance of acquiring the parasite.Although there has been only one reported case of congenital Tcruzi infection inthe United States (in an infant born in 2010 to a Bolivian mother), severalhundred undetected congenital T cruzi infections are estimated to occur in theUnited States each year. Diagnosis is difficult becausemost infected newborns areasymptomatic. A minority of infected infants demonstrate nonspecific signs andsymptoms, including low Apgar scores, low birthweight, respiratory distress,hepatosplenomegaly, anasarca, pericardial and pleural effusions, and meningo-encephalitis. The presentation can easily be confused with neonatal sepsis orTORCH infections (which include toxoplasmosis, rubella, cytomegalovirus, andherpes viruses). Clinicians may overlook T cruzi in the differential diagnosis,especially in nonendemic areas.To improve detection of congenital infections, the World Health Organizationrecommends antenatal T cruzi screening in all pregnant women who have everlived or received a blood transfusion in an endemic region. Infected women arenot treated prenatally to prevent vertical transmission because antitrypanosomalmedications are contraindicated during pregnancy and breastfeeding. Instead,children born to T cruzi-infected mothers should be tested during infancy andtreated if necessary. Unfortunately, prenatal screening recommendations are notwidely followed, even in endemic countries. Many at-risk infants are born tomothers with unknown Tcruzi status. Pediatricians should consider testing thesenewborns forTcruzi, especially if they are symptomatic. Diagnostic testing shouldAUTHOR DISCLOSURE Dr Tustin hasdisclosed no financial relationships relevant tothis article. Dr Bowman has disclosed that shereceives grant support from NIH (NIAID) andBWF/ASTMH to research Chagas disease(Grants K23 AI113197-02, P30 AI50410, andothers). This commentary does contain adiscussion of an unapproved/investigativeuse of a commercial product/device.Congenital Chagas Disease:Recommendations for Diagnosis,Treatment and Control of Newborns,Siblings and Pregnant Women. Carlier Y,Torrico F, Sosa-Estani S, et al. PLoS Negl TropDis. 2011;5(10):e1250Trypanosoma cruzi and Chagas Disease inthe United States. Bern C, Kjos S, Yabsley MJ,Montgomery SP. Clin Microbiol Rev.2011;24(4):655-681Congenital Transmission of Chagasdisease - Virginia, 2010. Centers for DiseaseControl and Prevention (CDC). MMWR MorbMortal Wkly Rep. 2012;61(26):477-479Congenital Chagas Disease: An Update.Carlier Y, Sosa-Estani S, Luquetti AO, BuekensP. Mem Inst Oswaldo Cruz. 2015;110(3):363-368adults. Cure rates of nearly 100%are observed in congenitallyinfected infants who receive treatment within the first post-natal year. The cure rate decreases to approximately 60% inolder children with chronic infections. Prompt detection andtreatment of congenital T cruzi infection is, therefore, essen-tial to avoid future complications.COMMENT: I found this In Brief fascinating because Ihave not been familiar with the presentation of Chagasdisease nor considered it in the differential diagnosis ofpatients. Yet, the World Health Organization estimates thatChagas disease is the most prevalent parasitic disease in theAmerican continents, including North, Central, and SouthAmerica.As the authors noted, the presentation in newborns isdiverse, making diagnosis challenging for those who are notfamiliar with the wide range of possibilities. CongenitalChagas disease must be considered in infants born to moth-ers who are from endemic areas, such as the southern portionof South America: Brazil, Paraguay, Argentina, and Bolivia.Early identification and treatment can prevent progression tomore serious manifestations associated with chronic infec-tion. Chronic Chagas disease can affect the heart, leading tocardiomyopathy, associated arrhythmias, and cardiac dys-function. Although less common, gastrointestinal involve-ment can affect the esophagus or colon and lead to motilitydisorders. Because treatment is available and effective,diagnosis in both congenital and chronic states is impor-tant to patient quality of life and prevention of resultantmorbidity.– Janet Serwint, MDAssociate Editor, In Briefbe offered to siblings of any child diagnosed with Chagas disease, and the mother should also be referred for treat-ment evaluation.Newborns at risk for T cruzi infection should be tested with polymerase chain reaction (PCR), the preferred diagnos-tic technique in children younger than age 9 months. PCR is more sensitive than microscopy-based techniques to detect Tcruzi  in blood, although it may not be available in resource-limited areas. If the initial test result is negative, PCR should be repeated at 4 to 6 weeks of age because parasitemia may increase over the first postnatal month. Infants who lack detectable parasitemia should undergo serologic testing after age 9 months to confirm the absence of infection. Serologic methods such as enzyme-linked immunosorbent assay (ELISA) and immunofluorescent antibody test (IFA) should not be used in children younger than 9 months, in whom circulating maternal antibodies can cause false-positive results. After 9 months of age, serology becomes the diag-nostic method of choice because parasitic DNA is often undetectable by PCR during the chronic stage of infection. Positive serology should be confirmed with a second assay because these tests have imperfect sensitivity and specificity.All children diagnosed with T cruzi infection should receive antitrypanosomal therapy with either benznidazole or nifurtimox. Although these medications are not approved by the US Food and Drug Administration (FDA) in the United States, they can be obtained from the Centers for Disease Control and Prevention under investigational per-mits. Standard therapy is a 60- to 90-day course of benzni-dazole 5 to 7 mg/kg per day or nifurtimox 10 to 15 mg/kg per day divided in 2 to 3 daily doses. Both drugs have a high rate of adverse effects but are tolerated better in children than

Chagas disease

https://cdr.lib.unc.edu/downloads/rf55zf371

Chagas disease

Abstract

Similar works

Full text

Available Versions

Carolina Digital Repository