History

Fact Explanation
Asymptomatic [1,3,5] Patients can be asymptomatic for a long period of time.
Symptoms of cardiac complications [1,2] These include cardiomyopathy, heart failure and , altered heart rate or rhythm, and cardiac arrest. Patients with cardiomyopathy later develops congestive cardiac failure. Common symptoms are dyspnea, palpitations, reduced exercise tolerance, edema of the lower limbs and paroxysmal nocturnal dyspnea. sympathetic over activity due to destruction of the parasympathetic nerves influence the development of tachy-arrhythmias. [6] Patients can present with sudden death due to these cardiac complications. [4,5]
Intestinal complications Megaesophagus or megacolon develop due to destruction of intramural autonomic ganglia. [6] This is due to denervation and dysfunction of the bowel loops. Megacolon causes constipation, abdominal pain and distension. Megacolon can lead to acute abdominal pain due to bowel obstruction or volvulus. Megaesophagus causes dysphagia, odynophagia, regurgitation and epigastric discomfort. [5]
Thromboembolism Due to congestive cardiac failure. [5] Can result in stroke and pulmonary embolism. Stroke presents as unilateral numbness, unilateral weakness or paralysis. [7] Patients with pulmonary embolism will present as acute pleuritic chest pain, cough and hemoptysis. [8]
Sialorrhea Patients can have sialorrhea as a gastrointestinal complication of chronic Chagas disease. This is commonly seen in association with mega esophagus. [9]
References
  1. Parasites - American Trypanosomiasis (also known as Chagas disease). Centers for Disease Control and Prevention [online] [viewed 14 May 2014] Available from: http://www.cdc.gov/parasites/chagas/gen_info/detailed.html
  2. BERN CARYN. Antitrypanosomal Therapy for Chronic Chagas' Disease. N Engl J Med [online] 2011 June, 364(26):2527-2534 [viewed 14 May 2014] Available from: doi:10.1056/NEJMct1014204
  3. VILLALTA F., DOBISH M. C., NDE P. N., KLESHCHENKO Y. Y., HARGROVE T. Y., JOHNSON C. A., WATERMAN M. R., JOHNSTON J. N., LEPESHEVA G. I.. VNI Cures Acute and Chronic Experimental Chagas Disease. Journal of Infectious Diseases [online] December, 208(3):504-511 [viewed 14 May 2014] Available from: doi:10.1093/infdis/jit042
  4. LARANJA F. S., DIAS E., NOBREGA G., MIRANDA A.. Chagas' Disease: A Clinical, Epidemiologic, and Pathologic Study. Circulation [online] 1956 December, 14(6):1035-1060 [viewed 14 May 2014] Available from: doi:10.1161/01.CIR.14.6.1035
  5. Chagas disease (American trypanosomiasis). [online] [viewed 14 May 2014] Available from: http://www.who.int/neglected_diseases/diseases/chagas/en/
  6. ANIS RASSI, JOSÉ ANTONIO MARIN-NETO. Chagas disease. The Lancet [online] 17 April 2010: 375 (9723) 1388 – 1402. [viewed 14 May 2014] Available from: doi:10.1016/S0140-6736(10)60061-X
  7. GAO L, MESCHIA JF, JUDD S, MUNTNER P, et al. What Stroke Symptoms Tell Us: Association of Risk Factors and Individual Stroke Symptoms in the REasons for Geographic and Racial Differences in Stroke (REGARDS) study J Stroke Cerebrovasc Dis [online] 2012 Jul, 21(5):411-416 [viewed 14 May 2014] Available from: doi:10.1016/j.jstrokecerebrovasdis.2012.04.009
  8. DOBOSZYńSKA A, KOć M, KOć K, SWIETLIK E, SOSNOWSKA E, TOMASZEWSKA I. Pleuritis as the first symptom of pulmonary embolism: a case report. J Physiol Pharmacol [online] 2007 Nov, 58 Suppl 5(Pt 1):129-33 [viewed 14 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/18204123
  9. MATSUDA NM, MILLER SM, EVORA PR. The Chronic Gastrointestinal Manifestations of Chagas Disease Clinics (Sao Paulo) [online] 2009 Dec, 64(12):1219-1224 [viewed 14 May 2014] Available from: doi:10.1590/S1807-59322009001200013

Examination

Fact Explanation
Weight loss and cachexia This is seen in severe cases secondary to achalasia. [4]
Examination of the cardiovascular system Examination of the pulse will aid in detecting arrhythmia. [1] Signs of heart failure like lower extremity pitting edema, shifted apex beat due to cardiomegaly and pulmonary crackles are detected. [2]
Signs suggestive of thromboembolism Hemiparesis and hemi anesthesia will be detected. [3]
Hypertrophy of the salivary glands Salivary glands hypertrophy as a complication of chronic Chagas disease. [5]
Examination of the respiratory system Patients are susceptible to aspiration pneumonia because of the mega esophagus. [6] On examination patient will be febrile and there will be localized area of reduced chest expansion, dullness to percussion and bronchial breathing. [7]
Fecaloma A mass of very hard impacted feces is palpated. This occurs in patients with chronic constipation. [8]
References
  1. Parasites - American Trypanosomiasis (also known as Chagas disease). Centers for Disease Control and Prevention [online] [viewed 14 May 2014] Available from: http://www.cdc.gov/parasites/chagas/gen_info/detailed.html
  2. RANDY WEXLER, TERRY ELTON, ADAM PLEISTER, DAVID FELDMAN. Cardiomyopathy: An Overview. Am Fam Physician. [online] 2009 May 1;79(9):778-784. [viewed 14 May 2014] Available from: http://www.aafp.org/afp/2009/0501/p778.html
  3. GAO L, MESCHIA JF, JUDD S, MUNTNER P, et al. What Stroke Symptoms Tell Us: Association of Risk Factors and Individual Stroke Symptoms in the REasons for Geographic and Racial Differences in Stroke (REGARDS) study J Stroke Cerebrovasc Dis [online] 2012 Jul, 21(5):411-416 [viewed 14 May 2014] Available from: doi:10.1016/j.jstrokecerebrovasdis.2012.04.009
  4. MICHAEL SCHELD W. Consultations in Infectious Disease: A Case Based Approach to Diagnosis and Management. Oxford University Press, May 29, 2012, pp. 214.
  5. MATSUDA NM, MILLER SM, EVORA PR. The Chronic Gastrointestinal Manifestations of Chagas Disease Clinics (Sao Paulo) [online] 2009 Dec, 64(12):1219-1224 [viewed 14 May 2014] Available from: doi:10.1590/S1807-59322009001200013
  6. RANZANI MARCELO FERNANDO, MIRANDA NILSON SEBASTIãO, FREDERIGUE JUNIOR ULISSES, RIBEIRO SéRGIO MARRONE, MACHADO JUSSARA MARCONDES. Pneumonia lipoídica associada à forma digestiva da doença de Chagas. J. bras. pneumol. [online] 2004 October [viewed 14 May 2014] Available from: doi:10.1590/S1806-37132004000500016
  7. RICHARD R. WATKINS, TRACY L. LEMONOVICH. Diagnosis and Management of Community-Acquired Pneumonia in Adults. Am Fam Physician. [online] 2011 Jun 1;83(11):1299-1306. [viewed 14 May 2014] Available from: http://www.aafp.org/afp/2011/0601/p1299.html
  8. GARISTO JD, CAMPILLO L, EDWARDS E, HARBOUR M, ERMOCILLA R. Giant fecaloma in a 12-year-old-boy: a case report Cases J [online] :127 [viewed 14 May 2014] Available from: doi:10.1186/1757-1626-2-127

Differential Diagnoses

Fact Explanation
Causes of dysphagia Mega esophagus secondary to chronic Chagas disease can mimic idiopathic achalasia. Both history and radiological features are similar in both conditions. [7] Esophageal carcinoma is another differential diagnosis of dysphagia. Esophageal motility disorders, and spasm should also be considered if patient presents with dysphagia. [11]
Toxoplasmosis [1] Toxoplasmosis is acquired by consumption of food or raw meat contaminated with oocysts. Like Chagas disease infection during the pregnancy can cause congenital disease. Adults are usually asymptomatic or present with non-specific symptoms. [2]
Malaria A mosquito born disease which present with fever, chills and rigors. Blood picture will show malaria parasites in the red blood cells. [3]
Meningitis Meningoencephalitis is a complication of Chagas disease. Meningitis presents with fever, headache, neck pain and photophobia. [4]
Myocarditis Myocarditis usually presents with chest pain, dyspnea and palpitations. Cardiac MRI will help in making the diagnosis. [5]
Myocardial Infarction Chest pain in myocariditis may mimic a myocardial infarction. ECG and assessment of cardiac biomarkers will help in making the definitive diagnosis.
Arrhythmia Ventricular fibrillation and ventricular tachycardia are common tachyarrhythmias seen in chagas disease. ECG will aid the diagnosis. Other possible causes of arrhythmia should also be considered as differential diagnoses (ischemic heart disease is the commonest cause for ventricular tachycardia). [6]
Cardiomyopathy Dilated or hypertrophic cardiomyopathy are possible differential diagnoses of heart failure seen in chronic Chagas disease. Patients present with dyspnea, poor exercise tolerance, palpitations and orthopnea. [8]
Colonic obstruction Mega colon can cause colonic obstruction due to volvulus of the sigmoid colon and due to fecal impaction secondary to chronic constipation. Other causes of colonic obstruction like Sigmoid diverticulitis, Endometriosis of the colon, and colonic malignancy should be thought of. [9]
Constipation Other commoner causes of constipation like low fiber and water intake should be excluded first. Other than above causes electrolyte disturbances (hypercalcemia, hypokalemia, hypermagnesemia) and endocrine disorders (hypothyroidism, hypoparathyroidism) and chronic renal disease also present with constipation. [10] Hirschsprung disease can present in newborns with chronic constipation. [12]
Leishmaniasis Another flea born disease transmitted by infected sandflies. Leishmaniasis can present with muco-cutaneous manifestations or with splenomegaly secondary to visceral Leishmaniasis. [13]
References
  1. Chagas disease (American trypanosomiasis). [online] [viewed 14 May 2014] Available from: http://www.who.int/neglected_diseases/diseases/chagas/en/
  2. MONTOYA JG, LIESENFELD O. Toxoplasmosis. Lancet. [online]2004 Jun 12;363(9425):1965-76. [viewed 14 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15194258
  3. SNOW RW, GUERRA CA, NOOR AM, MYINT HY, HAY SI. The global distribution of clinical episodes of Plasmodium falciparum malaria. Nature. [online]2005 Mar 10;434(7030):214-7. [viewed 14 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15759000
  4. OLAF HOFFMAN, JOERG WEBER R. Pathophysiology and Treatment of Bacterial Meningitis. Ther Adv Neurol Disord. [online] Nov 2009; 2(6): 1–7. [viewed 14 May 2014] Available from: doi: 10.1177/1756285609337975
  5. SAGAR S, LIU PP, COOPER LT JR. Myocarditis. Lancet. [online]2012 Feb 25;379(9817):738-47. [viewed 14 May 2014] Available from: doi: 10.1016/S0140-6736(11)60648-X.
  6. ASHLEY EA, NIEBAUER J. Cardiology Explained. London: Remedica; 2004. [online] [viewed 14 May 2014] Available from: http://www.ncbi.nlm.nih.gov/books/NBK2219/
  7. MATSUDA NM, MILLER SM, EVORA PR. The Chronic Gastrointestinal Manifestations of Chagas Disease Clinics (Sao Paulo) [online] 2009 Dec, 64(12):1219-1224 [viewed 14 May 2014] Available from: doi:10.1590/S1807-59322009001200013
  8. RANDY WEXLER, TERRY ELTON, ADAM PLEISTER, DAVID FELDMAN. Cardiomyopathy: An Overview. Am Fam Physician. [online] 2009 May 1;79(9):778-784. [viewed 14 May 2014] Available from: http://www.aafp.org/afp/2009/0501/p778.html
  9. SULE AZ, AJIBADE A. Adult large bowel obstruction: a review of clinical experience. Ann Afr Med [online] 2011 Jan-Mar, 10(1):45-50 [viewed 14 May 2014] Available from: doi:10.4103/1596-3519.76586
  10. LEUNG L, RIUTTA T, KOTECHA J, ROSSER W. Chronic constipation: an evidence-based review. J Am Board Fam Med [online] 2011 Jul-Aug, 24(4):436-51 [viewed 14 May 2014] Available from: doi:10.3122/jabfm.2011.04.100272
  11. BLACHA MARIELLE MJ, SLOOTS CORNELIUS EJ, VAN MUNSTER IVO P, WOBBES THEO. Dysphagia caused by a fibrovascular polyp: a case report. Array [online] 2008 December [viewed 14 May 2014] Available from: doi:10.1186/1757-1626-1-334
  12. JENNIFER KESSMANN. Hirschsprung’s Disease: Diagnosis and Management. Am Fam Physician. [online] 2006 Oct 15;74(8):1319-1322. [viewed 14 May 2014] Available from: http://www.aafp.org/afp/2006/1015/p1319.html
  13. Leishmaniasis. [online] [viewed 14 May 2014] Available from: http://www.who.int/leishmaniasis/en/

Investigations - for Diagnosis

Fact Explanation
Detection of antibodies to Trypanosoma cruzi This is the best way in diagnosing chronic Chagas disease. Indirect immunofluorescence (IIF), enzyme-linked immunosorbent assay (ELISA), western blot and indirect hemagglutination test are used in detection of antibodies. [1]
Polymerase chain reaction (PCR) [1] Allows early and quick diagnosis of congenital Chagas disease. PCR has greater sensitivity than blood picture. [2,3]
ECG Arrhythmia is a common complication of Chagas disease. ECG will aid in the diagnosis of bundle branch block, ventricular premature beats and other arrhythmias. [1,2]
Holter monitoring Allows detection of ventricular premature beats and non-sustained ventricular tachycardia which might not be visible in ECG. [2]
References
  1. Chagas disease (American trypanosomiasis). [online] [viewed 14 May 2014] Available from: http://www.who.int/neglected_diseases/diseases/chagas/en/
  2. ANIS RASSI, JOSÉ ANTONIO MARIN-NETO. Chagas disease. The Lancet [online] 17 April 2010: 375 (9723) 1388 – 1402. [viewed 14 May 2014] Available from: doi:10.1016/S0140-6736(10)60061-X
  3. MORA MC, SANCHEZ NEGRETTE O, MARCO D, BARRIO A, CIACCIO M, SEGURA MA, BASOMBRÍO MA. Early diagnosis of congenital Trypanosoma cruzi infection using PCR, hemoculture, and capillary concentration, as compared with delayed serology. J Parasitol. [online]2005 Dec;91(6):1468-73. [viewed 14 May 2014] Available from: doi: http://dx.doi.org/10.1645/GE-549R.1

Investigations - Fitness for Management

Fact Explanation
Electrocardiogram [1] Frequently shows tachycardia. [2] Arrhythmias are seen. ECG will aid in the diagnosis of right bundle branch block, left anterior hemiblock, and third-degree heart block.
Chest X-ray [2] Shows signs of cardiac failure like alveolar edema, Kerley B lines, cardiomegaly, upper lobe diversion, and pleural effusions.
References
  1. Parasites - American Trypanosomiasis (also known as Chagas disease). Centers for Disease Control and Prevention [online] [viewed 14 May 2014] Available from: http://www.cdc.gov/parasites/chagas/gen_info/detailed.html
  2. ANIS RASSI, JOSÉ ANTONIO MARIN-NETO. Chagas disease. The Lancet [online]17 April 2010: 375 (9723) 1388 – 1402. [viewed 14 May 2014] Available from: doi:10.1016/S0140-6736(10)60061-X

Investigations - Followup

Fact Explanation
ECG Development of conduction-system abnormalities (bradyarrhythmias and tachyarrhythmias) is an early complication of the disease. [1,2] Asymptomatic patients with normal ECG have favorable prognosis. Patients should be followed up every one to two years. [2]
Echocardiogram Detects segmental left ventricular wall-motion abnormalities and left ventricular ejection fraction. [1,2]
Cardiac MRI Cardiac MRI will detect the areas of cardiac fibrosis and help in determination of the prognosis. [2]
Upper gastrointestinal endoscopy Detects esophageal carcinoma which is a complication of mega esophagus. [2] Allows taking biopsy specimens for definitive diagnosis.
Investigations to detect mega colon [2] Colonoscopy and barium enema will help in the detection of megacolon. These tests are not done if the patient is asymptomatic.
PCR PCR allows monitoring the treatment and early identification of the treatment failure. [2]
References
  1. BERN C. Antitrypanosomal Therapy for Chronic Chagas' Disease. N Eng J Med [online] 2011; 364(26):2527-2534. [viewed 14 May 2014] Available from: DOI: 10.1056/NEJMct1014204
  2. ANIS RASSI, JOSÉ ANTONIO MARIN-NETO. Chagas disease. The Lancet [online] 17 April 2010: 375 (9723) 1388 – 1402. [viewed 14 May 2014] Available from: doi:10.1016/S0140-6736(10)60061-X

Investigations - Screening/Staging

Fact Explanation
Serological tests Screening is done with serological tests. One positive test cannot diagnose the disease and need at least two positive tests to diagnose. [1,2]
References
  1. CARYN BERN, SONIA KJOS, MICHAEL J. YABSLEY, SUSAN P. MONTGOMERY. Trypanosoma cruzi and Chagas' Disease in the United States. Clin. Microbiol. Rev. [online]October 2011: 24(4) 655-681. [viewed 14 May 2014] Available from: doi: 10.1128/CMR.00005-11
  2. ANIS RASSI, JOSÉ ANTONIO MARIN-NETO. Chagas disease. The Lancet [online]17 April 2010: 375 (9723) 1388 – 1402. [viewed 14 May 2014] Available from: doi:10.1016/S0140-6736(10)60061-X

Management - General Measures

Fact Explanation
Health education Travelers to high prevalent areas should avoid bug bites. Sleeping indoors and covering the body will help in avoiding the bug bites. Spraying insecticides, using insecticide impregnated mosquito nets and use of insect repellents are also preventive measures. [1]
Treatment of cardiovascular complications Pacemaker placement or antiarrhythmic drugs [1] for arrhythmia and ablation procedures for tachycardia are treatment options for cardiovascular complications of chronic Chagas disease. Pharmacological management of heart failure is also important. Cardiac resynchronization therapy is one of the second line option to treat heart failure. End stage Chagas heart disease may require heart transplantation. [2]
Treatment of the mega esophagus This includes sublingual nitrates and nifedipine to relax the lower esophageal sphincter or wide esophagocardiomyectomy and valvuloplasty. [4] Surgery can be done either laparoscopically or as an open surgery. Endoscopic botulin toxin injection and balloon dilatation provides short term symptom control. [2] Heller's myotomy and fundoplication, or esophageal resection is used in advanced disease. [3]
Treatment of mega colon Patients with mega colon are adviced to take fiber rich diet and adequate fluid intake as the primary mode of treatment. [2] Duhamel-Haddad operation is used in the treatment.
References
  1. Parasites - American Trypanosomiasis (also known as Chagas disease). Centers for Disease Control and Prevention [online] [viewed 14 May 2014] Available from: http://www.cdc.gov/parasites/chagas/gen_info/detailed.html
  2. ANIS RASSI, JOSÉ ANTONIO MARIN-NETO. Chagas disease. The Lancet [online] 17 April 2010: 375 (9723) 1388 – 1402. [viewed 14 May 2014] Available from: doi:10.1016/S0140-6736(10)60061-X
  3. HERBELLA FA, AQUINO JL, STEFANI-NAKANO S, ARTIFON EL, SAKAI P, CREMA E, ANDREOLLO NA, LOPES LR, DE CASTRO POCHINI C, CORSI PR, GAGLIARDI D, DEL GRANDE JC. Treatment of achalasia: lessons learned with Chagas' disease. Dis Esophagus [online] 2008, 21(5):461-7 [viewed 13 May 2014] Available from: doi:10.1111/j.1442-2050.2008.00811.x
  4. MATSUDA NM, MILLER SM, EVORA PR. The Chronic Gastrointestinal Manifestations of Chagas Disease Clinics (Sao Paulo) [online] 2009 Dec, 64(12):1219-1224 [viewed 14 May 2014] Available from: doi:10.1590/S1807-59322009001200013

Management - Specific Treatments

Fact Explanation
Antitrypanosomal treatment [1,2] Benznidazole (5—10 mg/kg daily) or nifurtimox (15 mg/kg daily) is used in treatment. Treatment prevents the disease transmission and halt or reverse the disease progression. [3]
References
  1. Parasites - American Trypanosomiasis (also known as Chagas disease). Centers for Disease Control and Prevention [online] [viewed 14 May 2014] Available from: http://www.cdc.gov/parasites/chagas/gen_info/detailed.html
  2. BERN C. Antitrypanosomal Therapy for Chronic Chagas' Disease. N Eng J Med [online] 2011; 364(26):2527-2534. [viewed 14 May 2014] Available from: DOI: 10.1056/NEJMct1014204
  3. VIOTTI R, VIGLIANO C, LOCOCO B, et al. Long-term cardiac outcomes of treating chronic Chagas disease with benznidazole versus no treatment: a nonrandomized trial. Ann Intern Med [online] 2006; 144: 724-734. [viewed 14 May 2014] Available from: doi:10.7326/0003-4819-144-10-200605160-00006