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Chagas disease – who, how, what to do?
Dave MooreHospital for Tropical Diseases
26th March 2014
What do I know about Chagasdisease?
(jot down an answer to each ‐ true or false)1. Chagas disease in Latin America is largely
acquired through the bite of the assassin bug2. Transmission of Chagas disease is limited to
South American countries below Panama3. Chagas disease is common in Latin American
migrants in Europe4. Chagas disease can be passed from
asymptomatic mothers to their babies5. One week of treatment is generally well‐
tolerated and highly effective6. Chagas disease should be Chagas’ disease
Chagas disease is a parasitic infection
chronic infection
very rarely seen acute infectionacute infection
indeterminate determinate
lifelong infectiondisease‐free
20% of chronic infectionsover years‐decades
cardiomyopathygastrointestinal disease
most people with Chagasdon’t know they have it
person‐to‐person transmission of T. cruzi
• Transplant
• Blood transfusion
• Mother to child
acai juice anyone?
clinical importance 1
gastrointestinal cardiac• conduction system defects
• arrhythmias
• dilated cardiomyopathy and CCF
• apical aneurysm, thrombus, strokes
clinical importance 2
neonatal Chagas
• 4‐8% vertical transmission
• equally likely in indeterminate
• drugs not used in pregnancy
• effective neonatal therapy available
key steps to prevention
• maternal antenatal diagnosis
• early diagnosis of neonate
• early treatment of neonate
treatment is toxic and not licensed in UK(alchemy?)
nifurtimox
• 90 days treatment
• Anorexia
• Nausea
• Weight loss
• Tremors
• Insomnia
• Peripheral neuropathy
benznidazole
• 60 days treatment
• Anorexia
• Dermatitis
• Bone marrow suppression
• Peripheral neuropathy
evidence‐base for treatment efficacy is limited to specific subgroups
• Always treat – early congenital infection – good efficacy proven
• Generally offered– adults aged 19‐50 without advanced cardiomyopathy– might be useful in (non‐pregnant) women of child‐bearing age
• Individualised decision– adults > 50 years without advanced cardiomyopathy
MP, Bolivian F, 46 yrs
• Cleaner, living in UK 9 yrs• Palpitations whilst on holiday in Santa Cruz
– Resting ECG normal– T cruzi serology (antibody) POSITIVE
• Referred by GP to HTD on return– reports two brothers died suddenly playing football– confirmatory T cruzi serology positive– Resting ECG, echocardiogram, 3 day Holter – NORMAL– children aged 18, 21 and 29, need testing
CS‐N Colombian F, 39yrs
• Told she had Chagas in Colombia and would need attention if became pregnant
• Referred by GP because 9/40 pregnant
• T cruzi serology POSITIVE• Asymptomatic – ECG normal
= indeterminate Chagas disease• (T cruzi PCR negative)
CS‐N Colombian F, 39yrs, pregnant
Plan made• NOT for Chagas treatment of mother
– (a) indeterminate phase, so no evidence of benefit– (b) drugs contraindicated in pregnancy
• CLOSE FOLLOW‐UP of neonate– No need for special delivery arrangement– Can breast feed– PCR at 0, 3, 6, 9, 12 months– treat if positive – good efficacy and tolerability
CS‐N Colombian F, 39yrs
• Pregnancy lost at 12/40– Not believed to be related to maternal indeterminate Chagas
• Subsequent discussion about treatment of indeterminate Chagas– Likely efficacy not clear for patient, nor in reducing risk to future offspring
– Lack of indicators of response to therapy– Must avoid pregnancy whilst on treatment
CS‐N Colombian F, 39yrs
• Decided to take benznidazole
• 11 days into treatment – Marked myalgia
• 15 days into treatment– Extensive maculopapular rash
→ Treatment discontinued
CS‐N Colombian F, 39yrs
• 2 years later...
• Referred back as 28/40 pregnant• (T cruzi PCR negative)• ECG and CXR normal
• Arrangements made for monitoring of infant• PCR at 3, 6, 9 months all negative
Route of referral for Chagas patients
with thanks to Sophie Yacoub, HTD
“what will you do at HTD?”
T cruzi serology
History, exam, tropical screen investigations appropriate to epidemiological exposures
negative
positive
not Chagas
PCR
negative positive
ECG +/‐ 24 hour tape
CXR
echo
GI investigations
(if indicated)baseline
annual ECG
Diagnoses for Latin American migrants seen in HTD outpatients
with thanks to Sophie Yacoub, HTD
What do I know about Chagas disease now?
1. Chagas disease in Latin America is largely acquired through the bite of the assassin bug
2. Transmission of Chagas disease is limited to South American countries below Panama
3. Chagas disease is common in Latin American migrants in Europe
4. Chagas disease can be passed from asymptomatic mothers to their babies
5. One week of treatment is generally well‐tolerated and highly effective
6. Chagas disease should be Chagas’ disease
Take‐home messages
Chagas disease:• is a chronic parasitic infection
that passes unnoticed in most people
• can cause cardiac (and GI) end‐organ damage after many years which may be life‐threatening (esp. arrhythmias) ‐ detection and management is important
• simple serological testing should be considered in any Latin American migrant
• Drugs are toxic and efficacy is modest so treatment is on a case‐by‐case basis
• Congenital infection is the important exception for which early detection and (well‐tolerated) treatment is vital
• Antenatal screening of Latin American migrants is key
Management:
“I have a Latin American patient and am not sure if I should be concerned about Chagas.
What should I do?”
• Either send email inquiry
– Dr Dave Moore – [email protected]
• Or send text to 077 572 64153 with contact email address and we will call or email you back
• Or refer directly to HTD for outpatient appointment (can offer more extended tropical screen)
Gracias por su atención!