Chronic Chagas disease

Infectious diseases

Clinicals - History

Fact Explanation
Asymptomatic Patients can be asymptomatic for a long period of time. Asymptomatic
Patients can be asymptomatic for a long period of time.
Symptoms of cardiac complications 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. Patients can present with sudden death due to these cardiac complications. Symptoms of cardiac complications
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. Patients can present with sudden death due to these cardiac complications.
Intestinal complications Megaesophagus or megacolon develop due to destruction of intramural autonomic ganglia. 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. Intestinal complications
Megaesophagus or megacolon develop due to destruction of intramural autonomic ganglia. 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.
Thromboembolism Due to congestive cardiac failure. Can result in stroke and pulmonary embolism. Stroke presents as unilateral numbness, unilateral weakness or paralysis. Patients with pulmonary embolism will present as acute pleuritic chest pain, cough and hemoptysis. Thromboembolism
Due to congestive cardiac failure. Can result in stroke and pulmonary embolism. Stroke presents as unilateral numbness, unilateral weakness or paralysis. Patients with pulmonary embolism will present as acute pleuritic chest pain, cough and hemoptysis.
Sialorrhea Patients can have sialorrhea as a gastrointestinal complication of chronic Chagas disease. This is commonly seen in association with mega esophagus. Sialorrhea
Patients can have sialorrhea as a gastrointestinal complication of chronic Chagas disease. This is commonly seen in association with mega esophagus.

Clinicals - Examination

Fact Explanation
Weight loss and cachexia This is seen in severe cases secondary to achalasia. Weight loss and cachexia
This is seen in severe cases secondary to achalasia.
Examination of the cardiovascular system Examination of the pulse will aid in detecting arrhythmia. Signs of heart failure like lower extremity pitting edema, shifted apex beat due to cardiomegaly and pulmonary crackles are detected. Examination of the cardiovascular system
Examination of the pulse will aid in detecting arrhythmia. Signs of heart failure like lower extremity pitting edema, shifted apex beat due to cardiomegaly and pulmonary crackles are detected.
Signs suggestive of thromboembolism Hemiparesis and hemi anesthesia will be detected. Signs suggestive of thromboembolism
Hemiparesis and hemi anesthesia will be detected.
Hypertrophy of the salivary glands Salivary glands hypertrophy as a complication of chronic Chagas disease. Hypertrophy of the salivary glands
Salivary glands hypertrophy as a complication of chronic Chagas disease.
Examination of the respiratory system Patients are susceptible to aspiration pneumonia because of the mega esophagus. On examination patient will be febrile and there will be localized area of reduced chest expansion, dullness to percussion and bronchial breathing. Examination of the respiratory system
Patients are susceptible to aspiration pneumonia because of the mega esophagus. On examination patient will be febrile and there will be localized area of reduced chest expansion, dullness to percussion and bronchial breathing.
Fecaloma A mass of very hard impacted feces is palpated. This occurs in patients with chronic constipation. Fecaloma
A mass of very hard impacted feces is palpated. This occurs in patients with chronic constipation.

Investigations - 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. 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.
Polymerase chain reaction (PCR) Allows early and quick diagnosis of congenital Chagas disease. PCR has greater sensitivity than blood picture. Polymerase chain reaction (PCR)
Allows early and quick diagnosis of congenital Chagas disease. PCR has greater sensitivity than blood picture.
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. 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.
Holter monitoring Allows detection of ventricular premature beats and non-sustained ventricular tachycardia which might not be visible in ECG. Holter monitoring
Allows detection of ventricular premature beats and non-sustained ventricular tachycardia which might not be visible in ECG.

Investigations - Management

Fact Explanation
ECG Development of conduction-system abnormalities (bradyarrhythmias and tachyarrhythmias) is an early complication of the disease. Asymptomatic patients with normal ECG have favorable prognosis. Patients should be followed up every one to two years. ECG
Development of conduction-system abnormalities (bradyarrhythmias and tachyarrhythmias) is an early complication of the disease. Asymptomatic patients with normal ECG have favorable prognosis. Patients should be followed up every one to two years.
Echocardiogram Detects segmental left ventricular wall-motion abnormalities and left ventricular ejection fraction. Echocardiogram
Detects segmental left ventricular wall-motion abnormalities and left ventricular ejection fraction.
Cardiac MRI Cardiac MRI will detect the areas of cardiac fibrosis and help in determination of the prognosis. Cardiac MRI
Cardiac MRI will detect the areas of cardiac fibrosis and help in determination of the prognosis.
Upper gastrointestinal endoscopy Detects esophageal carcinoma which is a complication of mega esophagus. Allows taking biopsy specimens for definitive diagnosis. Upper gastrointestinal endoscopy
Detects esophageal carcinoma which is a complication of mega esophagus. Allows taking biopsy specimens for definitive diagnosis.
Investigations to detect mega colon Colonoscopy and barium enema will help in the detection of megacolon. These tests are not done if the patient is asymptomatic. Investigations to detect mega colon
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. PCR
PCR allows monitoring the treatment and early identification of the treatment failure.
Electrocardiogram Frequently shows tachycardia. Arrhythmias are seen. ECG will aid in the diagnosis of right bundle branch block, left anterior hemiblock, and third-degree heart block. Electrocardiogram
Frequently shows tachycardia. 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 Shows signs of cardiac failure like alveolar edema, Kerley B lines, cardiomegaly, upper lobe diversion, and pleural effusions. Chest X-ray
Shows signs of cardiac failure like alveolar edema, Kerley B lines, cardiomegaly, upper lobe diversion, and pleural effusions.
Serological tests Screening is done with serological tests. One positive test cannot diagnose the disease and need at least two positive tests to diagnose. Serological tests
Screening is done with serological tests. One positive test cannot diagnose the disease and need at least two positive tests to diagnose.

Management - Supportive

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. 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.
Treatment of cardiovascular complications Pacemaker placement or antiarrhythmic drugs 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. Treatment of cardiovascular complications
Pacemaker placement or antiarrhythmic drugs 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.
Treatment of the mega esophagus This includes sublingual nitrates and nifedipine to relax the lower esophageal sphincter or wide esophagocardiomyectomy and valvuloplasty. Surgery can be done either laparoscopically or as an open surgery. Endoscopic botulin toxin injection and balloon dilatation provides short term symptom control. Heller's myotomy and fundoplication, or esophageal resection is used in advanced disease. Treatment of the mega esophagus
This includes sublingual nitrates and nifedipine to relax the lower esophageal sphincter or wide esophagocardiomyectomy and valvuloplasty. Surgery can be done either laparoscopically or as an open surgery. Endoscopic botulin toxin injection and balloon dilatation provides short term symptom control. Heller's myotomy and fundoplication, or esophageal resection is used in advanced disease.
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. Duhamel-Haddad operation is used in the treatment. 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. Duhamel-Haddad operation is used in the treatment.

Management - Specific

Fact Explanation
Antitrypanosomal treatment 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. Antitrypanosomal treatment
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.

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