Reactivation of Chagas' Disease in Patients with AIDS: Report of Three New Cases and Review of the Literature

Abstract

Three new cases of reactivation of Chagas' disease in patients with AIDS, with central nervous system and/or cardiac involvement, are reported. One patient had histological evidence of acute esophageal and gastric Trypanosoma cruzi myositis, a previously unrecognized finding in patients with reactivated Chagas' disease. The patients had a low CD4 lymphocyte count and had other AIDS-defining opportunistic infections. One patient's condition improved with benznidazole therapy. Analysis of these three cases and review of the 13 others published in the literature revealed that the central nervous system is the most commonly involved site (75%), followed by the heart (44%). Early diagnosis and treatment with benznidazole or nifurtimox probably improve the survival rate. Long-term secondary prophylaxis should be recommended for patients who respond to therapy, although it is uncertain which drug to use for this purpose. T. cruzi should be included in the list of opportunistic pathogens causing infection in severely immunocompromised patients with AIDS.

Co-infection Trypanosoma cruzi/HIV: systematic review (1980 - 2010)

“…The study on the liquor of co-infected individuals, but without evidence of alterations in the nervous system, was not related in the researched literature. The finding of the parasite in other organic fluids was related in the pericardial 32 and ascetic 40 fluid which shows that in situations of high parasitemia, the T. cruzi can spread, and during the co-infection it must be searched systematically in all organic fluids. The histopathological evaluation was reported in only 15% of the cases, with the places most studied the central nervous system (70%) and the myocardium (14%), places where the Chagas disease usually has its most severe forms during the acute phase 96 .…”

“…Other authors utilized the PCR for lineage specifications of the parasite isolated by other methods 62,64,73 . The study of the parasite on a direct way took as reference, mainly, the peripheral blood and liquor. However, the utilized method was not specified in some articles 29,30,32,70 . Yet, the research between slide and cover slip of fresh material, thick smear with May-GrunwaldGiemsa coloration, Strout, microhematocrit and buffy-coat was reported in several studies in order to increase the sensitivity when verifying the presence of the protozoa 23,33,39,42,45,46,63,68,81 , not having, however, in any of those reference to the superiority of this methods compared to the study of the parasite directly on fresh material.…”

“…The histopathological evaluation was reported in only 15% of the cases, with the places most studied the central nervous system (70%) and the myocardium (14%), places where the Chagas disease usually has its most severe forms during the acute phase 96 . Also, were described histopathological evaluations in the stomach 32 , duodenum 51 , skin 48,61,81 and uterine cervix 55 . In all this locations were found parasites and inflammatory reaction suggestive of the Chagas disease.…”

“…The fact that the clinical picture presented in the reactivation in the heart, usually occurred in the natural evolution of the chronic chagasic cardiopathy 88,102 making the diagnosis difficult, unlike the central nervous system which does not present exuberant symptomatology in the chronic phase of the disease. Other less common locations of reactivations cited were the pericardium 32 , peritoneum 40 , skin 48 , intestine 32,51 and cervix 55 . Although the reactivation has been described in the extrinsic eye muscles in a case of co-infection with reactivation of the Chagas disease in the brain 47 , parasites were not found at the lesion site, only myositis.…”

“…The clinical condition is nonspecific for including reactions from the acute phase: fever, poor general condition, disorientation, hepatosplenomegaly, lymphadenopathy, among others 22,23,32,42,81,93 . Specifically, the clinical condition refers to the place of the reactivation.…”