Chagas-related myocardial injury identifiable on cardiac MRI
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Researchers in Brazil used cardiac MRI and ECG to identify evidence of myocardial injury as a result of acute Chagas disease, an infection considered endemic across countries in South America.
In a small group of patients with acute Chagas disease, half exhibited evidence of late gadolinium enhancement on cardiac MRI at 1 year after initial diagnosis, according to the findings published in the Journal of the American Heart Association.
“In Latin America, the disease is endemic in 21 countries, including Brazil, where it is estimated that more than 1 million people are living with Chagas disease, and this results in [approximately] 4,000 deaths every year,” Katia do Nascimento Couceiro, MD, PhD, FESC, of the postgraduate program in tropical medicine at Universidade do Estado do Amazonas in Manaus, Brazil, and colleagues wrote.
Causes of Chagas disease
According to a 2016 report published in Circulation, Chagas disease is caused by an organism called Trypanosoma cruzi, a parasite transmitted by biting insects called triatomine bugs or “kissing bugs.”
The CDC states that kissing bugs are nocturnal insects typically found in the southern U.S., Mexico, Central America and South America that feed on the blood of mammals.
Researchers posit that many acute cases of Chagas disease in the Amazon region are associated with oral transmission of the T. cruzi parasite due to contamination of juices made from palm fruits such as açaí berry, palm tree wine, sugar cane and guava juices, according to the study.
Chagas disease is labeled by WHO as an endemic in areas of 21 Latin American countries, with an estimated 6 million to 7 million people infected with T. cruzi worldwide.
As Healio previously reported, the incidence of Chagas-related myocardial injury may even be on the rise in the U.S., with one Los Angeles hospital estimating that approximately one in five patients with cardiomyopathy who lived in Latin America for at least 1 year had Chagas cardiomyopathy.
“Chagas cardiomyopathy is the main cause of morbidity and mortality, and myocardial injury can be precisely detected by cardiovascular magnetic resonance (CMR) with late gadolinium enhancement technique,” the researchers wrote. “The aim of this study was to investigate the presence and magnitude of myocardial injury in autochthonous patients with Chagas disease in the acute and posttreatment phases in the Brazilian Amazon using CMR.”
‘Easily accessible tests’ for early detection
The analysis included 23 patients at a Chagas disease outpatient clinic of the Tropical Medicine Foundation Doctor Heitor Vieira Dourado in Amazonas, Brazil (mean age, 44 years; 65% men).
Researchers assessed Chagas-related myocardial injury in patients with acute infection before and after treatment.
Participants were separated into two groups: Group 1 consisted of 12 patients evaluated during the acute phase of Chagas disease, at the time of diagnosis and 1 year after treatment. Group 2 consisted of 11 patients in the late post-acute phase and evaluated on average 5.2 years after diagnosis and treatment.
All participants were diagnosed via direct parasitological examination and a thick smear test and treated with benznidazole (Rochagan) for 60 days.
Researchers performed Selvester QRS score 12-lead ECG, 24-hour Holter exam and cardiac MRI.
ECG findings were present in 69.6% of the overall cohort, with left anterior fascicular block and ventricular repolarization being the most common.
Twenty four-hour Holter exam identified atrial tachycardia in 25% of patients (n = 3) and ventricular extrasystoles in 16.7% patients in group 1 (n = 2).
Use of cardiac MRI was able to identify myocardial injury in 58.3% of patients in the acute phase of Chagas disease in group 1. Myocardial injury was found at 1 year in 50% of patients in group one and, at 5.2 years, 18.2% of group 2.
“The correlation between fibrosis detected by CMR and [Sylvester QRS score] — a simple and easily accessible test — represents a good tool for the early detection and stratification of patients with myocardial involvement in the acute and subacute phases of Chagas disease,” the researchers wrote. “This is even more pertinent when one remembers that the Amazon is a region of vast territorial extension with many remote areas and access to CMR may prove difficult for many patients.”
References:
- Chagas disease (American trypanosomiasis). www.who.int/health-topics/chagas-disease#tab=tab_1. Accessed Oct. 18, 2021.
- de Alcantara Lima N, et al. JAMA Netw Open. 2021;doi:10.1001/jamanetworkopen.2021.29959.
- Kuehn BM. Circulation. 2021;doi:10.1161/CIRCULATIONAHA.116.024839.
- Parasites - American Trypanosomiasis (also known as Chagas Disease). https://www.cdc.gov/parasites/chagas/gen_info/vectors/index.html. Page last reviewed Oct. 14, 2020. Accessed Oct. 18, 2021.
Perspective
Back to TopNeiberg de Alcantara Lima, MD
Chagas heart disease is a common cause of cardiomyopathy in South and Central America caused by the Trypanosoma cruzi. In its chronic phase, it can cause arrhythmias, congestive HF and embolism. Acute Chagas disease is rare, and studies in this phase are scarce. In this interesting paper published by Couceiro and colleagues in the Journal of the American Heart Association, cardiac MRI was used to evaluate 23 patients with acute Chagas disease. Myocardial injury was proved to be present in patients with acute Chagas heart disease and persisted despite treatment. Cardiac MRI was already an important tool in the evaluation of patients with chronic Chagas disease, and it should now be considered in patients with acute Chagas disease.
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