Cerebral trypanosomiasis in a renal transplant recipient

Abstract

Chagas disease is a lifelong, systemic, parasitic infection caused by the protozoan Trypanosoma cruzi. The main form of disease transmission is vector borne, but vertical transmission, such as by organ transplantation from a chronically infected donor, is also possible. The brain tumor-like form can occur years after infection and has been described in patients with acquired immunodeficiency syndrome, and in a very few cases in transplant recipients. We describe the case of a kidney transplant patient who was human immunodeficiency virus negative and infected with T. cruzi, and developed cerebral trypanosomiasis that was successfully treated with benznidazole at 7 mg/kg/day for 60 days. The risk of Chagas disease transmission should not be underestimated in renal transplant patients, even in non-endemic areas. Chagas disease can present as a tumor-like brain lesion, very difficult to differentiate from other opportunistic infectious or neoplastic processes. Frequent monitoring for T. cruzi infection is essential to promptly implement treatment, which, in our patient, proved to be effective and safe.

Prevalence of Chagas Disease among Solid Organ–Transplanted Patients in a Nonendemic Country

“…Moreover, in addition to common clinical presentation of Chagas disease reactivation (myocarditis and meningoencephalitis), it may present with skin lesions such as panniculitis and erythema nodosum-like lesions. 7,8,[25][26][27] The migration flows from rural endemic areas to urban areas and nonendemic areas have contributed that Chagas disease patients increasingly participate in transplantation programs. 2 Furthermore, since Chagas disease is usually asymptomatic, patients awaiting organ transplantation are often unaware of the diagnosis.…”

Receiving the Unwanted Gift: Infection Transmission through Organ Transplantation

“…Strongyloides has come from donors typically from the Caribbean, amoebae from warm, fresh water sources, Chagas' disease from individuals spending substantial time in Central America, and toxoplasmosis from just about anyone exposed to infected cats [21][22][23][24]. Certainly, not every donor from a specific geographic area will transmit an infection to an organ recipient, but when there is a substantial risk, caution must be exercised.…”

Chagas Disease, Leishmaniasis, and Malaria in Solid Organ Transplant Recipients

“…Acute CD has been diagnosed following kidney, heart, liver, and lung transplantation from T. cruzi seropositive donors; the clinical picture ranges from asymptomatic parasitaemia detected only by polymerase chain reaction (PCR) performed on peripheral blood samples to an acute disease presenting with daily high fever or with involvement and dysfunction of the kidney, heart, and brain [19,20,22,23,50,51]. Besides fever in patients experiencing post-transplant acute infection several clinical pictures have been reported: acute chagasic myocarditis, cerebral trypanosomiasis with space-occupying brain lesions or kidney failure [18,20,51,52]. In the above cited cases, trypomastigotes were identified in the bloodstream, peritoneal fluid, and cerebrospinal fluid, and T. cruzi amastigotes were found in endomyocardial biopsies [20,51,52].…”

“…Besides fever in patients experiencing post-transplant acute infection several clinical pictures have been reported: acute chagasic myocarditis, cerebral trypanosomiasis with space-occupying brain lesions or kidney failure [18,20,51,52]. In the above cited cases, trypomastigotes were identified in the bloodstream, peritoneal fluid, and cerebrospinal fluid, and T. cruzi amastigotes were found in endomyocardial biopsies [20,51,52]. In an autopsied kidney transplant recipient, disseminated CD was demonstrated with intense T. cruzi parasitism involving the heart, liver, spleen, kidney, bladder, and pancreas [51].…”

“…Quantitative real-time PCR monitoring during the first 6 to 24 months post-transplant is actually recommended and employed in the centers transplanting the organs of Chagas disease patients [1,5,9,31,45]. Direct parasitological examination (Strout method or blood smear) on peripheral blood, cerebrospinal fluid, or pericardial fluid as well as histopathology are less sensitive, although usually employed [20,51,52]. Blood culture and xenodiagnosis are also less sensitive and time-consuming methods.…”