Manifestations of Chagas disease (American trypanosomiasis) in patients with HIV/AIDS

Abstract

Between June 1989 and December 2005, an observational study of adults co-infected with HIV and Trypanosoma cruzi was conducted, to investigate the spectrum of manifestations of chronic Chagas disease (American trypanosomiasis) in the HIV-positive. The 31 men and 22 women investigated were aged 23-59 years. Each subject was investigated by ambulatory (Holter) and non-ambulatory electrocardiography, chest X-ray, oesophagography and echocardiography (to determine the clinical form of trypanosomiasis), by xenodiagnosis, blood culture and the microscopical examination of blood (to explore their T. cruzi parasitaemia), and by counting their CD4 T cells (to stage their HIV infection). The subjects were followed-up for 1-190 months (median = 58 months) and checked for re-activation of their Chagas disease, which was usually defined by the occurrence of unusual clinical manifestations and/or the detection, by microscopical examination, of trypanosomes in the blood or cerebrospinal fluid. Eleven (20.8%) of the subjects showed re-activation, another nine (17.0%) were found to have developed high T. cruzi parasitaemias but these were only detected by xenodiagnosis or culture, and 15 (28.3%) had illnesses typical of chronic Chagas disease in HIV-negative individuals, with low parasitaemias. Anti-T. cruzi therapy (benznidazole), recommended for 17 patients, resulted in the sustained reduction of parasitaemia in 11 of the 12 subjects who completed treatment. Chagas disease was the cause of death of eight of the 14 subjects who died during the study. Four of the women investigated gave birth, each to a single child, during follow-up, and three of the four babies showed evidence of the congenital transmission of T. cruzi.

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

“…However, when the parasitemia is analyzed by xenodiagnosis or blood culture, the co-infected individuals have a higher chagasic parasitemia than patients without the co-infection with the HIV, suggesting that this reactivation may occur asymptomatic, with a higher frequency 44,60,61 . In this revision, it was reported the occurrence of 41,2% of reactivations, this percentage higher than the ones related in series of cases, which varies between 10 and 15% 81,93,97 , reflecting that, probably, the more severe cases must have been diagnosed and related. Considering the estimates presented in this review, the occurrence of reactivations of Chagas disease in the co-infection with HIV is underestimated 99,100 .…”

“…The exception to these types of publication was the analysis of a series of cases from Brazilian authors 81,93 where the topic was discussed in a broad way with detailed description of cases of individuals with the co-infection, clinical and evolutive profile. Also, the majority of articles were published in Latin American countries, led by Brazil, reflecting the regional importance of Chagas disease as an endemic in this region.…”

“…More recently both exams have been receiving special care in order to make them quantitative. Therefore, 30ml of blood distributed in vials with five milliliters have been used for the T. cruzi culture, as well as the xenodiagnosis started to be analyzed quantitatively through the individual examination of the nymphs, obtaining the proportion of parasitized nymphs, as reported by Brazilian authors in a series of cases 81 . This way was possible to quantify the parasitemia and suggest a classification of very high when the parasites could be identified by microscopic examination of the peripheral blood, high when more than 20% of the utilized nymphs on the xenodiagnosis were infected and, low, when less than 20% of those were found parasitized by T. cruzi.…”

“…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 peripheral blood was the site where the parasite was most searched, but the liquor was where the largest proportion of positivity on the T. cruzi research (78%) occurred, which shows that it is indispensable the use of this evaluation during the investigation of cerebral impairment in patients with the co-infection, considering the feasibility of the exam.…”

“…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.…”