Neurochagas: atualização clínica / Neurochagas: clinical update

A doença de Chagas ainda é uma doença tropical muito prevalente no Brasil. Pode apresentar duas fases (aguda e crônica) e exibe grandes repercussões, sobretudo as que envolvem o sistema nervoso periférico e/ou central. Com o aumento do número de pessoas vivendo em estado (transitório ou permanente) de imunossupressão, os casos de manifestações neurológicas por neurochagas aumentaram, e este tornou-se um importante diagnóstico diferencial com outras doenças oportunistas. Este artigo teve como objetivo revisar os principais aspectos clínicos e terapêuticos da doença de Chagas no sistema nervoso central.

Chagas disease is still a very prevalent tropical disease in Brazil. It can have two phases - acute and chronic ­ and shows major repercussions, especially those involving the peripheral and/ or central nervous system. With the increase in the number of people living in the (transient or permanent) state of immunosuppression the cases of neurological manifestations of Chagas disease increased and this became an important differential diagnosis with other opportunistic diseases. This article aimed to review the main clinical and therapeutic aspects of central nervous system Chagas disease

Influence of Angiotensin-converting Enzyme Insertion/Deletion Gene Polymorphism in Progression of Chagas Heart Disease

Abstract INTRODUCTION: Chagas disease (CD) is a neglected disease caused by the parasite Trypanosoma cruzi. One-third of infected patients will develop the cardiac form, which may progress to heart failure (HF). However, the factors that determine disease progression remain unclear. Increased angiotensin II activity is a key player in the pathophysiology of HF. A functional polymorphism of the angiotensin-converting enzyme (ACE) gene is associated with plasma enzyme activity. In CD, ACE inhibitors have beneficial effects supporting the use of this treatment in chagasic cardiomyopathy. METHODS: We evaluated the association of ACE I/D polymorphism with HF, performing a case-control study encompassing 343 patients with positive serology for CD staged as non-cardiomyopathy (stage A; 100), mild (stage B1; 144), and severe (stage C; 99) forms of Chagas heart disease. For ACE I/D genotyping by PCR, groups were compared using unconditional logistic regression analysis and adjusted for nongenetic covariates: age, sex, and trypanocidal treatment. RESULTS: A marginal, but not significant (p=0.06) higher prevalence of ACE I/D polymorphism was observed in patients in stage C compared with patients in stage A. Patients in stage C (CD with HF), were compared with patients in stages A and B1 combined into one group (CD without HF); DD genotype/D carriers were prevalent in the HF patients (OR = 2; CI = 1.013.96; p = 0.04). CONCLUSIONS: Our results of this cohort study, comprising a population from the Northeast region of Brazil, suggest that ACE I/D polymorphism is more prevalent in the cardiac form of Chagas disease with HF.

Human acute Chagas disease: changes in factor VII, activated protein C and hepatic enzymes from patients of oral outbreaks in Pará State (Brazilian Amazon)

Oral transmission of Chagas disease has been increasing in Latin American countries. The present study aimed to investigate changes in hepatic function, coagulation factor levels and parasite load in human acute Chagas disease (ACD) secondary to oral Trypanosoma cruzi transmission. Clinical and epidemiological findings of 102 infected individuals attended in the State of Pará from October 2013 to February 2016 were included. The most common symptoms were fever (98%), asthenia (83.3%), face and limb edema (80.4%), headache (74.5%) and myalgia (72.5%). The hepatic enzymes alanine aminotransferase (ALT) and aspartate aminotransferase (AST) of 30 ACD patients were higher compared with controls, and this increase was independent of the treatment with benznidazole. Moreover, ACD individuals had higher plasma levels of activated protein C and lower levels of factor VII of the coagulation cascade. Patients with the highest parasite load had also the most increased transaminase levels. Also, ALT and AST were associated moderately (r = 0.429) and strongly (r = 0.595) with parasite load respectively. In conclusion, the present study raises the possibility that a disturbance in coagulation and hepatic function may be linked to human ACD.

Use of tissue doppler imaging for the early detection of myocardial dysfunction in patients with the indeterminate form of Chagas disease

Abstract INTRODUCTION: Chagas disease is one of the most common diseases in Latin America and heart involvement is the main cause of death. This study aimed to determine differences in tissue Doppler imaging (TDI) parameters in the assessment left and right ventricular function in patients with the indeterminate form of Chagas disease compared to those in healthy controls. METHODS: We compared 194 patients with the indeterminate form of Chagas disease to 72 age-matched healthy individuals. We considered p-values <0.05 to be statistically significant. RESULTS: TDI analysis of the right ventricular (RV) showed lengthened isovolumic relaxation time (IRT) and higher RV index of myocardial performance (RIMP) and left ventricle (LV) index of myocardial performance (LIMP) in the Chagas group than in the control group, indicating RV and LV systolic and diastolic myocardial damage. TDI analysis of the myocardial velocities of the interventricular septum and the lateral wall of the LV also showed a systolic and diastolic myocardial damage. CONCLUSIONS: The study results demonstrated early LV systolic and diastolic myocardial damage in the RV and LV in patients with the indeterminate form of Chagas disease by TDI. These early findings of RV and LV dysfunction may help identify patients who will progress to heart failure during the disease course. TDI should be included in initial patient evaluations because it allows adequate follow-up and treatment.

Doença de chagas: uma atualização bibliográfica / Chagas disease: a bibliographic update

É uma doença infecciosa causada por um protozoário parasita chamado Trypanosoma cruzi,nome dado por seu descobridor, o cientista brasileiro Carlos Chagas, em homenagem a outro cientista, também brasileiro, Oswaldo Cruz. Essa doença é conhecida popularmente como doença do coração crescido, além disso, os locais com mais índices dessa doença são as regiões do Norte e Sudeste e tem como formas de diagnósticos exames de sorologiaparasitários e xenodiagnóstico. E uma das principais formas de prevenção da doença vem sendo o uso de telas e repelentes.

It is an infectious disease caused by a protozoan parasite calledTrypanosoma cruzi, named after its discoverer, the Brazilian scientistCarlos Chagas, in honor of another scientist, also, Brazilian, Oswaldo Cruz. This disease is popularly known as a disease of the heart grown, in addition, the sites with the most indexes of this disease are the regions of the North and southeast and have as diagnostic methods serologica tests parasitic and xenodiagnosis. And one of the main forms of prevention of the disease has been the use of screens and repellents.

Association between Chagas disease and changes in the optic nerve and retinal nerve fiber layer / Associação entre doença de Chagas e alterações do nervo óptico e camada de fibras nervosas

ABSTRACT Purpose: To test the hypothesis that Chagas disease predisposes to optic nerve and retinal nerve fiber layer alterations. Methods: We conducted a cross-sectional study including 41 patients diagnosed with Chagas disease and 41 controls, paired by sex and age. The patients underwent ophthalmologic examinations, including intraocular pressure measurements, optic nerve and retinal nerve fiber layer screening with retinography, optical coherence tomography, and standard automated perimetry. Results: All of the patients with Chagas disease had a recent cardiologic study; 15 (36.6%) had heart failure, 14 (34.1%) had cardiac form without left ventricular dysfunction, and 12 (29.3%) had indeterminate form. Optic nerve/retinal nerve fiber layer alterations were observed in 24 patients (58.5%) in the Chagas disease group and 7 controls (17.1%) (p£0.01). Among these, optic nerve pallor, optic nerve alterations suggestive of glaucoma, notch, peripapillary hemorrhage, and localized retinal nerve fiber layer defect were detected. Alterations were more prominent in patients with Chagas disease and heart failure (11 patients), although they also occurred in those with Chagas disease without left ventricular dysfunction (7 patients) and those with indeterminate form (6 patients). Optical coherence tomography showed that themean of the average retinal nerve fiber layer thickness measured 89 ± 9.7 mm, and the mean of retinal nerve fiber layer superior and inferior thickness measured 109 ± 17.5 and 113 ± 16.8 mm, respectively were lower in patients with Chagas disease. In controls, these values were 94 ± 10.6 (p=0.02); 117 ± 18.1 (p=0.04), and 122 ± 18.4 mm (p=0.03). Conclusion: Changes in optic nerve/ retinal nerve fiber layer were more prevalent in patients with Chagas disease.

RESUMO Objetivo: Testar a hipótese de que a doença de Chagas predispõe a alterações no nervo óptico e camada de fibras nervosas peripapilar. Métodos: Foi realizado um estudo transversal com 41 pacientes diagnosticados com doença de Chagas e 41 controles, pareados por sexo e idade. Os pacientes foram submetidos a exames oftalmológicos, incluindo medida da pressão intraocular, avaliação do nervo óptico e camada de fibras nervosas através de retinografia, tomografia de coerência óptica e perimetria automatizada padrão. Resultados: Todos os pacientes com doença de Chagas apresentavam estudo cardiológico recente; 15 pacientes (36,6%) apresentavam insuficiência cardíaca; 14 (34,1%) forma cardíaca sem disfunção de ventrículo esquerdo e 12 (29,3%), forma indeterminada. Alterações do nervo óptico/camada de fibras nervosas foram observadas em 24 pacientes (58,5%) do grupo com doença de Chagas e 07 controles (17,1%) (p£0,01). Dentre estas, palidez do nervo óptico, alterações do nervo óptico sugestivas de glaucoma, entalhe, hemorragia peripapilar e defeito da camada de fibras localizado foram detectados. As alterações foram mais proeminentes nos pacientes com doença de Chagas e insuficiência cardíaca (11 pacientes) embora também ocorressem naqueles com doença de Chagas sem disfunção de ventrículo esquerdo (7 pacientes) e com forma indeterminada (6 pacientes). A tomografia de coerência óptica mostrou que a média da espessura da camada de fibras nervosas da retina mediu 89 ± 9,7 mm), e a média da espessura da camada de fibras nervosas superior e inferior mediu 109 ± 17,5 e 113 ± 16,8 mm, respectivamente, foi menor em pacientes com doença de Chagas. Nos controles, esses valores foram de 94 ± 10,6 mm (p=0,02); 117 ± 18,1 (p=0,04) e 122 ± 18,4 mm (p=0,03). Conclusão: Alterações do nervo óptico/camada de fibras nervosas da retina foram mais prevalentes nos pacientes com doença de Chagas.

Electrocardiogram in Chagas disease

Abstract Since the initial descriptions of Chagas cardiomyopathy (ChCM), the electrocardiography has played a key role in patient evaluations. The diagnostic criterion of chronic ChCM is the presence of characteristic electrocardiographic (ECG) abnormalities in seropositive individuals, regardless of the presence of symptoms. However, these ECG abnormalities are rarely specific to ChCM and, particularly among the elderly, can be caused by other simultaneous cardiomyopathies. ECG abnormalities can predict the occurrence of heart failure, stroke, and even death. Nevertheless, most prognostic studies have included Chagas disease (ChD) populations and, not exclusively, ChCM. Thus, more studies are required to evaluate the efficacy of ECG in predicting reliable prognoses in established chronic ChCM. This review exclusively discusses the role of the 12-lead ECG in the clinical evaluation of chronic ChD.

Reduced functional capacity in patients with Chagas disease: a systematic review with meta-analysis

Abstract Reduced peak oxygen uptake (VO2peak) is a common clinical finding in progressive Chagas disease. However, the disease stage in which functional impairment is detectable remains uncertain. The present study compared functional capacity between healthy controls and patients with different clinical forms of Chagas disease. A systematic review and meta-analysis (PROSPERO database CRD42017058353) was conducted following a search of the MEDLINE, Web of Science, CINAHL, and LILACS databases from September to December 2017 for articles published in English, Spanish, or Portuguese, with no date restrictions. We included studies that compared the VO2peak between healthy and Chagas disease patients, stratified according to 3 clinical forms [no apparent cardiac disease, non-dilated Chagas heart disease (CHD), and dilated CHD]. Seven cross-sectional studies were included. Chagas disease patients without apparent cardiac disease (n=208) had VO2peak values [mean difference, -1.55ml/kg/min; 95% confidence interval (CI), -4.98ml/kg/min to 1.88ml/kg/min] similar to those of healthy controls (n=105; p=0.38, I2=52%). In non-dilated CHD (n=159), VO2peak was 8.71ml/kg/min lower (95% CI, -13.99 to -3.42ml/kg/min) than in healthy controls (n=59; p=0.001, I2=75%). VO2peak was also significantly lower (mean difference, -9.30ml/kg/min; 95% CI, -11.34 to -7.25ml/kg/min) in dilated CHD patients (n=131) than in healthy controls (n=53; p<0.001, I2=0%). Exercise capacity in Chagas disease patients without apparent cardiac disease is similar to that in healthy controls. Functional impairment in Chagas disease is detectable in the early stages of cardiac involvement, even in the absence of systolic dysfunction and signs of heart failure.

Pupillometry in Chagas disease / Pupilometria na doença de Chagas

ABSTRACT Purpose: We investigated parasympathetic innervation abnormalities of the iris sphincter and ciliary muscles in chronic Chagas disease by measuring pupillary diameter and intraocular pressure. Methods: A group of 80 patients with Chagas disease was compared with 76 healthy individuals without chagasic infection. The following procedures were performed: pupillometry, hypersensitivity test to pilocarpine 0.125%, intraocular pressure measurement (IOP), basal pupil diameter (BPD), absolute pupillary constriction amplitude (ACA), relative pupillary constriction amplitude (RCA) and the presence of anisocoria. Results: The prevalence of anisocoria was higher in chagasic patients (p<0.01). These patients had mean basal pupillary diameter, mean photopic pupillary diameter and mean value of absolute pupillary constriction amplitude significantly lower than non-chagasic ones (p<0.01, mean difference -0.50mm), (p=0.02, mean difference -0.20mm), (p<0.01, mean difference -0.29mm), respectively. The relative pupillary constriction amplitude did not differ between the two groups (p=0.39, mean difference -1.15%). There was hypersensitivity to dilute pilocarpine in 8 (10%) of the chagasic patients in the right eye and in 2 (2.5%) in the left eye and in 1 (1.25%) in both eyes. The mean value of intraocular pressure had a marginal statistical significance between the two groups (p=0.06, mean difference -0.91mmHg). Conclusions: Patients with chagasic infection may exhibit ocular parasympathetic dysfunction, demonstrable by pupillometry and the dilute pilocarpine hypersensitivity test.

RESUMO Introdução: Investigaram-se anormalidades da inervação parassimpática dos músculos esfíncter da íris e ciliar na doença de Chagas crônica, através de medidas pupilares e da pressão intraocular. Métodos: Foram estudados dois grupos, um com 80 chagásicos e outro com 76 indivíduos saudáveis sem infecção chagásica. Foram realizados os seguintes procedimentos: pupilometria, teste de hipersensibilidade à pilocarpina a 0,125%, medida da pressão intraocular (PIO), diâmetro basal da pupila (DBP), amplitude de constrição pupilar absoluta (ACA), amplitude de constrição pupilar relativa (ACR), e presença de anisocoria. Resultados: A prevalência de anisocoria foi maior nos chagásicos (p<0,01). Estes pacientes apresentaram diâmetro basal pupilar médio, diâmetro fotópico médio e valor médio da amplitude de constrição pupilar absoluta, significativamente menores que os não chagásicos, (p<0,01, diferença de média -0,50mm), (p=0.02, diferença de média -0,20mm), (p<0,01, diferença de média -0,29mm), respectivamente. A amplitude de constrição pupilar relativa não diferiu entre os dois grupos (p=0,39, diferença de média -1,15%). Houve hipersensibilidade à pilocarpina diluída em 8 (10%) chagásicos no olho direito em 2 (2,5%) no olho esquerdo e em 1 (1,25%) em ambos os olhos. O valor médio da pressão intraocular teve significância marginal entre os dois grupos (p=0,06, diferença de média -0,91mmHg). Conclusões: Pacientes com infecção chagásica podem apresentar disfunção parassimpática ocular, demonstrável pela pupilometria e pelo teste de hipersensibilidade à pilocarpina diluída.

Association between Microvolt T-Wave Alternans and Malignant Ventricular Arrhythmias in Chagas Disease / Associação entre Microalternância de Onda T e Arritmias Ventriculares Malignas na Doença de Chagas

Abstract Background: Sudden cardiac death is the most frequent death mechanism in Chagas disease, responsible for 55% to 65% of the deaths of patients with chronic Chagas cardiomyopathy (CCC). The most often involved electrophysiological mechanisms are ventricular tachycardia and ventricular fibrillation. The implantable cardioverter defibrillator (ICD) has a beneficial role in preventing sudden death due to malignant ventricular arrhythmias, and, thus the correct identification of patients at risk is required. The association of microvolt T-wave alternans (MTWA) with the appearance of ventricular arrhythmias has been assessed in different heart diseases. The role of MTWA is mostly unknown in patients with CCC. Objectives: To evaluate the association between MTWA and the occurrence of malignant ventricular arrhythmias in patients with CCC. Method: This is a case-control study including patients with CCC and ICD, with history of malignant ventricular arrhythmias (case group), and patients with CCC and no history of those arrhythmias (control group). The MTWA test results were classified as negative and non-negative (positive and indeterminate). The significance level adopted was a = 0.05. Results: We recruited 96 patients, 45 cases (46.8%) and 51 controls (53.1%). The MTWA test was non-negative in 36/45 cases (80%) and 15/51 controls (29.4%) [OR = 9.60 (95%CI: 3.41 - 27.93)]. After adjustment for known confounding factors in a logistic regression model, the non-negative result continued to be associated with malignant ventricular arrhythmias [OR = 5.17 (95%CI: 1.05 - 25.51)]. Conclusion: Patients with CCC and history of malignant ventricular arrhythmias more often have a non-negative MTWA test as compared to patients with no history of arrhythmia.

Resumo Fundamento: A morte súbita cardíaca é o mecanismo de morte mais comum na doença de Chagas, responsável pelo óbito de 55% a 65% dos pacientes com cardiomiopatia chagásica crônica (CCC). Os mecanismos mais frequentemente envolvidos são as taquiarritmias ventriculares. O cardioversor-desfibrilador implantável (CDI) apresenta impacto na redução da mortalidade por arritmias ventriculares e faz-se necessária a correta identificação de pacientes sob risco. A associação de microalternância de onda T (MTWA) com o aparecimento de arritmias ventriculares foi avaliada em diferentes cardiopatias através de um teste. O papel da MTWA na identificação de pacientes sob risco na CCC permanece incerto. Objetivo: Avaliar a associação entre MTWA e a ocorrência de arritmias ventriculares malignas na CCC. Método: Trata-se de um estudo caso-controle, que incluiu pacientes com CCC em uso de CDI, com história prévia de arritmias ventriculares malignas (casos) ou sem história prévia (controles). Os resultados do teste foram classificados em negativo e não negativo (positivo e indeterminado). O nível de significância foi a = 0,05. Resultado: Foram recrutados 96 pacientes, 45 no grupo caso (46,8%) e 51 no grupo controle (53,1%). O teste de MTWA apresentou resultado não negativo em 36/45 pacientes no grupo caso (80%) e 15/51 no grupo controle (29,4%), OR = 9,60 (IC95%: 3,41 - 27,93). Após ajuste para fatores de confusão num modelo de regressão logística, o resultado não negativo continuou associado à presença de arritmias ventriculares malignas, com OR = 5,17 (IC95%: 1,05 - 25,51). Conclusão: Na CCC, pacientes com história de arritmia ventricular maligna apresentam maior frequência de teste de MTWA não negativo quando comparados a pacientes sem ocorrência prévia de arritmias.

Diet Quality of patients with chronic Chagas disease in a tertiary hospital: a case-control study

Abstract INTRODUCTION: Nutritional status has been implicated in the modulation of the immune response, possibly augmenting the pathogenesis of Chagas disease (Cd). We evaluated diet quality and nutritional status in adults and elderly patients with chronic Cd in a tertiary hospital. METHODS: A case-control study of Cd patients was conducted, paired for gender, age, and co-morbidities with non-Cd patients. Anthropometric measurements and food frequency questionnaire was used, and diet quality was assessed by the Brazilian Healthy Eating Index-Revised (BHEI-R). The Estimated Average Requirement cut-off points were used to determine the dietary micronutrient adequacy. The Cd group was further grouped according to Los Andes classification. RESULTS: The study participants were 67 ± 10 years old, 73.6% elderly and 63% female. The prevalence of overweight/obesity and abdominal fat was high in both groups; however, Cd group showed a lower prevalence of obesity and increased risk of disease according to waist circumference classification. There was no difference in BHEI-R score between groups (p=0.145). The Cd group had sodium and saturated fat intake above recommendations and low intake of unsaturated fat, vitamin D, E, selenium, magnesium, and dairy products; but higher intake of iron. According to Los Andes classification, group III presented lower intake of whole fruit and dietary fiber. CONCLUSIONS: Patients with Cd were overweight and the quality of their diet was unsatisfactory based on the recommended diet components for age and sex.

Influence of environmental enrichment on the behavior and physiology of mice infected by trypanosoma cruzi

Abstract INTRODUCTION: Enriched environments normally increase behavioral repertoires and diminish the expression of abnormal behaviors and stress-related physiological problems in animals. Although it has been shown that experimental animals infected with microorganisms can modify their behaviors and physiology, few studies have evaluated how environmental enrichment affects these parameters. This study aimed to evaluate the effects of environmental enrichment on the behavior and physiology of confined mice infected with Trypanosoma cruzi. METHODS: The behaviors of 20 T. cruzi-infected mice and 20 non-infected mice were recorded during three treatments: baseline, enrichment, and post-enrichment. Behavioral data were collected using scan sampling with instantaneous recording of behavior every 30s, totaling 360h. Plasma TNF, CCL2, and IL-10 levels and parasitemia were also evaluated in infected enriched/non-enriched mice. Behavioral data were evaluated by Friedman's test and physiological data by one-way ANOVA and area under the curve (AUC) analysis. RESULTS: Results showed that environmental enrichment significantly increased exploratory behaviors and diminished inactivity. The use of environmental enrichment did not diminish circulating levels of TNF and IL-10 but diminished circulating levels of CCL2 and parasitemia. CONCLUSIONS: Positive behavioral and physiological effects of environmental enrichment were observed in mice living in enriched cages. Thus, environmental enrichment improved the welfare of these animals.

Terapia de Resgate com Nifurtimox e Dipiridamol na Miocardite Chagásica Aguda Grave com Insuficiência Cardíaca em Camundongos NMRI / Rescue Therapy with Nifurtimox and Dipyridamole for Severe Acute Chagas Myocarditis with Congestive Heart Failure in NMRI Albino Mice

Fundamento: A doença de Chagas é um problema de saúde global, sendo necessário o desenvolvimento de novos protocolos terapêuticos. Nosso grupo demonstrou recentemente que o nifurtimox associado ao dipiridamol tem efeitos curativos em camundongos com doença de Chagas aguda. Neste estudo, avaliamos o efeito deste protocolo terapêutico em camundongos chagásicos com insuficiência cardíaca. Objetivo: Avaliar se o nifurtimox e o dipiridamol são úteis no tratamento de resgate em camundongos com miocardite chagásica aguda com insuficiência cardíaca. Métodos: Foram divididos em três grupos 42 camundongos com miocardite chagásica aguda e insuficiência cardíaca congestiva: Controle Chagas (n = 11); Nif-Dip, tratados com nifurtimox e dipiridamol (n = 14); e Nif-Dip-Insuficiência Cardíaca, tratados com nifurtimox e dipiridamol, associados com digoxina, furosemida e captopril (n = 17). As doses de nifurtimox e dipiridamol foram de 40 e 30mg/kg/dia, respectivamente, durante 6 semanas. Os camundongos foram submetidos a avaliações clínicas, eletrocardiográficas, hemoparasitológicas e histopatológicas. Resultados: Observou-se menor mortalidade no Grupo Nif-Dip (n = 4; 28,57%) em relação ao Controle Chagas (n = 6; 54,54%) e ao Nif-Dip-Insuficiência Cardíaca (n = 9; 52,9%). Clinicamente, os camundongos tratados com nifurtimox e dipiridamol aumentaram o peso corporal e melhoraram a insuficiência cardíaca, sem mostrar esplenomegalia. Nestes grupos, foram erradicadas as parasitemias e os parasitas teciduais; a fibrose, a miocitólise, o infiltrado de células inflamatórias e os mastócitos diminuíram. Os distúrbios de repolarização, os intervalos QRS e o QT prolongados, o aumento da amplitude da onda S e a dissociação atrioventricular foram revertidos pelo tratamento. Conclusão: O tratamento com nifurtimox e dipiridamol pode ser usado no resgate em camundongos com doença chagásica aguda grave, já que o nifurtimox teve atividade tripanocida, e o dipiridamole potenciou seu efeito. O dipiridamol seria útil na insuficiência cardíaca chagásica

Background: Chagas disease is a global health problem; therefore, the development of new therapeutic protocols is necessary. Our group recently demonstrated that nifurtimox associated with dipyridamole has curative effects in mice with acute Chagas disease. In this study, we assess the effect of this therapeutic protocol in chagasic mice with heart failure. Objective: To evaluate whether nifurtimox and dipyridamole are useful to rescue mice with severe acute chagasic myocarditis with heart failure. Methods: 42 mice with acute chagasic myocarditis and congestive heart failure were divided into three groups: control chagas (n = 11), Nif-Dip treated with nifurtimox and dipyridamole (n = 14) and Nif-Dip-heart failure treated with nifurtimox and dipyridamole associated with digoxin, furosemide, and captopril (n = 17). Nifurtimox and dipyridamole doses were 40 and 30 mg/kg/day, respectively, for 6 weeks. Mice underwent clinical, electrocardiographic, hemoparasitological and histopathological assessments. Results: Lower mortality in Nif-Dip (28.57%; n = 4) compared to control chagas (54.54%; n = 6) and Nif-Dip-heart failure (52.9%; n = 9) was observed. Clinically, nifurtimox and dipyridamole-treated mice increased body weight and improved heart failure without splenomegaly. In these groups, parasitemia and tissue parasites were eradicated; fibrosis, myocytolysis, inflammatory cell infiltrate and mast cells decreased. Repolarization disorders, prolonged QRS and QT intervals, increase of S wave amplitude and atrioventricular dissociation were reversed by the treatment. Conclusion: Nifurtimox with dipyridamole can rescue NMRI mice from severe acute chagas disease, as nifurtimox showed trypanocidal activity and dipyridamole potentiated its effect. Dipyridamole would be useful in chagasic heart failure

Evaluating respiratory musculature, quality of life, anxiety, and depression among patients with indeterminate chronic Chagas disease and symptoms of pulmonary hypertension

Abstract INTRODUCTION: Chagas disease (CD) is progressive and incapacitating, especially when cardiopulmonary function is affected. For example, respiratory muscle weakness can cause dyspnea upon exertion and fatigue, which may be exacerbated when it is associated with pulmonary hypertension (PH). The present study aimed to evaluate respiratory musculature, quality of life, anxiety, and depression among patients with indeterminate chronic CD and symptoms of PH. METHODS: All individuals completed a clinical evaluation, spirometry, a 6-min walking test, respiratory musculature testing using maximum inspiratory pressure (PImax) and maximum expiratory pressure (PEmax), the Hospital Anxiety and Depression Scale, and the SF-36 questionnaire. RESULTS: We evaluated 107 patients who were assigned to a control group with only CD (G1, 8 patients), a group with CD and possible PH (G2, 93 patients), and a group with CD and echocardiography evidence of PH (G3, 6 patients). The three groups had similar values for PImax and PEmax. Compared to the G1 and G2 groups, the G3 group covered significantly less distance during the 6-min walking test and had a significantly shorter predicted distance (p < 0.05 vs. the G1 group). All three groups had similar values for their spirometry results, Hospital Anxiety and Depression Scale scores, and SF-36 questionnaire results. CONCLUSIONS: Patients with indeterminate chronic CD and symptoms of PH did not experience significant impairment in the studied variables, with the exception of the 6-min walking test, which suggests a low exercise tolerance.

Dobutamine Stress Echocardiography Safety in Chagas Disease Patients / Segurança do Ecocardiograma sob Estresse com Dobutamina-Atropina em Pacientes com Doença de Chagas

Abstract Background: A few decades ago, patients with Chagas disease were predominantly rural workers, with a low risk profile for obstructive coronary artery disease (CAD). As urbanization has increased, they became exposed to the same risk factors for CAD of uninfected individuals. Dobutamine stress echocardiography (DSE) has proven to be an important tool in CAD diagnosis. Despite being a potentially arrhythmogenic method, it is safe for coronary patients without Chagas disease. For Chagas disease patients, however, the indication of DSE in clinical practice is uncertain, because of the arrhythmogenic potential of that heart disease. Objectives: To assess DSE safety in Chagas disease patients with clinical suspicion of CAD, as well as the incidence of arrhythmias and adverse events during the exam. Methods: Retrospective analysis of a database of patients referred for DSE from May/2012 to February/2015. This study assessed 205 consecutive patients with Chagas disease suspected of having CAD. All of them had their serology for Chagas disease confirmed. Results: Their mean age was 64±10 years and most patients were females (65.4%). No patient had significant adverse events, such as acute myocardial infarction, ventricular fibrillation, asystole, stroke, cardiac rupture and death. Regarding arrhythmias, ventricular extrasystoles occurred in 48% of patients, and non-sustained ventricular tachycardia in 7.3%. Conclusion: DSE proved to be safe in this population of Chagas disease patients, in which no potentially life-threatening outcome was found.

Resumo Fundamento: Até poucas décadas atrás, os pacientes chagásicos eram predominantemente trabalhadores rurais, com baixo perfil de risco para doença obstrutiva coronária. Com a crescente urbanização, passaram a ter os mesmos fatores de risco para doença aterosclerótica que indivíduos não infectados. O ecocardiograma sob estresse com dobutamina (EED) é uma importante ferramenta no diagnóstico de coronariopatia. É referido, porém, como um método potencialmente arritmogênico, mas seguro, em pacientes coronarianos não chagásicos. Entretanto, há insegurança na prática clínica de indicá-lo no paciente chagásico, devido ao potencial arritmogênico já intrínseco nesta cardiopatia. Objetivos: Analisar a segurança do EED em uma população de chagásicos com suspeita clínica de coronariopatia. Métodos: Análise retrospectiva de um banco de dados de pacientes encaminhados para a realização do EED entre maio/2012 e fevereiro/2015. Avaliou-se pacientes consecutivos portadores de doença de Chagas e com suspeita de coronariopatia. Confirmou-se a sorologia para doença de Chagas em todos os pacientes. Resultados: A média etária dos 205 pacientes analisados foi de 64 ± 10 anos, sendo a maioria do sexo feminino (65,4%). Nenhum paciente apresentou eventos adversos significativos, como infarto agudo do miocárdio, fibrilação ventricular, assistolia, acidente vascular encefálico, ruptura cardíaca ou morte. Quanto às arritmias, extrassístoles ventriculares frequentes ocorreram em 48% dos pacientes, taquicardia ventricular não sustentada em 7,3%, bigeminismo em 4,4%, taquicardia supraventricular e taquicardia ventricular sustentada em 1% e fibrilação atrial em 0,5%. Conclusão: O EED mostrou ser um exame seguro nessa população de pacientes chagásicos, onde nenhum desfecho grave foi encontrado.

Ingesta alimentaria y estado nutricional de pacientes con enfermedad de chagas / Dietary intake and nutritional status of patients with Chagas disease

La enfermedad de Chagas es una infección parasitaria que afecta a 17 millones de personas en Latinoamérica. Es aún desconocida la real influencia del efecto del estado nutricional y la ingesta alimentaria sobre la evolución de la enfermedad hacia la miocardiopatía chagásica crónica, así como los factores de riesgo cardiovascular que pueden influir en la evolución de la patología. Con el objetivo de caracterizar la ingesta alimentaria y determinar el estado nutricional de las personas con enfermedad de Chagas, se llevó a cabo un estudio descriptivo transversal de una muestra de pacientes atendidos en el servicio de cardiología del Hospital Centenario de Rosario. Se recolectaron datos sobre las características generales de la muestra, se realizaron mediciones antropométricas y se entrevistó sobre el consumo de alimentos a través de un cuestionario de frecuencia de consumo y un atlas fotográfico. Se reclutaron 113 paciente, de los cuales el 70% de los hombres y el 90 % de las mujeres presentaban sobrepeso u obesidad. Además el 78.9% de las mujeres y el 27% de los hombres, presento un Índice cintura/cadera de riesgo cardiovascular. En el análisis de la ingesta de macronutrientes se observa que se superan las recomendaciones del aporte de lípidos. Al analizar la ingesta de alimentos por grupos se encontró que los hombres consumen más carne vacuna magra, fiambres y embutidos, carne de cerdo y bebidas alcohólicas, en cambio las mujeres ingieren más lácteos enteros y bebidas azucaradas. Esta muestra urbana de pacientes con enfermedad de Chagas, presenta un perfil nutricional similar al de la población general, y el consumo alimentario se encuentra influenciado por la vida en las grandes ciudades(AU)

Chagas disease is a parasitic infection that affects 17 million people in Latin America. The real influence of nutritional status and food intake effect over the course of the disease to chronic Chagas Cardiomyopathy is still unknown. Furthermore, some cardiovascular risk factors might influence the evolution of the disease. A cross-sectional study of a sample of patients with Chagas disease attending the Cardiology Section of the Hospital Centenario of Rosario was carried out in order to characterize their food intake and nutritional status. Data on the general characteristics of the sample was collected; anthropometric measurements were performed and food consumption was investigated using a food frequency questionnaire and a n photographic atlas. One hundred and thirteen patients were enrolled; 70% of men and 90% of women were overweight or obese. In addition 78.9% of women and 27% of men presented a waist-hip ratio according to cardiovascular risk. When analyzing macronutrient intake, it was observed that lipid intake recommendations were exceeded. When the food intake groups were analyzed separately, it was found that men consume more lean beef, cold cuts, pork and alcoholic drinks, while women eat more whole dairy products and sugary drinks. This patients´ urban sample with Chagas disease, he presents a nutritional profile similar to that of the general population, and the food consumption is influenced by life in big cities(AU)

Postfundoplication dysphagia causes similar water ingestion dynamics as achalasia

ABSTRACT Background - After surgical treatment of gastroesophageal reflux disease dysphagia is a symptom in the majority of patients, with decrease in intensity over time. However, some patients may have persistent dysphagia. Objective - The objective of this investigation was to evaluate the dynamics of water ingestion in patients with postfundoplication dysphagia compared with patients with dysphagia caused by achalasia, idiopathic or consequent to Chagas' disease, and controls. Methods - Thirty-three patients with postfundoplication dysphagia, assessed more than one year after surgery, together with 50 patients with Chagas' disease, 27 patients with idiopathic achalasia and 88 controls were all evaluated by the water swallow test. They drunk, in triplicate, 50 mL of water without breaks while being precisely timed and the number of swallows counted. Also measured was: (a) inter-swallows interval - the time to complete the task, divided by the number of swallows during the task; (b) swallowing flow - volume drunk divided by the time taken; (c) volume of each swallow - volume drunk divided by the number of swallows. Results - Patients with postfundoplication dysphagia, Chagas' disease and idiopathic achalasia took longer to ingest all the volume, had an increased number of swallows, an increase in interval between swallows, a decrease in swallowing flow and a decrease in water volume of each swallow compared with the controls. There was no difference between the three groups of patients. There was no correlation between postfundoplication time and the results. Conclusion - It was concluded that patients with postfundoplication dysphagia have similar water ingestion dynamics as patients with achalasia.

RESUMO Contexto - Após o tratamento cirúrgico da doença do refluxo gastroesofágico, disfagia é um sintoma presente na maioria dos pacientes, com diminuição de intensidade ao longo do tempo. No entanto, alguns pacientes podem ter disfagia persistente. Objetivo - O objetivo deste trabalho foi avaliar a dinâmica da ingestão de água em pacientes com disfagia persistente após tratamento cirúrgico da doença do refluxo gastroesofágico comparando-os com os pacientes com disfagia causada por acalásia, idiopática ou consequente à doença de Chagas, e controles. Métodos - Trinta e três pacientes com disfagia pós fundoplicatura, que persiste a mais de um ano após a cirurgia, em conjunto com 50 pacientes com doença de Chagas, 27 pacientes com acalásia idiopática, todos com disfagia, e 88 controles foram avaliados pelo teste de ingestão de água. Eles ingeriram, em triplicata e sem pausas, 50 mL de água, o tempo de ingestão foi precisamente cronometrado e contado o número de deglutições necessário para ingerir todo volume. Com estes resultados foram calculados: (a) intervalo entre deglutições - tempo para completar a ingestão dividido pelo número de deglutições; (b) fluxo de ingestão - volume ingerido dividido pelo tempo necessário; (c) volume em cada deglutição - volume ingerido dividido pelo número de deglutições. Resultados - Os pacientes com disfagia pós fundoplicatura, doença de Chagas e acalásia idiopática levaram mais tempo para ingerir todo volume, tiveram maior número de deglutições, maior intervalo entre as deglutições, diminuição do fluxo de ingestão e diminuição no volume de água de cada deglutição em comparação com os controles. Não houve diferença entre os três grupos de pacientes. Não houve correlação entre o tempo após a operação e os resultados. Conclusão - Os pacientes com disfagia pós fundoplicatura tem dinâmica de ingestão de água semelhante aos pacientes com acalasia.