Chagas cardiomyopathy (CCM) is traditionally considered a disease restricted to areas of endemicity. However, an estimated 300,000 people living in the United States today have CCM, of which its majority is undiagnosed. We present a case of CCM acquired in an endemic area and detected in its early stage. A 42-year-old El Salvadoran woman presented with recurrent chest pain and syncopal episodes. Significant family history includes a sister in El Salvador who also began suffering similar episodes. Physical exam and ancillary studies were only remarkable for sinus bradycardia. The patient was diagnosed with symptomatic sinus bradycardia and a pacemaker was placed. During her hospital course, Chagas serology was ordered given the epidemiological context from which she came. With no other identifiable cause, CCM was the suspected etiology. This case highlights the underrecognized presence of Chagas in the United States and the economic and public health importance of its consideration in the etiological differential diagnosis of electrocardiographic changes among Latin American immigrants. While the United States is not considered an endemic area for Chagas disease, the influx of Latin American immigrants has created a new challenge to identify at-risk populations, diagnose suspected cases, and provide adequate treatment for this disease.
Chagas cardiomyopathy is a vector-borne parasitic infection caused by the protozoa
The infection is most commonly transmitted by insects of the Reduviidae family at blood meal bite sites but may also be transmitted vertically from mother to child, through blood transfusions, organ donation [
While Chagas has traditionally been considered a disease restricted to areas of endemicity, the ever-increasing mobility of populations across regions and borders has changed disease distribution dynamics [
In this paper, we present a case of Chagas cardiomyopathy acquired in an endemic area, detected in its early stages of chronic manifestation and before the classic late-stage morphologic changes to the myocardium. This case is representative of the underappreciated prevalence of the disease and its consequences in an area with a large immigrant population of Latin American origin.
A 42-year-old El Salvadoran woman presented to the ED after a syncopal episode. The patient’s symptoms began with left sided chest pain radiating to her left arm followed by dizziness. She had loss of consciousness for 5 minutes and had suffered multiple syncopal episodes with increasing frequency over the past year. She was advised to see a cardiologist for slow heart rate but did not follow up. She denied palpitations, vision or hearing changes, or seizure activity.
The patient grew up in rural El Salvador and immigrated to the United States 10 years ago. Of note, her sister of 40 years of age, who currently lives in El Salvador, also recently began suffering similar episodes over the past 2 years.
On examination, her blood pressure was 105/66 mmHg and was found to be bradycardic; her heart rate fluctuated between 30 and 42 beats per minute. The patient’s lungs were clear. There was no lymphadenopathy or peripheral edema. Investigations showed negative serial troponin levels and normal hematologic and blood chemistry tests. The patient’s electrocardiogram was remarkable for sinus bradycardia, with conserved axis and segment intervals and no other conduction abnormalities (Figure
EKG of the patient on admission. This EKG shows marked sinus bradycardia with borderline low voltage QRS (QRS amplitude max: 7 mm in limb leads and 8 mm in precordial leads; HR: 41 beats/min (R-R interval: 1460 ms); PR: 146 ms; QRS 76 ms; QT/QTc 518/427 ms).
Systolic (a) and diastolic (b) apical 4 chamber transthoracic echocardiographic images. Ejection fraction estimated to be 62%. No regional wall abnormalities or valve pathology was described.
During her initial hospital course, a first Chagas serology test was ordered given the fact that the patient had no other identifiable causes or risk factors for cardiomyopathy beyond the epidemiological context from which she came. This result came back positive after discharge, and the patient was followed up as an outpatient for a confirmatory second serology, which was also positive. Without any other clear etiology, it is suspected that Chagas was the cause of the cardiomyopathy.
It was agreed upon by the medical team that, given the seropositive status of the patient with only electrocardiographic evidence of disease and no appreciable cardiomegaly or congestive changes, antiparasitic treatment should be offered. This issue was discussed at length in follow-up visits with the patient. While she initially expressed interest in receiving pharmacological treatment, she has been persistently hesitant to commence therapy. This remains an active discussion with the patient.
This case highlights several key points as a result of the underrecognized prevalence of Chagas in the United States and the importance of considering Chagas in the etiological differential diagnosis of electrocardiographic changes among Latin American immigrants. Two clear issues that must be addressed from the clinical and public healthcare stewardship standpoint are the fact that the patient has 4 children who could potentially be seropositive and in the indeterminate phase and must therefore be screened and the fact that the patient has no macroevidence of CCM, and the question remains of whether or not to offer her treatment that could change the course of disease.
One key aspect of this case is recognizing the heterogeneity of the endemic nature of Chagas. In the case of El Salvador, the country of origin of this patient, the countrywide prevalence is 3.37% [
Additionally, there is an inherent obligation from the part of the medical profession in the United States to maintain an index of suspicion for Chagas, as it is frequently underappreciated by the immigrant population as well, as was observed in a study in Latin American immigrants living in Los Angeles [
Chagas disease follows a biphasic progression in which the acute phase typically culminates in a 4- to 8-week mild febrile illness and skin welt at the site of infection. This gives way to an indeterminate phase, of which 20–30% of infected persons will evolve to become symptomatic in 15–25 years with CCM [
While there is clear indication that treatment of Chagas disease in the acute phase has proven efficacy [
The only large scale trial to date showed that while treatment in patients with established CCM reduced serum parasite detection, a reduction in cardiac clinical deterioration was not appreciated over the following 5 years of follow-up [
In consideration of the side-effect profile of antitrypanosomal treatment, a Cochrane review found that severe side effects occurred in 2.4% of patients to benznidazole, with mild skin reactions, severe GI intolerance, lymphadenopathy, neuritis, and fever, while nifurtimox carried a 6.7% incidence and included neuritis and hepatitis [
Regarding prevention of sudden cardiac death in patients with CCM presenting with symptomatic bradyarrhythmias, placement of a pacemaker, as was done in this patient, follows best practices guidelines established in areas in which Chagas is endemic [
Vertical transmission of Chagas disease from a seropositive mother to offspring carries a risk of 5% [
An economic analysis of the cost-effectiveness of screening versus no screening done in Spain, a nonendemic area with Latin American immigrants like the United States, showed that antenatal screening of Latin American mothers, their offspring in positive cases, and consequent treatment resulted to be more cost-effective than not screening when projecting the long-term healthcare costs a seropositive person would place upon the system [
While the United States is not considered an endemic area for Chagas disease, the significant influx of immigrant populations from Latin America has created a new challenge to identify susceptible populations, diagnose suspected cases, and provide adequate treatment for this disease. The opportunity to carry out appropriate population based screening and offer secondary and tertiary prevention of disease progression is emblemized by this case and is an area that offers the opportunity to improve population-directed patient care and cost-effectiveness of healthcare delivery.
Although there is inconclusive evidence regarding the etiologic treatment of the indeterminate form of Chagas disease, small studies have reported a decrease in disease advancement after treatment. This is an area that should continue to be investigated in the future. With respect to prevention of sudden cardiac death, current guidelines for pacemaker placement prove to be beneficial.
Finally, there is substantial evidence to suggest that the realization of screening to suspected cases, especially during the indeterminate form, as in the children of the index patient in this case, would lead to a substantial savings for the healthcare system.
The authors declare that they have no conflicts of interest.
Special thanks are due to Dr. Farshad Bagheri of the Infectious Disease Department of Jamaica Hospital for the valuable insight and Maria del Pilar Fernandez for insight and guidance during manuscript preparation and to the patient and her family for their disposition to participate and follow through.