Chagas disease natural history, complications and prognosis: Difference between revisions

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{{Chagas disease}}
{{Chagas disease}}
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==Overview==
==Overview==
==Natural history==
The incubation period of ''T. cruzi'' is 1-2 weeks following transmission. The majority (90%-95%) of infected individuals remain asymptomatic in the acute phase following Chagas disease infection. Nonetheless, patients typically remain chronically infected and demonstrate clinical manifestations several years/decades following infection. Approximately 1/3 of patients develop manifestations of the chronic Chagas disease, namely cardiac conduction system dysfunction, GI denervation with esophageal and/or colonic dysfunction (megaesophagus and megacolon). Chagas cardiomyopathy is the most common chronic manifestation of the disease and accounts for approximately 80-90% of chronic manifestations. The majority of patients with Chagas cardiomyopathy die within 2 years of symptom onset.
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==Natural History==
===Acute Phase===
*The incubation period of ''T. cruzi'' is 1-2 weeks following transmission. Nonetheless, the majority (90%-95%) of infected individuals remain asymptomatic in the acute phase following Chagas disease infection.<ref name="pmid26222561">{{cite journal| author=Bern C| title=Chagas' Disease. | journal=N Engl J Med | year= 2015 | volume= 373 | issue= 5 | pages= 456-66 | pmid=26222561 | doi=10.1056/NEJMra1410150 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26222561  }} </ref><ref name="pmid17148699">{{cite journal| author=Teixeira AR, Nitz N, Guimaro MC, Gomes C, Santos-Buch CA| title=Chagas disease. | journal=Postgrad Med J | year= 2006 | volume= 82 | issue= 974 | pages= 788-98 | pmid=17148699 | doi=10.1136/pgmj.2006.047357 | pmc=PMC2653922 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17148699  }} </ref>
 
*Some individuals may experience mild and non-specific clinical manifestations, such as fever, anorexia, and fatigue. These symptoms usually self-resolve within 4-8 weeks.<ref name="pmid26222561">{{cite journal| author=Bern C| title=Chagas' Disease. | journal=N Engl J Med | year= 2015 | volume= 373 | issue= 5 | pages= 456-66 | pmid=26222561 | doi=10.1056/NEJMra1410150 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26222561  }} </ref>
 
*Rarely, the acute phase of Chagas disease is life-threatening, and patients may present with either myocarditis of meningoencephalitis that require hospitalization.<ref name="pmid26222561">{{cite journal| author=Bern C| title=Chagas' Disease. | journal=N Engl J Med | year= 2015 | volume= 373 | issue= 5 | pages= 456-66 | pmid=26222561 | doi=10.1056/NEJMra1410150 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26222561  }} </ref>
 
===Asymptomatic (Indeterminate) Chronic Phase===
*The majority of patients are asymptomatic during the acute phase but remain chronically infected.<ref name="pmid8021449">{{cite journal| author=Prata A| title=Chagas' disease. | journal=Infect Dis Clin North Am | year= 1994 | volume= 8 | issue= 1 | pages= 61-76 | pmid=8021449 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8021449  }} </ref>
 
*Early during the chronic state, patients are asymptomatic.
===Symptomatic Chronic Phase===
*Several years/decades following the initial acute phase, approximately 1/3 of patients develop manifestations of the chronic Chagas disease, namely cardiac conduction system dysfunction, GI denervation with esophageal and/or colonic dysfunction (megaesophagus and megacolon).<ref name="pmid17148699">{{cite journal| author=Teixeira AR, Nitz N, Guimaro MC, Gomes C, Santos-Buch CA| title=Chagas disease. | journal=Postgrad Med J | year= 2006 | volume= 82 | issue= 974 | pages= 788-98 | pmid=17148699 | doi=10.1136/pgmj.2006.047357 | pmc=PMC2653922 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17148699  }} </ref>
 
*Chagas cardiomyopathy is the most common chronic manifestation of the disease and accounts for approximately 80-90% of chronic manifestations. It is highly arrhythmogenic and often manifests with right bundle branch block, AV block, tachyarrhythmia/bradyarrhythmia. Patients typically progress to congestive heart failure and may develop thromboembolic events due to thrombus formation (often due to either dilation of the left ventricle or aneurysm formation). The majority of patients with Chagas cardiomyopathy die within 6 months - 2 years of onset of cardiac symptoms.<ref name="pmid8021449">{{cite journal| author=Prata A| title=Chagas' disease. | journal=Infect Dis Clin North Am | year= 1994 | volume= 8 | issue= 1 | pages= 61-76 | pmid=8021449 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8021449  }} </ref>
 
*Less commonly (10-20%), patients develop GI manifestations of chronic Chagas disease. Early esophageal Chagas disease often manifests with dysphagia, odynophagia, cough, reflux, and regurgitation. As the disease progresses, individuals experience significant weight loss and aspiration. Similarly, patients with colonic Chagas disease usually complain of constipation early in the disease that often progresses to development of fecaloma, volvolus, and ischemic bowel disease.<ref name="pmid8021449">{{cite journal| author=Prata A| title=Chagas' disease. | journal=Infect Dis Clin North Am | year= 1994 | volume= 8 | issue= 1 | pages= 61-76 | pmid=8021449 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8021449  }} </ref>
 
==Complications==
==Complications==
Complications of Chagas disease include:
Complications of Chagas disease include:<ref name="pmid17148699">{{cite journal| author=Teixeira AR, Nitz N, Guimaro MC, Gomes C, Santos-Buch CA| title=Chagas disease. | journal=Postgrad Med J | year= 2006 | volume= 82 | issue= 974 | pages= 788-98 | pmid=17148699 | doi=10.1136/pgmj.2006.047357 | pmc=PMC2653922 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17148699  }} </ref><ref name="pmid8021449">{{cite journal| author=Prata A| title=Chagas' disease. | journal=Infect Dis Clin North Am | year= 1994 | volume= 8 | issue= 1 | pages= 61-76 | pmid=8021449 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8021449  }} </ref><ref name="pmid26222561">{{cite journal| author=Bern C| title=Chagas' Disease. | journal=N Engl J Med | year= 2015 | volume= 373 | issue= 5 | pages= 456-66 | pmid=26222561 | doi=10.1056/NEJMra1410150 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26222561  }} </ref>
 
* [[Myocarditis]]
* [[Myocarditis]]
* [[Tachyarrhythmia]]
* [[Bradyarrhythmia]]
* [[AV block]]
* [[RBBB]]
* Apical [[aneurysm]]
* [[Congestive heart failure]]
* [[Meningoencephalitis]]
* [[Meningoencephalitis]]
* [[Congestive heart failure]]
* [[Apical aneurysm]]
* [[Thromboembolism]]
* [[Thromboembolism]]
* [[Sudden death]]
* [[Sudden death]]
Line 17: Line 42:
* [[Fecaloma]]
* [[Fecaloma]]
* [[Volvulus]] of sigmoid colon
* [[Volvulus]] of sigmoid colon
* [[Ischemic bowel disease]]
* [[Aspiration pneumonia]]


==Prognosis==
==Prognosis==
An index for classification of patients who have Chagas' disease was published in the August 24, 2006 edition of the ''[[New England Journal of Medicine]]''.<ref>{{cite journal | author = Rassi A Jr, Rassi A, Little W, Xavier S, Rassi S, Rassi A, Rassi G, Hasslocher-Moreno A, Sousa A, Scanavacca M | title = Development and validation of a risk score for predicting death in Chagas' heart disease | journal = N Engl J Med | volume = 355 | issue = 8 | pages = 799–808 | year = 2006 | id = PMID 16928995}}</ref> Based on over 500 patients, this index includes clinical aspects, [[X-ray]] findings, [[Electrocardiogram|EKG]], [[echocardiography]] and [[Holter monitor|Holter]].
*Approximately 1/3 of chronically infected patients develop clinical manifestations of chronic Chagas disease.
 
*Development of cardiac symptoms is a poor prognostic factor. The majority of patients die within 6 months to 2 years following onset of cardiac symptoms.
*Patients with HIV are at an increased rate of developing complications, even during the early phase of Chagas disease. HIV-positivity is associated with increased risk of Chagas [[myocarditis]] and [[meningoencephalitis]].
*The following Chagas disease prognosis index estimates the 10-year risk of Chagas disease-related mortality:<ref>{{cite journal | author = Rassi A Jr, Rassi A, Little W, Xavier S, Rassi S, Rassi A, Rassi G, Hasslocher-Moreno A, Sousa A, Scanavacca M | title = Development and validation of a risk score for predicting death in Chagas' heart disease | journal = N Engl J Med | volume = 355 | issue = 8 | pages = 799–808 | year = 2006 | id = PMID 16928995}}</ref>. Based on data from approximately 500 patients, this index incorporates individual information from the clinical aspects, [[X-ray]] findings, [[Electrocardiogram|EKG]], [[echocardiography]] and [[Holter monitor|Holter]].
<br>
{|border="1" cellpadding="5" cellspacing="0"
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|+ '''Chagas' risk factors'''
|+ '''Chagas Disease Prognosis Index'''
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!style="background:#efefef;" |Risk factor!!style="background:#efefef;"|points
!style="background:#efefef;" |Clinical Feature!!style="background:#efefef;"|Points
|-
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|[[New York Heart Association Functional Classification|NYHA class]] III or IV||5
|[[New York Heart Association Functional Classification|NYHA class]] III or IV||5
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|Male gender||2
|Male gender||2
|}
|}
 
<br>
{|border="1" cellpadding="5" cellspacing="0"
{|border="1" cellpadding="5" cellspacing="0"
|- style="background:#efefef;"
|- style="background:#efefef;"
!Total points!!Risk of death in 10 years
!Total Points!!10-year Risk of Chagas Disease-related Mortality
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|-
|0–6||10%
|0–6||10%
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==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
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{{WS}}
[[Category:Needs content]]
 
[[Category:Disease]]
[[Category:Up-To-Date]]
[[Category:Neurology]]

Latest revision as of 20:52, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

The incubation period of T. cruzi is 1-2 weeks following transmission. The majority (90%-95%) of infected individuals remain asymptomatic in the acute phase following Chagas disease infection. Nonetheless, patients typically remain chronically infected and demonstrate clinical manifestations several years/decades following infection. Approximately 1/3 of patients develop manifestations of the chronic Chagas disease, namely cardiac conduction system dysfunction, GI denervation with esophageal and/or colonic dysfunction (megaesophagus and megacolon). Chagas cardiomyopathy is the most common chronic manifestation of the disease and accounts for approximately 80-90% of chronic manifestations. The majority of patients with Chagas cardiomyopathy die within 2 years of symptom onset.

Natural History

Acute Phase

  • The incubation period of T. cruzi is 1-2 weeks following transmission. Nonetheless, the majority (90%-95%) of infected individuals remain asymptomatic in the acute phase following Chagas disease infection.[1][2]
  • Some individuals may experience mild and non-specific clinical manifestations, such as fever, anorexia, and fatigue. These symptoms usually self-resolve within 4-8 weeks.[1]
  • Rarely, the acute phase of Chagas disease is life-threatening, and patients may present with either myocarditis of meningoencephalitis that require hospitalization.[1]

Asymptomatic (Indeterminate) Chronic Phase

  • The majority of patients are asymptomatic during the acute phase but remain chronically infected.[3]
  • Early during the chronic state, patients are asymptomatic.

Symptomatic Chronic Phase

  • Several years/decades following the initial acute phase, approximately 1/3 of patients develop manifestations of the chronic Chagas disease, namely cardiac conduction system dysfunction, GI denervation with esophageal and/or colonic dysfunction (megaesophagus and megacolon).[2]
  • Chagas cardiomyopathy is the most common chronic manifestation of the disease and accounts for approximately 80-90% of chronic manifestations. It is highly arrhythmogenic and often manifests with right bundle branch block, AV block, tachyarrhythmia/bradyarrhythmia. Patients typically progress to congestive heart failure and may develop thromboembolic events due to thrombus formation (often due to either dilation of the left ventricle or aneurysm formation). The majority of patients with Chagas cardiomyopathy die within 6 months - 2 years of onset of cardiac symptoms.[3]
  • Less commonly (10-20%), patients develop GI manifestations of chronic Chagas disease. Early esophageal Chagas disease often manifests with dysphagia, odynophagia, cough, reflux, and regurgitation. As the disease progresses, individuals experience significant weight loss and aspiration. Similarly, patients with colonic Chagas disease usually complain of constipation early in the disease that often progresses to development of fecaloma, volvolus, and ischemic bowel disease.[3]

Complications

Complications of Chagas disease include:[2][3][1]

Prognosis

  • Approximately 1/3 of chronically infected patients develop clinical manifestations of chronic Chagas disease.
  • Development of cardiac symptoms is a poor prognostic factor. The majority of patients die within 6 months to 2 years following onset of cardiac symptoms.
  • Patients with HIV are at an increased rate of developing complications, even during the early phase of Chagas disease. HIV-positivity is associated with increased risk of Chagas myocarditis and meningoencephalitis.
  • The following Chagas disease prognosis index estimates the 10-year risk of Chagas disease-related mortality:[4]. Based on data from approximately 500 patients, this index incorporates individual information from the clinical aspects, X-ray findings, EKG, echocardiography and Holter.


Chagas Disease Prognosis Index
Clinical Feature Points
NYHA class III or IV 5
Cardiomegaly 5
Wall motion abnormalities 3
Non-sustained ventricular tachycardia 3
Low voltage on ECG 2
Male gender 2


Total Points 10-year Risk of Chagas Disease-related Mortality
0–6 10%
7–11 40%
12–20 85%

References

  1. ↑ 1.0 1.1 1.2 1.3 Bern C (2015). "Chagas' Disease". N Engl J Med. 373 (5): 456–66. doi:10.1056/NEJMra1410150. PMID 26222561.
  2. ↑ 2.0 2.1 2.2 Teixeira AR, Nitz N, Guimaro MC, Gomes C, Santos-Buch CA (2006). "Chagas disease". Postgrad Med J. 82 (974): 788–98. doi:10.1136/pgmj.2006.047357. PMC 2653922. PMID 17148699.
  3. ↑ 3.0 3.1 3.2 3.3 Prata A (1994). "Chagas' disease". Infect Dis Clin North Am. 8 (1): 61–76. PMID 8021449.
  4. ↑ Rassi A Jr, Rassi A, Little W, Xavier S, Rassi S, Rassi A, Rassi G, Hasslocher-Moreno A, Sousa A, Scanavacca M (2006). "Development and validation of a risk score for predicting death in Chagas' heart disease". N Engl J Med. 355 (8): 799–808. PMID 16928995.

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