An approach to the management of Trypanosoma cruzi infection (Chagas’ disease) in immunocompromised patients

Abstract

The epidemiology of Chagas disease has changed in the last decades due to migration movements, population ageing and the emergence of new transmission routes. In endemic countries, health facilities and access to healthcare are improving and T. cruzi infected patients are also benefiting from medical advances. The HIV epidemic has spread to both endemic and non-endemic areas for T. cruzi, organ transplant rates have increased recently, especially in Latin America, and other medical conditions affecting the immune system are increasing their global burden. The natural course of Chagas disease is mainly determined by the host’s cellular immune response. These conditions may therefore overlap with T. cruzi infection and alter the disease’s natural history which may present with atypical clinical forms and a higher associated morbidity and mortality in immunocompromised patients. The present review aims to contribute to the management of immunosuppressed patients with T. cruzi infection.

Keywords::

• autoimmune disease
• Chagas disease
• HIV
• immunosupression
• neglected diseases
• neoplasm
• transplantation
• Trypanosoma cruzi

Financial & competing interests disclosure

This manuscript has been supported by the ‘Red de Investigación Cooperativa en Enfermedades Tropicales’ (RICET), VI PN de I+D+I 2008-2011, ISCIII -Subdirección General de Redes y Centros de Investigación Cooperativa. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Patients with HIV and risk factors should be screened for Trypanosoma cruzi infection.

• T. cruzi in an HIV-infected patient may behave as an opportunistic parasite typically affecting the CNS and the heart, with high associated mortality.

• Early diagnosis of HIV status and prompt antiretroviral therapy can improve prognosis and prevent reactivation in T. cruzi coinfected patients.

• Specific antiparasitic therapy should be started as soon as possible in case of reactivation although specific treatment schedules have not clearly been defined.

• Management of T. cruzi infection in the context of transplantation may be complex and updated reviews and guidelines are necessary as new data become available.

• Potential donors and transplant candidates with risk factors should be tested for T. cruzi infection using serology (if the patient is immunocompromised and serology is negative, parasitological tests should be considered).

• Transplanting the heart from a T. cruzi-infected donor is contraindicated; use of other organs (including bone marrow) may be considered with appropriate informed consent and adequate post-transplant monitoring with parasitological tests.

• Predonation antitrypanosomal treatment may be administered to infected living donors to decrease the potential parasite inoculation.

• Post-transplantation monitoring rather than prophylaxis is generally recommended and treatment with specific antiparasitic drugs should be initiated if there is parasitological evidence of acute infection (organ-derived transmission) or reactivation of pre-existing chronic infection.

• Screening for T. cruzi should be performed in patients with neoplasia or autoimmune diseases and risk factors for the infection.

• Patients with neoplasia or autoimmune disease with reactivation of T. cruzi infection should receive prompt antiparasitic therapy.