CC: “Chest pain”
HPI: 67 year old male from Bolivia presents to the Emergency Department with chest pain that is central, non-radiating, sharp, and lasts for only a few seconds. Chest pain has been present for years, however it has been acting up more lately. He has never gone to the doctor before today. Today his son felt that he should have his chest pain evaluated. He also endorses the occasional brief episode of palpitations. He denies pre-syncope, syncope, and diaphoresis. At his baseline he does become short of breath when he goes upstairs or walks more than a half kilometer. This shortness of breath has been present for years. He feels that he occasionally has fevers but he does not own a thermometer. He also has a long history of constipation for which he tries to drink plenty of fluids and eat foods that are high in fiber. He denies headache, abdominal pain, weakness, dysuria, melena, hematochezia, hematuria, bleeding disorders, hearing loss, emesis, and dysphagia. He immigrated to the United States to live with his son who works at the embassy. The patient speaks no English, but is able to communicate with you via the interpreter. He grew up in a small village in the cloud forest of Bolivia. He is a farmer.
ROS: Negative except as listed above in the HPI.
PMH: Has never gone to the doctor and is not sure.
Past Surgical History: None
Family History: Both his mother and father had diabetes and HTN
Social History: Denies smoking. Endorses drinking “canaso” a sugar cane based home made liquor occasionally during holidays. He later states that he does love to dance cumbia and when he dances he drinks. Denies ever snorting cocaine or other recreational drug use. However, he did chew coca leaves daily for the majority of his life until he moved to the US.
Vital signs: BP 120/86, HR 102, RR 17, Temp 38.0, Pulse Ox 96% on room air
General: Appears his stated age.
Eyes: PERRL, mild conjunctival pallor, EOMI
Neck: Supple, no cervical LAD, no stiffness
Cardiac: Regular rhythm and tachycardic. No MRG.
Respiratory: CTAB except for some faint bibasilar crackles.
GI: Abdomen is soft, non tender. No distention, rebound, guarding, or masses.
Musculoskeletal: Moves all extremities equally. Strength bilaterally 5/5 with regards to bicep flexion, tricep extension, hip flexion and extension, knee flexion and extension, dorsiflexion and plantar flexion.
Skin: Multiple large scars on his lower leg. He states that they are from machete accidents.
Neurological: Awake and moving all extremities spontaneously. No facial droop. Pupils are equal, round and reactive to light. Strength is 5/5 in upper and lower extremities bilaterally. No ataxia.
Extremities: +2 pitting edema.
#1. Which is associated with the most likely cause of the patient’s presentation.
A. Anopheles mosquito
B. Reduviid bug
C. Sandfly- L. donovani
D. Taenia Solium
#2. What other symptom/exam finding is most associated with this disease?
C. Painless skin ulcers
#3. What is the disposition for this patient based on the information presented above?
A. Admit to medicine with Infectious Disease Consult
B. Cardiac Catheterization
C. Discharge to home
D. Observation unit with telemetry
1 . B: This case is most consistent with a patient suffering from Chagas disease ( T. Cruzi). The triad of dysphagia, cardiomyopathy, and constipation are most commonly seen. The vector lives in the walls and roofs of houses in Central and South America. It can be eradicated completely with simple public health home remodeling. Chagas disease can be obtained from bug bites or via blood transfusion. Trypomastigotes migrate to the smooth muscle, cardiac muscle and autonomic ganglia of the heart, esophagus, and colon (1).
The problem transcends the borders of Bolivia. In Latin America 18 million people are infected and approximately 30% these individuals develop major heart disease decades after the acute infection. The WHO warns that 100 million people are at risk, and it is estimated that Chagas disease causes four times the burden of malaria, schistosomiasis, leprosy and leishmaniasis combined (2). Great strides have been made in eliminating the vector through public health strategies; however, many patients will continue to progress from the Intermediate Stage (seropositive but asymptomatic) to the chronic symptomatic phase (irreversible dilated cardiomyopathy, megacolon, and mega-esophagus). Thus a treatment for the larger number of patients with Intermediate Chagas disease is crucial.
Chagas disease includes patients with both asymptomatic and symptomatic disease. It is unclear on how we should go about treating these different subgroups of patients, especially those in the chronic phase.
The majority of experts agree that acute Chagas should be treated with Benznidazole (BZD). Acute infection is asymptomatic in most cases, but can present with malaise, fever, lymphadenopathy, mild splenomegaly, myocarditis and meningoencephalitis. If acute Chagas is detected, the patient should receive treatment. Up to 70% of these acute patients remain xenodiagnostically and serologically cured. No RCTs have been conducted on long term benefits of treating acute Chagas; however, it is generally accepted that all acute disease and reactivated disease should be treated with trypanocidal therapies (3).
Chagas can be diagnosed with the Chagas StatPak. The manufacturer reports a sensitivity of 98% and specificity of 95%. In order to officially have the diagnosis of Chagas a patient also needs to test positive with either the PCR or ELISA technique.
The two main trypanocidal medicines in use since the 1960s are Nifurtimox (NFTMX) and Benznidazole (BZD). Both of these medications are reported to have high noncompliance rates due to side effects, especially NFTMX. Side effects of NFTMX include nausea, vomiting, abdominal pain, weight loss, severe anorexia, paresthesias, insomnia and seizure. Side effects are seen in up to 40% of patients treated with NFTMX. The most serious side effects seen are leucopenia, peripheral neuropathy, and allergic dermopathy (4).
The Romana sign, painless unilateral swelling of the eye, which is often quoted in the literature is extremely rare. Many seasoned Bolivian physicians have never seen it.
- B: Anemia is most consistent with Malaria. The Sandfly is associated with both cutaneous and visceral leishmaniasis which are associated with a painless skin ulcer. Seizure is most associated with cysticercosis and cerebral malaria.
Mega-esophagus is a known complication of Chagas disease. Dysphagia is one of the classic findings of Chagas disease. This is due to damage to the myenteric plexus of the colon.
- B: The patient has a LBBB. A new LBBB is no longer considered an automatic trip to the cath lab. We need to apply Sgarbossa’s criteria to help us look for signs of ischemia. This patient has concordant ST depression of greater than 1 mm in leads V2 and V3 which is consistent with a myocardial infarction.
Sgarbossa’s criteria states that ST segment elevation of 1 mm or more that is concordant to the QRS in any lead receives a score of 5 points. ST segment depression of at least 1 mm that is concordant in leads V1-V3 is worth 3 points. ST segment elevation of greater than 5 mm that is discordant values a score of 2. If a patient has a score of at least 3 there is a 90% specificity for myocardial infarction. However, the criteria are not very sensitive (5).
- Marx, Hockberger, & Walls. (2010). Rosen’s Emergency Medicine Concepts and Clinical Practice. 7th Edition. Philadelphia:Mosby. Page 1765.
- Schmunis G. American Tripanosomiasis as a public health problem. Chagas’ disease and the nervous system. Washington, DC: PAHO, 1994:3–29.4
- Bern C, Montgomery SP, Herwaldt BL, Rassi A Jr, Marin-Neto JA, Dantas RO, Maguire JH, Acquatella H, Morillo C, Kirchhoff LV, Gilman RH, Reyes PA, Salvatella R, Moore AC 2007. Evaluation and treatment of Chagas disease in the United States. A systematic review. JAMA 298: 2171-2181.
- Marin-Neto J Antonio, Rassi Anis. The BENEFIT trial: testing the hypothesis that trypanocidal therapy is beneficial for patients with chronic Chagas heart disease Mem Inst Oswaldo Cruz, Rio de Janeiro, Vol. 104(Suppl. I): 319-324, 2009
- Goldberger. Up to Date. Electrocardiographic diagnosis of myocardial infarction in the presence of bundle branch block or a paced rhythm. Viewed 4/20/14.