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Chagas Cardiomyopathy: from Romaña Sign to Heart Failure and Sudden Cardiac Death

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Chagas Cardiomyopathy: from Romaña Sign to Heart Failure and Sudden Cardiac Death pathogens Review Chagas Cardiomyopathy: From Romaña Sign to Heart Failure and Sudden Cardiac Death Antonia Pino-Marín 1,* , Germán José Medina-Rincón 1 , Sebastian Gallo-Bernal 1,2, Alejandro Duran-Crane 3 , Álvaro Ignacio Arango Duque 4, María Juliana Rodríguez 1,2, Ramón Medina-Mur 2, Frida T. Manrique 2 , Julian F. Forero 1,5 and Hector M. Medina 1,2 1 School of Medicine and Health Sciences, Universidad del Rosario, Bogotá 110131, Colombia; [email protected] (G.J.M.-R.); [email protected] (S.G.-B.); [email protected] (M.J.R.); [email protected] (J.F.F.); [email protected] (H.M.M.) 2 Division of Cardiology, Fundación Cardio-Infantil-Instituto de Cardiología, Bogotá 110131, Colombia; [email protected] (R.M.-M.); [email protected] (F.T.M.) 3 Internal Medicine Residency Program, Cleveland Clinic Foundation, Cleveland, OH 44195, USA; [email protected] 4 Department of Infectious Diseases, Fundación Cardio-Infantil-Instituto de Cardiología, Bogotá 110131, Colombia; [email protected] 5 Division of Radiology, Fundación Cardio-Infantil-Instituto de Cardiología, Bogotá 110131, Colombia * Correspondence: [email protected]; Tel.: +57-(1)-667-2727 Abstract: Despite nearly a century of research and accounting for the highest disease burden of any parasitic disease in the Western Hemisphere, Chagas disease (CD) is still a challenging diagnosis, Citation: Pino-Marín, A.; primarily due to its poor recognition outside of Latin America. Although initially considered endemic Medina-Rincón, G.J.; Gallo-Bernal, S.; to Central and South America, globalization, urbanization, and increased migration have spread Duran-Crane, A.; Duque, Á.I.A.; the disease worldwide in the last few years, making it a significant public health threat. The inter- Rodríguez, M.J.; Medina-Mur, R.; national medical community’s apparent lack of interest in this disease that was previously thought Manrique, F.T.; Forero, J.F.; Medina, H.M. Chagas Cardiomyopathy: From to be geographically restricted has delayed research on the complex host–parasite relationship that Romaña Sign to Heart Failure and determines myocardial involvement and its differential behavior from other forms of cardiomyopa- Sudden Cardiac Death. Pathogens thy, particularly regarding treatment strategies. Multiple cellular and molecular mechanisms that 2021, 10, 505. https://doi.org/ contribute to degenerative, inflammatory, and fibrotic myocardial responses have been identified and 10.3390/pathogens10050505 warrant further research to expand the therapeutic arsenal and impact the high burden attributed to CD. Altogether, cardiac dysautonomia, microvascular disturbances, parasite-mediated myocardial Academic Editor: Jyothi F Nagajyothi damage, and chronic immune-mediated injury are responsible for the disease’s clinical manifes- tations, ranging from asymptomatic disease to severe cardiac and gastrointestinal involvement. Received: 19 March 2021 It is crucial for healthcare workers to better understand CD transmission and disease dynamics, Accepted: 13 April 2021 including its behavior on both its acute and chronic phases, to make adequate and evidence-based Published: 22 April 2021 decisions regarding the disease. This review aims to summarize the most recent information on the epidemiology, pathogenesis, clinical presentation, diagnosis, screening, and treatment of CD, Publisher’s Note: MDPI stays neutral emphasizing on Chagasic cardiomyopathy’s (Ch-CMP) clinical presentation and pathobiological with regard to jurisdictional claims in published maps and institutional affil- mechanisms leading to sudden cardiac death. iations. Keywords: Ch-CMP/Chagas cardiomyopathy; Chagas disease; trypanosoma; heart failure; sudden cardiac death Copyright: © 2021 by the authors. Licensee MDPI, Basel, Switzerland. 1. Introduction This article is an open access article distributed under the terms and Chagas disease (CD)—or American trypanosomiasis—accounts for the highest disease conditions of the Creative Commons burden of any parasitic disease in the Western Hemisphere. Nevertheless, it remains a Attribution (CC BY) license (https:// challenging diagnosis, mostly due to a complex host–parasite interrelationship and low creativecommons.org/licenses/by/ recognition outside of Latin America (LATAM) despite massive migration to developed 4.0/). countries in the last four decades and nearly a century of research. Pathogens 2021, 10, 505. https://doi.org/10.3390/pathogens10050505 https://www.mdpi.com/journal/pathogens Pathogens 2021, 10, x FOR PEER REVIEW 2 of 27 Pathogens 2021, 10, 505 2 of 26 recognition outside of Latin America (LATAM) despite massive migration to developed countries in the last four decades and nearly a century of research. AlthoughAlthough differentdifferent historicalhistorical registriesregistries indicateindicate thatthat CDCD waswas presentpresent sincesince thethe Pre-Pre- ColumbianColumbian era,era, itsits firstfirst formal description was was made made by by Carlos Carlos Chagas Chagas in in 1908 1908 during during an ananti anti-malaria-malaria campaign campaign to tosupport support a railway a railway track track’s’s construction construction in the in the state state of Minas of Minas Ge- Gerais,rais, Brazil Brazil [1] [1.]. He He identified identified many many large large hematophagous insectsinsects calledcalled triatominestriatomines that that bitbit individuals individuals (particularly (particularly on on the the face) face) and and later later found found multiple multiple trypanosomes trypanosomes in in their their hindgut.hindgut. HeHe namednamedit itTrypanosoma Trypanosoma cruzi cruziin in honor honor of of his his mentor mentor Oswaldo Oswaldo Cruz. Cruz. Later, Later, he he mademade the the first first formal formal clinical clinical description description of of the the acute acute phase phase and and linked linked the the infection infection with with thethe onset onset of of chronic chronic manifestations manifestations [ 1[1––33]].. He He became became a a remarkable remarkable doctor doctor and and researcher researcher asas he he had had discovered discovered a a new new infectious infectious disease disease andand describeddescribed itsits pathogen,pathogen, vector,vector, host,host, clinicalclinical manifestations, manifestations, and and epidemiology. epidemiology. TheThe acute acute phasephase ofof the infection is typically typically asymptomatic, asymptomatic, and and approximately approximately 5% 5% of ofpatients patients experience experience mild mild symptoms, symptoms, incl includinguding fever, fever, malaise, malaise, and and the thecharacteristic characteristic uni- unilaterallateral edema edema of ofthe the eyelids eyelids that that occurs occurs when when the the insect insect bites bites near near the the eye, eye, also also known known as asthe the Romaña Romaña sign sign (Figure (Figure 1)1 [4])[.4 Afterward,]. Afterward, the the chronic chronic asymptomatic asymptomatic infection infection begins, begins, and andabout about 50% 50% of patients of patients will willremain remain in this in thisphase, phase, characterized characterized by the by absence the absence of any of clini- any clinicalcal signs signs [5]. Among [5]. Among the long the- long-termterm manifestations manifestations in the inchronic the chronic phase, phase,Ch-CMP Ch-CMP is argu- isably arguably the most the severe most severeform of form the disease. of the disease. It is a condition It is a condition with a wide with range a wide of clinical range ofmanifestations, clinical manifestations, including includingheart failure, heart arrhythmias, failure, arrhythmias, high degree high heart degree block, heart thrombo- block, thromboembolismembolism due to ventricul due to ventricularar aneurysms, aneurysms, and sudden and suddencardiac cardiacdeath (SCD) death [6,7] (SCD). [6,7]. FigureFigure 1. 1.Romaña Romaña sign.sign. CDC/Dr. Mae Mae Melvin Melvin Image Image - -PHIL. PHIL. https://phil.cdc.gov/De- https://phil.cdc.gov/Details.aspx? tails.aspx?pid=15814 (accessed 20 April 2021) https://www.cdc.gov/parasites/chagas/gen_info/vec- pid=15814 (accessed on 20 April 2021) https://www.cdc.gov/parasites/chagas/gen_info/vectors/ tors/index.html#list. (accessed 16 February 2021). index.html#list (accessed on 16 February 2021). OnOn average, average, 25% 25% of of chronically chronically infected infected individuals individuals develop develop Ch-CMP, Ch-CMP, making making it it the the leadingleading cause cause of of non-ischemic non-ischemic cardiomyopathy cardiomyopathy inin LATAM LATAM [ 5[5,8],8].. The The disease disease is is usually usually restrictedrestricted to to rural rural and and peri-urban peri-urban tropical tropical regions, regions, closely closely related related to low-incometo low-income neighbor- neigh- hoods.borhoods. However, However, recent recent globalization, globalization, urbanization, urbanization, and increased and increased migration migration have spread have the disease to other unusual areas such as North America, Europe, Australia, and Japan, forcing healthcare workers in these locations to become more aware of this condition. This Pathogens 2021, 10, 505 3 of 26 review aims to summarize the most recent information on the epidemiology, pathogenesis, clinical presentation, diagnosis, screening, and treatment of CD, emphasizing Ch-CMP clinical presentation and the mechanisms leading to SCD. 2. Epidemiology Chagas disease is part of the list of neglected tropical diseases
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