Review Article Pramod Kumar et al. / Journal of Pharmacy Research 2010, 3(11),2700-2705 ISSN: 0974-6943 Available online through www.jpronline.info An awareness towards the chagas disease: A review Pramod Kumar1*, Peeyush Kumar1, Devendra Singh Thakur1, Champal Lal 1, Vinod Kumar Swami 2 1SLT Institute of Pharmaceutical sciences, Guru Ghasidas Vishwavidyalaya, Bilaspur, (C.G.) India, 495001. 2Lachoo Memorial College of sciences & Technology, Jodhpur, (Rajasthan), India 342003. Received on: 15-06-2010; Revised on: 18-08-2010; Accepted on:13-09-2010

ABSTRACT American trypanosomiasis (Chagas disease) is an important cause of heart disease, megaesophagus and megacolon among people in Mexico, Central and South America. Many mammals can be infected with the parasite that causes this disease; however, among animals, clinical cases have been reported mainly in dogs. Chagas disease is transmitted by the bites of triatomine insects, or “kissing bugs.” Some infected insects occur in sylvatic environments, where humans are exposed only occasionally. These “sylvatic cycles” are found from the U.S. through South America. From Mexico through South America, triatomine insects have also become adapted to human dwellings, particularly substandard housing where the insects hide in cracks during the day and emerge to feed on humans and animals at night. Most human cases are acquired from insects in these “domestic cycles,” and campaigns to eliminate the bugs, together with testing to prevent congenital cases and transmission in blood transfusions, have significantly reduced the incidence of Chagas disease. Antiparasitic treatment is most effective early, before irreversible damage occurs to the heart or gastrointestinal tract.

Key words: Chagas disease, Trypanosoma cruzi, ELISA, Prevention

INTRODUCTION The discovery of American trypanosomiasis by Carlos Chagas was one of the Chagas disease is an autochthonous disease of 22 countries in the continental most successful and completes findings in the whole history of tropical medi- Western Hemisphere caused by the protozoa Trypanosoma cruzi (T. cruzi). cine. The natural history of Chagas disease began millions of years ago as an Human infection is primarily transmitted by domestic and sylvatic insects of enzootic disease among wild animals, and this still persists in enzootic areas the subfamily Triatominae (Hemiptera, Reduviidae), the kissing bug, whose such as the Amazon region. When mankind ventured into the natural ecotopes habitat in the Americas ranges from the US and Mexico in the north to of the infection, it began to be transmitted accidentally to humans as an Argentina and Chile in the south. T. cruzi infection may be also transmitted to anthropozoonosis. Because of the extensive deforestation for agriculture and humans congenitally, by blood transfusion and organ transplant and by the oral 3 livestock rearing over the last 200–300 years in Latin America, triatomines route. The possibility that vector transmission may occur in Europe or in that were left without their food sources due to the removal of wild animals other continents by autochthonous triatominae is considered remote. More started to colonize areas surrounding human dwellings, and the dwellings them- feasible however, is the risk of accidental transport of domestic Latin Ameri- can species of triatominae to other regions or continents (i.e. in the baggage selves. They adapted to this new niche, including feeding on the blood of of airline passengers). In the US, the social conditions in the rural areas are not humans and domestic animals. Fig. 1 shows the domestic and wild cycles of 1,2 usually adequate for the intimate contact between vectors and humans. There- Chagas disease discovered by Carlos Chagas. fore, the probability of vector transmission is low and few autochthonous Chagas disease cases have been documented in the US.4,5

Currently, Chagas’ disease affects 10 to 12 million individuals worldwide.6 Its geographic distribution extends from the 40th parallel north, in the southern part of North America, to 45th parallel south, in Argentina and Chile.7 Latin American urbanization, which intensified in the second half of the 20th cen- tury, has altered the epidemiologic profile of the disease, and migratorymovements from endemic countries have led to the diagnosis of Chagas’ disease in regions in which it is not endemic.8,7

Spain has become one of the European countries that receive the largest number of immigrants from Latin American. As of December 31, 2005 close to a million individuals from Latin America were included in the records of foreign nationals holding a Spanish resident’sidentity card,10 although mu- nicipal census records for the year 2005 indicated higher figures (1445796 individuals). Units and services specialized in tropical medicine and interna- tional health in Spain have already begun to diagnose and treat individuals with the disease.9 The recent meeting of the Pan-American Health Organization in Montevideo discussed this situation and in its final report mentioned the needs of countries receiving immigrants from endemic areas in order to deal with Chagas’disease and to be able to provide appropriate treatment to affected individuals, as well as to prevent vertical and blood borne transmission of T cruzi.10

1. TRYPANOSOMA CRUZI LIFE CYCLE AND MODE OF TRNSMISSION The life cycle of T cruzi involves four distinct forms in insect vectors and mammalian hosts: (1) the epimastigote, present in the intestinal tract of the insect, that replicates; (2) the infective metacyclic trypomastigote in the vector’s hindgut; (3) a blood stage form (trypomastigote) that penetrates Fig. 1. Domestic and wild cycles of Chagas disease discovered by Carlos Chagas mammalian cells; and (4) an intracellular form (amastigote) that replicates. *Corresponding author. Infection occurs when an infected bloodsucking bug bites and it defecates on Pramod Kumar the skin of a susceptible host. The metacyclic trypomastigotes in the feces SLT Institute of Pharmaceutical sciences produce a local infection when it is rubbed into the site of the bite (chagoma) G. G.V. Bilaspur(C.G.) India, 495001 Tel.: + 91-9770765502 E-mail:[email protected] Journal of Pharmacy Research Vol.3.Issue 11.November 2010 2700-2705 Pramod Kumar et al. / Journal of Pharmacy Research 2010, 3(11),2700-2705 or by penetrating the intact mucous membrane of the eye (Romaiia’s sign). disease, with myocarditis or encephamomyelitis; without treatment, around Once inside the local reticuloendotelial and connective cells, the infective 5–10% of these patients die.15 cruzi differentiates into amastigotes that begin replicating. When the cell is full of amastigotes, they transform once more and become trypomastigotes Detection of antibodies to T. cruzi has been and is the main method for the by growing flagellae. The trypomastigotes lyse the cells, infect adjacent tis- diagnosis of Chagas’ disease. Antibodies are detected by an array of available sue, and enter the bloodstream. Circulating trypomastigotes disseminate the commercial tests; among them, the most employed are indirect hemagglutina- infection by penetrating muscle cells (cardiac, smooth, and skeletal), neurons, tion (IHA), indirect immunofluorescence (IFA), and ELISA. The antigens lymph nodes, liver, and spleen. The cycle is completed when areduviid bug employed in these tests are whole or semipurified antigenic fractions of T. becomes infected by ingesting the blood from an infected human or animal. cruzi epimastigote forms, giving rise to unspecific reactions (false positives) Most Trypanosoma cruzi infections in humans are acquired from the insect and a sensitivity that is far from ideal. Thus, two or three tests must be vector, but may occur by transfusion of blood from an infected donor, even in employed to reach a definitive conclusion. The WHO recommends using at nonendemic countries.11 Congenital transmission, accidental contamination, least two tests in parallel. Variation in the reproducibility and reliability of the and transmission by organ transplantation are other possible routes of infec- results has been reported and it could be explained by poor standardization of tion. the reagents.16,17

1.1. ACUTE AND CHRONIC INFECTION There are three methods for diagnosis of chagas disease Trypanosoma cruzi produces disease during the initial infection (acute phase) 1.Conventional serologic tests and again decades later.12 Acute Chagas’ disease usually affects children or 2.ELISA young adults in endemic areas. It produces local inflammation at the parasite 3.TESA blot entry site, as well as malaise; fever; enlargement of the liver, spleen, and lymph nodes; and subcutaneous edema. Mortality in the acute phase occasion- 3.1.Conventional serologic tests ally occurs (< 5% of cases) due to acute myocarditis and or meningoencepha- The epi-ELISA, IFA, and IHA for Chagas’ disease diagnosis were carried out at litis. In most infected persons, the illness is not diagnosed because of the the Faculty of Medicine of Goiania, Federal University of Goia´s (Goia´s, nonspecific nature of the signs and symptoms and the lack of access of poor Brazil). The epi-ELISA was performed using a crude extract of epimastigote patients to medical care. In this phase, treatment with an antiparasitic drug, forms of T. cruzi (Y strain).18 The results were expressed as an index obtained such as benznidazole, will usually cure the infectied and prevent the chronic by division of the values of absorbance read at 492 nm (A492nm) of each manifestations.13 If untreated, the manifestations of the acute disease resolve serum sample by the plate cutoff, being considered inconclusive when the spontaneously within 4 to 8 weeks in approximately 90% of infected individu- index was 0.9 to 1.1 and as positive when it was at least 1.2. IFA was performed als. About half of these patients will never develop chronic lesions. They can using formaldehyde-treated epimastigote forms of T. cruzi (strain Y) as anti- be recognized by positive serological tests, but do not have electrocardio- gen and a FITC anti-human IgG conjugates (Fluoline G, Biolab Diagno´stica graphic (ECG) and radiological evidences of involvement of the heart, esopha- SA, Rio de Janeiro, Brazil). The IFA was consideredinconclusive when titer was gus, or colon. The other half of patients will develop megaesophagus, megaco- 20 to 40 and positive when it was at least 80. The IHA was purchased from lon, and or cardiac disease 10 to 30 years after the acute infection.14 A direct Immunologic Technology Industry and Commerce, Sa˜o Paulo, Brazil. The progression from the acute phase to a clinical form of Chagas’ disease occurs results were expressed as the reciprocal of titer dilution for each serum; a titer in a few patients (5 to 10%). Cardiac involvement is the most frequent and of 8 was considered inconclusive and titers of at least 16 were considered serious manifestation of chronic Chagas’ disease and typically leads to positive. The in-house EAE-ELISA, Y strain, was carried out as previously arrhythmias, cardiac failure, thromboembolic phenomena, and sudden death. described.19,20 EAE-ELISA was considered positive at A492nm _ 0.20.

2. SYMPTOMS OF CHAGAS DISEASE 3.2. EILISA The list of signs and symptoms mentioned in various sources for Chagas Three recombinant proteins were selected for this study: B13, 1F8, and H49. disease includes the symptoms listed below: These antigens were expressed as fusion polypeptides with the Schistosoma japonicum glutathione S-transferase and purified by affinity chromatography 2.1.ACUTE FORM SYMPTOMS on glutathione-agarose beads as previously described.16 Protein content was The symptoms of the acute form may include: Chagoma - erythematous quantified by a macrobicinchoninic acid protein assay reagent kit (Pierce, nodule at the bite sites, Fever - usually high fever , High fever , Anemia , Facial Rockford, IL). Plastic 96-well flat-bottom microtiter plates (high binding, swelling - one-sided , Eyelid edema, Regional lymphadenopathy , Hepatosple- Costar Inc., Corning, NY) were coated with 50 µL of a solution containing the nomegaly Meningoencephalic inflammation, Lethargy , Apathy , Sleepiness recombinant protein B13 (500 ng/ml), 1F8 (1000 ng/ml), or H49 (300 ng/ml) ,Headaches ,Convulsions. or with 50 µL per well of a mixture of three recombinant antigens B13, 1F8, and H49 (320 ng/ml), diluted in 0.05 M carbonate-bicarbonate buffer (pH 9.6). 2.2. MILD CHAGAS SYMPTOMS Plates were incubated for 18 hours at 40 C. For use, unbound material was Mild fever , Severe asthenia, Generalized lymphadenopathy. discarded and plates were blocked for 1 hour with 0.01 M PBS (pH 7.2) 0.05 percent Tween 20 (PBS-T) containing 5 percent defatted milk (Molico, Nestle´, 2.3.CHRONIC FORM SYMPTOMS Sa˜o Paulo, Brazil). The serum samples (50 µL per well) were added, diluted 1 Heart symptoms: heart rhythm symptoms, rapid heart beat, slow heart beat, in 50 in PBS-T containing 1 percent defatted milk, and incubated for 1 hour at palpitations, cardiac abnormalities, pericarditis,.Digestive symptoms: Nausea, 370 C. After five washes in PBS-T, peroxidase-conjugate goat anti-human IgG vomiting, diarrhea, constipation, belching, flatulence, Abdominal symptoms, (1 in 6000 diluted in PBS; Sigma Chemical Co., St Louis, MO) was added and abdominal pain. incubated for 1 hour at 37 0C. After new cycles of washes, the immune com- plexes were revealed by addition of hydrogen peroxide and O-phenylenedi- 2.4.OTHER SYMPTOMS amine dihydrochloride (Sigma Chemical Co.). Following 30 minutes of incuba- Enlarged colon , Swelling around eyes infection through conjunctiva of the tion at 370 C in the dark, the reaction was stopped with 4N HCl and A 492 nm eye, Malaise, Leg swelling Meningoencephalitis, Lymphadenopathy, Enlarged was measured in a plate ELISA reader (Multiskan MS, Thermo Labsystems, liver, Enlarged spleen Presence of parasite in blood ,Enlarged heart , Atrophy Waltham, MA). All the experiments were carried out in duplicate and repeated of heart , Heart fibrosis Dilated cardiomyopathy, Arrhythmia, Thromboem- at least twice on different days. The mix-ELISA was considered positive at bolism, Congestive heart failure ,Swallowing difficulty ,Chest pain , Regurgita- A492nm _ 0.24. tion , Aspiration ,Constipation, Abdominal pain. 3.3 TESA BLOT 3. DIAGNOSIS OF CHAGAS DISEASE The TESA were obtained as previously described for the Y strain.24 T. cruzi Vectorial transmission of T. cruzi occurs only in endemic countries of the was maintained in LLC-MK2 cells at 37 0C in 5 percent CO2 on RPMI 1640 Western Hemisphere. The haematophagous triatomine insect vector deposits (Sigma Chemical Co.) containing 2 percent FCS. The supernatants of LLCMK2- excreta containing the parasite on the host while taking a blood meal; inocu- infected cells containing TESA were harvested 5 days after infection, centri- lation of the parasite into the bite wound, conjunctivae or mucus membranes fuged at 2800 g for 10 minutes at 4 0C, filtered through a cellulose acetate can result in T. cruzi infection. Recently, oral transmission has been reported membrane, and used fresh or stored at –70 0C. TESA fractions were separated in several outbreaks. Other routes such as blood transfusion, organ transplants electrophoretically on 7 percent SDSPAGE gels, blotted onto nitrocellulose and vertical transmission occur in non-endemic countries as well as in Latin membranes, and probed with sera.21,22 The immune complexes were revealed America. The acute phase of Chagas disease lasts 6–8 weeks; some patients after incubation with 1 in 4000 diluted anti-human IgG peroxidase conjugate have fever, lymphadenopathy, splenomegaly and/or oedema, but most cases by addition of H2O2 and 4-chloro-1-naphthol, as described. All the chronic are asymptomatic or oligosymptomatic. Rarely, patients may develop severe chagasic patients’ samples recognized a broad band of 150 to 160 kDa.20

Journal of Pharmacy Research Vol.3.Issue 11.November 2010 2700-2705 Pramod Kumar et al. / Journal of Pharmacy Research 2010, 3(11),2700-2705 Chagas’ heart disease is an arrhythmogenic cardiomyopathy. Frequent, complex 4. EFFECT OF CHAGAS DISEASE IN HEART ventricular premature beats, including runs of ventricular tachycardia, are a 4.1. PATHOGENESIS OF CARDIAC LESIONS: common finding on Holter monitoring or stress testing.37, 38T hey correlate with The pathogenesis of the cardiac lesions appearing decades after the initial the severity of ventricular dysfunction, but can also occur in patients with infection is incompletely understood. The failure of conventional histological preserved ventricular function. Episodes of nonsustained ventricular tachycar- methods to find parasites in the myocardium led to the hypothesis that au- dia are present in approximately 40% of patients with mild wall motion abnor- toimmune responses are involved in the late clinical manifestation.23 Studies malities and in 90% of those with heart failure, an incidence that is higher than in animals suggest involvement of cellular mechanisms, particularly CD4+ T that observed in other cardiornyopathies.38 lymphocytes, along with macrophage activation and inflammatory cytokine mediators.24, 25 It appears that self-reactive cytotoxic T lymphocytes develop Sustained ventricular tachycardia is another important finding.39, 40 It can be following the initial infection and are able to lyse nonparasitized myocardial reproduced during programmed ventricular stimulation in approximately 85% cells.26 Humoral immunity, expressed by a variety of antibodies against endot- of patients and seems to result from an intramyocardial or subepicardial helium, vascular structures, and interstitium, have been implicated in the macroreentry circuit usually located at the inferolatero wall of the left ventricle pathogenesis of Chagas’ myocarditis, although not confirmed by other stud- and not at the apex where the wall motion abnormalities are more predomi- ies.27 nant.41 Bradyarrhythmias are also prevalent in Chagas’ heart disease third degree AV blocks are the most common. Not infrequently, ventricular tachyarrhythma Using very sensitive immunohistochemical techniques and the in situ poly- and AV conduction abnormalities coexist in the same patient. Another typical merase chain reaction amplification method28, parasitic antigens have been feature of Chagas’ heart disease is sudden death,42 which is caused by ventricular found recently in the hearts of patients with chronic Chagas’ disease. In fibrillation in the vast majority of cases (Fig. 2). It can occur as the initial addition, an association between the presence of T cruzi antigens and the clinical manifestation of the disease. Bradyarrhythmia, thromboembolic phe- intensity of the inflammatory process was observed, suggesting a direct par- nomena, and, in exceptional cases, the rupture of the apical aneurysm, are other ticipation of the parasite in the genesis of chronic Chagas’ myocarditis.29 It is possible causes of sudden death. possible that even low-grade persistent parasitisms serve as a continuous anti- genic stimulus and that both I: cruzi inflammation and an autoimmune re- 4.3.2. CONGESTIVE HEART FAILURE sponse may play important roles in the pathogenesis of Chagas’ heart disease. Congestive heart failure usually evolves slowly, presenting in patients 20 years Another hypothesis, based on the focal nature of the myocytolytic necrosis or more after the acute infection. Isolated left heart failure may be present in and experimental evidence of dynamic abnormalities of the coronary mi- the early stages of cardiac decompensation, but by the time of presentation, crovasculature associated with formation of platelet aggregates and thrombi, biventricular failure is frequently present with peripheral edema, hepatomegaly, proposes that the microcirculation could participate in the disease process.30 and limited cardiac output more prominent than pulmonary congestion. Autonomic denervation is another typical finding and explains the digestive alterations (megaesophagus and megacolon).31 The specific cardiac parasym- 4.3.3. THMMBOEMBOLISM pathetic impairment does not seem to produce myocyte damage, 32 but could Thromboembolic manifestations arising from mural thrombi in the cardiac predispose patients to arrhythrmas and sudden cardiac death. chambers are relatively frequent35, Although brain embolism is by far the most common clinically recognized feature (followed by limbs and lungs), at necropsy 4.2. PATHOPHYSIOLOGIC CHARACTERISTICS: emboli are found more frequently in the lungs, kidneys, and spleen. The chronic cardiac form of Chagas’ disease is characterized by a focal inflam- matory process composed of lymphomononuclear cells that produce progres- 5. EFFECT OF CHAGAS DISEASE IN CNS SYSTEM sive destruction of cardiac fibers and marked reactive and reparative fibrosis 5.1 CLINICAL PRESENTATION OF CHAGAS DISEASE IN CNS affecting multiple areas of the myocardium.12, 33 The parasympathetic cardiac The clinical presentation of Chagas disease may be acute or chronic. The initial nerves and the conduction system are preferentially involed34 producing in- acute phase of Chagas disease is usually asymptomatic, subclinical and undiag- traventricular and atrioventricular (AV) blocks, sinus node dysfunction, and nosed in 66-99% of infected individuals, most of whom are babies or children. ventricular arrhythmias (Fig. 2). The right bundle and the left anterior fascicle The symptomatic acute phase lasts a few weeks and follows a course of fever, are most frequently affected. The focal myocardial fibrosis provides the ana- swollen eyelids and face, anasarca, hepato splenomegaly and enlarged lymph tomic substrate for ventricular and/or atrial arrhythmias, predisposes to car- nodes. During this phase, T. cruzi can be easily detected by direct examination of diac dilation and failure, and leads to formation of narrow necked left ven- fresh blood. tricular apical aneurysms, a hallmark of Chagas’ heart disease 35 Thrombi are often present in the left ventricular aneurysm and in the right atrial append- In the chronic phase of Chagas disease, parasites are difficult to detect in age. This may explain the common occurrence of thromboembolic phenom- peripheral blood, and the diagnosis depends on detecting IgG antibodies. With- ena in the systemic . out treatment, the chronic phase persists a lifetime, and most of the infected individuals will remain asymptomatic for the rest of their lives. This asymp- 4.3. CLINICAL FEATURES tomatic, or indeterminate, phase has been defined based on criteria such as: Chagas’ heart disease is the most common cause of cardiomyopathy in South absence of symptoms; positive specific IgG antibody test and/or parasitological and Central America and, in endemic areas, it is the leading cause of cardiovas- demonstration; and no electrocardiographic or radiologic changes in the heart, 43,44 cular death among patientsbetween the ages of 30 and 50 years pulmonary esophagus and colon. circulation.36 Autonomic dysfunction occurs since the early phases of Chagas disease. Com- plex cardiac arrhythmias may be shown by 24-hour Holter and ergometric tests during this phase and get worse with progression of Chagas disease.45 There are reports of sympathetic and parasympathetic cell destruction, although a direct vagus nerve lesion could not be demonstrated.46,47 Autonomic disturbances may cause these arrhythmias and cardiomyopathy. 45 Apart from autonomic fibers, the peripheral nervous system can also rarely be affected, but central nervous system affection is controversial.48- 50 Alencar described cerebral and cerebrellar atrophy without any inflammation. Even though the existence of direct central nervous system lesions is still disputed, Chagas disease is strongly associated with cardioembolic strokes.51-53 Other stroke mechanisms are described with some authors suggesting an association between Trypanosome infection and stroke even in the absence of cardiomyopathy or cardiac arrhythmias.54,55 There is no study evaluating cerebral hemodynamics in Chagas disease patients, but in other circumstances, like heart surgery, hemodynamic dysfunction may cause stroke.56,57

6.TREATMENT OF CHAGAS DISEASE 6.1 TREATMENT BY ANTIMICROBIALS Antiparasitic therapy is indicated in the infectious acute phase of the disease and for the prophylaxis of reactivation of the infection in immunosuppressed pa- tients.13 The recent findings suggesting that T: cruzi may play a role in mainte- Fig. 2. Diagram of the pathophysiology of Chagas’ heartdisease. AV = nance of myocardial inflammation in the chronic phase of Chagas’ disease28,29 atrioventricular, IV = intraventricular, SSS = sick sinus syndrome

Journal of Pharmacy Research Vol.3.Issue 11.November 2010 2700-2705 Pramod Kumar et al. / Journal of Pharmacy Research 2010, 3(11),2700-2705 and the experimental observation of regression of hystopathologic57 lesions in 6.2.2 CONGESTIVE HEART FAILURE mice chronically infected with T: cruzi treated with antiparasitic agents,suggest Congestive heart failure responds to routine management, including sodium that antitrypanosornal drugs should also be administered to chronic patients. restriction, diuretics, digitalis, and angiotensin- converting enzyme (ACE) Furthermore, it has now been reported by some author 58-60 that chronically inhibitors. For patients with severe cardiac failure, higher doses of diuretics are infected patients treated with antiparasitic agents and followed for up to 16 usually necessary. Although no long-term controlled trial demonstrating ben- years were much less likely to develop cardiac abnormalities subsequently than efits of ACE inhibitors in Chagas’ heart disease has been reported, we recom- do untreated patients. mend their use, even in asymptomatic patients with reduced left ventricular ejection fraction, based on their efficacy in left ventricular systolic dysfunc- The two effective antitrypanosomal agents for clinical use are benznidazole and tion of other etiologies. A lthough beta bloker and spironolactone65 improve nifurtimox, which was recently withdrawn from the market. Benznidazole is survival in heart failure due to other etiologies, they have not been studied in given in an adult dose of 5 mg/kg/day (5 -1 0 mg/kg/day for children) adminis- Chagas’ disease. Beta blockers have been avoided in patients with Chagas’ tered every 12 h for 60 days. Both drugs may cause side effects includingdermatitis, polyneuritis, leukopenia, and gastrointestinal intolerance, sometimes requiring disease because of bradyarrhyhmas and AV conduction defects, but spironolac- discontinuation of treatment. tone is a theoretically attractive therapy because of the major role that cardiac fibrosis plays in the disease. o O O 2 N S For selected patients with end-stage heart failure, cardiac transplantation o N remains an. It has been performed in some patients with promising results. N However, patients must be treated with antitrypanosomal agents, because of the possibility of T. cruzi infection reactivation with the concomitant use of immunosuppressive drugs.66 Dynamic cardiomyoplasty, another surgical op- C H 3 Nifurtimox tion, was performed in a few patients with disappointing results. More re- cently, the Brazilian cardiac surgeon Randas Batista introduced a left O ventriculectomy applying it first to some patients with Chagas’ disease with end-stage cardiomyopathy. H N N 6.2.3.THROMBOEMBOLISM Because of the high incidence of thromboembolic phenomena in Chagas’ heart disease, anticoagulants are recommended in patients with atrial fibrilla- N N O 2 tion, previous embolic episodes, and apical aneurysm with thrombus, even in the absence of controlled clinical trials demonstrating their efficacy. 67 Benznidazole 6.3. TREATMENT BY NANOTECHNOLOGY 6.2 TREATMENT OF CARDIAC MANIFESTATIONS The delivery of nanoparticulate material to the myocardium by nanoDDS. Management of the clinical manifestations of Chagas’ heart disease is based on Since the success of nanoDDS-based strategies depends on the targeting ability the treatment of similar cardiac abnormalities produced by other cardiomyo- taking place when nanoDDS leak from circulation to a defined micro or pathies. macrosite in the body, the targeted gene delivery has to be achieved employing highly invasive techniques. Still under development, a noninvasive technol- 6.2.1. RHYTHM DISTURBANCE ogy is the ultrasound-targeted micro-bubble destruction (UTMD). 68 The UTMD Severe bradyarrhyhuas are treated with pacemaker implantation, but the elec- consists of the destruction of gas-filled microbubbles with an albumin or phos- trode should be placed in the subtricuspid area, not in the right ventricular pholipid shell IV administered, by means of the application of local ultra- apex. Apical fibrosis is common in Chagas’ disease and may result in failure of sound. Micro-bubble destruction causes the rupture of the endothelial capillary a pacemaker placed in the apex to capture. Ventricular pacing in patients with wall, a phenomenon leading to increased local leakage of nanoparticulate Chagas’ heart disease and advanced conduction abnormalities appears to im- material up to 100 nm diameter 69, namely naked plasmid DNA or viral vec- prove survival compared with historic controls in whom this treatment was 70 42 tors. However, in this technique the heart is exposed to high US peak pres- not possible. sure and high concentration of microbubbles for a prolonged period of time and to the induction of significant bio-effects such as transient tissue damage, Although there is no evidence from randomized controlled trials that microvascular rupture, premature ventricular contraction and left ventricle antiarrhythrmc drugs prolong life or prevent sudden cardiac death in Chagas’ dysfunction. Thus, the benefits of delivering trypanocidal drugs in the case of heart disease, we recommend the use of empiric amiodarone for patients with patients suffering Chagas disease must be carefully evaluated. sustained and nonsustained ventricular tachycardia, particularly in the pres- ence of significant myocardial dysfunction. Amiodarone is a potent antiar- To passively target infected cardiomyocytes or, at least, their neighbourhoods, rhythmic drug that markedly reduces the severity and complexity of ventricu- 61 nanoDDS must first extravasate. The loss of filtering/ sieving function of the lar arrhythmias in patients with Chagas’ disease, does not have negative basal membrane could enable the access of nanoDDS to the sarcolemma. inotropic properties, is well tolerated (when administered at low doses), has Then, cardiomyocytes should recognize and uptake the nanoDDS by means of fewer proarrhythmic effects than class I agents, and may reduce total mortal- clathrin or caveolin-dependent endocytosis and follow an appropriate path- ity and sudden cardiac death in patients with heart failure of other etiologies. 62 way towards cytoplasmic amastigote nests. A potential drawback associated with the use of the clathrin route has aroused from recent in vitro studies, where T. cruzi infected cardiomyocytes were employed to show that the para- For example, Rassi et al. compared the survival of 34 patients with Chagas’ site induces a decrease of the clathrin-dependent endocytic activity.71 On the disease and sustained ventriculartachycardia, treated with amiodarone, with an other hand, cardiomyocytes can also perform caveolin (3)-dependent en- earlier matched cohort of 42 patients not treated or receiving class I agents. docytosis72, a pathway that does not end up in lysosomes and allows the escape Survival rate at 1 year (87 vs. 57%), 4 years (65 vs. 22%), and 8 years (59 vs. 42 to the cytoplasm upon endoplasmic reticulum transposition. A recent study 7%) was significantly greater in the treated. showed the delivery to caveolae of rat lung endothelium with aminopeptidase P antibody specifically targeted nanoparticles.73 The caveolae then operated In patients failing empiric amiodarone therapy, electrophysiologic guided 40 as a pump, transporting the antibody-conjugated nanoparticles from the blood antiarrhythmic therapy has been advocated by some authors. Implantation across the endotheliuminto the lung tissue. Approximately 80% injected dose/ of a cardioverter-defibrillator should be considered for patients with refrac- g of tissue was uptaken within 30 min, with minimal uptake by other tissues. tory and hemodynamically unstable sustained ventricular tachycardia or for 38 This new approach opens a new window for improving the tissue targeting of survivors of sudden cardiac death. However, to reduce frequent shocks, anti- nanoparticles to the heart. arrhythmic drug therapy is required in most patients because of the high prevalence of nonsustained ventricular tachycardia. Aneurysmectorny, surgi- 63,64 7. PREVENTION OF CHAGAS DISEASE cal ablation, transcoronary chemical ablation, and catheter ablation have Vaccines are not available for humans; however, precautions can be taken to been attempted in some patients, but efficacy and/or long term effects on reduce the risk of infection, particularly in countries where the prevalence of survival and arrhythmia recurrence are not established. Chagas disease is high. Triatomine insects usually feed at night and withdraw

Journal of Pharmacy Research Vol.3.Issue 11.November 2010 2700-2705 Pramod Kumar et al. / Journal of Pharmacy Research 2010, 3(11),2700-2705 to their hiding places in daylight. In endemic areas, houses can be improved by reactivity of CD4+ T cells against myosin in mice chronically infected with Trypanosoma cruzi.Infect Immun,57,1989,264-84. plastering walls; improving flooring and taking other measures to remove the 25. Cunha-Neto E, Rizzo LV, Albuquerque F, Abel L, Guilherme L, Bocchi E et al. Cytokine cracks where these insects hide. Triatomine insects are often found in base- production profile of heart-infiltrating T cells in Chagas’ disease cardiomyopathy. Bruz ments, which should be avoided. Sleeping inside a screened area, under a JMedBiolRes,31,1998,133-137. 26. Andrade ZA, Andrade SG, Correa R, Sadigursky M, Ferrans VJ. Myocardial changes in acute permethrin-impregnated bed net, or in an air-conditioned room is safest. Bed Trypanosoma cruzi infection. Ultrastructuralevidence of immune damage and the role of nets should be tucked tightly under the mattress before dusk. Animal pens and microangiopathy. Am J Pathol,144,1994,1403-11. 27. Szarfman A, Luquetti A, Rassi A, Rezende JM, SchmuNs GA. Tissue-reacting immunoglobu- storage areas should be kept away from homes. Regular spraying of insecti- lins in patients with different clinicalforms of Chagas’ disease. Am J Tmp Med Hyg,1981,304- cides in and around houses can reduce the number of insects, and in some cases, 46. eliminate them.74 28. Jones EM, Colley DG, Tostes S, Lopes ER, Vnencak-Jones CL, McCurley TL, Amplification of a Trypanosoma cruzi DNA sequence from inflammatory lesions in human chagasic car- diomyopathy. Am JTmp MedHyg,48,1993,348-357. Some triatomine bugs such as Triatoma infestans and Rhodnius prolixus have 29. Bellotti G, Bocchi EA, De Moraes AV, Higuchi ML, Barbero N, Marcial M et al. 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