1. Introduction
Chagas disease is caused by the protozoan parasite Trypanosoma cruzi. The main form of transmission occurs by contact of damaged skin and mucous membranes with feces contaminated with insect vectors (1). The epidemiological profile of the disease has changed due to urbanization and globalization, and has currently placed non-endemic countries at risk because of immigration of infected individuals to developed countries, mainly Europe and North America (2, 3).
Approximately 95% of acute cases of Chagas disease are asymptomatic. The remaining symptomatic cases present fever, malaise, muscle, joint pains, somnolence, cramps, diarrhea, edema, respiratory disturbances, cyanosis, and comma (4). Acute cases (with or without symptoms) of infection lead to chronic illness, while 66% of people with chronic infection do not show any detectable clinical manifestation. However, 33% of the chronically infected human population develops clinical manifestations of Chagas disease (4, 5). These chronic clinical manifestations affect the heart in 94.5% of cases.
Previous studies have shown that patients with Chagas disease are at a higher risk of death by sudden cardiac death when compared with the general population (6, 7), especially due to cardiac arrest (CA). Braggion-Santos et al. (6) conducted a study that evaluated 4501 autopsies and found that 5.5% (n = 49) of patients that suffered sudden cardiac death had Chagas disease.
Considering that Chagas disease remains a serious health problem in Latin America and others tropical regions, it is important to investigate and report these cases. The aim of this study was to present 2 patients with Chagas diseases, which presented CA, and were treated at the emergency department of a reference hospital in Brazil. The patients were extracted from a sample of a prospective study (performed from February 2011 to January 2012), previously published by the research group (8).
2. Case Presentation
2.1. Case One
Male patient: (73-year-old and Caucasian) with a history of systemic arterial hypertension, diabetes mellitus, liver cirrhosis, and Chagas disease associated with megacolon and megaesophagus. He used an enteric catheter and was moderately dependent for daily-life activities and was admitted to the emergency department presenting breath discomfort and apathy. He was diagnosed with hypoactive delirium. After 5 days of hospitalization and treatment with antibiotics, he experienced CA. The patient was observed by a health team, who attributed the CA to respiratory insufficiency with initial asystole rhythm. Ventilations, external chest compressions, tracheal intubation, multi-parametric monitoring, venous access puncture, administration of epinephrine, and defibrillation were performed. The time between cardiac collapse and onset of cardiopulmonary resuscitation (CPR) maneuvers was 1 minute, the first shock was performed 4 minutes after the cardiac collapse, tracheal intubation was performed 6 minutes after the cardiac collapse, and the first dose of epinephrine was administered 1 minute after the cardiac collapse; CPR lasted 30 minutes. The patient died due to acute respiratory failure.
2.2. Case Two
Female patient: 64 years old and Caucasian with a history of systemic arterial hypertension, obesity, and Chagas disease. Independent for daily-life activities. She was admitted to the emergency department due to fainting followed by palpitations and was diagnosed with atrial fibrillation with high ventricular response and submitted to synchronized electrical cardioversion. However, during the procedure, the patient developed CA. Ventilation, external chest compressions, defibrillation, tracheal intubation, and multi-parametric monitoring were performed. The time between cardiac collapse and onset of CPR maneuvers was 2 minutes, the first shock was applied 5 minutes after cardiac collapse, and a tracheal intubation was performed 7 minutes after cardiac collapse; the CPR lasted 7 minutes. The patient returned to spontaneous circulation, and developed three more CA, all with an initial rhythm of ventricular fibrillation, yet reverted after the first shock. The diagnosis during 23 days of hospitalization was cardiogenesis followed by septic shock. The patient was treated with cardiotonic agents and antibiotics, and was later discharged without neurological alterations, after an implantation of a cardioverter defibrillator.
3. Discussion
Chagas disease is an infectious condition, which effects approximately 6 to 7 million people worldwide. Most of these cases live in Latin America (9). Heart is affected in 94.5% of symptomatic patients and these patients are considered to have chronic Chagas heart disease. Heart insufficiency is associated with the cause of death cause in 58% of the patients, whereas arrhythmias have been associated with unexpected deaths in 36.5% of the patients (particularly due to CA). The other 4.5% of patients with chronic Chagas infection show mega syndromes, especially in gastrointestinal tract, a disease state that involves the enlargement of esophagus (mega-esophagus) and the colon (megacolon) (4, 10).
Furthermore, CA could be defined as abrupt loss of heart function in a person, who may or may not have been diagnosed with heart disease (11, 12). Vancini-Campanharo et al. (8) conducted a study to characterize patients, who had suffered CA, and to identify factors related to their mortality. In this study, 285 patients (66.3 ± 17.2 years) were followed for 1 year after treatment for CA. Respiratory failure was the most common presumed immediate cause of death (30.8%), while pulseless electrical activity was the most frequent initial rhythm (58.7%). The authors concluded that the mortality rate among CA patients was high (95.4%) and that the variable that best explained mortality was the initial CA rhythm.
Even though both patients presented alterations of their initial cardiac rhythm only the male died. The researchers believe that the female survived CA because she was younger and had a better clinical condition than the male patient (i.e. independence to perform daily-life activities).
The male subject presented diabetes mellitus, liver cirrhosis, megacolon, and megaesophagus. These clinical conditions confirm a more deteriorated health. The digestive form of Chagas disease, presented by the male, may effect all organs in the gastrointestinal tract, especially esophagus and large intestine resulting in megaesophagus and megacolon, respectively. It is worth mentioning that 65% of patients present megaesophagus, megacolon, and heart disease, simultaneously.
The female patient presented atrial fibrillation. Atrial fibrillation was the most frequently observed sustained supraventricular arrhythmia in chronic manifestation of Chagas disease; it is found in 4% to 12% of cases (13). It tends to manifests later on and is often associated with a marked cardiomegaly.
Both patients presented alteration in ventricular function. Bestetti and Cardinalli-Neto (7) pointed that patients with Chagas disease and ventricular tachyarrhythmias are at a higher risk of sudden cardiac death. These patients should undergo primary and secondary prevention programs, such as programmed ventricular stimulation, implantable cardioverter defibrillator, amiodarone therapy, and catheter ablation.
Despite of the decrease in infected people and death cases, Chagas disease is still prevalent in Latin America; the disease morbidity and mortality is still higher than it should be. Unfortunately, Chagas continues to be relatively ignored by the society and it is generally neglected by government authorities. Governments, especially in Latin America, need to give higher priority to this health issue. It is also necessary to mobilize resources and capabilities from different society sectors, such as non-governmental and private organizations to combat and prevent this disease (14).
In addition, educational programs for CA recognition (despite that the frequency of treated and attended patients, at an emergency department, have been low) targeted at health professionals and caregivers could improve the prognoses of individuals already infected with Chagas disease. It is also advisable to educate the general public on CA recognition since this knowledge may increase the chances of survival before the arrival of advanced life support.
