Chagas disease is a pathogenic parasitic infection caused by Trypanosoma cruzi, with a prevalence of approximately 8 million cases worldwide and greater than 300,000 cases in the United States of America (U.S.) [1]. Chagas disease is endemic to Latin American and well known to cause significant cardiac complications. About 50% of immigrants to the U.S. are from highly endemic Latin American countries including Mexico and may carry the parasite with them occultly [2, 3]. In the U.S., Chagas disease is primarily acquired vertically during childbirth causing congenital Chagas disease [4–6]. An estimated 40,000 women of childbearing age in the U.S. are infected with Chagas disease, with a 1–5% risk of vertical transmission, and up to 300 congenital cases in the U.S. annually [2, 7, 8]. Chagas disease can be transmitted through blood transfusion or organ donation, though this risk is decreased with implementation of screening programs [9]. In most rural parts of Latin America, Chagas disease is mainly transmitted through the feces of the vector, the triatomine bug, which is also present in the southern half of the U.S. Despite the prevalence of Chagas disease in the United States, it is rarely considered for patients with otherwise unexplained cardiac disease [2, 3].
The impact of this disease can be extensive and difficult to treat with 30% of infected persons developing long term consequences, most importantly cardiomyopathy [1, 4]. Although congenital Chagas disease and/or pediatric Chagas disease cases comprise a small proportion of cases, a survey of U.S. obstetricians and pediatric infectious disease doctors showed a lack of comfort and knowledge of the disease presentations [8, 10]. Pediatric cardiologists may be the first point of contact in children with undiagnosed Chagas disease; therefore, knowledge of its clinical presentation and epidemiology is essential for these providers. The earlier the presence of the parasite is recognized and treated, the better the outcomes; therefore, pediatric recognition and diagnosis of Chagas disease would reduce morbidity and mortality [11].
The cardiac presentations of Chagas disease can be highly variable in pediatrics and limited data are available regarding the cardiac status of children in the U.S. with Chagas disease. Data from endemic countries shows cardiac presentations in neonates and infants with congenital Chagas disease, to adolescents showing pathologic and non-pathologic electrocardiographic changes, and even some adolescents with signs of cardiomyopathy [12–20]. Congenital Chagas disease is typically asymptomatic, but can present with heart failure, electrocardiogram (EKG) changes or myocarditis. When congenital Chagas is fatal, it is most often related to myocarditis or meningoencephalitis [8, 20]. Two infants with congenital Chagas disease recognized in the U.S. presented with hydrops fetalis [8]. Acute Chagas disease can present with myocarditis in any age group as well [14]. A metanalysis found that EKG changes in children and adolescents are found just as frequently as in adults but with more rapid time to death and more diagnostic difficulty [15]. The most common findings are right bundle branch block, atrioventricular block and left anterior fascicular block [15, 19, 21]. A study in Mexico looked at 37 cases of Chagas disease in adolescents under 18 and found that 25 of them already had cardiac pathology consistent with Chagas disease cardiomyopathy [12].
The purpose of our study is to survey pediatric cardiologists to assess their knowledge, awareness and practice with the recognition and management of Chagas disease. Our hope is to identify gaps in knowledge and comfort level of pediatric cardiologists, so that specific educational curriculum can be designed to increase diagnostic consideration of Chagas disease and initiate earlier treatment.