Chagas

Chagas disease is a neglected chronic condition with a high burden of morbidity and mortality. It has considerable psychological, social, and economic impacts. The disease represents a significant public health issue in Brazil, with different regional patterns. This document presents the evidence that resulted in the Brazilian Consensus on Chagas Disease. The objective was to review and standardize strategies for diagnosis, treatment, prevention, and control of Chagas disease in the country, based on the available scientific evidence. The consensus is based on the articulation and strategic contribution of renowned Brazilian experts with knowledge and experience on various aspects of the disease. It is the result of a close collaboration between the Brazilian Society of Tropical Medicine and the Ministry of Health. It is hoped that this document will strengthen the development of integrated actions against Chagas disease in the country, focusing on epidemiology, management, comprehensive care (including families and communities), communication, information, education, and research.

Chagas disease (CD) is caused by the infection with the protozoan haemoflagellate Trypanosoma cruzi. This disease is still a great menace to public health, and is largely neglected as it affects mostly the poorest populations of Latin America. Nonetheless, there are neither effective diagnostic markers nor therapeutic options to accurately detect and efficiently cure this chronic infection. In spite of the great advances in the knowledge of the biology of natural transmission, as well as the immunobiology of the host-parasite interaction, the understanding of the pathogenesis of CD remains largely elusive. In the recent decades, a controversy in the research community has developed about the relevance of parasite persistence or autoimmune phenomena in the development of chronic cardiac pathology. One of the most notable aspects of chronic CD is the progressive deterioration of cardiac function, derived mostly from structural derangement, as a consequence of the intense inflammatory process. Here we review the evidence supporting the multifactorial nature of Chagas heart disease comprising pathogen persistence and altered host immunoregulatory mechanisms.

Chagas disease affects 7.7 million people and 28 million people are at risk of acquiring the disease in 15 endemic countries of Latin America. Benznidazole and nifurtimox are drugs that have been used to treat the disease. However, both drugs induce severe side effects. Treatment with benznidazole has been recommended for the acute phase (0-4 months after infection), recent chronic phase (children 0-14 years of age, treated 4 months after infection) and congenital infection. Average cure rates for Chagas disease patients obtained from clinical trials were 97.9% (congenital infection, treatment performed 0-6 months of age), 71.5% (acute phase), 57.6% (recent chronic phase, children 0-13 years of age) and 5.9% (late chronic phase, great majority of patients between 15 and 69 years of age). Clinical evidence about the capacity of antiparasitic treatment to avoid, stop or revert heart pathology in indeterminate and cardiac chronic patients is contradictory. The investigation of novel therapeutic strategies against Chagas disease remains a priority in the research of tropical diseases. Unfortunately, Chagas disease remains neglected in the formulation of strategies toward control of this disease. This article focuses on current therapeutic approaches to Chagas disease.

An effective innate immune recognition of the intracellular protozoan parasite Trypanosoma cruzi is critical for host resistance against Chagas disease, a severe and chronic illness that affects millions of people in Latin America. In this study, we evaluated the participation of nucleotide-binding oligomerization domain (Nod)-like receptor proteins in host response to T. cruzi infection and found that Nod1-dependent, but not Nod2-dependent, responses are required for host resistance against infection. Bone marrow-derived macrophages from Nod1(-/-) mice showed an impaired induction of NF-kappaB-dependent products in response to infection and failed to restrict T. cruzi infection in presence of IFN-gamma. Despite normal cytokine production in the sera, Nod1(-/-) mice were highly susceptible to T. cruzi infection, in a similar manner to MyD88(-/-) and NO synthase 2(-/-) mice. These studies indicate that Nod1-dependent responses account for host resistance against T. cruzi infection by mechanisms independent of cytokine production.

The strong inflammatory reaction that occurs in the heart during the acute phase of Trypanosoma cruzi infection is modulated by cytokines and chemokines produced by leukocytes and cardiomyocytes. Matrix metalloproteinases (MMPs) have recently emerged as modulators of cardiovascular inflammation. In the present study we investigated the role of MMP-2 and MMP-9 in T. cruzi-induced myocarditis, by use of immunohistochemical analysis, gelatin zymography, enzyme-linked immunosorbent assay, and real-time polymerase chain reaction to analyze the cardiac tissues of T. cruzi-infected C57BL/6 mice. Increased transcripts levels, immunoreactivity, and enzymatic activity for MMP-2 and MMP-9 were observed by day 14 after infection. Mice treated with an MMP inhibitor showed significantly decreased heart inflammation, delayed peak in parasitemia, and improved survival rates, compared with the control group. Reduced levels of cardiac tumor necrosis factor-alpha, interferon-gamma, serum nitrite, and serum nitrate were also observed in the treated group. These results suggest an important role for MMPs in the induction of T. cruzi-induced acute myocarditis.

The infection with Trypanosoma cruzi leads to a vigorous and apparently uncontrolled inflammatory response in the heart. Although the parasites trigger specific immune response, the infection is not completely cleared out, a phenomenon that in other parasitic infections has been attributed to CD4+CD25+ T cells (Tregs). Then, we examined the role of natural Tregs and its signaling through CD25 and GITR in the resistance against infection with T. cruzi. Mice were treated with mAb against CD25 and GITR and the parasitemia, mortality and heart pathology analyzed. First, we demonstrated that CD4+CD25+GITR+Foxp3+ T cells migrate to the heart of infected mice. The treatment with anti-CD25 or anti-GITR resulted in increased mortality of these infected animals. Moreover, the treatment with anti-GITR enhanced the myocarditis, with increased migration of CD4+, CD8+, and CCR5+ leukocytes, TNF-alpha production, and tissue parasitism, although it did not change the systemic nitric oxide synthesis. These data showed a limited role for CD25 signaling in controlling the inflammatory response during this protozoan infection. Also, the data suggested that signaling through GITR is determinant to control of the heart inflammation, parasite replication, and host resistance against the infection.

The ruthenium complex, trans-[Ru(Bz)(NH 3) 4SO 2](CF 3SO 3) 2 1, Bz = benznidazole ( N-benzyl-2-(2-nitro-1 H-imidazol-1-yl)acetamide), is more hydrosoluble and more active (IC 50try/1 h = 79 +/- 3 microM) than free benznidazole 2 (IC 50try/1 h > 1 mM). 1 also exhibits low acute toxicity in vitro (IC 50macrophages > 1 mM) and in vivo (400 micromol/kg < LD 50 < 600 micromol/kg) and the formation of hydroxylamine is more favorable in 1 than in 2 by 9.6 kcal/mol. In murine acute models of Chagas' disease, 1 was more active than 2 even when only one dose was administrated. Moreover, 1 at a thousand-fold smaller concentration than the considered optimal dose for 2 (385 micromol/kg/day = 100 mg/kg/day), proved to be sufficient to protect all infected mice, eliminating the amastigotes in their hearts and skeletal muscles as observed in H&E micrographics.

Trypanosoma cruzi infection causes intense myocarditis, leading to cardiomyopathy and severe cardiac dysfunction. Protective adaptive immunity depends on balanced signaling through a T cell receptor and coreceptors expressed on the T cell surface. Such coreceptors can trigger stimulatory or inhibitory signals after binding to their ligands in antigen-presenting cells (APC). T. cruzi modulates the expression of coreceptors in lymphocytes after infection. Deregulated inflammation may be due to unbalanced expression of these molecules. Programmed death cell receptor 1 (PD-1) is a negative T cell coreceptor that has been associated with T cell anergy or exhaustion and persistent intracellular infections. We aimed to study the role of PD-1 during T. cruzi-induced acute myocarditis in mice. Cytometry assays showed that PD-1 and its ligands are strongly upregulated in lymphocytes and APC in response to T. cruzi infection in vivo and in vitro. Lymphocytes infiltrating the myocardium exhibited high levels of expression of these molecules. An increased cardiac inflammatory response was found in mice treated with blocking antibodies against PD-1, PD-L1, and to a lesser extent, PD-L2, compared to that found in mice treated with rat IgG. Similar results in PD-1(-/-) mice were obtained. Moreover, the PD-1 blockade/deficiency led to reduced parasitemia and tissue parasitism but increased mortality. These results suggest the participation of a PD-1 signaling pathway in the control of acute myocarditis induced by T. cruzi and provide additional insight into the regulatory mechanisms in the pathogenesis of Chagas' disease.

ABSTRACT
Introduction: Serological tests are used to confirm Trypanosoma cruzi infection and their discriminatory accuracy depends on the established decision threshold. Both, the standard methodology and the receiver operating characteristic (ROC) curve methodology allow obtaining such threshold. Objective: To compare the discriminatory accuracy of the standard methodology and the ROC curve methodology regarding serological tests for cofirming T. cruzi infection. Materials and methods: A set of anti-T. cruzi antibodies values from subjects previously classified as healthy or as having Chagas disease were used, and computer simulations were performed in homoscedasticity and heteroscedasticity conditions. Sensitivity, specificity, 100% sensitivity, 100% specificity, and perfect-decision were calculated. Results: The discriminatory accuracy obtained with the standard methodology favored specificity (98.22% to 99.56%) over sensitivity (67.25% to 87.14%), while in the ROC curve methodology a balance balance between sensitivity (94.56% and 96.44%) and specificity (90.35% and 92.11%) was observed. Also, in the ROC curve methodology a greater perfect-decision ratio was observed, which, under homoscedasticity conditions, was >90%. Decisions thresholds were affected by heterocedasticity conditions. Conclusion: The ROC curve methodology showed a better discriminatory accuracy, therefore its use for calculating decision thresholds in serological tests for detecting Chagas disease is recommended.
Keywords: Trypanosoma cruzi; Serology; ROC Curve; Sensitivity and Specificity (MeSH).

RESUMEN
Introducción. Las pruebas serológicas se utilizan para detectar infección por Trypanosoma cruzi y su precisión discriminatoria depende del umbral de decisión establecido. La metodología estándar y la de curva característica operativa del receptor (COR) permiten obtener tal umbral. Objetivo. Comparar la precisión discriminatoria de la metodología estándar y la metodología de curva COR en lo que respecta a pruebas serológicas para detectar infección por T. cruzi. Materiales y métodos. Se utilizó un conjunto de valores de anticuerpos contra T. cruzi de individuos clasificados como chagásicos o sanos y se realizaron simulaciones computarizadas en condiciones homocedásticas y heterocedásticas. Se calculó sensibilidad, especificidad, sensibilidad=100%, especificidad=100% y decisión-perfecta. Resultados. La precisión discriminatoria de la metodología estándar favoreció la especificidad (98.22% a 99.56%) sobre la sensibilidad (67.25% a 87.14%), mientras que la de la curva COR mostró un equilibrio entre sensibilidad (94.56% y 96.44%) y especificidad (90.35% y 92.11%). Esta última metodología también evidenció una mayor proporción de decisión-perfecta, la cual llegó a ser >90% en condiciones de homocedasticidad. Los umbrales de decisión fueron afectados por las condiciones de heterocedasticidad. Conclusión. La metodología de la curva COR mostró una mejor precisión discriminatoria, por lo que se recomienda su uso para el cálculo de umbrales de decisión en pruebas serológicas para la enfermedad de Chagas.
Palabras clave: Trypanosoma cruzi; Serología; Curva ROC; Sensibilidad y especificidad (DeCS).

Resumen: Los modelamientos estadísticos y estocásticos son en la actualidad una herramienta importante para comprensión de fenómenos ecológicos. En este trabajo, se realizaron modelamientos de nicho de la especie Triatoma dimidiata vector de la enfermedad de Chagas con cuatro técnicas de modelamiento ecológico: Regresión logística, DOMAIN, Bioclim y Maxent; los cuales fueron evaluadas con el uso del test estadístico AUC. En virtud de este resultado, se determinó el modelo que permite comprender de una manera correcta la dinámica de esta especie y su distribución, la regresión logística es el modelo que presentó mayor exactitud, además se determinó que la relación de variables es importante para ejecutar cualquier tipo de modelamiento discutiendo la práctica de ejecutar modelamientos ecológicos simplemente aplicando todas las variables e insumos disponibles. El modelo de regresión logística fue utilizado para hacer una distribución de rangos con la finalidad de asignar valores categóricos y determinar la superficie con mayor idoneidad para la presencia de la especie, además de utilizar este como un ejemplo para la gestión de territorio, tomándolo como una herramienta de entomología médica. Se utilizó el sector geográfico con alta idoneidad como límite de un posible riesgo epidemiológico en el cual, se debería considerar trabajar en medidas de prevención para evitar una infección masiva de la enfermedad de Chagas.

Abstract: Nowadays, statistical and stochastic models and their application have become important tools for understanding natural phenomena. In this work, ecologycal niche modeling was performed for the specie Triatoma dimidiata vector of the Chagas disease. For this purpose, four ecological modeling techniques were used: Logistic regression, DOMAIN, Bioclim and Maxent. These models were evaluated using the statistical test AUC. Results showed that logistic regression determined the highest specificity (0.8). Categorical values were assigned through ranking, in order to locate the most suitable area for the presence of the studied species. Additionally, this model was applied for territory management, serving as a tool of medical entomology. The geographical area with higher suitability was established as a threshold at which a epidemiological risk occur. This threshold should be considered for developing preventive measures to avoid a massive spread of Chagas.

Chagas es una enfermedad endemoepidémica de transmisión vectorial en la Provincia de Rio Negro causada por Trypanosoma cruzi, transmitido por insectos vectores denominados triatominos (vinchucas). El programa de control de Chagas de la provincia de Rio Negro certifico, a través de indicadores serológicos y entomológicos, la interrupción de la transmisión vectorial en todo el territorio provincial. Sin embargo, en los últimos años se han generado condiciones que pueden posibilitar la reemergencia de la enfermedad, tal como la eventual domiciliación de vinchucas silvestres, tal el caso de Triatoma patagónica. El objetivo fue evaluar la situación epidemiológica del vector mediante estudios de infestación domiciliaria y peri domiciliaria por triatominos y efectuar análisis de resistencia al principal insecticida que fue aplicado durante muchos años en control. Como resultado se evaluaron 143 viviendas y se colocaron 66 trampas de luz. En el intradomicilio todas las viviendas resultaron negativas, resultando 3 positivas en el peri-domicilio (2.1%) con capturas de T- infestans y T. patagonica. Con las trampas de luz no se capturaron triatominos. Los insectos capturados fueron T. infestans y T. patagonica los que resultaron todos negativos a T. cruzi. Los estudios de resistencia a insecticidas mostraron que las colonias siguen siendo susceptibles a deltametrina

Se realizaron encuestas serológicas y entomológicas para determinar la prevalencia de la enfermedad de Chagas, la presencia del vector y el índice tripano triatomino, en la población escolar de la parroquia Juan Gómez Rendón, en la provincia del Guayas, Ecuador. Se procesaron
muestras sanguíneas de los estudiantes en 12 escuelas, utilizando la técnica de ELISA para detectar reactivos y se realizaron pruebas de confirmación en el Instituto de Salud Pública e Investigación por medio de ELISA (prueba inmuno enzimática para la detección de anticuerpos anti Trypanosoma cruzi) + HAI (hemaglutinación indirecta). Se analizaron 1.967 muestras resultando 23 reactivas y se confirmaron 8 casos. Fueron inspeccionadas 1.831 viviendas en 6 localidades a nivel intra y peridomiciliar, capturándose 8.702 triatominos identificados como Triatoma dimidiata en el área de entomología del Servicio Nacional de Control de la Malaria (SNEM). En cinco de las seis localidades se detectó la presencia del vector, el índice de infestación vectorial varió en un rango de 10,2 a 33,9% y el de colonización de 62 a 91,9%, se examinaron microscópicamente 5.650 Triatominos resultando 2.170 con infección natural con un índice Tripano Triatomino de 38,4%. La enfermedad de Chagas es un problema que afecta a la población menor de 15 años en 4 de las 12 escuelas estudiadas, el vector identificado fue Triatoma dimidiata.