Dados do Trabalho

Título

Mimics of nervous system Chagas disease reactivation in heart transplantation patients

RESUMO

Case report
A 48-year old male underwent heart transplantation for heart failure secondary to Chagas disease. On the second postoperative day, he had a tonic-clonic seizure and developed hemiparesis and aphasia. CT revealed superior sagittal sinus thrombosis, venous infarct and subarachnoid hemorrhage. Despite adequate anticoagulation, anti-seizure drugs adjustments and hemorrhage reabsorption, seizures and neurological deficit persisted. MRI revealed a necrohemorrhagic lesion suggestive of chagoma and a hypoplastic superior sagittal sinus.
Another 48-year old male with a history of Chagas disease started, 24 days after heart transplantation, a confusional state in the absence of clinical findings that could justify a delirium followed by seizure two days later. Initial cerebrospinal fluid (CSF) analysis was normal and CT scan suggested posterior reversible encephalopathy syndrome (PRES). Tacrolimus was suspended and improvement was noticed afterwards. He was later readmitted confused and hemiparetic. Repeated CT showcased a new lesion with imprecise limits, vasogenic edema, cortical necrosis and hemorrhage indicative of chagoma.
T. cruzi was identified in both CSF analyses.
Discussion
Central nervous system (CNS) reactivation in a rare complication of heart transplantation in Chagas disease. It is manifested as meningoencephalitis (altered mental status, seizures, focal deficits) or tumor-like lesions called chagomas (causing seizure, focal deficits). Single or multiple necrotic-hemorrhagic nodular lesions in white matter can be seen in neuroimage. Diagnosis is usually made by a combination of clinical symptoms and detection of the parasite in blood, CSF or cerebral tissue biopsy. Treatment is recommended in asymptomatic or symptomatic patients. Benznidazole is the first line of treatment in the recommended dose of 10-15mg/kg/day, even though there are few studies on its interaction with immunosuppressive drugs. Although there is a relevant risk of chagas reactivation, transplant outcomes of end-stage Chagas cardiac disease are usually similar to other transplantation indications.
Final comments
We present two heart transplantation neurological complications that were first diagnosed as central venous thrombosis and PRES, but during follow-up were recognized as CNS manifestation of Chagas disease. This report highlights potential clinical and radiologic findings and the importance of Chagas disease reactivation as a mimic of other neurological diseases.