A 22 year-old man presented to the emergency department in Cochabamba, Bolivia, with headache and left-sided weakness. Both were present for three weeks, both progressively worsening. The patient was from Aiquile, a rural part of Bolivia, and had grown up in a home made of adobe. He had had multiple sexual partners, both men and women, in the last three years.
On physical exam the patient was alert and oriented. Papilledema was noted bilaterally. He had 2/5 strength in his left upper and lower extremities, and 5/5 strength in his right upper and lower extremities. He was unable to walk without assistance because of left-sided weakness.
Treatment for suspected toxoplasmosis was initiated empirically with clindamycin, pyrimethamine, and dexamethasone. Laboratory studies revealed CD4 56 and HIV viral load 689,568 copies/mL. Toxoplasma gondii IgG antibody was positive, however T. gondii IgM antibody was negative. Conventional and recombinant ELISA for Trypanosoma cruzii were positive. Additionally, Trypanosoma cruzii trypomastigotes were visualized on direct microscopy, providing evidence for reactivation of chronic Chagas’ disease. CT head showed a lesion of the right posterior fossa with marked edema surrounding the lesion. With these results, treatment with benznidazole was initiated to treat reactivation of Chagas’ disease. Additionally, antiretroviral therapy with zidovudine, lamivudine, and efavirenz was initiated.
The patient improved clinically with resolution of his headache after one week and was able to walk with a normal gait by day 30 of treatment. Repeat CT of the head on day 7, day 30 and day 60 of treatment showed gradual improvement of the lesion.
Chagas disease is caused by infection with the protozoan parasite Trypanosoma cruzi, and is endemic to many countries in Latin America. In immunocompetent patients, the most common manifestations of Chagas disease are cardiac and gastrointestinal symptoms. In immunocompromised patients the most common manifestation is neurologic symptoms ranging from meningoencephalitis to space-occupying lesions.
With the persistence of chronic Chagas’ disease in Latin America, and with increased migration from rural to urban settings, it is suspected that there has been an increase in the number of persons co-infected with HIV/AIDS and chronic Chagas’ disease in recent years, although there is little data on the prevalence of this co-infection. The patient described above was seen in Cochabamba, Bolivia while on a global health rotation.
Although Chagas disease is endemic to Central and South America, it is likely that we will see an increased number of cases of patients co-infected with HIV and Chagas disease in the immigrant populations the United States. Chagas reactivation has a clinical presentation similar to toxoplasmosis, tuberculosis (with tuberculoma), neurocysticercosis, or CNS lymphoma. Reactivation of chagas disease is diagnosed by direct microscopy of whole blood, although PCR is increasingly being used to detect and quantify levels of parasitemia.
Increasing, HIV/AIDS and Chagas disease are co-existing. If patient presents with AIDS and CNS symptoms, a reactivation of Chagas disease should be considered.
To cite this abstract:Reimer-McAtee M, Mejia C, Reimer D, Gilman R. A Case of Co-Infection with Hiv and Chagas Disease with Improvement of Chagoma After Treatment with Benznidazole. Abstract published at Hospital Medicine 2015, March 29-April 1, National Harbor, Md. Abstract 665. Journal of Hospital Medicine. 2015; 10 (suppl 2). https://www.shmabstracts.com/abstract/a-case-of-co-infection-with-hiv-and-chagas-disease-with-improvement-of-chagoma-after-treatment-with-benznidazole/. Accessed July 16, 2019.