A 29 y.o. woman from Guatemala presents with dysphagia and weight loss.

The patient is 4ft 11 inches tall and weighs 67 lbs.  she has had difficulty swallowing for one year and the image above is her barium swallow. 

This patient has Chagas disease with mega esophagus.

 

Chagas disease was discovered by a Brazilian physician in 1909. It is cause by the parasite trypanosoma cruzi and is found in rural areas of Latin America where it is transmitted by the bite of the triatomine ( reduviid) bug. It affects 8-11 million people globally. It can be transmitted by bites of the bug or ingesting the bug in food or drink. 

The disease consists of an acute phase and a chronic phase.  Initially, children are often bitten at night while they sleep.  After a blood meal, the bug defecates leaving infected feces near the skin wound.  The patient may rub this area introducing parasites into the wound or on the conjunctiva. The eyelid swelling that results is termed Romana’s sign. In the acute phase parasites can be seen on a Giemsa blood smear.   Following the acute phase, there is a prolonged asymptomatic period. 20-30% of the infected people will develop complications of chronic Chagas which include: a dilated esophagus , dilated colon , or cardiomyopathy.there is a marked loss of neurons in the bowel wall. The different theories forselective destruction of these ganglion cells includes: direct action of parasites, local toxins produced by the parasites or an immune response to the parasites.  In the chronic phase  T. Cruzi PCR andanti-T cruzi antibodies can confirm the presence of the disease. 

 Romana's sign

Romana's sign

trypanosome with Giesma stain

Teaching point: Women who are pregnant can transmit the disease to their offspring.  A mother with a chronic infection who transmitted the trypanosomes to her baby was reported in 2010.  The baby had hydrops fetalis and was treated with benznidazole and recovered.

 

Clinical course: Our patient was admitted with severe weight loss and an esophagus full of food .  She was scoped and the esophagus irrigated to remove the food impaction. She was then able to swallow liquids and was discharged home to await esophageal surgery.

Lazarte R, Litman-Mazo F, Crewalk J, Keim D, et al. Congenital transmiaaion of Chagas Disease—Virginia, 2010. Morbidity and Mortality Weekly Report 2012 61(26): 477-479.

Okumura M, Brito T, Silva L, et al .  Gastrointestinal aspects of Chagas’ disease. Am J Dig Dis 17:559-571.1960