Pediatric Chagas Disease in Europe
Pediatric Chagas Disease in Europe
Forty-five children, all from Latin American origin, 35 in Spain and 10 in Switzerland have been diagnosed with T. cruzi infection in the 2 hospitals (). Children were aged 1 month to 18 years at time of diagnosis. They originated from Bolivia (n = 41), Argentina (n = 3) and Nicaragua (n = 1). About 18 (40%) were born in Europe and 27 (60%) in Latin America. Two children (4.4%) were diagnosed during the acute phase and the remaining 43 (95.6%) were in the chronic phase of the infection. One (2.2%) child, a 9-year-old girl from Bolivia, was suffering from the digestive form of the chronic infection in presence of a megaesophagus confirmed by characteristic imaging and endoscopic exams. All others were in the indeterminate form of the chronic phase. No child presented or developed symptoms or ECG alteration suggestive of cardiac complication during the follow-up period. Besides the 2 cases responding to the criteria of an acute congenital infection, transplacental transmission was the route of infection for those children born in Europe who never travelled abroad. For those born in Latin America, this was also the most likely route although vectorial transmission could not be formerly ruled out.
All children received antiparasitic treatment, 3 of whom in their country of origin and 1 in another hospital in Barcelona. Of the 41 treated in our 2 hospitals, 35 (85.4%) received benznidazole, 5 (12.2%) received nifurtimox and 1 (2.4%) received both drugs consecutively. Thirteen (31.7%) presented 1 adverse event (AE), while 2 (4.9%) had 2. The most frequent AEs were rash (n = 10, 24.4%), anorexia or insufficient weight gain (n = 6, 14.6%) and anemia (n = 1, 2.4%). There were 2 (4.9%) treatment interruptions due to drug intolerance. The first case followed a generalized rash appearing at day 13 after benznidazole initiation, leading to definite treatment interruption. The second followed a nifurtimox-related generalized rash appearing at day 8, leading to a switch to benznidazole without complication. In other patients with rash, antihistaminic use and/or transient antiparasitic treatment dose reduction were effective in alleviating symptoms without the need for treatment interruption. The occurrence of AEs was neither associated with the type of drug (P = 1) nor with age (P = 0.14).
Serological follow up at 2 years was possible in 29 children (64.4%). In 8 cases, the follow-up serology is not available yet and 8 children were lost to follow up after treatment. At 2 years, 5 patients (17.2%) presented negative serology indicating definitive cure and 24 (82.8%) still presented positive results. Of those, 17 (58.6%) showed a serological titer reduction <50% compared with pretreatment levels and 7 (24.1%) had a ≥0% titer reduction. When comparing cured with not cured children, there was no significant statistical difference in origin (Bolivia vs. other South American countries, P = 0.32), gender (P = 0.34), type of drug received (P = 0.17) and polymerase chain reaction positivity at time of diagnosis (P = 0.48). The only factor associated with cure was the age at diagnosis and treatment (P = 0.008). All infants (n = 4) treated before 1 year of age were cured, whereas only 1 (4.2%) of 24 children diagnosed and treated after 1 year of age was cured.
Results
Demographic and Clinical Characteristics
Forty-five children, all from Latin American origin, 35 in Spain and 10 in Switzerland have been diagnosed with T. cruzi infection in the 2 hospitals (). Children were aged 1 month to 18 years at time of diagnosis. They originated from Bolivia (n = 41), Argentina (n = 3) and Nicaragua (n = 1). About 18 (40%) were born in Europe and 27 (60%) in Latin America. Two children (4.4%) were diagnosed during the acute phase and the remaining 43 (95.6%) were in the chronic phase of the infection. One (2.2%) child, a 9-year-old girl from Bolivia, was suffering from the digestive form of the chronic infection in presence of a megaesophagus confirmed by characteristic imaging and endoscopic exams. All others were in the indeterminate form of the chronic phase. No child presented or developed symptoms or ECG alteration suggestive of cardiac complication during the follow-up period. Besides the 2 cases responding to the criteria of an acute congenital infection, transplacental transmission was the route of infection for those children born in Europe who never travelled abroad. For those born in Latin America, this was also the most likely route although vectorial transmission could not be formerly ruled out.
Treatment
All children received antiparasitic treatment, 3 of whom in their country of origin and 1 in another hospital in Barcelona. Of the 41 treated in our 2 hospitals, 35 (85.4%) received benznidazole, 5 (12.2%) received nifurtimox and 1 (2.4%) received both drugs consecutively. Thirteen (31.7%) presented 1 adverse event (AE), while 2 (4.9%) had 2. The most frequent AEs were rash (n = 10, 24.4%), anorexia or insufficient weight gain (n = 6, 14.6%) and anemia (n = 1, 2.4%). There were 2 (4.9%) treatment interruptions due to drug intolerance. The first case followed a generalized rash appearing at day 13 after benznidazole initiation, leading to definite treatment interruption. The second followed a nifurtimox-related generalized rash appearing at day 8, leading to a switch to benznidazole without complication. In other patients with rash, antihistaminic use and/or transient antiparasitic treatment dose reduction were effective in alleviating symptoms without the need for treatment interruption. The occurrence of AEs was neither associated with the type of drug (P = 1) nor with age (P = 0.14).
Follow up and Assessment of Cure
Serological follow up at 2 years was possible in 29 children (64.4%). In 8 cases, the follow-up serology is not available yet and 8 children were lost to follow up after treatment. At 2 years, 5 patients (17.2%) presented negative serology indicating definitive cure and 24 (82.8%) still presented positive results. Of those, 17 (58.6%) showed a serological titer reduction <50% compared with pretreatment levels and 7 (24.1%) had a ≥0% titer reduction. When comparing cured with not cured children, there was no significant statistical difference in origin (Bolivia vs. other South American countries, P = 0.32), gender (P = 0.34), type of drug received (P = 0.17) and polymerase chain reaction positivity at time of diagnosis (P = 0.48). The only factor associated with cure was the age at diagnosis and treatment (P = 0.008). All infants (n = 4) treated before 1 year of age were cured, whereas only 1 (4.2%) of 24 children diagnosed and treated after 1 year of age was cured.
