Monitoring

Asymptomatic patients with normal ECG findings have a good prognosis, and follow-up should rely on annual history, physical examination, and ECG findings.

Complete blood count (CBC) should be repeated every 2 to 3 weeks during etiologic treatment, and patients should be monitored for dermatitis beginning 9 to 10 days after initiation of treatment. Patients receiving benznidazole should be weighed and monitored for symptoms and signs of peripheral neuropathy fortnightly, especially during the second and third months of treatment.

The level of follow-up care depends mostly on the clinical condition of the patient. Patients who present with acute-phase disease require follow-up for many years.

Monitoring involves the following measures:

  • At diagnosis: baseline evaluations before onset of treatment (complete blood count [CBC], liver function tests [LFTs], coagulation tests, ECG, echocardiogram if indicated, and upper digestive endoscopy in case of epigastralgia)

  • Days 0 to 89 of treatment: fortnightly evaluation with CBC, LFTs, coagulation tests, ECG, blood urea nitrogen, serum creatinine

  • Days 60 to 90: blood culture for Trypanosoma cruzi, polymerase chain reaction (PCR) of buffy coated blood, serology (IgM/IgG)

  • Day 90: barium contrast x-ray (esophagus, stomach, duodenum), abdominal ultrasound

  • Day 90 to month 6: monthly evaluation with CBC, ECG, echocardiogram if indicated, and chest x-ray

  • Month 6: blood culture for T. cruzi; PCR of buffy coated blood; barium contrast x-ray (esophagus, stomach, duodenum); abdominal ultrasound; upper digestive endoscopy (in case of previous or recent epigastralgia); enema (in case of symptoms)

  • Month 9: chest x-ray, ECG, echocardiogram, barium contrast x-ray (esophagus, stomach, duodenum), abdominal ultrasound

  • Month 12: CBC, ECG, echocardiogram, chest x-ray, serology (IgM/IgG), blood culture for T. cruzi, PCR of buffy coated blood, barium contrast x-ray (esophagus, stomach, duodenum), abdominal ultrasound, upper digestive endoscopy (in cases of previous or recent epigastralgia), enema (if indicated by symptoms)

  • Month 13: initiate 6-monthly ECG and chest x-ray; also 12-monthly serology (IgM/IgG), blood culture for T. cruzi, PCR of buffy coated blood, barium contrast x-ray (esophagus, stomach, duodenum), abdominal ultrasound, enema (if indicated by symptoms), exercise test.

There are no clinical criteria that accurately define cure from acute Chagas disease. Using a serologic criterion, cure is based on negativation of serology (in most cases, up to 5 years after treatment). The performance of conventional serologic tests (IgG) is recommended every 6 months or annually, for 5 years. The follow-up can be discontinued when two successive examinations are negative.

In the offspring of Chagasic mothers, serologic titers of IgG for T. cruzi may be positive for up to 9 months. By the 6th month, most children will have negative serology. In rare cases of persisting positive serologic results, a final test after 9 months will be sufficient. If this test is positive, congenital Chagas disease is diagnosed, and the child should undergo specific treatment.[175]

Children born of mothers with acute Chagas disease, or with T cruzi-HIV co-infection, should be investigated thoroughly in the first two months after birth (direct parasitologic methods, xenodiagnosis, blood culture).[7]

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