Case Presentation:
A 59‐year‐old Hispanic man presented with 3 days of intermittent substernal chest pain radiating to the left axilla, occurring at rest, and associated with shortness of breath, diaphoresis, and nausea. His medical history was significant for hypertension. On presentation, the patient's blood pressure was 170/103, and he was bradycardic; all other vital signs were normal. Physical examination including cardiovascular exam was unremarkable. Laboratory studies revealed a normal complete blood count and basic metabolic panel. Initial cardiac troponins were 0.07‐0.08 ng/mL. Electrocardiogram (ECG) demonstrated sinus bradycardia, low‐voltage QRS, left anterior fascicular block, and atrial abnormality. A dobutamine stress echocardiogram showed moderate left ventricular systolic dysfunction (ejection fraction, 35%) and segmental wall motion abnormalities. Coronary angiography revealed nonischemic cardiomyopathy, an akinetic left ventricle, and an apical aneurysm. These findings suggested myocarditis, in particular, Chagas disease, which was confirmed with a positive Trypanosoma cruzi IgG. Further questioning of the patient revealed that he had lived until age 40 in an adobe house in rural Guatemala. He also complained of difficulty swallowing and nearly daily vomiting.
Discussion:
Brazilian physician Carlos Chagas identified an infectious tropical disease caused by the parasite Trypanosoma cruzi, named after Dr. Oswaldo Cruz. Paleoparasitology data suggest Chagas has existed for approximately 9000 years. Transmission occurs via the bite of an infected triatomine insect, or “kissing bug,” endemic to the Americas. Triatomes thrive in low‐socioeconomic rural areas of Latin America with poor housing conditions such as houses made of mud walls with thatched roofs. Immigration has transformed Chagas into an important public health issue in the United States, with an estimated 300,000 cases in immigrants. Cardiac manifestations of Chagas include biventricular enlargement, thinning of the ventricular walls, damage to the cardiac conduction system, and development of apical aneurysms, resulting in symptoms of heart failure, palpitations, syncope, and thromboembolic disease. Atypical chest pain relates to microvascular perfusion defects. ECG findings may include right bundle branch block, left anterior fascicular block, bradycardia, ventricular premature beats, low‐voltage QRS, and high‐degree heart block. Gastrointestinal involvement is less common but can result in significant morbidity from dilation of the esophagus or colon.
Conclusions:
Our patient exhibited conduction system abnormalities, a dilated left ventricle, and an apical aneurysm, all common in Chagas disease. The patient's description of typical chest pain led us to evaluate for ischemic causes. However, demographics, ECG, angiography results, and gastrointestinal complaints suggested infectious cardiomyopathy. Although a thorough workup for ischemia was unavoidable, this case reinforces the importance of historical clues and demographic data in making the diagnosis.
Disclosures:
E. Boswell ‐ none; I. Grundy ‐ none; N. Rodden ‐ none; C. Chakraborti ‐ none