### Microbiology A protozoa; _Trypanosoma_ *brucei* subs. gambiense, *Trypanosoma* *brucei* subs. rhodesiense and _Trypanosoma_ *cruzi*. There are a variety of *Trapanosomes* that has evolved to infect many animals. ### Epidemiologic Risks _Trypanosoma_ *brucei* subs. *gambiense*: bit by a tsetse fly in W. Africa. _Trypanosoma_ *brucei* subs. *rhodesiense*: bit by a tsetse fly in E. Africa. _Trypanosoma_ *cruzi*: bit by a blood-sucking triatomine insects, or kissing bugs, in S. America and US South. Many animals serve as a reservoir. It is estimated there are 300,000 immigrants in the US are infected with *T*.*cruzi*; in NY the plurality were from San Salvador. [^1] There have been outbreaks of Chaga's due to drinking contaminated fresh guava juice [^2] and acai, [^3] a 'superfood" whose only superpower is giving people Chaga's. Chaga's can also be transmitted sexually. [^4] It can be found in semen (the Navy has so many ID issues), so it could be an STD. [^5] And perhaps bed bugs. [^6] Curiously, in Arizona, 41.5% of triatomines (the vector of Chaga's) were infected with *T*. *cruzi*. [^7] However, the bugs in Arizona do not feed usually on humans. It turns out the US South is rife with Chagas and they are feeding on humans, indoor and out. [^8] It has been spread in S. California [^9] and north into Delaware [^10] and its range will likely change with global warming. So far, autochthonous (one of HP Lovecraft's Old Ones?) spread is rare. Chagas is spread when the triatomine feeds and at the same time takes a crap. The human then itches, driving the bug crap into the skin along with the Chaga's. In the US the triatomine is more fastidious, leaving its feeding site before taking a crap. Perhaps this is why there is less Chaga's in the US. In Texas, one in 6,500 tested positive for the Chagas, much higher than the usual one in 300,000 of the CDC. So there may be more Chaga's in the US than we are aware. And reports of disease in Texas go back to 1935. [^11] But one report suggests while triatomines bites are common in the US, disease transmission is rare. [^12] The rates in those born south of the border in LA are 1.24% with different countries of origin at different rates of seropositivity. [^13] Since the fall of 2014 serology is done as part of blood donation, so expect the occasional case as a result. I saw a couple such patients. The CDC will assist in confirmation serology as well as acquiring medications. Test close family members; around 7% will be seropositive. [^14] One case of _T_.*evansi* in Vietnam acquired by slaughtering cows. ### Syndromes _Trypanosoma_ *brucei* subs. *gambiense*: Sleeping Sickness; a more chronic form of the illness of months duration with CNS findings late in the course of the disease. It causes chronic illness by changing its outer cell glycoprotein. _Trypanosoma_ *brucei* subs. *rhodesiense*: Sleeping Sickness a more acute form of the illness with CNS finding early. _Trypanosoma_ cruzi: Chagas. - Acute Chagas' disease: a chagoma (an indurated area of erythema and swelling with local lymph node involvemen_T_, The Romaña sign consists of painless edema of the palpebrae and periocular tissues; then fever, malaise, anorexia, and edema of the face and lower extremities, sometimes with generalized lymphadenopathy and mild hepatosplenomegaly. Encephalitis and myocarditis may also occur early. - Chronic Chagas' disease: occurs years after the initial infection with cardiomyopathy and megaesophagus, chronic constipation and abdominal pain. Can reactivate with immunosuppression. [^15] Pathology and serology are needed to make the diagnosis. Look for organisms on with blood smear and lumbar puncture. ### Treatment Get the CDC involved for diagnosis and treatment. Don't trust this. _T_. *rhodesiense*, hemolymphatic stage: Suramin 1 gm IV on days 1, 3, 7, 14, and 21. *T*. rhodesiense, CNS involvement: Melarsoprol 2-3.6 mg/kg/day IV x 3 days. After 7 days, 3.6 mg/kg/day x 3 days. Give the 3rd series of 3.6 mg/kg/d after 7 days. _T_. *gambiense*, hemolymphatic stage: Pentamidine 4 mg/kg/day IM or IV x 7-10 days. _T_. *gambiense*, CNS involvement: Eflornithine 400 mg/kg/day in 4 doses x 14 days. _Trypanosoma_ *brucei* subs. *gambiense*: > "oral fexinidazole is effective and safe for the treatment of T b gambiense infection compared with nifurtimox eflornithine combination therapy in late-stage HAT patients." [^16] _Trypanosoma_ *cruzi*: acute: Nifurtimox is 8 to 10 mg/kg/day. Nothing works for chronic disease, although benznidazole in adults at 5 to 7.5 mg per kilogram of body weight q day, for 60 days looks promising. [^17] Since the fall of 2014 serology is done as part of blood donation, so expect the occasional case. The CDC will assist in confirmation serology as well as acquiring medications. Call the Parasitic Diseases Public Inquiries Line (770-488-7775); [email protected]; [www.cdc.gov/parasites/chagas](www.cdc.gov/parasites/chagas)), the CDC Drug Service (404-639-3670). ### Notes Insecticide--impregnated collars for dogs decreased disease in children in Iran. [^18] There is a 20-30 million-year-old Tyrpanosom inside a sand fly in fossilized amber ([See it here](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2491605/)). [^19] ### Puswhisperers [The Bird That Wasn't There.](http://www.pusware.com/PW6/TheBird.html) [Audio. The Gobbet 'o Pus Podcast](http://www.pusware.com/gobbet/gop741.mp3) [Something Parasitic This Way Comes](http://www.pusware.com/PW7/SomethingParasitic.html) [Audio. The Gobbet 'o Pus Podcast](http://www.pusware.com/gobbet/gop908.mp3) ### Rationalizations [^1]: Crystal Zheng, Orlando Quintero, Elizabeth K Revere, Michael B Oey, Fabiola Espinoza, Yoram A Puius, Diana Ramirez-Baron, Carlos R Salama, Luis F Hidalgo, Fabiana S Machado, Omar Saeed, Jooyoung Shin, Snehal R Patel, Christina M Coyle, Herbert B Tanowitz, Chagas Disease in the New York City Metropolitan Area, _Open Forum Infectious Diseases_, Volume 7, Issue 5, May 2020, ofaa156, [https://doi.org/10.1093/ofid/ofaa156](https://doi.org/10.1093/ofid/ofaa156) [^2]: Alarcón de Noya B, Díaz-Bello Z, Colmenares C, Ruiz-Guevara R, Mauriello L, Zavala-Jaspe R, Suarez JA, Abate T, Naranjo L, Paiva M, Rivas L, Castro J, Márques J, Mendoza I, Acquatella H, Torres J, Noya O. Large urban outbreak of orally acquired acute Chagas disease at a school in Caracas, Venezuela. J Infect Dis. 2010 May 1;201(9):1308-15. doi: 10.1086/651608. PMID: 20307205. [^3]: Santana RG, Guerra M, Sousa DR, et al. Oral Transmission of Trypanosoma cruzi, Brazilian Amazon. _Emerging Infectious Diseases_. 2019;25(1):132-135. doi:10.3201/eid2501.180646. [^4]: Gomes C, Almeida AB, Rosa AC, Araujo PF, Teixeira ARL. American trypanosomiasis and Chagas disease: Sexual transmission. Int J Infect Dis. 2019 Apr;81:81-84. doi: 10.1016/j.ijid.2019.01.021. Epub 2019 Jan 18. PMID: 30664986. [^5]: Crespillo-Andujar C, Díaz-Menéndez M, Mora-Rillo M. Evidence for Previously Unidentified Sexual Transmission of Protozoan Parasites. _Emerging Infectious Diseases_. 2018;24(3):602-603. doi:10.3201/eid2403.171838. [^6]: Salazar R, Castillo-Neyra R, Tustin AW, Borrini-Mayorí K, Náquira C, Levy MZ. Bed bugs (Cimex lectularius) as vectors of Trypanosoma cruzi. Am J Trop Med Hyg. 2015 Feb;92(2):331-335. doi: 10.4269/ajtmh.14-0483. Epub 2014 Nov 17. PMID: 25404068; PMCID: PMC4347337. [^7]: Reisenman CE, Lawrence G, Guerenstein PG, Gregory T, Dotson E, Hildebrand JG. Infection of kissing bugs with Trypanosoma cruzi, Tucson, Arizona, USA. Emerg Infect Dis. 2010 Mar;16(3):400-5. doi: 10.3201/eid1603.090648. PMID: 20202413; PMCID: PMC3322010. [^8]: Klotz SA, Schmidt JO, Dorn PL, Ivanyi C, Sullivan KR, Stevens L. Free-roaming kissing bugs, vectors of Chagas disease, feed often on humans in the Southwest. Am J Med. 2014 May;127(5):421-6. doi: 10.1016/j.amjmed.2013.12.017. Epub 2014 Jan 4. PMID: 24398362; PMCID: PMC4096837. [^9]: Hernandez S, Flores CA, Viana GM, Sanchez DR, Traina MI, Meymandi SK. Autochthonous Transmission of _Trypanosoma Cruzi_ in Southern California. Open Forum Infect Dis. 2016 Dec 20;3(4):ofw227. doi: 10.1093/ofid/ofw227. PMID: 28018928; PMCID: PMC5170498. [^10]: Eggers P, Offutt-Powell TN, Lopez K, Montgomery SP, Lawrence GG. _Notes from the Field:_ Identification of a _Triatoma sanguisuga_ “Kissing Bug” _—_ Delaware, 2018. MMWR Morb Mortal Wkly Rep 2019;68:359. DOI: [http://dx.doi.org/10.15585/mmwr.mm6815a5](http://dx.doi.org/10.15585/mmwr.mm6815a5). [^11]: Garcia MN, Woc-Colburn L, Aguilar D, Hotez PJ, Murray KO. Historical Perspectives on the Epidemiology of Human Chagas Disease in Texas and Recommendations for Enhanced Understanding of Clinical Chagas Disease in the Southern United States. PLoS Negl Trop Dis. 2015 Nov 5;9(11):e0003981. doi: 10.1371/journal.pntd.0003981. PMID: 26540273; PMCID: PMC4634991. [^12]: Behrens-Bradley N, Smith S, Beatty NL, Love M, Ahmad N, Dorn PL, Schmidt JO, Klotz SA. Kissing Bugs Harboring Trypanosoma cruzi, Frequently Bite Residents of the US Southwest But Do Not Cause Chagas Disease. Am J Med. 2020 Jan;133(1):108-114.e13. doi: 10.1016/j.amjmed.2019.06.016. Epub 2019 Jul 8. PMID: 31295438. [^13]: Meymandi SK, Forsyth CJ, Soverow J, Hernandez S, Sanchez D, Montgomery SP, Traina M. Prevalence of Chagas Disease in the Latin American-born Population of Los Angeles. Clin Infect Dis. 2017 May 1;64(9):1182-1188. doi: 10.1093/cid/cix064. PMID: 28329123; PMCID: PMC5399937. [^14]: Hernandez S, Forsyth CJ, Flores CA, Meymandi SK. Prevalence of Chagas Disease Among Family Members of Previously Diagnosed Patients in Los Angeles, California. Clin Infect Dis. 2019 Sep 13;69(7):1226-1228. doi: 10.1093/cid/ciz087. PMID: 31220221; PMCID: PMC6743820. [^15]: Mary M Czech, Ashwin K Nayak, Kavitha Subramanian, Jose F Suarez, Jessica Ferguson, Karen Blake Jacobson, Susan P Montgomery, Michael Chang, Gordon H Bae, Shyam S Raghavan, Hannah Wang, Eugenia Miranti, Indre Budvytiene, Stanford Mervyn Shoor, Niaz Banaei, Kerri Rieger, Stan Deresinski, Marisa Holubar, Brian G Blackburn, Reactivation of Chagas Disease in a Patient With an Autoimmune Rheumatic Disease: Case Report and Review of the Literature, _Open Forum Infectious Diseases_, Volume 8, Issue 2, February 2021, ofaa642, [https://doi.org/10.1093/ofid/ofaa642](https://doi.org/10.1093/ofid/ofaa642) [^16]: Mesu VKBK, Kalonji WM, Bardonneau C, Mordt OV, Blesson S, Simon F, Delhomme S, Bernhard S, Kuziena W, Lubaki JF, Vuvu SL, Ngima PN, Mbembo HM, Ilunga M, Bonama AK, Heradi JA, Solomo JLL, Mandula G, Badibabi LK, Dama FR, Lukula PK, Tete DN, Lumbala C, Scherrer B, Strub-Wourgaft N, Tarral A. Oral fexinidazole for late-stage African Trypanosoma brucei gambiense trypanosomiasis: a pivotal multicentre, randomised, non-inferiority trial. Lancet. 2018 Jan 13;391(10116):144-154. doi: 10.1016/S0140-6736(17)32758-7. Epub 2017 Nov 4. Erratum in: Lancet. 2018 Jan 13;391(10116):124. PMID: 29113731. [^17]: Bern C. Antitrypanosomal therapy for chronic Chagas' disease. N Engl J Med. 2011 Jun 30;364(26):2527-34. doi: 10.1056/NEJMct1014204. PMID: 21714649. [^18]: Courtenay O, Bazmani A, Parvizi P, Ready PD, Cameron MM. Insecticide-impregnated dog collars reduce infantile clinical visceral leishmaniasis under operational conditions in NW Iran: A community-wide cluster randomised trial. PLoS Negl Trop Dis. 2019 Mar 4;13(3):e0007193. doi: 10.1371/journal.pntd.0007193. PMID: 30830929; PMCID: PMC6417739. [^19]: Poinar G Jr. Lutzomyia adiketis sp. n. (Diptera: Phlebotomidae), a vector of Paleoleishmania neotropicum sp. n. (Kinetoplastida: Trypanosomatidae) in Dominican amber. 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