Gilles H. Parasitic disease affecting the heart in childhood. Images Paediatr Cardiol


*Invited article* (0.6M)	*Gilles H. Parasitic disease affecting the heart in childhood. Images Paediatr Cardiol 2000;5:29-40**
*	Emeritus Professor of Tropical Medicine, University of Liverpool, 3 Conifers Avenue, Birkdale, Southport PR8 4SZ, Merseyside UK

MeSH

Myocarditis	Pericarditis	Myocardial Diseases
Chagas Disease	Trypanosomiasis, African	Larva Migrans, Visceral
Toxoplasmosis	Trichinella spiralis	Amebiasis
Echinococcus

Abstract
Parasitic diseases may occasionally affect the cardiovascular system, albeit rarely in childhood. In this paper, I list the main features of tropical diseases which may affect the heart.

Article
Several parasitic diseases occasionally affect the heart, causing myocarditis, cardiomyopathy and pericarditis as follows:

Myocarditis	American trypanosomiasis
	African trypanosomiasis
	Visceral larva migrans
	Toxoplasmosis
	Trichinella spiralis
	Amoebiasis
	Echinococcus
Cardiomyopathy	Chagas' disease
	Toxoplasmosis
Pericarditis	Amoebiasis
	African trypanosomiasis
	Chagas disease'
	Toxoplasmosis
	Echinococcus

In the majority of instances, adults are predominantly affected, cardiac pathology being uncommon in children except in Chagas' disease.

Chagas' disease - return to top - back

Distribution	South and Central America Figure 1: Distribution of Chagas' disease
The parasite	Trypanosoma cruzi
The reservoir	Humans and arborial animals
The vector	Various species of reduviid bugs (Triatoma) Figure 2: Reduviid bug - triatoma species Figure 3: Ideal habitat for reduviid bugs
Transmission	Rubbing infected bug species onto skin Blood transfusion Congenital infection
Acute stage	Seen mainly in children: Reddish area at site of bite (chagoma) Unilateral painless orbital oedema (Romana's sign) High fever Tachycardia persisting through apyrexial periods Acute myocarditis with arrhythmias Pericarditis Heart failure Hepatosplenomegaly Lymphadenopathy Figure 4: Romana's sign in acute Chagas' disease
Chronic stage	Seen mainly in adult life: Cardiomyopathy with right bundle branch block Left anterior hemiblock Complete heart block Premature ventricular beats Atrial fibrillation T wave changes Heart failure (left and right ventricular decompensation) Cardiac arrest with sudden death Megasyndromes of the intestines Figure 5: X-ray of chest: cor pulmonale due to pulmonary hypertension Figure 6: X-ray of chest showing global cardiac enlargement Figure 7: Large ventricular apical aneurysm in chronic Chagas' disease Figure 8: Cardiomegaly in chronic Chagas' disease Figure 9: Megacolon Figure 10: Complete heart block
Diagnosis	Trypanosomes found in blood Serological tests (IFAT or ELISA) Polymerase chain reaction
Treatment	Supportive Benznidazole or nifurtimox The elimination of the disease is being achieved in several South American countries

African trypanosomiasis - return to top - back

Distribution	Africa
The parasite	Trypanosoma brucei gambiense & rhodesiense Figure 11: T brucei gambeinse in blood film (C/O WHO)
The reservoir	Humans and wildlife
The vector	Various species of Glossina (Tsetse) flies Figure 12: Tsetse fly - Glossina species
Transmission	Bite by fly
Clinical features	Local lesion at site of bite Fever Lymphadenopathy Myocarditis with disproportionate tachycardia Tachycardia persisting through apyrexial periods Arrhythmias Heart failure Pericardial effusion Figure 13: Trypanosomal chancre in child (C/O WHO)
Diagnosis	Trypanosomes found in blood, lymph and cerebrospinal fluid Serological tests (IFAT) Direct and indirect agglutination Antigen detection
Treatment	Suramin Pentamidine (T. gambiense only) Melarsoprol Alpha-difluoromethlyornithine (DFMO)

Trichinosis - return to top - back

Distribution	Worldwide
The parasite	Trichinella spiralis
The reservoir	Pigs and many wild animals
Transmission	Ingestion of raw or undercooked animal flesh - predominantly pork or wild boar
Clinical features	Fever Orbital oedema Myalgia Myocarditis Arrhythmias Heart failure
Diagnosis	Serological tests (ELISA) Eosinophilia
Treatment	Mebendazole Corticosteroids

Visceral larva migrans - return to top - back

Distribution	Worldwide
The parasite	Toxocara canis & Toxocara catis
The reservoir	Dogs and cats
Transmission	Ingestion of toxocara eggs deposited on the ground in dog faeces
Clinical features	Fever Nocturnal cough and wheezing Myocarditis Unilateral loss of vision
Diagnosis	ELISA with larval stage antigens Eosinophilia Hypergammaglobulinaemia with raised IgM and IgG levels
Treatment	Diethylcarbamazine Thiabendazole

Echinococcus - return to top - back

Distribution	Africa, Middle East, Latin America
The parasite	Echinococcus granulosus
The reservoir	Dogs
Transmission	Ingestion of echinococcal eggs
Clinical features	Often none and found on routine X-rays or at autopsy Specific features relate to affected organ: liver, lung, bone and brain Myocarditis Pericarditis
Diagnosis	Ultrasonography Radiology - crescent shadow or 'water-lily' effect Antigen detection
Treatment	Surgical removal Albendazole Praziquantel

Toxoplasmosis - return to top - back

Distribution	Worldwide
The parasite	Toxoplasma gondii
The reservoir	Cats and migratory birds
Transmission	Ingestion of oocysts and meat; congenital
Clinical features	Fever Lymphadenopathy Retinochoroiditis Myocarditis Cardiac hypertrophy and dilatation Pericarditis
Diagnosis	Biopsy and staining Serology e.g. dye test Immunohistochemistry for antigen Polymerase chain reaction
Treatment	Sulphonamide and diaminopyrimidine

Amboebiasis - return to top - back

Distribution	Worldwide but more frequent in the tropics and subtropics
The parasite	Entamoeba histolytica & Entamoeba dispar
The reservoir	Humans
Transmission	Faeco-oral route
Clinical features	Diarrhoea with blood and mucus Extra-intestinal manifestations e.g. amoebic liver abscess Pericardial effusion
Diagnosis	Microscopy of fresh stools Antibody detection Sigmoidoscopy
Treatment	Tissue amoebicides e.g. metronidazole Lumen amoebicides e.g. diloxanide furoate

Schistosomiasis - return to top - back

Distribution	South America and the Caribbean, Middle East, Africa, Far East
The parasite	Schistosoma haematobium (urinary schistosomiasis) Schistosoma mansoni (intestinal schistosomiasis) Schistosoma japonicum (intestinal schistosomiasis)
The reservoir	Humans; various animals (japonicum only)
Intermediate host	Various species of fresh water snails
Clinical features of S. haematobium	Painless haematuria Dull ache in urethral or suprapubic areas Pulmonary hypertension Cor pulmonale
Clinical features of intestinal schistosomiasis	Recurrent bloody diarrhoea Polyposis Hepatosplenic disease Pulmonary hypertension Cor pulmonale Spinal cord involvement Epilepsy with expanding intracranial mass
Diagnosis	Eggs in urine or faeces Rectal biopsy Renography Ultrasonography Monoclonal antibody-based dipstick assay
Treatment	Praziquantel

Contact information

Professor Herbert Gilles Emeritus Professor of Tropical Medicine University of Liverpool 3 Conifers Avenue Birkdale Southport PR8 4SZ Merseyside - UK fahy@liv.ac.uk