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Eosinophil blood count and anemia are associated with trypanosoma cruzi infection reactivation in chagas' heart transplant recipientsInternational Journal of Cardiology xxx (2009) xxx–xxx j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / i j c a r d Eosinophil blood count and anemia are associated with Trypanosoma cruzi infectionreactivation in Chagas' heart transplant recipients Tatiana A.D. Theodoropoulos, Achilles Gustavo Silva, Reinaldo B. Bestetti Division of Cardiology, Hospital de Base, São José do Rio Preto Medical School, Brazil Trypanosoma cruzi infection reactivation is a constant threat for Chagas' heart transplant recipients. From September 2000 to September 2007, 54 patients underwent heart transplantation at our institution. Fourteen (70%) out of 20 Chagas' disease patients who survived the perioperative period were entered into the study.
Mean eosinophil count and mean hemoglobin plasma levels were associated to T. cruzi infection reactivation.
2009 Elsevier Ireland Ltd. All rights reserved.
Keywords:EosinophilAnemiaTrypanosoma cruzi reactivationChagas' diseaseHeart transplantation The Kaplan–Meyer curve presented the probability of freedom from T. cruzi infectionreactivation. A p value b0.05 was considered statistically signiﬁcant.
Trypanosoma cruzi (T. cruzi) infection reactivation is a constant threat for Chagas' heart transplant recipients. The incidence of clinical T. cruzi infection reactivation varies from 27% to 90% and manifestsby paniculitis and/or myocarditis and more rarely by intracerebral Six (43%) out of 14 patients had documented T. cruzi infection reactivation: 3 in the heart, and 3 in the subcutaneous tissue. Six The histological aspect of myocardial T. cruzi infection reactivation (43%) patients had acute myocardial inﬂammation consistent with on endomyocardial biopsy usually mimics acute graft rejection. This acute rejection graded 3A or more, which had not improved with might lead to inadvertent treatment with steroid pulsotherapy, steroid pulsotherapy, but improved after speciﬁc treatment for dissemination of T. cruzi infection, or septicemia due to opportunistic T. cruzi infection (benznidazol, 5 mg/kg, during 60 days). Such The aim of this study, therefore, was to look for other risk factors for T. cruzi infection reactivation in an attempt to provide the correct diagnosis as well as the proper treatment for Chagas' heart transplant Baseline characteristics of Chagas' heart transplant recipients cohort (n = 14).
recipients with this infection recrudescence.
From September 2000 to September 2007, about 54 patients underwent 55 orthotopic heart transplantation procedures at our institution. Twenty (37%) of them had a positive serology for Chagas' disease.
Fourteen (70%) out of 20 Chagas' disease patients, who survived the perioperative period, were entered the study. Baseline characteristics of Chagas' heart transplant recipients are illustrated in Continuous variables were compared with two-sample T test or Mann–Whitney test, whereas categorical variables were compared by the X2 test or Fisher exact test.
⁎ Corresponding author. Division of Cardiology, Hospital de Base da FAMERP, Av. Faria Lima, 5544, CEP: 15090-000, São José do Rio Preto, SP, Brazil. Fax: +55 17 3201 5065.
SBP = Systolic Blood Pressure; DBP = Diastolic Blood Pressure; HR = heart rate; bpm = 0167-5273/$ – see front matter 2009 Elsevier Ireland Ltd. All rights reserved.
doi: Please cite this article as: Theodoropoulos TAD, et al, Eosinophil blood count and anemia are associated with Trypanosoma cruzi infectionreactivation in Chagas' heart transplant recipients, Int J Cardiol (2009), doi: T.A.D. Theodoropoulos et al. / International Journal of Cardiology xxx (2009) xxx–xxx Table 2Variables associated with T. cruzi infection reactivation.
patients were considered to have T. cruzi infection reactivation. Atotal of 17 episodes of T. cruzi infection reactivation were detected: 8patients had 1 episode, 3 patients had 2 episodes, and 1 patient had3 episodes. Mean T. cruzi infection reactivation episodes per patientwas 1.21 ± 0.80. Four (23%) out 17 episodes of T. cruzi infectionreactivation occurred in the ﬁrst trimester after cardiac transplanta-tion, 3 (18%) in the second trimester, 4 (23%) in the second semester,and 6 (35%) after 1 year.
Mean eosinophil count per mm3 and mean hemoglobin plasma levels were associated to Chagas' reactivation (). Six of 12 (50%)patients had increased levels of immunosuppressant.
One (8%) patient died because of T. cruzi infection reactivation.
Fig. 1. Probability of freedom from T. cruzi infection reactivation.
Probability of freedom from T. cruzi infection reactivation was 86%at 58 days, 43% at 202 days, and 29% at 297 days after cardiac trans-plantation Mean time to the ﬁrst episode of T. cruzi infection appearance of anemia or eosinophylia in the follow up are associated with T. cruzi recrudescence in Chagas' heart transplant recipients.
This study shows that a slight increase in eosinophil count as well The authors of this manuscript have certiﬁed that they comply as a marginal decrease in hemoglobin levels can be detected in with the Principles of Ethical Publishing in the International Journal of patients with T. cruzi infection reactivation.
A lower increase in eosinophil blood count and in bone marrow has been detected in T. cruzi-infected rats in comparison to non- susceptible animals . Increased eosinophil count has been ob-served in blood circulation as well as in endomyocardial biopsy  Bestetti RB, Theodoropoulos TA. A systematic review of studies on heart transplantation for patients with end-stage Chagas' heart disease. J Card Fail tissue during acute rejection in non-Chagas heart transplant re- cipients . It is noteworthy that blood eosinophil count increases  Fiorelli AI, Stolf NA, Honorato R, et al. Later evolution after cardiac transplantation in 3–4 days before the diagnosis of acute rejection. Thus, increased Chagas' disease. Transplant Proc 2005;37:2793–8.
 Bestetti RB, Cury PM, Theodoropoulos TAD, Villafanha D. Trypanosoma cruzi eosinophil count can be a marker of inﬂammation. In the context of infection reactivation presenting as complete atrioventricular block in a Chagas' Chagas' heart transplant recipient, it can be a marker of T. cruzi heart transplant recipient. Cardiovasc Path 2004;13:323–6.
 Herskowitz A, Soule LM, Mellits ED, et al. Histologic predictors of acute cardiac rejection in human endomyocardial biopsies: a multivariate analysis. J Am Coll Anemia was also associated with T. cruzi infection reactivation.
Experimentally, anemia can be observed in T. cruzi infected animals.
 Nakhle MC, de Menezes Mda C, Irulegui I. Eosinophil levels in the acute phase of Therefore, the appearance of anemia may raise the diagnostic experimental Chagas' disease. Rev Inst Med Trop São Paulo 1989;31:384–91.
 Malvezi AD, Cecchini R, de Souza F, Tadokoro CE, Rizzo LV, Pinge_Filho P.
possibility of T. cruzi infection reactivation Involvement of nitric oxide (NO) and TNF-alpha in the oxidative stress associated Over-immunosuppression is one of the mechanisms proposed to with anemia in experimental Trypanosoma cruzi infection. FEMS Immunol Med account for recrudescence of T. cruzi infection in Chagas' heart trans-  Coats AJ. Ethical authorship and publishing. Int J Cardiol 2009;131:149–50.
plant recipients. In this study, 50% of patients were found to haveincreased levels of immunosuppressant. Therefore, it is conceivablethat over-immunossuppression can account for the high frequency ofT. cruzi infection reactivation observed in this study.
In conclusion, the majority of T. cruzi infection reactivation episodes occurs in the ﬁrst year after cardiac transplantation. The Please cite this article as: Theodoropoulos TAD, et al, Eosinophil blood count and anemia are associated with Trypanosoma cruzi infectionreactivation in Chagas' heart transplant recipients, Int J Cardiol (2009), doi:
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