Editor's Corner
World Chagas Disease Day (April 14)
Chagas Disease in the Emergency Department: A Silent Global Threat
By Nagi Souaiby, MD, MPH Chief Editor, PoEM – Panorama of Emergency Medicine
Keywords: Chagas disease, emergency medicine, global health, cardiomyopathy, tropical infections
On April 14, the international medical community pauses to observe World Chagas Disease Day, marking over a century since the first documented case of human Trypanosoma cruzi infection. Despite this historical milestone, Chagas disease remains one of the most neglected and underrecognized parasitic infections, even as its global footprint expands. For emergency physicians, this elusive disease is not just a tropical anomaly—it is increasingly a frontline reality.
Chagas disease, also known as American trypanosomiasis, affects 6 to 7 million people globally, with over 10,000 deaths annually, primarily due to cardiac complications [1]. While historically endemic to Latin America, it now spans continents due to global migration and medical travel. In countries like the United States, Spain, and parts of the Middle East, emergency physicians may be the first—and sometimes only—clinicians to encounter patients affected by this disease.
The Long Silence of Chagas
Chagas disease is insidious. It moves quietly through its acute phase, where symptoms are mild or absent, and then lies dormant for years. Decades later, it may emerge with irreversible cardiac damage—arrhythmias, heart failure, or sudden death.
The disease progresses in two major phases:
• Acute phase: Often asymptomatic or non-specific (fever, fatigue, hepatosplenomegaly). Romaña’s sign—a painless unilateral orbital swelling—is rarely observed outside endemic regions.
• Chronic phase: Lifelong parasitemia persists. Around 30–40% of infected individuals will develop cardiac or gastrointestinal complications [2,3].
Chagas cardiomyopathy, the most clinically significant form, is characterized by:
• Conduction abnormalities (e.g., right bundle branch block, AV blocks)
• Ventricular arrhythmias
• Progressive heart failure
• Apical aneurysms and systemic emboli
• Sudden cardiac death—particularly in young to middle-aged adults [4]
For emergency departments, these presentations can easily be mistaken for more common cardiologic pathologies unless epidemiological risk is recognized.
What Every Emergency Physician Should Ask
A high index of suspicion remains the key to recognition. Emergency physicians should consider Chagas disease in patients who:
• Were born in or have lived in endemic Latin American countries
• Are offspring of mothers from endemic regions
• Received blood transfusions or transplants in endemic areas
• Present with idiopathic cardiomyopathy, unexplained arrhythmias, or stroke without vascular risk factors
A simple history question—“Where are you from originally?”—can open the door to life-saving suspicion.
What We Can Do in the ED
Although emergency departments are not the place for confirming Chagas disease serologically (which requires dual testing by ELISA and IFA), our role is to recognize, stabilize, and refer. The following steps can be crucial:
• ECG to identify conduction abnormalities or arrhythmias
• POCUS or chest X-ray to evaluate cardiac silhouette or pulmonary congestion
• Management of acute heart failure, ventricular tachycardia, or syncope
• Initiate discussions with infectious disease and cardiology teams for follow-up
Treatment with benznidazole or nifurtimox is more effective in the acute phase, but can still benefit selected chronic cases, especially younger patients [5,6].
The Public Health Dimension
Chagas is also a maternal and neonatal concern. Infected mothers can transmit the parasite congenitally, with vertical transmission rates of 5% or more [7]. An ED visit during pregnancy may be one of the few opportunities for early detection in non-endemic countries. Identifying these cases can break the cycle of silent transmission across generations.
A Call from the Frontlines
Emergency medicine sits at the intersection of acute care and global health. Chagas disease, long ignored by mainstream health systems, now enters our departments through complex patient pathways—migration, displacement, and health inequities. We must rise to meet it.
This World Chagas Disease Day, I invite all emergency clinicians to broaden their diagnostic lens. In our high-pressure, time-constrained environments, thinking globally and acting locally is not just possible—it’s necessary. Recognizing Chagas disease at the bedside can mean preventing heart failure, averting sudden death, or stopping congenital transmission. These are not small victories.
Let us not wait another century for Chagas disease to be seen. In the ED, awareness is action.
References
1. World Health Organization. Chagas disease (American trypanosomiasis). 2024. https://www.who.int/news-room/fact-sheets/detail/chagas-disease-(american-trypanosomiasis)
2. Schmunis GA, Yadon ZE. Chagas disease: a Latin American health problem becoming a world health problem. Acta Trop. 2010;115(1-2):14–21.
3. Rassi A Jr, Rassi A, Marin-Neto JA. Chagas disease. Lancet. 2010;375(9723):1388–1402.
4. Nunes MCP, et al. Chagas cardiomyopathy: an update of current clinical knowledge and management. Cardiol Clin. 2017;35(1):139–153.
5. Bern C. Chagas' Disease. N Engl J Med. 2015;373(5):456–466.
6. Morillo CA, et al. Benznidazole for chronic Chagas’ cardiomyopathy. N Engl J Med. 2015;373(14):1295–1306.
7. Carlier Y, Torrico F, et al. Congenital Chagas disease: recommendations for diagnosis, treatment and control. Rev Soc Bras Med Trop. 2011;44(suppl 2):60–64.
