Tropical Diseases: An Overview of Major Diseases Occurring in the Americas

PREFACE

Upon receiving a proposal for writing a book, my first thought was to bring current information in research activities for graduate students from all walks of Health, as well as for professionals who deal with daily difficulties in their work routine in countries where neglected diseases are endemic. I would like to show that alternatives for the treatment, diagnosis and control of these diseases exist, being necessary to promote the translation of scientific knowledge into practical applications. In addition to the need to overcome political barriers however, the latter are out of our reach. The eBook will present a content of interest to several areas, including diagnosis, therapy, vaccinology, immunology and molecular biology, aimed at tropical diseases.

The chapters will address various topics. Parasites and other microorganisms responsible for causing a variety of human and non-human diseases, of varying gravities, in both new and old worlds will be studied. In addition, the distribution and adaptation these different organisms in tropical and subtropical countries, as well as the usual habitats of vectors that favour contamination of poor neglected populations and the increasing expansion to periurban and urban areas, with different social and economic development will discussed.

Different methodologies, antigens, molecular targets and vaccine approaches will be detailed and discussed; its advantages and disadvantages, and the various applications including bioinformatics tools used for these surveys.

I hope that this book can help stimulate health professionals, whether medical, biologist, veterinarians, nurses, biomedical, among others, to implement control measures or initiate and continue studies aimed at improving the quality of life of affected populations. Scientific alternatives exist but, need to be associated with political actions; the sanitary education, the minimum conditions of food and housing.

All scientific knowledge generated by a privileged part of the world's population that has access to develop the intellect must be applied to the strengthening and sustainability of all. I hope that the addition of the informations placed in this book can contribute to spread these ideas.

Milena de Paiva Cavalcanti

Researcher at the Immunology Department of Aggeu Magahães Research Center,

Oswaldo Cruz Foundation (Fiocruz),

Recife, Pernambuco,

Brazil

Epidemiological, Clinical and Laboratorial Diagnosis of Trypanosomiasis

Rômulo Pessoa-e-Silva¹, ², Lays A. M. Trajano-Silva¹, Marina A. Souza¹, Beatriz C. Oliveira¹, Andresa P. O. Mendes¹, Valéria R. A. Pereira¹, Milena de Paiva-Cavalcanti¹, *

¹ Aggeu Magalhães Institute, IAM/FIOCRUZ-PE – PE, Recife, Pernambuco, Brazil

² Central Laboratory of Public Health Dr. Milton Bezerra Sobral, Brazil

Abstract

The Trypanosomatidae family is composed by protozoan parasites responsible for causing a variety of human and non-human diseases, of varying gravities, in both new and old worlds. The distribution and adaptation of the trypanosomatids in tropical and subtropical countries, as well as the usual habitats of vectors commonly favour contamination of poor neglected populations, despite the increasing expansion to peri-urban and urban areas, thus reaching other social and economic realities. Illnesses like leishmaniasis and American trypanosomiasis (or Chagas disease) share the fact that both have a great diversity of reservoirs associated to the cycle of the parasites, which include synanthropic mammalians and the Homo sapiens itself. Therefore, to an efficient epidemiological control, the continuous search for new human cases, as well as the monitoring and controlling of infected animals is fundamental. The laboratorial techniques routinely used for detection of these diseases may vary from simple parasitological analysis to cutting-edge molecular technology. Due to its easiness and diagnostic sensitivity, the immunology/serology is broadly applied in the laboratories and also in field, even with its limitations. The molecular biology and its tools are emerging as sensitive and specific alternative strategies for the trypanosomiasis diagnosis, but some challenges still remain, especially concerning the standardization of protocols and the establishment of gold-standard procedures. New serological and molecular methods arise annually aiming to overlap deficiencies that may reduce the feasibility for applying in routine and in epidemiological researches. In this chapter, the past and current diagnostic situation of leishmaniases, Chagas disease and Human African trypanosomiasis (HAT) or sleeping sickness will be described, highlighting the technological advances and the difficulties to be faced for the next years, mainly regarding the applicability for public health.

Keywords: African trypanosomiasis, American trypanosomiasis, Diagnosis, Leishmaniases.

* Corresponding author Milena de Paiva Cavalcanti: Aggeu Magalhães Institute, IAM/FIOCRUZ-PE, Oswaldo Cruz Foundation, Recife, Brazil; Tel/Fax: 55 81 21012677; E-mail: [email protected]

INTRODUCTION

For the accurate detection of any trypanosomiasis, the combination of laboratorial information to clinical and epidemiological data is essential for a safe differential diagnosis. Signs and symptoms may be similar among very divergent diseases, sometimes caused by microorganisms of distinct families, such as toxoplasmosis, malaria and schistosomiasis [1]. Other pathologies not primarily associated with microorganisms like leukemia and cardiomyopathy may suggest visceral leishmaniasis (VL) or Chagas disease (CD) progression, respectively. Conventional strategies for the leishmaniases and for the American and African trypanosomiasis diagnosis are based mainly on parasitological and serological techniques. Unfortunately, they have several important limitations, for example the low sensitivity and subjectivity of parasitological methods, and the cross-reactions of serology [2, 3]. In this context, the molecular biology and its tools (especially the Polymerase Chain Reaction - PCR) are emerging as sensitive and specific alternative strategies for the trypanosomiasis detection, but some challenges still remain, especially concerning to the standardization of protocols and the establishment of gold-standard procedures. In parallel, innovative immunological approaches have also been developed, with increasingly easiness, feasibility, sensitivity and specificity, for both humans and reservoirs [4].

In this chapter, the past and current diagnostic situation of the trypanosomiasis will be described, highlighting the technological advances and the difficulties to be faced for the next years, mainly regarding the applicability for public health.

LEISHMANIASES

American Tegumentary Leishmaniasis

Background

American tegumentary leishmaniasis (ATL) is an anthropozoonosis that causes considerable morbidity and mortality, widely spread throughout world, remaining a severe public health problem. Approximately 1.5 million new cases occur per annum, with two main clinical forms: cutaneous leishmaniasis (CL) and mucosal leishmaniasis (ML). CL is found primarily in Afghanistan, Algeria, Brazil, Colombia, the Islamic Republic of Iran, Pakistan, Peru, Saudi Arabia, the Syrian Arab Republic, and Tunisia. Almost 90% of mucosal leishmaniasis cases occur in Brazil, Peru, and Bolivia [5, 6].

The CL is the most frequent outcome skin disease, caused by parasites belonging to the genus Leishmania, being characterized by production of skin lesions mainly on the face, arms and legs, leaving atrophic scars [7, 8]. The causative etiologic agents are Leishmania aethiopica (L. aethiopica), L. major and L. tropica in old world and L. amazonensis, L. braziliensis, L. mexicana, L. venezuelensis, L. guyanensis, L. panamensis, and L. peruviana in new world (Fig. 1). In America, around 300,000 new cases of CL occur annually. Leishmania braziliensis is responsible for nearly 90% of all CL cases. The mucocutaneous form is the most aggressive, presenting infiltrative lesions, with ulceration and tissue destruction in the nasal cavity, pharynx and larynx [9]. The ML is triggered by species belonging to the subgenus Viannia (L. panamensis, L. peruviana, L. braziliensis and L. guyanensis).

Fig. (1))

Taxonomic classification of the etiologic agents of American tegumentary leishmaniasis.

Currently, ATL is considered a neglected disease with an alarming increase in its incidence. This fact is due to the increasing human contact with wild environments, which are rich in parasitic reservoirs. The deforestation and the uncontrolled urbanization are the main causal factors of this expansion [10]. Furthermore, living through this era of high-speed transport and globalization, national borders have been crossed by numerous purposes, including business, leisure or even emergencies brought about by natural disasters, climate change and wars [11]. As a consequence, there is a growing risk of people from non-endemic countries who are visiting endemic regions contracting leishmaniasis. The remarkable population and economic growth comes with new dilemmas concerning public health, which need urgent solutions. Given the current global trend and situation, the control of leishmaniasis is required through combination of intervention strategies; in which early treatment and the diagnosis are important aspects.

Epidemiological and Clinical Diagnosis

Obtaining epidemiological data is an important step in the case of a diagnostic suspicion of ATL. The patient must be asked about leisure activities, work and habitat [12]. Furthermore, it is relevant to know if the individual has a history of traveling to areas of native forest or other endemic areas. This is an important concern due to the increasing urban transmission of the disease, probably given by traveler's displacement and also the uncontrolled urban expansion into forest areas [13].

The correct definition of an ATL case is impaired by the diversity of clinical manifestations presented by the patients. Due to these, tegumentary leishmaniasis is classified in localized cutaneous leishmaniasis (LCL), leishmaniasis recidiva cutis (LR), disseminated leishmaniasis, diffuse cutaneous leishmaniasis (DCL), and mucosal leishmaniasis (ML). Thus, a judicious clinical examination, despite not giving a definite diagnosis, is a useful tool, especially in defining which diagnostic tests should be required to verify the disease [13].

In the localized form, the appearance of an erythematous spot at the site of a mosquito bite after an incubation period from 2 weeks to 3 months is the first sign of disease. A papule then evolves from the spot, and from 2 weeks to 6 months it may turn into a typical ulcerated lesion, that is rounded or oval in shape and measures a few millimeters to a few centimeters. It exhibits an erythematous, infiltrated base with firm consistency, high, well-defined edges, reddish background and coarse grits. Located mostly in the uncovered areas of the body, this type of lesion is liable to spontaneous clinical cure, leaving a hypopigmented, smooth, thin scar. However, some patients evolve to other clinical forms of the disease [14].

The leishmaniasis recidiva cutis, another clinical manifestation, may evolve with post-chemotherapy or self-healing. An active lesion that appears usually on the periphery of an already healed ulcer characterizes it. These lesions demand special attention once they indicate a possible treatment resistance [13].

The disseminated form of ATL is relatively rare, being reported in only 2% of the cases. It is characterized by the appearance of at least 10 lesions, which may be papular, disseminated acneiform, ulcerated, with a high incidence of mucosal involvement [15, 16]. The high number of ulcers is likely caused by hematogenous or lymphatic spread. Concomitant mucosal lesions have been observed in up to 30% of patients. Systemic manifestations such as muscle pain, fever, anorexia, malaise and weight loss are also reported.

ATL may also appear in the diffuse form, which is a rare and severe manifestation. It occurs in patients with anergy and specific deficiency in cellular immune response to Leishmania antigens. DCL has an insidious beginning, with single lesion and poor response to treatment, and slowly evolves with formation of multiple plaques and nodules covering large non-ulcerated skin extensions. It is reported in South America, Central America, and Ethiopia [14].

In contrast, an exacerbated immune response may contribute to the emergence of the mucosal form of ATL. It can occur after months to years from the resolution of primary lesions. The infection frequently results in a horribly disfiguring outcome, with a chronic local destruction of tissue of the nose, mouth oro- and naso-pharynx and eyelids and can affect respiratory function and impair nutrition [16]. It represents a form of ATL that is difficult to diagnose, especially because of the challenge of obtaining biological samples for laboratory tests [13].

In patients with Leishmaniaand Human Immunodeficiency Virus (HIV) co-infection, ATL appears as an opportunistic disease, being reported by some authors as a possibly AIDS-defining illness [17]. The clinical course of ATL is altered by the co-infection of HIV/Leishmania, due to a Th2 immune response polarization. This increases the susceptibility of the host to infection and is responsible for the development of anergic forms of ATL [13].

In addition, there is the need to perform differential diagnosis with other skin diseases due to their resemblance with ATL lesions. Some of the disorders evaluated are syphilis, leprosy, tuberculosis, atypical mycobacteriosis, paraco-ccidioidomycosis, histoplasmosis, lobomycosis, sporotrichosis, chromoblasto-mycosis, pyoderma, rhinoscleroma, facial midline granuloma, sarcoidosis, discoid lupus, psoriasis, Jessner lymphocytic infiltrate, vasculitis, insect bites, cutaneous lymphoma, Basal cell carcinoma, keratoacanthoma, squamous cell carcinoma, foreign body granuloma, histiocytoma, other tumors, etc.

Laboratorial Diagnosis

Concerning laboratory tests, the non-existence of a gold-standard method to diagnose ATL demands an association among parasitological, immunological and molecular approaches. The direct exam, a low-cost method that aims to visualize the parasite in the optical microscope, is performed with samples collected from lesions with scrapping by scalpel or brush, needle aspiration, imprint of excised fragments on slides and washing of oral or nasal mucosa [18]. After the sample being set on a microscope slide, stains such as Wright, Giemsa or Papanicolau can be used. The probability of presence of the parasite is inversely proportional to the evolution of the skin lesion, which is rare after a year. When positive, it gives a definite diagnosis, presenting as a useful tool for the early initiation of treatment. Secondary infection contributes to decrease the sensitivity of the method and should be pre-treated [5, 19].

The in vitro isolation of the parasite is another method to confirm the disease, and also allows the further identification of the Leishmania species involved. The skin samples obtained by biopsy from the edge of the ulcer is inoculated into culture media NNN - Neal Nicolle and Novy (modified agar blood) and LIT (Liver Infusion Tryptose) between 24° C and 26°C, in which the parasite grows relatively well. After the fifth day promastigote forms of the parasite can already be found. However, the culture should be kept under observation up to one month before the release of the negative result [13].

Another similar option is the in vivo isolation of the parasite. In this method, the material obtained by biopsy or scraping is triturated in sterile saline and injected intradermally on the hamster's (Mesocricetus auratus) nose and/or paws. The lesions generally develop up to a month. The animals must be accompanied by three to six months. By the complexity and high cost, this method is rarely used, despite its high sensitivity among various parasitological methods [20].

Immunological tests are also employed to help in the definition of an ATL case. The Montenegro's skin test (MST) evaluates the late cellular hypersensitivity response. It is performed by the subcutaneous injection of a solution containing an antigenic preparation of promastigotes in the patient's anterior forearm. The result is considered positive with the appearance of a hardened papule, equal or greater than 5mm after 48 hours of the antigen application. It is a test of high sensitivity, low cost and minimally invasive. The specificity varies around 75%, and that may be due to the overall large number of false positive results in cases of unapparent infection and cross-reactivity with some pathologies such as Chagas' disease, subcutaneous mycoses, tuberculosis and lepromatous leprosy, as well as technical problems [21].

In the diagnostic routine, the production of specific antibodies anti-Leishmania can also be evaluated. Indirect immunofluorescence assay (IIFA) and Enzyme-linked immunosorbent assay (ELISA) are the methods commonly used in the diagnosis of leishmaniasis, although with a low sensitivity in ATL. It may be higher in chronic lesions exhibited in leishmaniasis recidiva-cutis, mucosal and diffuse leishmaniasis [14]. It is important to emphasize that serological tests should not be used as an isolated criterion for ATL diagnosis. They should be associated with MST or parasitological techniques in the differential diagnosis with other diseases, especially in cases without any demonstration of etiologic agent.

The detection of Leishmania DNA through PCR is another approach to correctly diagnose Leishmaniasis. The most commonly addressed targets in the parasite are extrachromosomal DNA kinetoplast minicircle DNA (kDNA) and ribosomal RNA such as small subunit rRNA [19]. With high sensitivity and specificity (up to 100%), this technique is necessary to perform differential diagnosis prior therapy, and the results of PCR are consistently better than microscopy or parasite culture, especially in samples with low parasite loads (e.g., in ML patients). PCR performances also appear to be quite relevant in the diagnosis of Leishmania and HIV co-infection [22]. Additionally, PCR assays are useful in Leishmania species identification, which is fundamental for the clinical management of leishmaniasis patients, once there may be an established link between some Leishmania species and disease severity and treatment outcome [14, 23].

New Approaches on ATL Diagnosis

Recent advances on technology have facilitated the development of techniques based on immunological and molecular methods. An innovative methodology for ATL diagnosis, based on antibody detection, is Flow Cytometry [10, 24]. Recent studies from Oliveira et al. (2013) [25] show that this technique has potential to be used as an alternative method to detect the disease. This research has also proved that its accuracy is greater than one of the conventional methods used in ATL diagnosis, the IIFA. The flow cytometry assay is capable of measuring and analyzing several physical features of one single particle when it passes through a laser in a flow of saline fluid, thus enabling the detection of anti-Leishmania antibodies, which are bound to the antigen present in the sample [25]. The equipment will capture the fluorescence intensity of one or more than one fluorochrome and convert it to electronic signs that will be interpreted by the system’s software. Besides its high specificity and sensitivity, it can also be used as a cure criterion, since it is a quantitative test in which a cut-off point can be established [25, 26].

New molecularly defined antigens are also being developed in order to enhance some techniques specificity and sensitivity. The ELISA is one of the conventional methods used in the laboratorial routine for ATL’s detection, and the use of these antigens has improved its accuracy [8, 26]. Regarding the molecular methods, new approaches based on PCR assays have been developed over last years, like nested PCR (nPCR), multiplex PCR and the real-time quantitative PCR (qPCR), a highly sensitive and specific technique that has the potential for the monitoring of patients [27]. Studies using this approach have succeeded in proving its greater accuracy when comparing it with the conventional methods. However, one disadvantage of this methodology is that samples which are used to perform the assays generally require invasive collection procedures, such as biopsies, splenic or lymphatic aspiration and the bone marrow puncture; but recent works have tried to use non-invasive procedures to detect the disease in both human and animals [8, 27, 28]. Ceccareli et al. (2014) [29] have achieved sensitivity levels of 87% and 96% of specificity in qPCR using conjunctival swab in dogs. Regarding the diagnosis in humans using this approach, Paiva-Cavalcanti et al. (2013) [30] have shown that this technique proved to be a good tool for ATL diagnosis and that it also could be used for monitoring the treatment efficacy and preventing relapse in patients.

The Fig. (2) summarizes the diagnostic scheme of ATL.

Fig. (2))

Simplified scheme of ATL diagnosis. * Molecular diagnosis is normally not considered in routine, despite the increasingly exploration in reference research centers for definitive ATL diagnosis.

MIDR: Montenegro's intradermal reaction.

Visceral Leishmaniasis

Background

Considered a disease of poor and neglected populations, Visceral Leishmaniasis or Kala Azar affects 79 countries of the world, accounting 58,000 new cases to each year [31]. Ninety percent of all cases occur in five countries: India, Bangladesh, Nepal, Sudan, and Brazil. With an estimated 300,000 cases per year, India carries the largest VL burden [32]. The most important causative agents of the disease are Leishmania (Leishmania) donovani and Leishmania (Leishmania) infantum, closely-related members of the L. donovani complex.

According to the transmission, VL cases have been registered in two different types: the first one is the zoonotic form, caused mainly by L. infantum. Dogs are the main reservoir and it can appear in the Mediterranean Basin, China, the Middle East and South America. The anthroponotic form is characterized by human-to-human transmission without an animal reservoir. L. donovani, the main causative agent, is prevalent in East Africa, Bangladesh, India and Nepal [33]. Curiously, there are reports of VL caused by Leishmania tropica in the Middle East and Leishmania amazonensis in South America. In individuals infected with HIV, visceralization of a number of dermatotropic species has been documented as well [32].

Considering Leishmania/HIV co-infection, the majority of the countries endemic for VL also have HIV-infected populations, and this is remarkable in east Africa, and to a lesser extent in Brazil and India. Cases of co-infection are being notably reported in these territories, with rates ranging from 2 to 5% in India [34], 5% in Brazil [35] and up to 25 –40% in some parts of the Ethiopian territory [36].

The transmission of VL occurs by the bite of female hematophagous sandflies from the genus Phlebotomus in the Old World and Lutzomiya in the New World. Globally, over ten species of sand flies contribute to the transmission of VL, with at least one species involved per geographic region [23]. Rare modes of transmission for VL include intravenous drug use, blood transfusion, organ transplantation, congenital transmission, and laboratory accidents [32].

Subsequently to the infection, the parasites can disseminate in the host and colonize cells of the reticuloendothelial system in various tissues, predominantly infiltrating the spleen, bone marrow, liver, and lymph nodes [23, 37]. However, infection does not progress to overt disease in the majority of individuals, and in some highly endemic areas, up to 30% of habitants demonstrate evidence of asymptomatic infection [32].

Similarly to ATL, the treatment of Kala Azar is performed by the administration of pentavalent antimonials, which have been the cornerstone for leishmaniasis treatment for the last seventy years. Due to their cumulative toxicity and gradative resistance to the treatment by the patients, it is clear that new approaches are needed in terms of treatment. However, research and development in this field has not been prioritized, once VL is a disease that affects mainly the poor ones and, for that, has a low importance in the private sector. Even so, the public sector still struggles to promote the development of drugs and diagnostics in the absence of adequate funds and infrastructure [37]. Moreover, efforts such the continuous education of the population living in endemic areas about the disease and to utilize insecticides aiming the elimination of the vector must be made to help reducing the incidence of the disease.

Epidemiological and Clinical Diagnosis

VL diagnosis is made by combining the epidemiology and the patient's clinical signs with parasitological or serological tests (rapid diagnostic tests and others) [38]. The clinical manifestations (fever, fatigue, weight loss with enlarged spleen and liver and loss of appetite) in addition to epidemiological confirmation direct to specific laboratorial exams for VL detection.

Laboratorial Diagnosis

The final diagnosis is released when confirmed by the microscopic exam, which is based on the visualization of Leishmania amastigotes in the patient’s samples (aspirates or biopsies). Immunological tests have been developed from time to time [39], and these tests include: indirect haemagglutination (IHA), counter current immunoelectrophoresis, ELISA, immunodiffusion (ID), agglutination tests and most recently more studies are using flow cytometry as a diagnostic method for VL [9]. Molecular techniques are also used, and the PCR is a sensitive, specific and reliable method for the disease research. More recently new approaches on this area have been developed, and qPCR is a promising technique to be used as a post-therapeutic monitoring. To confirm suspected cases, the most used test is rk39-Based ELISA, which is a rapid test that identifies anti-Leishmania antibodies using the recombinant antigen k39. This test is highly sensitive, and is used in several reference centers [39, 40]. With the current advances in technology it is more likely that in a few years it will be possible to have higher sensitive and specific tests to diagnose this disease, reducing the time it takes to release the results and also being possible to monitor patient’s therapy [38, 39, 41].

New Approaches on Visceral Leishmaniasis Diagnosis

The immunological tests conventionally used in the VL diagnosis have some important limitations, like the inability to differentiate between clinically active and asymptomatic or subclinical infections, loss of accuracy in immuno-suppressed patients and the possibility to cross reactions [42, 43]. In this context, new tools have been introduced aiming to overcome these obstacles. A test in which is possible to identify asymptomatic disease versus active VL is still a key part to control this critical illness [44]. Due to the current worldwide trend and situation, the demand for quick, easy-to-perform, and reasonably priced diagnostic tests is elevated.

There are numerous new serological tests available for VL. As an example, the conserved portion of a kinesin-related protein recombinant antigen from two hydrophilic antigens of Leishmania chagasi were used (rk9 and rk26), leading to an increase in the list of available antigens for serodiagnosis of VL. Another kinesin recombinant related protein used in ELISA assay is rKE16. Another new assay is based on the detection of the K28 fusion protein in studies performed in Sudan and Bangladesh. However, these new assays do not apply to HIV-positive patients [5, 43]. The latex agglutination is one of the recently developed serological diagnostic tests for the quick detection of anti-Leishmania antibodies against the crude antigens derived from the promastigote form of an Iranian strain of L. infantum as well as those against A2 antigen derived from the amastigote form. This test shows a higher degree of similarity in accuracy to the direct agglutination test and low sensitivity to detection of VL [5, 28, 42, 43].

Monitoring treatment efficacy and preventing relapse is crucial for controlling VL. Unfortunately, the major drawbacks of the serological tests are their inability to discriminate between past and present infections [44]. VL diagnostic serological tests may continue positive for prolonged periods after healing; despite a decrease in antibody titer is apparent [28, 45]. Hence, this requires a search for identification of markers which have the potential for treatment, monitoring and diagnostic. Antibodies versus antigens peroxiredoxin, amastin, KMP11 and Lepp12 have been differentially found in pre- and post- therapy serum samples, thus showing potential to be exploited as markers for monitoring of treatment efficacy in VL [28, 46-48]. Among the many alternative immunological approaches employed, there is the flow cytometry [25]. Considering the applicability of the flow cytometry as a system free from methodological variability (inherent in the analyst) and with superior applicability to different protocols of conventional detection and revelation, a study showed the possibility by using the technology with IgG antibodies of anti-fixed L.chagasi, focused on the diagnosis and follow-up after treatment of VL [28, 49, 50].

The visible flexibility, specificity and sensitivity in the samples choice, have placed the molecular approaches as important diagnostic options. The LAMP (Loop-mediated isothermal amplification) is a new technology that quickly amplifies the respective targets, like kDNA [51] or 18s rRNA [52] in isothermal circumstances. The method is strongly specific (six primers are needed), requires less refined equipment (60-65° C of isothermal temperature), and also expend less time because it has no post-PCR steps. Moreover, the positivity can be estimated by visualizing the turbidity of the reaction mixture. Because LAMP-reagents are stable at room temperature (cold chain is not needed), the technique is perfectly suitable for research in field conditions [53]. The use of RNA amplification improves the sensitivity of the assay [52].

In order to reduce the risk of infection by blood-borne diseases and facilitating the collection of samples in infants, swab-based PCR from urine/conjunctival are being developed [54, 55]. qPCR provides rapid quantification of parasite load and identification of Leishmania species into the complex level, thus representing a helpful molecular tool to assist clinicians and epidemiologists. Multiplex qPCR from the blood/bone marrow aspirate has been optimized for concomitant determination of Yersinia pestis, L. donovani and Bacillus anthracis [56, 57]. In these works the real-time qPCR is indicated as a fast and precise diagnostic method used in reference centers and applied to samples coming from remote and poorly equipped endemic areas. Unfortunately, in most VL-endemic countries, PCR-based technologies are restricted to a few teaching hospitals and research centers [5]. This may be attributed, among other reasons, to the relatively-complex execution and interpretation of results and also to the high costs which still persist and impair its wider distribution.

CHAGAS DISEASE (AMERICAN TRYPANOSOMIASIS)

Background

In 1909, Carlos Justiniano Ribeiro das Chagas (1879–1934), a Brazilian scientist, discovered the etiologic agent of one of the most significant parasitic diseases to affect the humanity along its existence. The new flagellate protozoan parasite (Trypanosoma cruzi) was only the beginning of his several subsequent findings. The researcher dedicated a good part of his life studying its vectors and reservoirs hosts, their interaction in wild and domestic environments, the life cycle and the human involvement [58-60]. He also studied the clinical course, both acute and chronic phases and its pathogenesis [61, 62]. The American trypanosomiasis or Chagas disease (CD) is a zoonotic infection caused by the protozoan Trypanosoma cruzi (Kinetoplastida, Trypanosomatidae) [58, 63] and is considered by World Health Organization (WHO) as one of the world’s most neglected tropical diseases.

Despite the decreasing number of exposed and infected individuals during the last years, CD is still a serious public health problem in Latin America, bringing social and economic concerns, and causing thousands of deaths annually [64]. In addition, the increased migration from endemic to non-endemic countries has raised the awareness on CD around the world. Since vector-borne transmission occurs solely in the Americas, countries from Asia, Oceania and Europe have turned attention to blood transfusion, organ donation and congenital transmission [65-68].

Clinical manifestations of CD may range from an asymptomatic form to a severe dilated cardiomyopathy. In the acute phase (4 – 8 weeks), the symptoms are generally mild and non-specific, such as fever, lymphadenopathy and/or hepatosplenomegaly. Inoculation chagoma and Romaña Sign might occur in some individuals. Chronic phase (host’s lifetime) is majority indeterminate (no symptoms), but might present severe and fatal cardiac and/or gastrointestinal abnormalities [65, 69, 70]. According to these aspects, is evident the importance of the laboratorial diagnosis as a complement for the clinical and epidemiological information, improving thus the differential diagnosis.

Detection of CD may be parasitological, serological and molecular. Microscopy of fresh preparations of blood (or buffy coat) and Giemsa stained smears, enzyme-linked immunosorbent assay (ELISA), polymerase chain reaction (PCR) and its variants are examples of tools which may be used appropriately depending on the clinical phase of the disease and following an adequate scheme. Some specific situations (congenital CD, reactivations, etc.) also demand specific diagnostic methods [65, 71, 72]. Despite the number of standardized immunological tests, there is no assay considered a gold standard for chronic T. cruzi infection. This is due to variations in the reproducibility and reliability, as well as in the sensitivity and specificity rates of these tests. Moreover, cross-reactions with other trypanosomatids is still a limitation [73-75].

The diagnosis of Carlos Chagas’ disease is not simple, both in routine laboratories dealing with suspected infections and in screening laboratories (organs donors, blood banks, etc.) [74, 76]. Even presenting lower prevalence and death rates when compared to previous years, CD in South America is still an endemic and neglected illness, which affects millions and mainly from poor rural populations, though it is an emerging disease in some developed countries, as a result of migrations. Hence, an urgent need for new tools for detection of T. cruzi infection, treatment and test of cure persists [71, 77]. In this section, it will be briefly discussed about the etiology, epidemiology and clinical aspects of CD, as well as about the conventional and non-conventional diagnostic tools, the new strategies for clinical and laboratorial analysis improvement and also about challenges to be surpassed inside these contexts, for the next years.

Etiology

The transmission of the American trypanosomiasis for humans or domestic animals occurs mainly through the bite of hematophagous triatomine bugs (Hemiptera, Reduviidae, Triatominae), in which infected feces are inoculated through the intact mucous membranes or through a bite wound [78]. The vector-borne transmission occurs exclusively in the Americas, and affects mostly people living in rural areas, from Chile and Argentina to the southern half of the United States (USA). Despite the number of triatomine species (130 at least), just some are able to carry T. cruzi, and even less are associated with transmission to humans: Triatoma infestans, Panstrongylus megistus, Rhodnius prolixus, Triatoma brasiliensis and Triatoma dimidiata are some examples. They have distinct significance in the human epidemiology. Historically, T. infestans has been the most important vector. It is commonly found in the Southern Cone, which is composed by Argentina, Bolivia, Chile, Paraguay, southern Peru, Uruguay and southern Brazil. R. prolixus and T. dimidiata, the two other major vectors, are usually reported in northern South America and Central America (Fig. 3) [65, 78, 79].

Fig. (3))

The most important triatomine species in the transmission of T. cruzi to man. S: size at millimeters (considering both male and female). H: habitat. D: distribution.

The invasion of domestic and peridomestic areas by triatomines can be a consequence of humankind’s actions over nature. The invasion of wild ecotopes, the deforestation and construction of dwellings, as well as the reduction of wild animals as a consequence of it forced these bugs to find alternative sources of food among humans and domestic animals [80, 81]. The sylvatic and domestic transmission cycles are maintained by a large number of mammalian hosts (100 or more species). Opossums (Didelphis marsupialis), raccoons (Procyon lotor), rodents and armadillos are examples of important sylvatic hosts, while dogs (Canis familiaris), cats (Felis catus) and guinea pigs (Cavia porcellus) can act as perfect domestic sources of infection. Some reservoir hosts and vectors can interact to both environments, thus acting as bridges among the sites, allowing then an intercommunication of the wild, domestic and peridomestic cycles [66]. Fig. (4) shows the life cycle of T. cruzi.

Fig. (4))

The life cycle of Trypanosoma cruzi. When takes up a blood meal, the triatomine bug deposits its feces, containing the infective metacyclic trypomastigotes, in the surface of the skin, next to the bite wound. The infection may occur through the injured skin or the intact mucous or conjunctival membranes (A). The parasites then penetrate and infect the host's nucleated cells, forming thus the parasitophorous vacuole. Stimulation for recruitment and fusion of lysosomes is needed for penetrating the cells (B). The trypomastigotes wrapped into the parasitophorous vacuoles escape to the cytoplasm and then begin to differentiate into spherical forms called amastigotes, which replicate by binary fission (C). When the cell is swollen with the amastigotes, they differentiate back to trypomastigote flagellate forms, then promoting cell lysis (D). The parasites invade adjacent tissues and distant sites through lymphatic and bloodstream (E). When they do not infect additional host cells, they are taken up in a blood meal by the insect (F). Inside the triatomine, the parasites differentiate into epimastigotes (G) and enter the midgut, where again they replicate by binary fission (H). In the hindgut, the parasites differentiate into infective metacyclic trypomastigotes, being then eliminated through the feces (I), infecting humans or other reservoirs (J), such as dogs, armadillos and edentates. Perez et al. [113].

Non-vectorial mechanisms of infection, like congenital transmission and blood transfusion are increasing concerns, since CD has been documented in some developed and non-endemic countries, such as USA, Canada, Spain, Italy, France, Japan, and others [82]. Infants from infected mothers are born with T. cruzi infection in an estimated 5-6% (range 1-10%) [83, 84], and seems to be dependent of diverse factors, like the strain involved and the pregnant immunological status. The probability for infection by transfusion also depends of some factors: concentration of parasites, blood component (platelets have been pointed to bring a higher risk), and possibly the parasite strain [85, 86]. Solid organ or bone marrow donation is another important mechanism to occur in urban and non-endemic places. Orally-infected individuals have been reported in Brazil [87] and Venezuela [88], after ingestion of contaminated food such as açaí fruit juice and sugar cane juice. A severe acute clinical form normally observed in these cases is a result of a high parasitic burden usually associated. Accidental cases of laboratorial transmission were also recorded [89].

Epidemiological Aspects

Chagas disease affects nearly 7 – 8 million people around the world [90]. It is a typical tropical and rural parasitic disease, which cases are mostly concentrated in South and Central America, where vector-borne transmission is majority. Approximately 28 million people are considered to be at risk, and about 41,200 new cases occur each year [91]. In Latin America, nearly 7.7 million new cases were registered in 2005 [92], but screening of blood for T. cruzi, now compulsory in most countries [64], as well as the establishment of triatomine control strategies are helping to reduce these numbers. Bolivia, Argentina, El Salvador and Honduras are among the countries with the highest estimated prevalences. In Brazil, the pooled estimate of CD prevalence across studies in the period between 1980 and September 2012 was 4.2% (range 3.1-5.7%) [93].

Decrease of mortality (about 50,000 in 1990 versus 12,500 in 2006) [64] and morbidity on the last decades is a result of successful CD control programs, like The Southern Cone Initiative, implemented in the early 1990s for vector-to- human transmission reduction in South America, which resulted in the elimination of direct transmission by T. infestans in Uruguay (1997), Chile (1999) and Brazil (2006). Other important programs based on measures against domestic triatomine vectors were installed in some Latin countries along the years, for example the Andean Pact Initiative and Central America Initiative to Control/Eliminate Chagas disease [94-96]. Together with blood transfusion screening programs, these initiatives have helped the decreasing of incidence and prevalence rates of CD in Latin America, but despite the auspicious data, the disease is still considered as an important public health problem.

The global panorama is not optimistic. As a result of migration movements, congenital transmissions and blood-borne infections have been reported in non-endemic countries of Europe and Oceania for example [97]. This has led to a higher awareness about measures to identify infected mothers and blood/organ donors, avoiding a vector-independent spread. Nevertheless, the asymptomatic presentation, the unusual occurrence and the inexperience of physicians make monitoring more difficult. As an attempt to minimize the barriers, the Centers for Disease Control (CDC) in the USA (the most common destination for migrants from Latin America, especially from Mexico) offers consultation to clinicians regarding patients with suspected CD, and also provides information concerning serologic testing and treatment. The center also acts as a reference laboratory in T. cruzi PCR (for more details, visit: http://www.cdc.gov/parasites/chagas/ index.html). The epidemiological, clinical and laboratorial knowledge can act as keys for assessment and controlling this or any other disease. Thus, investments should be continuously made in order to elucidate, develop and prepare human resources.

Clinical Aspects

The clinical signs and symptoms of CD are broadly diverse and dependent of several factors. It ranges from no symptomatology to fatal heart complications. Classically, an initial (acute) phase is followed by a long-lasting chronic phase that can be classified into indeterminate, cardiac, digestive or cardio digestive forms with different clinical manifestations [98].

Acute Chagas Disease

After 1 – 2 weeks of the exposure to a T. cruzi infected vector (incubation period), the acute phase begins (lasting for 8 – 12 weeks) and when no asymptomatic, brings mild and nonspecific symptoms, like fever, malaise, hepatosplenomegaly and/or lymphadenopathy. Depending on the initial burden of infecting parasites, the lineage of the inoculated T. cruzi (see below) and the patient’s initial immunological response (among other factors), severe acute disease might occur, bringing acute myocarditis, pericardial effusion, and/or meningoencephalitis, but it correspond to less than 1% of the cases [78, 99]. During the acute phase, circulating trypomastigotes are able to invade all nucleated cells, but a special tropism for muscle and ganglion cells is observed. This may explain lesions also found in smooth muscle of the esophagus and colon, as well as in the central and peripheral nervous systems [65, 78]. In some cases, inoculation signs might lead to a clinical suspicion: an inflammatory reaction in the bite wound, showing a red swelling known as Chagoma, and also the unilateral swelling of the eyelids, known as Romaña sign, caused by penetration of the parasite by the conjunctiva. However, acute CD is unnoticed in the majority of cases. According to Pinto et al. [100], early application of an antiparasitic drug (in the case, benznidazole) might lead to cure of acute phase and prevention of chronic manifestations.

The congenital T. cruzi infection has decreased thanks to measures of control which have reduced the maternal parasite exposure, but it is still a concern since new cases are not so easy to detect, and the risk for abortion occurrences is increased comparing to normal pregnancy [101]. The infection may occur either through transplacental transmission or through the birth canal during delivery [66]. In the first months, congenital Chagas disease is an acute T. cruzi infection. The newborns are commonly asymptomatic or have subtle findings, which might be evident at birth or develop within some weeks after delivery [83, 102]. The manifestations include hypotonicity, fever, hepatosplenomegaly, anemia, and low birth weight, prematurity and low Apgar score (appearance [skin color], pulse [heart rate], grimace response [reflexes], activity [muscle tone] and respiration). A minority presents severe and uncommon symptoms associated with a higher mortality rate: myocarditis, meningoencephalitis, pneumonitis, respiratory distress and others [65, 83, 103].

As commented elsewhere, some factors are pointed out to contribute to higher risks of transmission and severity, such as immunological status (anti-T. cruzi response, co-infection HIV/CD), parasitic load and strain involved. A well-monitored pregnancy with complete clinical and laboratorial follow-up may help to prevent complications. Besides the greater hazard to the infant, undiagnosed mothers have contributed to a silent dissemination of CD in some non-endemic countries [97]. A woman with T. cruzi could give birth to an infected fetus at any stage of disease, during any of her pregnancies [78].

Acute CD can also occur due to T. cruzi transmission to an organ recipient or reactivation of chronic infection related to immunosuppression [104]. Heart transplant in chronic chagasic individuals is indicated in cases of severe cardiomyopathy, as a prompt necessity. The cumulative risk of reactivation in heart transplanted patients is estimated to be less than 50%, and its development might occur after few days or several years later. In addition to fever and acute Chagas myocarditis, inflammatory panniculitis and skin nodules are commonly observed [105]. Reactivation must be early detected, as well as differentiated from rejection or other infections for the correct implementation of treatment [77]. Thus, monitoring strategies, like quantification of parasite load in peripheral blood or in heart tissue (biopsy) by real-time quantitative (q) PCR have been studied (see the topic Laboratorial Diagnosis). Other immunosuppressive issues are linked to reactivation in chronic chagasic patients: chemotherapy, hematologic malignances, total-body irradiation, or infection with HIV [106, 107]. Manifestations from a reactivation mediated by HIV/AIDS can cause severe clinical disease with high risk of death. Meningoencephalitis and T. cruzi brain abscesses are most commonly reported in this situation, resembling lesions caused by cerebral toxoplasmosis; acute myocarditis is also frequent [108, 109].

Chronic Chagas Disease

After two or three months of acute phase, parasitemia levels decrease with or without an anti-trypanosomal therapy, becoming undetectable by microscopy. Then, the chronic stage begins and persists for the host`s lifetime. In the chronic phase, two-thirds of patients remain clinically asymptomatic, whereas one-third develop life-threatening clinical manifestations, with cardiac, digestive (mega-colon and/or megaesophagus) or cardio digestive impairment, but presenting a latency period which might reach 2 decades [98, 110]. Although the pathogenesis is not completely understood, the severity of chronic CD is possibly altered according with some factors, such as the parasite burden and severity of the initial infection, re-infections, the biological characteristics of the infecting strains and clones, host humoral and cellular responses and human genetic factors [65, 66]. T. cruzi Discrete Typing Units (DTUs) are different evolutionary lineages of the parasite (TcI to TcVI) which have been identified and associated with the virulence and with a higher likelihood for the development of specific symptoms. This is possibly attributed to distinct capacity for immune evasion and distinct cellular tropisms [65, 111, 112]. Additionally, these DTUs have been associated with different geographical distributions, trypanocidal drugs resistance and transmission cycles [113, 114]. Multiple synergic or competitive interactions between strains in mixed infections have raised attention to differences in the progression of the disease and in responses to treatment [113].

Clinically, the asymptomatic or indeterminate form is characterized by absence of signals and symptoms of the disease, in addition to a normal electrocardiogram (ECG) and normal radiological examinations of the chest, esophagus and colon. The life expectancy of chagasic indeterminate patients is similar to individuals without CD [115]. According to Coura and Borges-Pereira [66], PCR and xenodiagnosis may be repeatedly positive for a large proportion of them over a period of years, thus showing a true balance between parasite and host. Nevertheless, approximately 30% of these patients will develop a symptomatic chronic phase after a period of 10 – 30 years of the initial infection [66]. Due to its frequency and severity, heart disease is the most important among all manifestations of chronic CD. During chronic infection, lesions are mediated by the presence of the parasite in tissues, as well as by parasite-driven inflammation or even by autoimmune mechanisms, though the proportional role of each factor in this pathologic process is still unclear [116]. Histological examination of heat biopsy shows mononuclear cell infiltration of the myocardium, destruction of myocardial cells, diffuse fibrosis, edema, and scarring of the conduction system [117].

After confirmation of chronic CD (see Laboratorial Diagnosis below), the search for cardiovascular and gastrointestinal symptoms, in addition to the application of a 12-lead ECG can help to define the clinical form of the disease. Individuals with confirmation of indeterminate form should be monitored every 1 or 2 years, by reassessments, in association with decision for treatment by an antiparasitic drug, taking into account factors such as age, pregnancy and renal/hepatic insufficiency [78]. The appearance of ECG abnormalities implies in disease progression, and might characterize the beginning of the Chagas heart disease (CHD). The earliest manifestations of CHD are usually conduction system abnormalities [118], segmental left ventricular wall motion abnormalities [119], and diastolic dysfunction [120]. The late and most severe manifestation of CHD is the dilated cardiomyopathy, which can be manifested by ventricular dysfunction with heart failure, bradyarrhythmia and tachyarrhythmia, heart blocks, thromboembolism and sudden death [66, 82, 121, 122]. The lesions are in general a result of the persistence of small amounts of parasites in cardiac tissues; however, the host immune response is one of the many factors that might be associated with progression of cardiac CD (age; male sex; alcoholism; parasite strain; genetic information; nutritional status, and more) [98, 123, 124].

The complexity and diversity of heart injuries in the progression of CHD tend to difficult the understanding of the patient’s actual clinical course of the pathology by physicians, hindering then an effective intervention. As attempt to surpass this concern, some works have standardized schematic classifications for different CHD stages. One of the most complete classifications is the proposed by RASSI et al. [78], which have made a wide incorporation of clinical and functional factors, for example ECG changes, cardiomegaly (chest radiography), left ventricular wall motion abnormalities or apical aneurysm (2D echocardiogram) and non-sustained ventricular tachycardia (24-h Holter monitoring), for the establishment of four progressive stages (I-IV). The functional classification of the New York Heart Association (NYHA), considered as insufficient when is the sole reference, was also taken into account (see Table 1) [78, 125]. The scheme provides an excellent support to physicians for a better recognition of specific cardiac clinical situations.

Table 1 Simplified rational clinical and functional classification of chronic Chagas disease, elaborated by Rassi et al. [78]. Electrocardiogram changes and sustained ventricular tachycardia are also considered in the classification.

Nevertheless, clinical evaluation of cardiac injury is still challenging in terms of high costs and logistical problems, especially in poor endemic regions, but the continuous efforts of researchers for the development of new facilitating strategies have brought new perspectives for management of patients. For example, Saravia et al. [110] combined the measurement of two commonly used heart markers, the B-type natriuretic peptide and the cardiac troponin T for the identification of cardiomyopathy among chronic Chagas’ patients. The dual positivity for both markers was pointed out as an accurate tool to detect the heart failure, increasing thus the pre-test probability of cardiologic diagnostics. Additionally, Bautista-López et al. [126], through a cross-sectional study performed in Colombia, demonstrated that plasma matrix metalloproteinases 2 and 9 (MMP-2 and MMP-9), which are produced during a strong inflammatory reaction mediated by T. cruzi infection, appear to be useful biomarkers for detecting the early progression of Chagas cardiomyopathy. However, according to the authors, some further studies are needed for implementation of the potential screening test in endemic areas.

The digestive form is less common than cardiac form. It is observed almost exclusively in countries from the south of the Amazon basin (probably attributed to specific strains) [127]. The symptoms of megaesophagus include dysphagia, odynophagia, esophageal reflux, regurgitation, weight lost and malnutrition in severe cases. The risk for esophageal carcinoma is supposed to be increased [65]. Megacolon frequently affects the sigmoid segment, and/or rectum, and/or descending colon, and is characterized by prolonged constipation, abdominal distension and may lead to fecaloma, volvulus and bowel ischemia. The prognosis of the digestive form is generally good, except for specific cases with complications, such as esophageal cancer, obstruction with torsion and necrosis of the colons [66].

The Fig. (5) brings an abstract-scheme of the natural history of CD in human.

Fig. (5))

Abstract-scheme of the natural history of Chagas disease in humans.

The Economic Issues of Chagas Disease

Cardiac and digestive complications commonly lead to the need for long-term treatment and surgical procedures, such as pacemaker and implantable cardiac defibrillator insertion and heart transplantation [128]. These interventions, in association with the huge involvement of young adults (the most productive population) make American trypanosomiasis as one of the costliest neglected tropical diseases, with a global estimate of $ 7.19 billion per year [129]. The economic burden has a deeper impact over developing nations of the South America and Central America, especially for people from the poorest regions. The limited access for the most complex and efficient treatments, as well as for a complete and appropriate clinical evaluation indirectly increases the work disability and the early mortality, thus leading to further financial loss. Structural and financial issues are not easy challenges to be overcome in a short time. In this context, the vector control programs, together with screening of blood banks, pregnants and organ donors, and also the continuous efforts for monitoring old and new endemic areas are of enormous importance for the reduction and control of CD cases. For this, the availability of sensitive, specific and feasible diagnostic tools to each phase of the disease is pivotal.

Laboratorial Diagnosis

Each phase of CD has particular characteristics that allow the employment of different and specific diagnostic techniques for T. cruzi detection. Different statuses of patients also demand appropriate methods. The limitations of conventional parasitological and serological methods have hushed the development of new strategies that can provide a definitive and reliable diagnosis of CD. On the last years, several new immunological and molecular tools have been developed for humans and domestic animals, but some challenges remain, for example the divergent results concerning the sensitivity and specificity among assays, which have been associated with various issues, like the population tested, the genetic diversity of the parasites and particularities of each assay [65, 130]. A common and current approach in serology is the trials for the improvement of the efficiency by using pooled antigens or single/multiepitope recombinant proteins to detect anti-T. cruzi antibodies [131]. Multiple molecular targets have been investigated to an accurate and precise detection of the parasite. The usefulness of molecular biology for monitoring the efficacy of drugs and for predicting reactivation has been also investigated [71]. In brief, the continuous refinement of CD assessment is critical for a better clinical and epidemiological control of the disease, but to understand and to surpass the hindrances that still bias the diagnosis of the pathology, studies regarding the genetic complexity of T. cruzi strains, the host’s factors as well as the characteristics of each phase of the disease are imperative.

Acute T. Cruzi Infection

Acute CD can be detected by microscopy of fresh preparations of anti-coagulated blood or buffy coat [84], and also by GIEMSA-Stained smears or hemoculture. The high parasitemia level in this phase, which may last between 1 – 2 months, enables the visualization of trypomastigotes in peripheral blood. In fresh preparations, the parasite can be easily observed by its motility, but stained smears enable morphological characterization [132], despite the difficulty to distinguish from T. rangeli, which is not pathogenic to vertebrates. Blood concentration techniques (microhematocrit and Strout) increase the sensitivity of parasitological search. In the microhematocrit technique, the buffy coat layer formed after centrifugation is the portion specifically examined by microscopy [3]. The Strout technique is based on the search for the parasite in serum precipitate (10 mL of blood are needed, thus limiting its application for neonates) [133]. Otherwise, T. cruzi can be cultured from heparinized blood samples or tissues. Because this method is slow and laborious, require very experienced professionals and is not widely available, it is generally used to confirm a diagnosis if other tests are inconclusive. It is also used in research, and to isolate strains of parasites [3, 65]. In general, conventional parasitological methods are very specific, but the lack of sensitivity and other limitations have raised the exploration and application of molecular methods, which have been pointed out as more sensitive, being currently indicated to detect early congenital Chagas disease, organ recipient infection and reactivations [65, 134].

In congenital T. cruzi infection, the microscopic examination of peripheral blood or cord blood using microhematocrit technique (small amount of sample needed) is strongly recommended for the first months of life. Despite the protocol followed by the screening programs in Latin America (prenatal serologic screening plus parasitological search) [83], PCR has been increasingly used, because of its capacity to detect the disease days or weeks before the parasitological procedures, thus promoting an early diagnosis and a prompt implementation of treatment [3, 135]. Serological examination should be performed just after 9 months of newborn’s life, when anti-T. cruzi immunoglobulin G (IgG) antibodies from the mother are no longer present, and the congenital infection has passed into the chronic phase. Serology is recommended if the tests were not done early in life or if negative parasitological results repeatedly persisted [65, 72].

As commented elsewhere, reactivation of CD might occur from several immunosuppressive situations, like heart transplantation and co-infection with HIV, and the employment of microscopy can be useful to detect the increase in parasitic load over time. But, alternatively, some authors have explored the molecular biology for an earliest and more sensitive indication of reactivation. Bevenuti et al. [77] evaluated conventional PCR (cPCR) as a tool for previous detection of Chagas disease reactivation (CDR) in positive transplanted patients, using endomyocardial biopsies, and targeting nuclear DNA (nDNA) and kinetoplast DNA (kDNA). According to some authors [134, 136, 137], PCR could detect months before the reactivation. Nonetheless, the results showed positivity in control group (kDNA) and high negativity among pre-CDR patients (both targets), then concluding that the usefulness of qualitative PCR techniques to diagnose CDR should be critically assessed. However, it is important to emphasize that a positive cPCR does not prove reactivation [134]. As briefly commented, persistence of parasites in tissues occurs for the host’s lifelong. Therefore, the use of other tools like the real-time qPCR for an accurate monitoring of parasite burden is fundamental for the early detection of CDR.

Recently, Freitas et al. [138] compared some molecular methods (cPCR, Competitive [C-] PCR [semi-quantitative assay] and qPCR) with parasitological techniques (hemoculture and xenodiagnosis), in chronic CD patients with or without HIV infection. Their data show that C-PCR (kDNA) and qPCR (microsatellite DNA) had higher sensitivities than the parasitological tests. Moreover, it was demonstrated that qPCR was able to distinguish, by different parasitemia levels, between the groups of HIV/ T. cruzi–infected patients with and without CDR and between groups of patients with chronic CD without HIV. From this, the authors propose that the new optimized qPCR test be evaluated to determine the importance of parasitemia (persistent and/or increased) as a criterion for initiating a preventive therapy in chronic CD patients with HIV infection or immunosuppression, through prospective controlled studies. The earlier treatment significantly increases patient survival [139, 140].

Organ recipient (when the recipient receives an infected organ from a chagasic patient) and blood transfusion infections (emergent worries in non-endemic countries) and accidental T. cruzi exposure (infected food or laboratorial contamination) also induce a typical acute manifestation. Consequently, the same diagnostic strategies needed to detect an acute phase promoted by vectorial infection are required (see Table 2).

Table 2 Correlation among methodologies for Chagas disease diagnosis: their applicability and limitations. cPCR: conventional polymerase chain reaction. qPCR: quantitative PCR. ELISA: Enzyme-linked Immunosorbent Assay. IIF: Indirect Immunofluorescence. IHA: Indirect Hemagglutination Assay. ICT: Immunochromatographic Rapid Test. FC: Flow Cytometry.