Chagas disease, France.

Abstract

Chagas disease (CD) is endemic to Latin America; its prevalence is highest in Bolivia. CD is sometimes seen in the United States and Canada among migrants from Latin America, whereas it is rare in Europe. We report 9 cases of imported CD in France from 2004 to 2006.

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Chagas Disease,
Franc e
François-Xavier Lescure,* Ana Canestri,†
Hugues Melliez,‡ Stéphane Jauréguiberry,*
Michel Develoux,* Richard Dorent,*
Jean-Baptiste Guiard-Schmid,*
Philippe Bonnard,* Faïza Ajana,‡ Valeria Rolla,§
Yves Carlier,¶ Frederick Gay,†
Marie-Hélène Elghouzzi,# Martin Danis,†
and Gilles Pialoux*
Chagas disease (CD) is endemic to Latin America; its
prevalence is highest in Bolivia. CD is sometimes seen in
the United States and Canada among migrants from Latin
America, whereas it is rare in Europe. We report 9 cases of
imported CD in France from 2004 to 2006.
N
2004 through 2006 (online Appendix Table, available from
http://www.cdc.gov/EID/content/14/4/644-appT.htm.).
These included 1 case of acute Chagas myocarditis (ACM),
4 cases of chronic Chagas cardiomyopathy (CCC), and 4
cases of indeterminate chronic Chagas (ICC) (asymp-
tomatic patients seropositive for Trypanosoma cruzi) (1).
The ACM case involved an otherwise healthy 26-year-old
woman who was hospitalized in September 2004 when she
returned from a 2-month stay in French Guiana. Her symp-
toms included fever, headache, photophobia, intermit-
tent chest pain, and arthromyalgia. Physical examination
showed a typical Romaña sign, i.e., unilateral periorbital
swelling (Figure). No abnormalities were found on clinical
workup; blood smears and cultures were negative. Results
of lumbar puncture, chest radiography, and echocardiog-
raphy were also negative. The electrocardiogram (ECG)
showed anterior ST-segment depression. A smear of a blis-
ter adjacent to the eye showing the Romaña sign yielded T.
cruzi on direct examination. PCR was not performed. The
patient was treated orally with benznidazole, 150 mg twice
a day, and had a good clinical response. Benznidazole was
discontinued after 7 weeks because peripheral neuropathy
had developed. T. cruzi serologic results remained negative
until 4 months after ACM, either because of a lack of sensi-
tivity or because the patient was treated as soon as possible
at the onset of symptoms.
ine cases of Chagas disease (CD), although rare in
France, have been diagnosed in the country from
The median age of the other 8 patients (4 men and 4
women from Bolivia) with chronic CD was 38 years (24–
48). Seven patients had been living in France for 2 to 5 years.
One of the patients with ICC was the son of a woman with
CCC. Symptoms were mainly cardiologic, with atypical
chest pain, dyspnea (New York Heart Association [NYHA]
class 3–4), syncope, lipothymia, and fatigue (online Ap-
pendix Table). Two patients were symptom free, including
1 in whom relatively severe cardiac disease was later diag-
nosed with. Five of these 8 patients had a family history of
CCC. Clinically, all patients had bradycardia, hepatojugu-
lar refl ux, or lower limb edema. Four patients had a normal
clinical examination. No anomalies were found (complete
blood cell count, transaminases, creatinine phosphokinase,
troponin, C-reactive protein). The ECGs of all 4 patients
with CCC showed bradycardia, including sinoatrial block
(SAB) in 2 patients, and grade III atrioventricular block
(AVB) in 2 patients. One patient had a right bundle branch
block and a left anterior semiblock. Chest radiographs were
normal. Transthoracic echocardiography showed a severe
reduction in the left ventricular ejection fraction (20%) in
1 patient. Holter ECG confi rmed the conduction abnor-
malities in 3 of the 4 patients (SAB, AVB, and ventricular
hyperexcitability in 2 patients). All 8 patients had a posi-
tive indirect immunofl uorescence test (IIF) and a positive
ELISA test (2) for T. cruzi in serum (online Appendix
Table). The 8 patients were IIF-negative for Leishmania
(3). The 2 patients with AVB III had pacemakers implanted
and received angiotensin-converting-enzyme inhibitor and
β-blocker therapy. Eight patients received oral benznida-
zole, 5 mg/kg/day for 1 to 8 weeks, depending on toler-
ability. Antihistamine therapy was given throughout ben-
znidazole administration. One patient developed DRESS
syndrome (drug rash with eosinophilia and systemic symp-
toms) after 2 weeks of treatment and improved a few days
after benznidazole interruption. Nifurtimox was given (and
was well tolerated) after the patient’s cutaneous and blood
status had normalized. Three patients complained of numb-
ness of the extremities during weeks 4, 5, and 7 of treat-
ment; this pointed to benznidazole-induced peripheral neu-
ropathies, which effectively disappeared when treatment
was stopped. Three patients stopped taking their treatment
prematurely; 1 patient was switched to nifurtimox after 2
weeks of treatment with benznidazole. Two patients report-
ed a lessening of pain and improvements in their general
health after antiparasitic treatment.
The prevalence of CD in T. cruzi–exposed, asymptom-
atic persons living in Europe is about 0.6% to 4% (4,5). Al-
though CD remains extremely rare in Europe, a review of
the literature shows 5 symptomatic cases up to 2004. There
was 1 case of imported ACM in France in 1988 in a patient
from Colombia (6), 1 case of autochthonous ACM in Spain
in 1992 after blood transfusion (7), 1 case of imported CCC
DISPATCHES
644 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 14, No. 4, April 2008
*Hôpital Tenon, Paris, France; †Hôpital La Pitié Salpétrière, Paris,
France; ‡Le Centre Hospitalier de Tourcoing, Tourcoing, France;
§Instituto de Pesquisa Clinica Evandro Chagas – Fiocruz, Rio de
Janeiro, Brazil; ¶Université libre de Bruxelles, Brussels, Belgium;
and #Etablissement Français du Sang, Paris, France

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Chagas Disease, France
in Switzerland in 1996 in a patient from Bolivia (8), 1 case
of imported ACM in Italy in 1997 in a patient from Brazil
(9), and 1 case of imported ICC in Denmark in 2000 in a
patient from Venezuela (10). After 2004, 3 additional cases
were reported: 2 cases in Spain in 2005 (1 case of imported
CCC in a patient from Bolivia) (11), 1 case of autochtho-
nous neonatal ACM in the child of a Bolivian mother (12),
and 1 case of imported CCC in the Netherlands in 2006 in a
patient from South America (country not specifi ed) (13).
Acute forms of CD diagnosed in Europe usually in-
volve Europeans returning from stays in disease-endemic
areas. The acute case described here underlines, as previ-
ously stated by Brisseau et al. (6), that a short stay in a
disease-endemic zone, even for a few days, is suffi cient
to become a potential source of T. cruzi. In France, since
April 2007, all persons who have spent any time in Central
or South America are screened for T. cruzi before blood
donation. This recent measure followed a series of 4 acute
Chagas cases in French Guiana (14). Chronic imported
forms usually involve South American immigrants, whose
numbers are diffi cult to determine in Europe as many are
illegal. The number of persons of Latin American origin
living in metropolitan France has risen from 27,400 in 1999
to 105,000 in 2005 according to the National Institute for
Demographic Studies (www.ined.fr). These persons are an
underestimated potential source of transmission of disease.
As illustrated by the cases recently reported by C. Riera
(12), there is also a risk of transplacental transmission in
women of South American origin living in Europe. CCC is
sometimes life threatening, as in the case of patient 4 (on-
line Appendix Table), who had a very poor cardiac progno-
sis for a 38-year-old man.
The diagnosis of CD is not always straightforward in
France. The current rarity of CD in Europe and the purely
cardiologic (and sometimes gastrointestinal) manifesta-
tions of the chronic phase represent a diagnostic challenge.
In France, few cardiologists and gastroenterologists are
fully aware of this infectious disease. In the United States,
because imported cases of CD are no longer exceptional, a
Chagas screening test for blood donors was implemented in
2007 (15). The 9 cases we report, along with other recent
cases, may be a sign that CD is emerging in France. If this
imported disease becomes established in France, it could
represent a real risk for transfusional and congenital trans-
mission, not only in metropolitan areas in France but also
in other European countries with a high Latin American
immigrant population.
Dr Lescure works in the tropical and infectious diseases
unit of Tenon Teaching Hospital in Paris, France. His research
interests include the clinical epidemiology of HIV, hepatitis, non-
tuberculous mycobacteria, methicillin-resistant Staphylococcus
aureus, and tropical diseases.
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Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 14, No. 4, April 2008 645
Figure. Romaña sign. Photo of female patient from French Guiana
who lives in a metropolitan area of France. She had returned to
Maripassoula to visit her parents during the holidays between
July 13, 2004, and September 3, 2004. When the patient sought
treatment on September 3, 2004, she had fever and unilateral
periorbital edema.

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Address for correspondence: François-Xavier Lescure, Service des
Maladies Infectieuses et Tropicales, Hôpital Tenon, 4 rue de la Chine,
AP–HP, 75020 Paris, France; email: xavier.lescure@tnn.aphp.fr
DISPATCHES
646 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 14, No. 4, April 2008