Case Reports
Case 1, a 3.56 kilogram (kg) infant, was born at full-term to a Bolivian woman who had arrived in Ireland at 31 weeks gestation. She was diagnosed serologically with CD in Bolivia by routine antenatal screening at 23 weeks. Repeat maternal serology was tested at The Hospital for Tropical Diseases, London UK and was strongly positive.T. cruzi polymerase chain reaction (PCR) tested in the Diagnostic Parasitology Laboratory at The London School of Hygiene and Tropical Medicine, was also positive. As per World Health Organisation (WHO) recommendations, maternal trypanocidal treatment was delayed until after delivery. Newborn clinical examination was normal and microscopy of cord blood was negative for blood forms of T. cruzi . PCR of infant cord and venous blood (day 2) for T. cruzi were inconclusive (positive in 1 of 8 replicates and 2 of 12 replicates, respectively). Repeat PCR and microscopy of blood were negative at 4 weeks. Blood PCR for T. cruzi was strongly positive at 3 months of age and the infant was commenced on a 2-month course of oral Benznidazole 10 milligram/kg/day. The infant experienced mild self-limiting gastrointestinal upset and macular rash at the onset of treatment.T. cruzi PCR was negative after one month of treatment and at treatment completion. Monitoring full blood count and liver function tests remained normal throughout treatment. T. cruzi PCR was also negative at 9 months of age.
The mother discontinued her Benznidazole treatment after 3 weeks due to concerns that it might interfere with breast-feeding and she disengaged from follow-up. Further maternal follow up is planned following cessation of breast feeding at one-year post-partum to recommence treatment and she has been advised to avoid pregnancy until treatment completion.
Case 2 was an infant born 4 months after case 1. Routine placental examination for intrauterine growth restriction (IUGR) in a 2.4 kg infant delivered by caesarean section at 39 weeks gestation, demonstrated numerous T. cruzi blood forms within the placental membranes and umbilical cord (Figure 1a). The infant, then aged 4 weeks, was recalled. Examination was normal save for symmetrical growth retardation. Presence of T. cruzi trypomastigotes in blood films (Figures 1b and 1c) and positive blood PCR confirmed the diagnosis of cCD. The infant was commenced on a 2-month course of oral Benznidazole. Trypanocidal therapy was well tolerated. Iron supplementation was started at age 6 weeks for mild microcytic anaemia. PCR for T. cruzi and microscopy of venous blood were negative after 1 month of treatment and at treatment completion. The infant’s mother was born in Bolivia and moved to Brazil at age 2 years. She migrated to Ireland 2 years prior to pregnancy. Twenty years earlier she was diagnosed serologically with CD in Brazil when family members had tested positive. She had attended annual cardiology review there but had not received trypanocidal treatment as her CD was asymptomatic. She chose to discontinue breast-feeding due to concerns of ongoing T. cruzitransmission. She was commenced on oral Benznidazole treatment and was referred for cardiology review.
Both infants are thriving, developing normally and will be monitored clinically and serologically up to age 1 year. Echocardiograms were normal and cardiology follow up is scheduled for both infants.