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Case 317 - Discussion

Hematopathology Case

 

Trypanosoma cruzi infection in lymph node

  • My initial differential diagnosis was leishmania infection.

  • Called CDC, and I was told that leishmania is rare in US and Chagas disease should be considered.

  • Got more clinical history: Patient grew up in Mexico on farm with farm animals, and moved to US at age 18. He initially presented with non-ischemic cardiomyopathy in 2001 following viral illness, then developed heart failure in 2009, and eventually underwent heart transplant in 2010. No other family members had heart disease (11 siblings).

  • In 2010, the explanted heart was sent to a cardiac pathologist for consultation with a descriptive diagnosis as “chronic myocarditis”.

  • Histologic examination on 2010 explanted heart did not show convincing morphologic evidence of microorganisms.

  • Peripheral blood smears did not show active amastigotes

  • Both 2010 heart and 2013 lymph node were sent to CDC:

    • Immunohistochemical stains negative for Trypanosoma cruzi, Leishmania spp or Toxoplasma gondii

    • PCR positive for Trypanosoma cruzi but negative for Leishmania spp or T. gondii

  • Patient fresh serum was also sent to CDC for serology studies:

    • Positive serum antibody for Trypanosoma cruzi but negative for Leishmania spp or Toxoplasma gondii

 

  • Follow-up: Bendnidazole received from CDC to treat the patient. As of 08/02/2017 (4 years later), patient was doing well with no new lymphadenopathy or abnormal function of the transplanted heart.

  • Personal note: For reactive lymph nodes with areas of monocytoid B-cell hyperplasia, I often spend some time at high power magnification to search for possible infectious process in these areas. Luckily so far I have identified 3 cases of CMV infection and this Chagas disease.