Neurological Decline in a Patient of Venezuelan Descent
Immediate Priority: Screen for Chagas Disease
Given the patient's Venezuelan descent and neurological decline, Chagas disease must be immediately considered and excluded, as this is a treatable cause of progressive neurological and cardiac deterioration that affects millions of Latin American immigrants and can present decades after initial infection. 1
Epidemiology and Clinical Context
Venezuela is endemic for Chagas disease, with an estimated 68,636 T. cruzi-infected Latin American immigrants in Spain alone, and similar patterns exist in the United States where at least 300,000 cases of chronic Chagas disease are estimated among people from endemic Latin American countries. 1, 2
Cardiac and neurological manifestations typically appear 10-30 years after initial infection, meaning patients may present with symptoms decades after leaving endemic areas. 1, 3
Chagas disease causes syncope and neurological decline through multiple mechanisms: ventricular tachyarrhythmias, AV block, dilated cardiomyopathy with impaired cardiac output, and autonomic nervous system involvement. 1
Diagnostic Approach
Serological Testing (First-Line)
Obtain at least two different conventional serologic tests including indirect hemagglutination assay (IHA), immunofluorescence antibody assay (IFA), and/or enzyme-linked immunosorbent assay (ELISA) based on detection of antibodies against T. cruzi parasites. 4
Positive serology establishes chronic Chagas disease diagnosis in the appropriate clinical context with neurological or cardiac symptoms. 1, 5
Cardiac Evaluation (Essential)
12-lead ECG to identify arrhythmias, AV block, or conduction abnormalities characteristic of Chagasic cardiomyopathy. 1, 3
Echocardiography to assess for dilated cardiomyopathy, ventricular aneurysm, and wall motion abnormalities. 3, 6
24-hour Holter monitoring if syncope or palpitations are present, as ventricular tachyarrhythmias are a major cause of sudden death in Chagas disease. 1, 3
Neurological Imaging
MRI brain without and with contrast is the preferred modality to evaluate neurological decline and exclude other causes such as stroke, demyelinating disease, or mass lesions. 1
Brain imaging is indicated when neurological decline is present, as recommended for patients with neurologic symptoms that may result in cranial nerve palsies or other focal deficits. 1
Additional Laboratory Workup
Comprehensive metabolic panel including glucose, renal function, liver function, and electrolytes to identify metabolic causes. 7
Thyroid function tests (TSH, free T4) as thyroid dysfunction can cause neurological symptoms. 7
For patients under 40 years: serum ceruloplasmin, 24-hour urinary copper, and slit-lamp examination for Kayser-Fleischer rings to exclude Wilson's disease, which is a treatable cause that must not be missed. 7
Treatment Strategy
Antiparasitic Therapy
Benznidazole is FDA-approved for treatment of Chagas disease in pediatric patients 2-12 years of age, with dosing of 5-7.5 mg/kg/day for 60 days. 4
For adults with chronic Chagas disease, benznidazole is effective when given for initial infection and may be beneficial for the chronic phase, though FDA approval is limited to pediatric patients. 4, 3
Treatment should be considered in consultation with infectious disease specialists experienced in managing Chagas disease, as the role of antiparasitics in chronic Chagas cardiomyopathy with established organ damage is not definitively established. 5
Cardiac Management
Amiodarone for ventricular arrhythmias, angiotensin-converting enzyme inhibitors for heart failure, and pacemaker implantation for conduction disease may contribute to better survival in selected patients. 3
Dual antiplatelet therapy or anticoagulation should be considered given the high risk of thromboembolic events in Chagasic cardiomyopathy. 3, 6
Monitoring and Follow-up
Serial ECGs and echocardiograms to monitor progression of cardiac involvement. 3
Molecular PCR testing may be useful for treatment response follow-up, though current tests are technically demanding and restricted to referential laboratories. 8, 5
Critical Pitfalls to Avoid
Do not miss Chagas disease in Latin American immigrants with neurological or cardiac symptoms, as this is a treatable cause affecting millions and can present decades after leaving endemic areas. 1, 2, 5
Do not rely on single serologic test, as at least two different conventional tests are required for diagnosis. 4
Do not overlook cardiac evaluation, as syncope and sudden death from ventricular arrhythmias or AV block are major causes of mortality in Chagas disease. 1, 3
Do not assume vector-borne transmission only occurs in Latin America, as autochthonous cases have been documented in the southern United States, though this remains rare. 2, 5
Screen for reactivation in immunosuppressed patients, as exacerbations have been reported in those receiving immunosuppressive therapy or with AIDS. 6