Blocking bug – complete atrioventricular  block in chronic Chagas disease
Chagas disease is a parasitosis, commonly trans-mitted to humans by a blood sucking assassin bug (Tri-
atominae) serving as an insect vector. The bug’s faeces – contaminated with Trypanosoma cruzi – come in con-tact with human circulation by being rubbed into the puncture from the bug’s bite or onto mucus mem-branes.
Since symptoms of the acute infection are unspe-cific, the initial phase often remains unrecognised. If in this phase no specific treatment is applied, the disease evolves into a chronic (usually lifelong) stage. Chronic infection can be present without the development of re-lated symptoms or findings, which is then referred to as an indeterminate stage. However, about 30% of chronic infections lead to damage of the heart and/or the gastrointestinal tract [2]. Even though many patho-physiological concepts are currently discussed, para-site persistence is likely to be the main mechanism causing myocardial injury in patients with chronic cha-gasic cardiomyopathy [3].
Heart related clinical findings after years or even decades of chronic infection often include dilated cardio-myopathy and arrhythmia. About 17–28% of all in-fected patients develop heart failure. Dilatation of the left ventricle and apical aneurysms are echocardio-
A dual-chamber pacemaker (Medtronic ®, AAIR-DDDR) was implanted. In addition, we initiated heart failure treatment with an ACE inhibitor and referred the patient to the Swiss Tropical and Public Health
In-stitute, Basel, where she received an ambulant anti-parasitic medication with benznidazole (300 mg daily for 30 days).
At the one-year follow-up pacemaker interrogation revealed intermittent sinus rhythm and pacemaker  dependency of 55%. The left ventricular volume was  unchanged (EDVI 81 ml/m 2) and its function had in-creased (LVEF 67%) in sinus rhythm (55 bum). The api-cal aneurysm was unchanged. The patient did not show heart failure symptoms anymore. Serological titres were unchanged compared to the initial blood sample.
Discussion
Chagas disease is mainly endemic in Central and South America where about 8 million infected patients are suspected. The estimated prevalence of Trypano-soma cruzi in Latin American immigrants is 8–50 per 1000 in the USA, 9 per 1000 in Canada, 25 per 1000 in Spain, and 16 per 1000 in Australia [1]. Data for Swit-zerland is not available.
Figure 2
Echocardiography 4-chamber apical view after pacemaker implantation.A Dilated cardiomyopathy (enddiastolic freeze-frame).
B Ventricular aneurysm (arrows) in the apex of the left ventricle (endsystolic freeze-frame).LV = left ventricle; LA = left atrium; LV apex = apex of left ventricle.
case report
Conclusion
This case underlines the necessity to take Chagas dis-ease into diagnostic consideration in patients with se-vere conduction abnormalities in the absence of a known underlying cardiac disease – especially in pa-tients with Latin American background or respective travel history.
Acknowledgement: The authors thank Dr. J. Blum (Swiss Tropical and Public Health Institute, Basel, Switzerland) for his clinical help and advice.
References
1 Blum JA, Zellweger MJ, Burri C, Hatz C. Cardiac involvement in
African and American trypanosomiasis. Lancet Infect Dis. 2008;8(10): 631–41.
block truncated
2 Bern C, Montgomery SP , Herwaldt BL, Rassi A Jr, Marin-Neto JA, Dan-tas RO, et al. Evaluation and treatment of Chagas disease in the United States: a systematic review. JAMA. 2007;298(18):2171–81.
3 Marin-Neto JA, Cunha-Neto E, Maciel BC, Simões MV . Pathogenesis
of Chronic Chagas Heart Disease. Circulation. 2007;115(9):1109–23.4 Acquatella H. Echocardiography in Chagas heart disease. Circulation.
2007;115(9):1124–31.
5 Maguire JH, Hoff R, Sherlock I, Guimarães AC, Sleigh AC, Ramos NB,
et al. Cardiac morbidity and mortality due to Chagas’ disease: prospec-tive electrocardiographic study of a Brazilian community. Circulation. 1987;75(6):1140–5.
6 Rassi AJ, Rassi SG, Rassi A. Sudden death in Chagas’ disease. Arq Bras
Cardiol. 2001;76(1):75–96.
7 Gascón J, Albajar P , Cañas E, Flores M, Gómez i Prat, J., Herrera, et
al. Diagnosis, management and treatment of chronic Chagas’ heart dis-ease in areas where Trypanosoma cruzi infection is not endemic. En-fermedades infecciosas y microbiología clínica. 2008;26(2):99–106.
8 Epstein AE, Dimarco JP , Ellenbogen KA, Mark Estes NA, Freedman
RA, Gettes LS, et al. ACC/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities. A report of the American Col-lege of Cardiology/American Heart Association Task Force on practice guidelines (writing committee to revise the ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiar-rhythmia devices) developed in collaboration with the American Asso-ciation for Thoracic Surgery and Society of Thoracic Surgeons. J Am Coll Cardiol. 2008;51:e1–62.
9 Marin-Neto JA, Rassi A Jr, Morillo CA, Avezum A, Connolly SJ, Sosa-Estani S, et al. BENEFIT Investigators. Rationale and design of a ran-domized placebo-controlled trial assessing the effects of etiologic treat-ment in Chagas’ cardiomyopathy: the BENznidazole Evaluation For Interrupting Trypanosomiasis (BENEFIT). Am Heart J. 2008;156(1): 37–43.
graphic key features for confirmation of the diagnosis [4]. In end stage disease patients present with ful
l- blown dilated cardiomyopathy and corresponding heart failure.
Defects of the conduction system are usually pre-sent many years before clinically manifested heart fail-ure. While conduction disturbances like right bundle branch block (RBBB, 50%) and left anterior hemi-block (LAHB, 26%) are common, higher grade conduction ab-normalities like in the presented case are rare [5]. Complex premature ventricular contractions, ventricu-lar tachycardia, sinus node dysfunction and higher de-gree AVB normally develop in late stage disease but may be present even in clinically non-overt patients. Together with ventricular dysfunction and syncope they are major predictors of sudden death in chronic chagasic heart disease [6].
Since only few controlled studies have been per-formed, optimal treatment of Chagas cardiomyopathy remains controversial. Whether recovery of an altered conduction system can be expected from anti-parasitic medication remains unclear. Thus, in symptomatic bradycardia derived from third-degree and advanced second-degree AVB at any anatomic level, implanta-tion of a permanent cardiac pacemaker is the treat-ment of choice [7, 8]. As appropriate, ACE inhibitors or amiodarone should be prescribed and heart transplan-tation may be considered. In addition to these ap-proaches, encouraging data suggests that benznida-zole, an anti-parasitic drug, decelerates progression of the disease [1]. Negative seroconversion can be ex-pected after this treatment but may take years to de-cades. After a
nti-parasitic treatment our patient showed a partial recovery of the conduction distur-bance. This is remarkable since chronic Chagas cardio-myopathy seemed to be in an advanced stage and there was no change of the serological titres compared to the initial blood sample. A multicentre study (BENEFIT trial) currently being conducted will presumably pro-vide more data about efficacy and safety of benznida-zole [9].
This report underlines that in unclear cases of heart failure and conduction abnormalities Chagas dis-ease should be taken into consideration. In view of  migration from and tourism to endemic regions, Cha-gas disease may be seen more often in European coun-tries in the future.
Below is given annual work summary, do not need friends can download after editor deleted Welcome to visit again
XXXX annual work summary
Dear every leader, colleagues:
Look back end of XXXX, XXXX years of work, have the joy of success in your work, have a collaboration with colleagues, working hard, also have disappointed when encountered difficulties and
setbacks. Imperceptible in tense and orderly to be over a year, a year, under the loving care and guidance of the leadership of the company, under the support and help of colleagues, through their own efforts, various aspects have made certain progress, better to complete the job. For better work, sum up experience and lessons, will now work a brief summary.
To continuously strengthen learning, improve their comprehensive quality. With good comprehensive quality is the precondition of completes the labor of duty and conditions. A year always put learning in the important position, trying to improve their comprehensive quality. Continuous learning professional skills, learn from surrounding colleagues with rich work experience, equip themselves with knowledge, the expanded aspect of knowledge, efforts to improve their comprehensive quality.
The second Do best, strictly perform their responsibilities. Set up the company, to maximize the customer to the satisfaction of the company's products, do a good job in technical services and product promotion to the company. And collected on the properties of the products of the company, in order to make improvement in time, make the products better meet the using demand of the scene.
Three to learn to be good at communication, coordinating assistance. On‐site technical service personnel should not only have strong professional technology, should also have good communication
ability, a lot of a product due to improper operation to appear problem, but often not customers reflect the quality of no, so this time we need to find out the crux, and customer communication, standardized operation, to avoid customer's mistrust of the products and even the damage of the company's image. Some experiences in the past work, mentality is very important in the work, work to have passion, keep the smile of sunshine, can close the distance between people, easy to communicate with the customer. Do better in the daily work to communicate with customers and achieve customer satisfaction, excellent technical service every time, on behalf of the customer on our products much a understanding and trust.
Fourth, we need to continue to learn professional knowledge, do practical grasp skilled operation. Over the past year, through continuous learning and fumble, studied the gas generation, collection and methods, gradually familiar with and master the company introduced the working principle, operation method of gas machine. With the help of the department leaders and colleagues, familiar with and master the launch of the division principle, debugging method of the control system, and to wuhan Chen Guchong garbage power plant of gas machine control system transformation, learn to debug, accumulated some experience. All in all, over the past year, did some work, have also made some achievements, but the results can only represent the past, there are some problems to work, can't mee
t the higher requirements. In the future work, I must develop the oneself advantage, lack of correct, foster strengths and circumvent weaknesses, for greater achievements. Looking forward to XXXX years of work, I'll be more efforts, constant progress in their jobs, make greater achievements. Every year I have progress, the growth of believe will get greater returns, I will my biggest contribution to the development of the company, believe in
yourself do better next year!
I wish you all work study progress in the year to come.

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