Eritematous Cutaneous Nodules in Heart-Transplanted Patients: A Sign of Chagas' Disease Reactivation
SA Araujo, RS Laboissiere, MCV Moreira, SA Andrade, AJA Barbosa. Medical School, Federal University of Minas Gerais, Belo Horizonte, Brazil
Background: Eritematous cutaneous nodules may occur after organ transplantation due to several pathologic disorders such as graft-versus-host disease, cutaneous toxicities of drugs and numerous infectious diseases resulting mainly from bacteria, virus and fungus. Although there is limited information about its epidemiology, Chagas' disease reactivation should be one important differential diagnosis to consider in patients from Latin America, in those countries where the disease is endemic. We report here a series of five cases of heart transplanted chagasic patients who developed eritematous cutaneous nodules (skin chagoma) shortly after surgery.
Design: The five cases of chagasic patients underwent heart transplantation from 2007 to 2009 at a Brazilian University Hospital. The immunosuppression protocol was based on a combination of cyclosporin or tacrolimus with mycophenolate mofetil in addition to prednisone. All patients were on prednisone-free immunosuppression after the first 6 months following cardiac transplantation. Routine histological preparations (H&E) of skin biopsies were analyzed. The samples were also stained by immunoperoxidase technique using polyclonal rabbit antibodies against Trypanosoma cruzi amastigotes.
Results: The mean age of the group was 44.4 years. The patients presented their first episode of Chagas' disease reactivation, as eritematous cutaneous nodules, at a mean time of 8 weeks after surgery. One patient had a second Chagas' disease reactivation 20 months after the heart transplant. The biopsy specimen from these lesions revealed a diffuse inflammatory infiltrate, composed of lymphocytes and macrophages, presented in the upper and lower dermis, extending into the hypodermal adipose tissue (septal panniculitis). The T. cruzi amastigote-like microorganisms were observed in the H&E preparation and were confirmed by immunochemistry reaction. Numerous microorganisms with paranuclear kinetoplasts were seen in the cytoplasm of hystiocites, fibroblasts and endothelial cells. Some isolated amastigotes were apparently identified along the edematous interstitial space.
Conclusions: Chagas' disease reactivation in immunosuppressed patients after heart transplantation could be an important cause of cutaneous lesions. One should attempt to make this differential diagnosis when dealing with patients from endemic regions.
Monday, March 22, 2010 9:30 AM
Poster Session I Stowell-Orbison/Surgical Pathology/Autopsy Awards Poster Session # 200, Monday Morning