Intro: It's Your Health Radio, a special podcast series, presented by Henry Mayo Newhall Hospital.

Melanie Cole, MS (Host): Welcome to It's Your Health Radio with Henry Mayo Newhall Hospital. I'm Melanie Cole. And we're here today to shed light on Chagas disease, a serious but often overlooked illness. My guest will explain how the disease is transmitted, who might be at risk and its potential complications so that we can be better informed. Joining me is fan favorite, Dr. Anirudh Rai. He's a primary care physician on the medical staff at Henry Mayo Newhall Hospital. Dr. Rai, what is Chagas disease, and how is it most commonly transmitted?

Anirudh Rai, MD: Yeah, great question. It's always a pleasure to be on the show. So, Chagas disease is, honestly, a very well known illness. Typically, it resides in South America, in that region where this particular organism, it's a parasite, best way to describe it. The name of this parasite is Trypanosoma cruzi, or T. Cruzi, as we like to say. And it's a very well-studied organism. In fact, the name Chagas comes from the physician who studied it and got to know it and gave us this idea about it.

The way this organism works is it resides in bugs and insects that are essentially blood suckers. And we've actually recently found out it's gotten into mammals too, particularly bats. But this particular illness, we're pertaining only to insects. So, it's these bloodsucking insects. We classify them under the name kissing bugs, as you'll know, and it's pretty interesting how they interact. So, this parasite resides within that area, the GI tract, and it goes in their feces. So, how this is transmitted has been well-studied.

What they found out, particularly in South America, this kissing bug and there are multiple species of, it essentially resides in dark crevices and it comes out at night. And when it comes out at night, it likes to find moist, warm areas. And generally, the best place to find that is going to be the mouth or the oral orifice, as we like to say, of humans. And when they're sleeping, they'll be exhaling carbon dioxide and heat, and bugs can sense that in some degree and would essentially migrate towards that. And this kissing bug would get into those areas, particularly the oral orifice, the mouth, sometimes even the eye, and essentially defecate and leave some of its eggs in that area. The interesting thing about the T. cruzi protozoa or this parasite is, really, it can't penetrate through the skin, so it's not going to go through, if it just landed on the skin. It requires these micropunctates, meaning that the sucking bug would have to actually go in and actually produce these openings in your skin. And that's where the parasite actually goes in.

And historically speaking, it's very hard to even track and find out who's had it, honestly. It's been well-studied that this organism actually is coming more to Southern California region. So, it is migrating a little bit higher up. And part of the reason is because the world's become a smaller place, people are traveling more. And honestly, sometimes they could bring these bugs along and even this parasite along. And then, we'll talk more about the symptoms when we get to it as well.

Melanie Cole, MS: What are these kissing bugs? I mean, you're kind of freaking me out here. So in the night while we're sleeping and some of us sleep with our mouths open and this bug could get in there-- and you said defecate-- that's awful, but what kind of bugs are we talking about? What is a kissing bug?

Anirudh Rai, MD: So, a kissing bug, the name implies because it lands in the mouth. That's why they call it the kissing bug. It's not like it actually kisses you or anything like that. It's because it's attracted to your oral orifice. And it's basically a generic term for multiple of these blood suckers. Usually, the kissing bug does feed on human blood. So, it will puncture the skin and starts sucking the blood sometimes, and it's also seen in bats. So, these kissing bugs, again, it's a multiple species, are just these organisms. They're pretty small, but they're well noticed. If you were to actually look up the image, you'll see that it's not like any other bug you've ever seen. So, it is something that's very noticeable. But it is something that, for the most part, we as physicians want people to be aware of. If you see any bugs that are odd or you see some kind of insects that are around that you're a bit questioning, let your doctor know as well. And we'll be able to see, because the CDC does track these conditions well, and we can actually highlight where some areas might be more prone to this kind of bug infestation.

Melanie Cole, MS: Why is it called the silent or neglected disease?

Anirudh Rai, MD: Yes. So, the CDC, I believe, or was it the FDA, they did name it that recently, just because people have not been paying attention to it too much, especially in the North American side, just because we don't see it hardly in fact. The reason it was neglected, I personally theorize for multiple reasons. I know part of it's because we don't see it as often, but the other reason is the way this disease actually manifests is very subtle. So, it's something that most physicians may think of it as like a common cold or something that you might have a small infection about. And that goes into the symptoms of it a little bit as well. So, it's neglected partially because we as physicians think it's something else rather than this disease.

And it's neglected in the other sense that it's sometimes very hard to even know if you have the disease in the chronic phases, meaning that when you have it acutely, as it happens quickly within about eight weeks of you interacting with this, we could have some form of contact, but neglect in the sense that it's difficult to diagnose and difficult to even see. I wouldn't say it's neglect in the fact that we don't treat it. It's the fact that I think we lack, I guess, the wherewithal to know that if it's in certain regions or not, because we know it does reside in South America. We hardly think it would come up to North America, but we're seeing some cases of it.

Melanie Cole, MS: Symptoms, Dr. Rai, because I think that's what patients want to know. If we are seeing this sort of migrate into North America, what are some of the symptoms that people might experience that might let them know both in the earlier and the later stages of disease, that they might go see a doctor for?

Anirudh Rai, MD: The reason it is harder to diagnose particularly is there's two phases of the disease, or I going to say technically three. But the first phase is when you initially get the organism where the kissing bug lands on your mouth or your eyes or any of these wet mucus membranes where it loves to reside. It defecates, it feeds a little bit and the parasite gets in. The symptoms don't start until about-- they say on average about six to 10 days. So, give or take about two weeks, we start noticing these, what they call-- I guess, the best way to describe it is these symptoms are something you would commonly get. Things like fevers, you might get a little bit of a bigger spleen and liver, but usually you would see that on physical exam, it's not something that the patient will notice too much. You might get a little bit of nausea. You might get a lymph node being a bit more bigger. So, these symptoms are not very specific to any one condition. This is just a sign if your body's saying, "Hey, something's there," and is trying to fight the infection off. We usually won't see anything too drastic.

There've been some cases, what they call chagomas. Essentially, it's the area where the organism gets in and the inflammatory response is so vivid, that your swelling actually becomes very noticeable, quite large. And it's something that is a bit abnormal even for any kind of infection. And a famous sign called Romaña's sign has been documented by Dr. Chagas and where one eye gets extremely big and swollen. And the part of the reason is because of this inflammatory response this parasite incites, and it's very hard to actually get any particular symptoms that are noted for Chagas disease, but these are just symptoms that we, as physicians, encounter if you have a simple infection, honestly.

But another sort of subtle sign is sometimes your EKG can be a bit off. But again, these are not very specific symptoms, so it's very hard to even find out what the symptoms are without actually doing a thorough test, which is essentially a lab test, drawing the blood and looking at it under the microscope. And you actually see these organisms in the blood.

Melanie Cole, MS: Wow, that's fascinating. So even though it's a parasite, we're not seeing a lot of GI symptoms. Did you mention that it was in the GI system?

Anirudh Rai, MD: So, I guess, I should clarify a bit, it's just some in the GI system of the kissing bug. So, the kissing bug actually has been in that area where it defecates and it gets in your blood. And the fact that it's a parasite means that it actually just uses the nutrition of the host. It doesn't necessarily mean it resides in your gut. But it resides more than often in your blood.

And going on into the next phase, honestly, it can actually cause a lot of damage to your heart. So, one of the things we see with this organism, if you've had the symptoms, usually-- well, to give you a better idea, so the acute phase usually stops around six to eight weeks, meaning the first time symptoms occur, which is this swelling of your lymph nodes, you get a reaction, fever, chills, this will be present for about six to eight weeks. Once that goes away, typically, majority of the time patients don't have any symptoms at all. They feel like nothing's there, they're back to normal. And part of the reason for that is your immune system has a certain reaction to organisms that enter it, particularly a parasite.

But what happens after a time is your immune system and the parasite have a balance, what they call it immunological balance, meaning that the reaction that the parasite and the immune system have is low, meaning the parasite lives normally within the system and the immune system recognizes it and doesn't do anything and just has this kind of harmony with it. So, you may not have symptoms after the acute phase for quite a while actually. It takes about 10 to 25 years later where the fatal signs of Chagas disease actually come up. And usually, we see this in the most fatal way, would be it actually attacks the heart, what they call a chagomic cardiomyopathy, meaning that the parasite goes into your heart, has a certain region where it dilates, and essentially causes heart failure and essentially kills your heart in a certain sense. Very rare, but that is the most lethal form of this disease, and you may not see it until about 10 to 25 years later after you even get the illness. You may not even know you have it until the symptoms arise around that time.

So, that's why, in a sense, it is neglected because we don't know too much about it until 10 to 25 years later. But for the most part, 15-30% of patients who have no symptoms reach some symptomatic chronic phase, is what they call it. It's a bit complex, I know. But the main idea is the longer you have the disease, the more lethal it can be, and there's no really good way to screen for it, unfortunately.

Melanie Cole, MS: It may be complex, but Dr. Rai, you're explaining it so very well. So, how is it diagnosed? Obviously, medical history, right? And then, these symptoms that may or may not show up would send somebody to their primary care physician. But then, how is it figured out that this is what's going on?

Anirudh Rai, MD: So, thankfully, technology has come a long way. Back in the day, or I would say when we had less or a little bit more primitive technology, a good way to diagnose this is actually take your blood and look under the microscope and actually see if you have these T. cruzi organisms in the blood. And that's usually only seen in the acute phase, typically when you first get the organism and it starts swimming in your blood. And we can actually see in the microscope.

Nowadays, we have technologies where we actually do nucleic acid amplification or PCR, which is we actually get the DNA of this particular organism. We get a sample of your blood and we see if you have these DNAs in your blood. It has been very, very good in diagnosing Chagas in that sense.

I guess a little bit of a caveat, there are approximately six different types of these parasites. We know some of them here, particularly over the other continents. So, there are many different types of it. But when we see it here, we do have the specific mechanisms to test for it based on its DNA. So, our testing has become a lot better. It is a little bit expensive, but before ordering it, we as physicians should be aware and let the patient know it's like we're testing for these particular conditions.

Melanie Cole, MS: So, are there any steps that we can take to protect ourselves and maybe reduce our risk?

Anirudh Rai, MD: The best thing to do is to just be aware, cognizant about what's going on in your house. If you see certain organisms, certain bugs invading your house a bit more, let your local exterminator or bug specialists know and they could spray down the house and prevent that from even occurring.

The other thing you can do is keep a clean house. Sometimes even having food around, that will attract many of these bugs. Just being cognizant and just having daily hygiene is the best way to prevent this kind of condition. But at the same time, the CDC does do a good job of tracking it. So if we see a hot sector, we tend to be a bit more aware. And the CDC lets the general vicinity of that sector know, saying, "Hey, just be aware. We've had a couple cases of this organism." So, we are doing a pretty decent job of tracking it. And overall, technology's come a long way where we could actually even prevent it from getting worse in certain degrees.

Melanie Cole, MS: What an interesting episode this was Dr. Rai. Thank you so much for joining us again. As always, you really are an excellent educator and so informative with these episodes. Thank you again for joining us. And to book an appointment with Dr. Rai, you can visit our website at henrymayoprimarycare.com.

Thank you so much for joining us on this edition of It's Your Health Radio with Henry Mayo Newhall Hospital. I'm Melanie Cole.