A male patient of 38 years old, born in a rural area of the Trujillo state (Venezuela), where the seroprevalence to T. cruzi was 19.2-23.8% and the main triatomine vector was Rhodnius prolixus came to the emergency unit of the Caracas University Hospital with fever, generalized seizures, and progressive neurological impairment (day 0), whose symptoms appeared a week before admission (day 7). The patient was living in La Guaira city (Vargas state, Venezuela) where the mortality rate due to HIV-AIDS was the second highest of Venezuela in 2009 (10.5 deaths x 100,000 inhabitants) and an outbreak of oral Chagas disease occurred in Chichiriviche de la Costa in the same year, affecting 54 children and causing 3 deaths by acute heart failure.
Patient also reported to be bisexual with a promiscuous lifestyle and to have an HIV+ diagnosis. The physical examination revealed a body temperature of 38-39 C and a CD4+ T-lymphocytes count of <200 cells/mm3 (<14%) (AIDS C3 stage). According to the National Program of AIDS and Sexually Transmitted Infections of the Ministry of Health, the patient should have been treated with antiretrovirals, but, due to difficulties in obtaining these drugs, the patient was not following a retroviral therapy. The patient was hospitalized and a computed tomography (CT) of head was done revealing two rounded SOL ring-shaped in the frontal region and basal nuclei (CT images not shown). As a consequence of neuroimaging results, a presumptive diagnosis of toxoplasmosis was given to the patient, for which he received an empirical treatment with 200 mg of pyrimethamine in the first day and 75 mg/day since the second day, in combination with 100 mg/kg of body weight/day (4-6 g/day) of sulphadiazine (day 1). Since patient did not show improvement of his health condition, a lumbar puncture was done to obtain samples of cerebrospinal fluid (CSF) (day 4) which were cytologically studied. Because results from CSF cytology showed few parasitic flagellate protozoans morphologically compatible with trypomastigotes of Trypanosoma sp., the treating physicians consulted the departments of immunology and tropical medicine in order to confirm the diagnosis and to modify the treatment.
The characteristic morphology of flagellates and the epidemiological nexus of patient in Trujillo state (a Chagas' disease endemic area), without a specific diagnosis, allowed physicians not only to reformulate the case as probable infection of the CNS by Trypanosoma cruzi but also to start a specific treatment with Nifurtimox (6 mg/kg of body weight/day for 60 days in two daily fractions) due the absence of Benznidazole (day 7). The patient had a torpid evolution, without a favourable response to treatment, and died 3 days after the treatment beginning (day 10). Autopsy was done 1 hour after his death, according to the standards protocols at Jose A. O'Daly Institute for Pathology (Faculty of Medicine, Central University of Venezuela), in order to perform the corresponding pathological studies and confirmation of the pathological diagnosis at electron microscopical and molecular level by PCR.