Fulminant and fatal Trypanosoma cruzi reactivation in a patient with lymphoma

Trypanosoma cruzi is a protozoan parasite and the causative agent of Chagas disease. This case describes a fulminant and fatal reactivation of T. cruzi after immunosuppression in a patient with a history of follicular lymphoma, with parasitemia detectable in peripheral blood smears and parasites seen in multiple autopsy tissue specimens.

A 61-year-old woman who had immigrated from El Salvador and was receiving obinutuzumab and zanubrutinib for follicular lymphoma in remission was admitted with persistent COVID-19 pneumonia. After multiple therapies for COVID-19, including more than 3 weeks of corticosteroid therapy for the possibility of organizing pneumonia, a peripheral blood smear identified T. cruzi trypomastigotes, and later amastigotes were identified in a bone marrow biopsy. The patient was treated with benznidazole but ultimately died. At autopsy, amastigotes were observed in multiple organs, including the heart, esophagus, stomach, small intestine, colon, bladder, and skeletal muscle.

Most cases of Chagas reactivation are described in people living with HIV-1 or transplant recipients. Rarely, T. cruzi reactivation can occur in patients undergoing immunosuppressive therapies for malignancies or inflammatory states like COVID-19 infection, as seen in this case. If not recognized early, reactivation can be fatal despite antiparasitic treatment. Providers should consider screening patients from endemic areas who will start on immunosuppressive therapies. Repeating screening may be of value with periods of new immunosuppression. In patients with Chagas disease and malignancy, PCR from blood should be performed during enhanced immunosuppression so that preemptive treatment can be initiated prior to the presentation of fulminant disease.