Snapshot A 58-year-old man presents to the clinic with a two month history of cough, dyspnea on exertion, and leg swelling. He immigrated from rural Bolivia when he was 25-years-old and visits home regularly. Past medical history is unremarkable. He does not smoke or drink. Physical exam reveals an anxious-looking man in respiratory distress. Cardiovascular exam reveals an elevated JVD, displaced PMI, S3 gallop with a holosystolic murmur radiating to the axillae, and pitting edema of both ankles. There are bibasal crackles on chest exam. A chest radiograph showed cardiomegaly. Cardiac catheterization showed no evidence of coronary artery disease. Echocardiogram revealed biventricular dilatation with an EF of 35%. The patient experienced symptomatic improvement with an anti-heart failure regimen. Further questioning revealed patient had numerous insect bites as a child. Blood smear was negative for Trypanosoma cruzi, but serological testing was positive. Introduction Primarily seen in Latin America especially South America An infection by reduviid bug ("kissing bug") painless bite feeds on humans and defecates, transmitting trypanosome in feces Presentation Symptoms/Physical exam Romaña sign swelling around eye early indicator of disease chagoma develops at site of entry hardened red area acute phase fever, malaise, and lymphadenopathy tachycardia and EKG changes CNS involvement chronic phase cardiac conduction abnormailities cardiomyopathy megacolon/megaesophagus Evaluation Trypomastigote (motile, flagellated form) in blood smear Xenodiagnosis laboratory-grown bugs are allowed to feed on the patient and are examined one month later for the parasite Differential Etiology of dilated cardiomyopathy alcohol coxsackie virus drug induced Megaesophagus scleroderma Treatment Pharmacologic nifurtimox benzimidazole Prognosis, Prevention and Complications Complications worsening heart failure indication for AICD if EF is < 35% decreases mortality from VT/VF