B51-15 Kooky Conduction: When Cancer and Chagas Collide

Abstract Introduction Chagas reactivation in immunocompromised patients is a recognized phenomenon especially in patients with human immunodeficiency virus (HIV), stem cell transplant, or active chemotherapy. However, little is known about how Chagas reactivates during malignancy prior to initiation of treatment, including chemotherapy. Here, we present a curious case of syncope from Chagas reactivation in the setting of a recently diagnosed malignancy. Case A 50-year-old Spanish-speaking man from El Salvador with recently diagnosed Stage IE gastric diffuse large B-cell lymphoma (DLBCL), T-cell large granulocyte leukemia (T-LGL), and suspected chronic Chagas presented with dizziness, loss of consciousness, and fall. Outpatient, his total immunoglobulin G (IgG) for Trypanosoma cruzi (T. cruzi) was positive, but quantitative polymerase chain reaction (qPCR) and parasite smear were negative. On admission, he had complete heart block accompanied by syncope and elevated troponins. He received a transvenous pacemaker, which was converted to a leadless pacemaker. Cardiac catheterization at that time was negative for obstructive coronary disease. After leadless pacemaker placement, he developed sudden onset 10/10 chest pain with a heart rate of 260. Rhythm at that time was sustained monomorphic ventricular tachycardia, and the patient rapidly became hemodynamically unstable. He required 2 cardioversions, Amiodarone boluses with a continuous drip, and Lidocaine boluses to stabilize his ventricular rhythm. A repeat parasite smear at that time was negative for T. cruzi. However, he had a real-time PCR cycle threshold value of 32.2 (less than 40 is positive) concerning for Chagas reactivation. His hospital course was complicated by neutropenic fevers and new IgG positive result for cytomegalovirus, Epstein- Barr virus, herpes simplex virus 1, and toxoplasma. He had not yet started any treatment for his malignancies. After maintaining a stable cardiac rhythm with Amiodarone, he began cycle 1 of chemotherapy with Rituximab, Gemcitabine, Cyclophosphamide, Vincristine, and Prednisolone (R-GCVP) to avoid further cardiotoxicity from anthracyclines found in typical lymphoma regimens. He was also simultaneously started on a 90-day regimen of Nifurtimox to treat Chagas reactivation. He is now pending placement of a subcutaneous implantable cardioverter-defibrillator (S-ICD). Discussion This case provides a unique and severe presentation of Chagas-induced arrhythmia in a patient with malignancy. It begs the question of what patient populations would benefit most from Chagas reactivation screening, and how often such screenings should occur. Curiously, it also brings to light how Chagas reactivation should best be monitored, as in this case, the patient had a negative smear but positive qPCR. This abstract is funded by: None