Chronic chagas disease cardiomyopathy mimicking myocardial infarction: a case report

Description of Clinical Presentation: We present the case of a 75-year-old man with a history of atrial fibrillation and positive serology for Chagas disease. He required admission to the intensive care unit due to an episode of supraventricular tachycardia refractory to pharmacological cardioversion, which ultimately necessitated electrical cardioversion. Transthoracic echocardiography demonstrated global hypokinesia with a preserved left ventricular ejection fraction of 60%. Considering the documented arrhythmic events, a coronary angiography was requested to assess for coronary artery disease, as well as a cardiac magnetic resonance (CMR) study for structural evaluation.

Diagnostic Techniques and Their Most Important Findings: Cardiac MRI was performed with multiple sequences before and after administration of contrast agent (Gadolinium 0.2 mmol/kg). Morphological and functional assessment revealed left atrial enlargement, marked myocardial thinning, and akinesia, associated with late gadolinium enhancement (LGE) showing a transmural pattern, highly suggestive of ischemic injury (in the vascular territory of the circumflex artery), localized in the basal lateral segments. Dyskinetic motion was observed in the mid-anteroseptal and apical anteroseptal segments during early systole. Coronary anatomy was subsequently evaluated by coronary angiography, which revealed no hemodynamically significant lesions.

Learning Points from this Case: In this report, we describe the clinical course of a patient with confirmed Chagas disease (CD), an endemic condition in our country, associated with a high incidence and thus requiring familiarity with its diverse clinical and imaging manifestations. Cardiac MRI plays a pivotal role in the early detection of myocardial involvement and its complications. Pathogenetically, Chagas disease involves an inflammatory response leading to cellular injury and fibrosis, both of which can be identified across different CMR sequences. Classical findings of Chagas cardiomyopathy have been described, including biventricular involvement and the presence of an apical ventricular aneurysm (a hallmark of CD), best visualized on cine sequences. Regarding patterns of late gadolinium enhancement, typical involvement has been reported in the apical and inferolateral segments of the left ventricle, often in subepicardial regions. In contrast, the present case demonstrates an atypical enhancement pattern, with transmural involvement indistinguishable from the fibrosis seen in coronary artery disease—yet excluded here by normal coronary angiography. The relevance of this case lies in the recognition of atypical imaging patterns in a highly prevalent disease within our region, which may mimic ischemic cardiomyopathy, potentially complicating both diagnosis and therapeutic decision-making.

cardiac MR. cine sequences showing thinning of the myocardial wall in the basal lateral segments.
cardiac MR. Short-axis sequence. Transmural hyperintensity is seen in the basal lateral segments during LGE sequences, a pattern typical of ischemic heart disease.
Sequence obtained in a three-chamber view. Transmural hyperintensity is seen in the basal lateral segments during LGE sequences, a typical pattern of ischemic heart disease with myocardial wall thinning.