We read with great interest the article entitled “Persistent constipation. A case report”, recently published in your journal.1 This case illustrates the complexity of managing Chagas disease in its advanced chronic phase, particularly in older patients with significant visceral involvement, and invites us to reflect on the challenges and limitations of treatment with benznidazole in these circumstances.
Benznidazole is currently recommended in cases of acute Chagas disease, congenital infections or reactivations related to immunosuppression, as well as in chronic infections in children and women of childbearing potential.2 However, evidence regarding its efficacy in chronic disease progression is limited. Several clinical trials have shown that benznidazole does not significantly prevent disease progression or death in patients with advanced Chagas cardiomyopathy.3 Although there is even less available data on its impact on gastrointestinal disease in Chagas, extrapolating the results in patients with advanced cardiac involvement, we can deduce that its utility in the progression of gastrointestinal disease would also be limited.
The case reported also raises a common clinical challenge: balancing the potential benefits of antiparasitic treatment with the associated risks, particularly in older patients with irreversible organ damage. Available evidence suggests that, in the advanced chronic phase, treatment with benznidazole has limitations not only in terms of efficacy4 but also in terms of its tolerance. A recent meta-analysis suggests that adverse effects, especially dermatological, gastrointestinal and neurological, are more common and severe in older patients.5
For all these reasons, current guidelines recommend personalising the therapeutic strategy in patients with advanced Chagas disease. Factors such as age, general clinical condition and the potential impact of treatment on quality of life must be carefully considered to ensure a personalised and safe approach. In line with the recommendations of the World Health Organization, treatment in the chronic phase should be prioritised in patients with a lower risk of adverse events and a higher likelihood of therapeutic response.2 This approach makes it possible to optimise the benefits of treatment and minimise its risks, especially in vulnerable populations, such as older adults with irreversible organic damage.
This case also highlights the importance of early diagnosis and screening in at-risk populations. The prolonged period since the onset of constipation in this patient raises the question of whether a timely diagnosis of Chagas disease, before the appearance of obvious symptoms, would have allowed early treatment to be started and prevented progression to advanced stages with irreversible organic damage. Identifying and treating the infection in its early stages is essential to improve the clinical prognosis and prevent severe complications in these patients.
To offer patients with chronic Chagas disease the best therapeutic option, comprehensive approaches that combine symptomatic management with treatments tailored to each patient’s specific needs must be developed. Furthermore, it is crucial to promote research aimed at identifying biomarkers that can better predict response to treatment and design safer and more effective regimens, especially for the most vulnerable populations.
As the authors of the case report pointed out, “every late diagnosis is a lost opportunity”.1 Cases like this invite us to reflect on the importance of optimising care and diagnosis to improve outcomes in patients with advanced Chagas disease.
Declaration of Generative AI and AI-assisted technologies in the writing processDuring the preparation of this work the authors used ChatGPT to correct spelling and grammatical errors and to improve the clarity and readability of the article. After using this tool/service, the authors reviewed and edited the content as necessary and take full responsibility for the contents of the publication.
