Nutritional Status Evaluation of a Critically Ill Patient with Chagasic Cardiopathy Treated in an Intensive Care Unit in Santo Antonio de Jesus, Bahia, Brazil: A Case Report

Background: Malnutrition at hospital admission has negative impact on clinical outcomes such as patients’ hospital length of stay, rehospitalization and death. The aim of the current study is to present a case report describing the nutritional status of a critically ill patient with chagasic heart disease who was hospitalized in the intensive care unit of a hospital in Santo Antonio de Jesus County, Bahia State. Methods: Socioeconomic data, laboratory exams, anthropometric parameters and objective measurements such as Prognostic Nutritional Index, Nutritional Risk Index and Controlling Nutritional Status were taken of the patient in the current study is a 62-year-old with chronic Chagas’ cardiomyopathy present electrocardiographic abnormalities with progressive myocardial injury, heart failure or dilated cardiomyopathy pattern when hospitalized in the intensive care unit. Results: Laboratory exams were associated with severe cardiac impairment, decompensation and myocardial damage. Nutritional indicators, such as arm circumference, elbow width, body mass index, serum albumin, lymphocyte count, Prognostic Nutritional and Nutritional Risk Indexes and Controlling Nutritional Status showed a poor nutritional prognosis. Conclusion: There are no formal guidelines for follow-up screening directed specifically at Chagas cardiomyopathy. The present case study corroborates the relevance of as sessing plasma albumin levels, Prognostic Nutritional and Nutritional Risk Indexes and Controlling Nutritional Status to predict the poor prognosis in critically ill patient with Chagasic heart disease.


Introduction
Chagas disease (Human American trypanosomiasis) is an infection caused by protozoan parasite species Trypanosoma cruzi. According to estimates, approximately 10 million people worldwide are currently infected with T. cruzi. Chagas disease remains a major public health issue in Brazil. Approximately 2-3 million individuals are infected with this parasite and ~ 6,000 deaths are recorded on a yearly basis due to it [1]. According to a descriptive cross-sectional study (2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015)(2016)(2017)(2018) conducted in HEMOBA (Hematology and Hemotherapy Foundation of Bahia) database, T. cruzi infection recorded higher in-

Abstract
Background: Malnutrition at hospital admission has negative impact on clinical outcomes such as patients' hospital length of stay, rehospitalization and death. The aim of the current study is to present a case report describing the nutritional status of a critically ill patient with chagasic heart disease who was hospitalized in the intensive care unit of a hospital in Santo Antonio de Jesus County, Bahia State.
Methods: Socioeconomic data, laboratory exams, anthropometric parameters and objective measurements such as Prognostic Nutritional Index, Nutritional Risk Index and Controlling Nutritional Status were taken of the patient in the current study is a 62-year-old with chronic Chagas' cardiomyopathy present electrocardiographic abnormalities with progressive myocardial injury, heart failure or dilated cardiomyopathy pattern when hospitalized in the intensive care unit. Check for updates cidence in 30-year-old individuals (or older) and in individuals with up to 12-year schooling in Bahia State (Brazil) -seroprevalence was significantly higher in men [2].

Results
More than 10,000 individuals die from chronic clinical manifestations every year, mainly from Chagasic cardiopathy, which is a dilated and arrhythmogenic cardiomyopathy whose subacute, although constant, chronic inflammatory process often leads to progressive heart tissue destruction and to extensive fibrosis [3]. Patients with chronic Chagas cardiomyopathy have shown poorer prognosis than patients with Idiopathic Dilated Cardiomyopathy. In addition, Bambuí (Minas Gerais State, Brazil) Project has observed the coexistence of chronic Chagas disease and poor nutritional status, as well as reduced fat tissue reserve and muscle mass, in elderly individuals who lived in a Chagas disease-endemic area [4].
Heart failure (HF) worsens health-related quality of life; early identification of malnutrition can enable early nutritional intervention and better clinical outcomes. Malnutrition at hospitalization time has negative impact on clinical outcomes such as patients' hospital length of stay, rehospitalization and death. Therefore, it is essential identifying the risk of cardiovascular disease development and conducting early risk stratifications to enable the effective application of risk-reduction strategies [5,6].
With no formal guidelines for follow-up screening directed specifically at Chagas cardiomyopathy [7], the aim of the current study is to present a case study describing the nutritional status of a critically ill patient with Chagasic heart disease at the time of his admission to the intensive care unit of a hospital in Santo Antonio de Jesus County, Bahia State.

Case Description
The patient in the current study is a 62-year-old Af-rican Brazilian, illiterate and retired male farmer, who does not live alone, is married, father of six children and lives with monthly income of two minimum wages. He has been a former-smoker and recovering alcoholic for fifteen years and reported to not exercise. He was admitted to the Emergency Care Unit of a hospital in Maragogipe County, Bahia State, due to heart failure resulting from dilated cardiomyopathy of dilated Chagasic etiology. He complained about having respiratory distress and anasarca for two weeks, which had progressively worsened despite the use of medication. He presented paleness, chest pain, lucidity, orientation in time and space, dyspnea, lack of fever, hypotension, spontaneous diuresis, normal dejections and lack of appetite. Electrocardiogram has shown dilated cardiomyopathy with enlarged left ventricle, left ventricular ejection fraction (LVEF by Simpson's rule 31%); diffuse hypokinesia, pseudonormal diastolic dysfunction of the left ventricle, slightly increased cardiac cameras, mild systolic dysfunction in the right ventricle, mild mitral regurgitation and mild pulmonary hypertension.
The patient was hospitalized in the intensive care unit of a hospital in Santo Antonio de Jesus County, Bahia State on December 05 th , 2019. Although he was oriented in time and space, he presented moderate respiratory distress, dyspnea at rest and anasarca. He was diagnosed with congestive heart failure, acute pulmonary edema and renal dysfunction. On December 06 th , 2019, he was invited to participate in the project "study on the prevalence of malnutrition in cardiopathic patients admitted in hospital located in Santo Antônio de Jesus, Bahia". The study was approved by the Ethical Committee of our institution (approval number: 97118618.2.0000.0056/2018). The participant was assessed after he signed the Informed Consent Form. Data collected to assess patient's nutritional status are described in Table 1 and Table 2. have found robust independent association between low plasma albumin and cardiovascular disease, which was partly explained by plasma albumin action as negative acute-phase reactant. The present case study corroborates the relevance of assessing plasma albumin levels in critically ill patient with Chagasic heart disease.
The current study did not collect any data about patient's weight and dietary changes, as well as about his functional capacity and physical assessment. Consequently, it was not possible performing the Nutritional Risk Screening (NRS), the Subjective Global Assessment (SGA) and/or the Mini Nutritional assessment (MNA). Clear evaluation criteria, universally accepted definitions, and a gold-standard methodology for using nutritional status to predict adverse outcomes remain to be established [14]. For that reason, Prognostic Nutritional Index (PNI, based on albumin and lymphocytes), Nutritional Risk Index (NRI, based on albumin and usual body weight percentage) and Controlling Nutritional Status (CONUT, based on albumin, lymphocytes and total cholesterol) [5] were adopted in the current case study. PNI, NRI and CONUT are objective measurements used to assess the nutritional status and to predict the poor prognosis of hospitalized patients.
Although not yet validated for heart failure cases resulting from dilated cardiomyopathy of Chagasic etiology, PNI, NRI and CONUT are coherent with arm circumference, elbow width, body mass index and APACHE II results to nutritional risk observed.

Conclusions
Despite the poor nutritional prognosis, the patient

Discussion
According to the I Latin American Guidelines for the Diagnosis and Treatment of Chagas' Heart Disease [8], many patients with chronic Chagas' cardiomyopathy present electrocardiographic abnormalities with progressive myocardial injury, heart failure or dilated cardiomyopathy pattern. The clinical description in the present report features disease between stages C (patients with left ventricular dysfunction and HF symptoms -NYHA I, II, III and IV) and D (patients with NYHA IV requiring specialized and intensive interventions). In addition, the algorithm used for risk stratification in the chronic Chagas disease stage [8] has shown high mortality risk due to abnormal electrocardiogram results. APACHE II scoring [9] and nutritional status evaluation has confirmed the severity of the case.
The patient is retired, married and does not live alone, a fact that diminishes the lack of interest in preparing meals and eating food [6]. However, he is a former smoker and recovering alcoholic. His old lifestyle, in association with his place of residence (countryside) and low socioeconomic level, can worsen Chagas disease, mainly the cardiac form of it [10].
Laboratory exams did not show anemia, although it is often diagnosed in approximately one third of congestive heart failure patients. However, higher urea, alanine transaminase, bilirubin serum concentrations, leukopenia (rare), activated partial thromboplastin time, gamma-glutamyl transferase and lactate dehydrogenase are typical of severe cardiac impairment and decompensation, hepatobiliary dysfunction, prothrombotic state and myocardial damage in chronic chagasic patients, respectively [11]. Lower lymphocyte and albumin levels have indicated likely inadequate diet, as well  in the current study was successfully treated. He was discharged from the intensive care unit and taken to the medical clinic on December 08 th , 2019. Three days later, on December 11 th , 2019, he was discharged from the hospital after he received medical and nutritional guidelines.