Correspondence

Treatment of Achalasia in Chagas' Disease with Botulinum Toxin

N Engl J Med 1995; 332:824-825March 23, 1995

Article

To the Editor:

Chagas' disease, which is common in Brazil, often involves the esophageal neural plexus, resulting in clinical, manometric, and histologic findings resembling those of achalasia. Therefore, its management could be similar.

Patients with achalasia or Chagas' disease involving the esophagus may be treated with drugs, endoscopic dilation, or surgery. Pasricha et al.1 described the successful treatment of achalasia by the endoscopic injection of botulinum toxin into the lower esophageal sphincter; their initial report has now been confirmed by their more extensive studies [reported in this issue of the Journal 2]. We used the same technique to treat a patient who had esophageal dysfunction caused by Chagas' disease.

The patient was a 40-year-old woman who had dysphagia, positive serologic tests for Chagas' disease, and esophageal dilatation on esophagography. Radionuclide imaging after the ingestion of 0.5 mCi (18.5 MBq) of ^99mTc-pertechnetate diluted in 3 ml of water demonstrated slow esophageal clearance (disappearance from the esophagus of 40 percent of the radionuclide in 330 seconds). The patient had no other manifestations of Chagas' disease (i.e., she had a normal heart rate, normal chest film and electrocardiogram, and normal bowel movements). Twenty units of botulinum toxin were injected into each quadrant of the inferior esophageal sphincter. The patient's dysphagia improved promptly, and radionuclide imaging performed one week after the injections revealed more rapid esophageal clearance (58 percent in 330 seconds). Three months after the injections the patient was eating well but had more dysphagia than was present soon after the treatment.

Botulinum toxin should be considered in the treatment of esophageal dysfunction in patients with Chagas' disease.

Angelo P. Ferrari, Jr., M.D.
Eduardo S. Siqueira, M.D.
César Q. Brant, M.D.
Escola Paulista de Medicina, 04044-001 São Paulo, Brazil

2 References

1. 1

   Pasricha PJ, Ravich WJ, Kalloo AN. Botulinum toxin for achalasia. Lancet 1993;341:244-245
   CrossRef | Web of Science | Medline

2. 2

   Pasricha PJ, Ravich WJ, Hendrix TR, Sostre S, Jones B, Kalloo AN. Intrasphincteric botulinum toxin for the treatment of achalasia. N Engl J Med 1995;332:774-778
   Full Text | Web of Science | Medline

Citing Articles (12)

Citing Articles

1. 1

   Deog Young Kim, Chang-il Park, Suk Hoon Ohn, Ja Young Moon, Won Hyuk Chang, Seung-woo Park. (2006) Botulinum Toxin Type A for Poststroke Cricopharyngeal Muscle Dysfunction. Archives of Physical Medicine and Rehabilitation 87:10, 1346-1351
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2. 2

   C. Brant, J. P. P. Moraes-Filho, E. Siqueira, A. Nasi, E. Libera, M. Morais, M. Rohr, E. P. Macedo, G. Alonso, A. P. Ferrari. (2003) Intrasphincteric botulinum toxin injection in the treatment of chagasic achalasia*. Diseases of the Esophagus 16:1, 33-38
   CrossRef

3. 3

   Eduardo B. V. da Silveira, Arvey I. Rogers. (2002) Treatment of Achalasia with Botulinum A Toxin. American Journal of Therapeutics 9:2, 157-161
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4. 4

   Eduardo B. V. Silveira, Arvey I. Rogers. (2002) Achalasia: A review of therapeutic options and outcomes. Comprehensive Therapy 28:1, 15-22
   CrossRef

5. 5

   Ricardo Vitor Cohen, T??lio Marcos Rodrigues da Cunha, Frederico Aun, Carlos Aur??lio Schiavon. (2001) Chagas Disease: Esophageal, Colonic, and Other Manifestations. Problems in General Surgery 18:4, 27-36
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6. 6

   Álvaro Antônio Bandeira Ferraz, Balduı́no Guedes Nóbrega, Carlos Augusto Mathias, Tércio Souto Bacelar, Francisco Eduardo de Albuquqerque Lima, Edmundo Machado Ferraz. (2001) Late results on the surgical treatment of Chagasic megaesophagus with the Thal-Hatafuku procedure. Journal of the American College of Surgeons 193:5, 493-498
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7. 7

   Joachim H. Schneider, Jeffrey H. Peters, Erlinda Kirkman, Cedric G. Bremner, Tom R. DeMeester. (1999) Are the motility abnormalities of achalasia reversible? An experimental outflow obstruction in the feline model. Surgery 125:5, 498-503
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8. 8

   C. Quintao Brant, Siqueira, Ferrari. (1999) Botulinum toxin for oropharyngeal dysphagia: case report of flexible endoscope-guided injection. Diseases of the Esophagus 12:1, 68-73
   CrossRef

9. 9

   Quintao Brant, Nakao, Ardengh, Nasi, Ferrari. (1999) Echoendoscopic evaluation of botulinum toxin intrasphincteric injections in Chagas' disease achalasia. Diseases of the Esophagus 12:1, 37-40
   CrossRef

10. 10

    Ricardo Brandt Oliveira, LuizErnestoA. Troncon, RobertoOliveira Dantas, UlyssesG. Meneghelli. (1998) Gastrointestinal manifestations of chagas' disease. The American Journal of Gastroenterology 93:6, 884-889
    CrossRef

11. 11

    Jacob C. Langer, Elisa E. Birnbaum, Robert E. Schmidt. (1997) Histology and Function of the Internal Anal Sphincter after Injection of Botulinum Toxin. Journal of Surgical Research 73:2, 113-116
    CrossRef

12. 12

    Cohen, Sidney, Parkman, Henry P., . (1995) Treatment of Achalasia — From Whalebone to Botulinum Toxin. New England Journal of Medicine 332:12, 815-816
    Full Text