A 40-year-old man from rural Bihar has chronic heart failure with a large apical left ventricular aneurysm on echocardiography. He previously lived in mud houses with exposure to triatomine bugs. Serology shows positive IgG against Trypanosoma cruzi. Which structural feature is most characteristic of this cardiomyopathy?

• A Asymmetric interventricular septal hypertrophy
• B Diffuse subendocardial fibrosis of both ventricles
• C Apical aneurysm with mural thrombus ✓
• D Right ventricular dysplasia with fatty infiltration

Explanation

Chagas cardiomyopathy characteristically produces an apical aneurysm with overlying mural thrombus, a source of embolic stroke, along with conduction abnormalities such as right bundle branch block. Asymmetric septal hypertrophy defines hypertrophic cardiomyopathy, diffuse endomyocardial fibrosis describes EMF/Loffler endocarditis, and RV fatty infiltration defines arrhythmogenic cardiomyopathy. Indian exam convention accepts apical aneurysm as the hallmark of chronic Chagas disease.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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