SciELO - Scientific Electronic Library Online

vol.61Hantavirus pulmonary syndrome in children: case report and case series from an endemic area of BrazilSpatial analysis of leishmaniasis in Brazil: a systematized review índice de autoresíndice de assuntospesquisa de artigos
Home Pagelista alfabética de periódicos  

Serviços Personalizados




Links relacionados


Revista do Instituto de Medicina Tropical de São Paulo

versão On-line ISSN 1678-9946

Rev. Inst. Med. trop. S. Paulo vol.61  São Paulo  2019  Epub 20-Dez-2019 


Lingual salivary gland hypertrophy and decreased acinar density in chagasic patients without megaesophagus

Bárbara Bellocchio Bertoldo1 

Renata Margarida Etchebehere2 

Taíssa Cássia de Souza Furtado3 

Juliana Barbosa de Faria1 

Camilla Beatriz Silva4 

Márcia Fernandes de Araújo1 

Denise Bertulucci Rocha Rodrigues1  3  4  5 

Sanivia Aparecida de Lima Pereira1  3  4  5

1Universidade Federal do Triângulo Mineiro, Programa de Pós-Graduação em Ciências da Saúde, Uberaba, Minas Gerais, Brazil

2Universidade Federal do Triângulo Mineiro, Curso de Pós-Graduação em Ciências da Saúde, Uberaba, Minas Gerais, Brazil

3Universidade de Uberaba, Programa de Mestrado em Odontologia, Uberaba, Minas Gerais, Brazil

4Universidade de Uberaba, Laboratório de Biologia Celular e Molecular, Uberaba, Minas Gerais, Brazil

5Universidade Federal do Triângulo Mineiro, Centro de Educação Profissional (Cefores), Uberaba, Minas Gerais, Brazil


Although the salivary glands present several functions, there are few studies evaluating these glands in Chagas disease (CD). This study aimed to compare the percentage of collagen, the presence of inflammation, the density of chimase and tryptase mast cells, the area and density of lingual salivary gland acini in autopsied individuals with and without (CD). We analyzed 400 autopsy reports performed in a tertiary public hospital from 1999 to 2015 and selected all the cases in which tongue fragments were collected (27 cases), 12 with chronic CD without megaesophagus (CH) and 15 without CD (non-chagasic - NC). The histological sections of the tongue were stained by Picrosirius red for collagen evaluation and Hematoxylin-eosin for morphometric evaluation of salivary gland acini and inflammation. Anti-chimase and anti-tryptase antibodies were used for the immunohistochemical evaluation of mast cells. The chagasic patients presented higher volume and lower density of salivary glands acini. There was no difference in the collagen percentage, inflammation and density of mast cell chymase and tryptase between the groups. Although we did not observe a significant difference between the groups regarding the collagen percentage, inflammatory process and mast cell density, our results suggest that even without megaesophagus, chagasic patients present hypertrophy of the lingual salivary glands and lower acinar density probably due to mechanisms independent of the esophagus-glandular stimulus.

Key words: Acinar density; Chagas disease; Megaesophagus; Morphometry; Salivary glands; Tongue


Chagas disease (CD), described by Carlos Chagas (1909), is caused by the monophlagetic protozoan Trypanosoma cruzi and is transmitted to man by the triatomine insect ( Triatoma infestans )1 . Approximately 6 to 7 million people are estimated to be infected worldwide, most of them in Latin America. CD is responsible for the high morbidity and mortality rate in endemic countries, including Brazil2 .

It has been demonstrated, in the acute phase of CD, that the lingual salivary glands present disorganized parenchyma with alterations in the acini and presence of amastigotes in the acinar and ductular cells, in the interacinar connective tissue and in the acinar lumen3 . On the other hand, it has already been demonstrated, in the chronic phase of CD, dilation of parotid glands4 , submandibular glands and sublingual glands5 . Similarly, a study by our group showed that the lingual salivary glands of patients with chronic CD present a higher number of alterations when compared to non-chagasic patients, such as ductal dilation, inflammatory infiltrate, perineuritis and myositis6 .

Patients with chronic CD may have megaesophagus due to the destruction of Meissner’s and Auerbach’s intramural nerve plexuses of the esophagus with consequent decrease in peristalsis and failure of the lower sphincter in response to swallowing. Consequently, esophageal stasis, ataxia, dilation and decreased esophageal contraction capacity occur7 . In chagasic patients with megaesophagus, there is an increase in the sensitivity of the salivary glands to all secretory stimuli, from chewing to pharmacological stimulation by pilocarpine. This hypersensitivity was attributed to the impairment of innervation in these glands, triggering hypersalivation and consequent salivary gland hypertrophy, which are common manifestations of all obstructive esophagopathies due to the difficulty of food transit in the esophagus3 , 8 .

It is known that saliva plays an essential role in the maintenance of health, such as lubrication of the oral tissues, antimicrobial action, maintenance of mucosal integrity, cleaning, dental remineralization, digestion and phonation9 , besides contributing to the formation of film acquired through the adsorption of salivary glycoproteins that protect teeth from chemical and mechanical aggressions10 . A study performed on parotid gland biopsies of individuals with chronic CD and megaesophagus showed glandular hypertrophy, fibrosis, inflammatory infiltrate and dilation of salivary gland ducts4 .

However, there have been few studies evaluating the salivary glands in CD, and our team was the pioneer in the investigation of lingual salivary glands in response to T. cruzi infection6 . However, the involvement of the salivary glands in CD has not yet been fully clarified. In the present study, we hypothesized that the salivary glands of patients with CD have a higher presence of inflammation, a greater density of chymase and tryptase mast cells, and a larger acini area and lower acinar density.

Therefore, the aim of the present study was to compare the percentage of collagen, the inflamatory response, the density of chymase and tryptase mast cells and the area and density of lingual salivary glands acini in autopsied individuals with or without CD.


This study was approved by the Human Research Ethics Committee of the University of Uberaba (UNIUBE), protocol Nº CAAE 64945517.1.0000.5145. This is a cross-sectional study with the analysis of 400 autopsy reports performed at the Clinical Hospital of the Federal University of Triangulo Mineiro (UFTM) from 1999 to 2015. During this analysis, all CD patients without megaesophagus that had tongues collected during autopsy (CH) (n = 12) and 15 patients without CD (NC), totaling 27 cases were selected.

Inclusion criteria for the CD group were three positive serology tests in pericardial fluid collected during autopsy (complement fixation, indirect immunofluorescence and hemagglutination). CD patients with megaesophagus were excluded to rule out the possibility of mechanical interference in salivation. In the NC group, the exclusion criterion was the diagnosis of infectious diseases or any esophageal disease.

Tongue fragments in the region of the lingual salivary glands were evaluated. Paraffin blocks containing tongue fragments were serially cut into four sections measuring about 5 µm thick. Subsequently, they were placed on glass slides and stained by the hematoxylin-eosin method to evaluate the presence of inflammation and to perform the morphometric analysis of acini. Then, sections were also stained by the Picrosirius red for collagen evaluation. The other two slides were salinized for immunohistochemical analysis of mast cells chimase and tryptase.

Morphometric analysis of collagen

For the morphometric evaluation of collagen, an Axio 4.1 common light microscope (Zeiss, Berlin, Germany), 20 X objective, polarizing filter, AxioCam image capture camera (Zeiss, Berlin, Germany) as well as a computer and Axiovision 4.8 software (Zeiss, Berlin, Germany) were used. This analysis was performed in all the fields in which lingual salivary glands were observed, both in the interacinar and submucosal regions. The images were transmitted to the computer monitor. In the polarized image, the collagen presented birefringence with yellowish, reddish or greenish coloration, being semi-automatically quantified.

Morphometric evaluation of salivary gland acini

For the morphometric evaluation of the salivary gland acini area, an Axio 4.1 common light microscope with a 20 X objective and an AxioCam color video camera connected to a video capture card in a computer with ImajeJ software (National Institutes of Health, Bethesda, USA) were used. To determine the area occupied by each gland, the contour of each acinus was determined with the aid of a cursor. This analysis was performed in all fields in which lingual salivary glands were observed.

To assess the acinar density, initially, acini counts were performed in all of the fields of the fragment. Then the total area evaluated was calculated by multiplying the area of each field (0.31 mm2 ) by the number of evaluated fields. Considering the number of acini and total area, the acinar density was determined and expressed in mm2 .

Immunohistochemical analysis

For immunohistochemical evaluation of mast cells anti-tryptase antibodies (1:20; R&D, Minesota, USA) and anti-chimase antibodies (1: 2000; R&D, Minesota, USA) were employed in peroxidase-conjugated Avidin-Biotin techniques (DAKO, Carpinteria, USA).

As some cases presented fragments with only 10 evaluable fields, the evaluation was standardized considering 10 high-magnification fields for all cases. Immunolabeled mast cells were counted using a 40 X objective and a common light microscope. In the slides where there were more than 10 evaluable high-magnification fields, the 10 fields with the highest number of immune-labeled mast cells were selected.

Inflammatory infiltrate assessment

Regarding inflammatory infiltrates, an Axio 4.1 common light microscope was used to evaluate all the fields in which salivary glands were present. The inflammatory infiltrate was initially classified as: a) present or absent; b) superficial: when present in the submucosa; deep: when it was located among salivary acini. The inflammatory infiltrate was classified as absent (0), mild (1), moderate (2) and intense (3) according to the amount of inflammatory cells present in the tissue11 , 12 . Due to the low frequencies, during the statistical analysis, we have arbitrarily chosen to group the mild (1) and absent (0) cases, which were then classified as 0 (mild + absent = 0), aside from the moderate (2) and intense (3) cases, that were also grouped and classified as 1 (moderate + intense = 1).

Statistical analysis

Data were entered into a Microsoft Excel spreadsheet and analyzed using GraphPad Prism 7 statistical software (GraphPad, San Diego, California, USA). To compare the variables with non-normal distributions between two groups, the Mann Whitney test was performed. For qualitative variables (male/female; Caucasian/non-Caucasian) the Fisher exact test was used. To compare the ages in both groups, the Student’s “t” test was used and the results were expressed as mean and standard deviation. The assumed significance level was 5% (p <0.05).


Demographic data of the groups of individuals with Chagas disease (CH) and without Chagas disease (NC) are shown in Table 1 .

Table 1 Demographic characteristics of individuals with and without Chagas disease 

CH Group (n = 12) NC Group (n=15)
Ethnicitya (Caucasian: Non-Caucasian) 11:1 (91.6%: 8.3%) 13:2 (86.6%:16.6%)
Genderb (Male: Female) 7:5 (58.3%: 41.6%) 10:5 (66.6%:33.3%)
Agec (Years: Mean ± SD) 68.23 ± 2.87 59.36 ± 3.36

CH Group: Chagas disease patients; NC Group: patients without Chagas disease; SD: Standart desviation; aFisher exact test (p = 1.0); bFisher exact test (p = 0.70); cStudent t test (p = 0.79).

The acini area of lingual salivary glands was significantly larger in the CH group when compared to the NC group (p < 0.0001) ( Figure 1A ).

Figure 1 - Area and density of lingual salivary glands of individuals with Chagas disease (CH) and without Chagas disease (NC). A) Acini area, Mann-Whitney test; p <0.0001; B) Acini density, Mann-Whitney test; p = 0.0016 (B). 

The individuals in the CH group had lower acini densities compared to the NC group (p = 0.0016) ( Figure 1B ).

No significant difference in collagen percentages were observed between CH and NC groups (p = 0.4987) ( Figures 2A , 2B , 2C and 2D ).

Figure 2 Presence of collagen in the lingual salivary glands of individuals with Chagas disease (CH) and without Chagas disease (NC). A) and B): CH group: in A) common light microscopy; in B) polarized light (yellowish-orange refringent collagen); C) and D): NC group: in C) common light microscopy; in D) polarized light (yellowish-orange refringent collagen) (Hematoxylin and Eosin and Picrosirius red, 400 X). 

There was no significant difference between the groups regarding the immunostaining for chimase and tryptase mast cells ( Figures 3A , 3B , 3C and 3D ).

Chronic inflammatory infiltrates were present in both, the interacinar and submucosal regions, with no significant difference between the groups regarding location (p = 0.7152) and presence of infiltrates (p = 1.0) ( Figures 4A , 4B , 4C and 4D ).

Figure 4 Mononuclear inflammatory infiltrate permeating acini from lingual salivary glands and in the submucosal region of the tongue in individuals with Chagas disease (CH) and without Chagas disease (NC). Inflammatory infiltrate permeating the acini in an individual from a CH group (A) and from a NC group (B); mononuclear inflammatory infiltrate in the submucosal region from a CH group (C) and a NC group (D) (Hematoxylin and Eosin, 400 X). 


Although an increase in the acini area of rat submandibular glands has been demonstrated in the acute phase of CD13 , glandular hypertrophy is more common in the chronic phase of the disease. Studies performed on parotid glands have demonstrated the presence of hypertrophy in chronic chagasic patients with megaesophagus14 , 15 . It is known that in patients with megaesophagus, the difficulty of food passage may cause reflex stimulation in the lingual salivary glands with consequent increase of saliva production and glandular hypertrophy3 .

Although we did not find in the literature a description of increased volumes of lingual salivary gland acini in patients with non-digestive form of CD, in the present study we observed a higher volume of lingual salivary gland acini in chagasic patients when compared to non-chagasic patients. Chagasic patients with megaesophagus have already been shown to present increased sensitivity of the salivary glands to all secretory stimuli, from chewing to pharmacological stimulation by pilocarpine, which occurs due to impaired innervation of these glands8 . Thus, we believe that this hypersensitivity occurs in all chagasic patients, even those without megaesophagus, probably due to stimuli triggered by T. cruzi antigens, which would justify the acinar hypertrophy observed in the lingual salivary glands of chagasic patients without megaesophagus in the present study.

We have also observed a lower density of lingual salivary gland acini in chagasic patients compared to non-chagasic patients. Although a reduction in acinar density of salivary glands has already been described in other diseases such as diabetes16 and Sjogren’s syndrome17 , we did not find studies that evaluated the acin density of salivary glands in chagasic patients. However, we believe that the decrease in acinar density in chagasic patients was due to glandular acini hypertrophy that occupied a larger area of the tissue.

Increased collagen deposition is common in chronic diseases, which is stimulated by fibroblast growth factor (FGF) and secreted extracellular matrix, contributing to healing. Under the influence of transforming growth factor-β1 (TGF-β1), fibroblasts differentiate into myofibroblasts, expressing the smooth muscle actin. Thus, in addition to collagen synthesis, fibroblasts are able to contract, shrinking scar tissues, because they have actin filaments associated with myosin18 . In chronic disease, inflammation is intense resulting in more extensive scarring.

Since CD is a chronic disease, we hypothesized that there would be higher collagen deposition in the lingual salivary glands as already shown in other organs, such as the myocardium1 , the esophagus19 , the colon20 and in the tongue21 . However, in the present study there was no significant difference in the percentage of collagen between groups. Thus, we believe that in chagasic patients, the increment in acini volume of lingual salivary glands leads to collapse and overlaping of the inter-acinar collagen fibers, impairing the analysis. In addition, increased acinar volumes would cause vascular compression and ischemia, as has already been demonstrated with subsequent fibroblast hypotrophy. Thus, the hypotrophic fibroblasts would deposit small diameter collagen fibers.

Mast cells are hematopoietic cells involved in inflammatory response, granulation tissue formation, wound healing, angiogenesis, tissue remodeling22 , allergic reactions, innate and adaptive T cell-mediated immune responses as well as chronic inflammation23 - 25 . Although several studies have already shown that in CD there is an increase in the number of mast cells and a higher intensity of inflammation in organs such as the heart26 , esophagus27 , colon20 and in the submucosa and tongue musculature21 , we did not find significant differences regarding the density of chimase or tryptase mast cells or the presence of inflammation in the lingual salivary glands when chagasic and non-chagasic individuals were compared.

Thus, as we did not find differences regarding the intensity of inflammation, mast cell density and percentage of collagen between the groups, we believe that the inflammatory response to T. cruzi in the lingual salivary glands behaves differently than already shown in other organs. Furthermore, we suggest that the same stimulus that cause hypertrophy of lingual salivary glands in chagasic patients without megaesophagus could also be acting on other glands with consequent hormonal overproduction and dysregulation of chagasic patients homeostasis.

Therefore, although a significant difference between groups regarding collagen percentage, inflammatory process and mast cell density was not observed, our results suggest that, even without megaesophagus, chagasic patients present hypertrophy of lingual salivary glands and lower acinar density probably due to mechanisms independent of esophageal-glandular stimulation. However, further studies are needed to better understand the pathogenesis of chronic CD in lingual salivary glands.

Figure 3 - Chimase mast cells and tryptase mast cells in the lingual salivary glands of individuals with Chagas disease (CH) and without Chagas disease (NC). Positive immunostaining for chimase in a CH group (A) and in a NC group (B); positive tryptase immunostaining in a CH group (C) and in a NC group (D) (Immunohistochemistry, 400 X). 


1. Simões MV, Romano MM, Schmidt A, Martins KS, Marin-Neto JA. Chagas disease cardiomyopathy. Int J Cardiovasc Sci. 2018;31:173-89. [ Links ]

2. Dias JC, Cláudio LD, Lima MM, Albajar-Viñas P, Silva RA, Alves RV, et al. Changes in the paradigm of clinical and therapeutic management of Chagas’ disease: progress and perspectives in the pursuit of comprehensive health. Epidemiol Serv Saude. 2016;25 N Esp:87-90. [ Links ]

3. Albuquerque S, Lopes RA, Ribeiro RD, Abrahão AA, Sala MA. Estudo morfométrico das glândulas salivares linguais de von Ebner de camundongos infectados com a cepa RAL de Trypanosoma cruzi, em função do sexo. Investigação. 2007;7:61-7. [ Links ]

4. Vieira CB, Hadler WA. Estudo histológico da glândula parótida e do pâncreas no megaesôfago. Rev Assoc Med Bras. 1961;7:89-96. [ Links ]

5. Martini AS, Lopes RA, Ribeiro RD, Utrilla LS, Reis CC. Histopathological study of the major salivary glands in Trypanosoma cruzi infected mice. Ann Parasitol Hum Comp. 1989;64:512-5. [ Links ]

6. de Lima Pereira SA, Rodrigues DB, Fonseca Ferraz ML, Cunha Castro EC, Reis MA, Paula Antunes Teixeira V. Inflammation and glandular duct dilatation of the tongue from patients with chronic Chagas disease. Parasitol Res. 2006;98:153-6. [ Links ]

7. Kamiji MM, Oliveira RB. O perfil dos portadores de doença de Chagas, com ênfase na forma digestiva, em hospital terciário de Ribeirão Preto, SP. Rev Soc Bras Med Trop. 2005;38:305-9. [ Links ]

8. Rezende JM. O aparelho digestivo na doença de Chagas: aspectos clínicos. In: Dias JC, Coura JR, organizadores. Clínica e terapêutica da doença de Chagas: uma abordagem prática para o clínico geral. Rio de Janeiro: Fiocruz; 1997. p.153-76. [ Links ]

9. Llena-Puy C. The rôle of saliva in maintaining bucal health and as an aid to diagnosis. Med Oral Patol Oral Cir Bucal. 2006;11:E449-55. [ Links ]

10. Edgar WM. Saliva: its secretion, composition and functions. Br Dent J. 1992;172:305-12. [ Links ]

11. Reis LG, Almeida EC, Silva JC, Pereira GA, Barbosa VF, Etchebehere RM. Tonsillar hyperplasia and recurrent tonsillitis: clinical-histological correlation. Braz J Otorhinolaryngol. 2013;79:603-8. [ Links ]

12. Silva JH, Almeida EC, Sousa JC, Reis LG, Sousa JB, Etchebehere RM. Tonsillar hyperplasia and recurrent acute tonsillitis in children: immunohistochemical evaluation of the lymphatic tissue. Int J Pediatr Otorhinolaryngol. 2019;121:15-9. [ Links ]

13. Alves JB, Ulrich-Karine MC, Alves MS. Morphology of rat submandibular gland acinar secretory granules and their alteration during the acute phase of experimental Chagas’ disease. Braz J Med Biol Res. 1995;28:761-6. [ Links ]

14. Silva AL, Salles JM, Almeida HM, Castro MH. Sialografia da glândula parótida em pacientes portadores de megaesôfago chagásico. Arq Cent Estud Cur Odont. 1976;13:137-47. [ Links ]

15. Vieira CB, Câmara-Lopes LH, Menegucci W. Variações de volume das glândulas salivares e da amilasemia em pacientes com megaesôfago chagásico operado. Rev Goiana Med. 1962;8:11-9. [ Links ]

16. Alves AM, Buttow NC, Christmann C, Yamamoto E, Mello JM, Prado MA, et al. Resveratrol atenua a atrofia e a perda de ácinos da glândula salivar parótida de ratos com diabetes crônico. Rev Uningá. 2017;30:6-10. [ Links ]

17. Barcellos KS, Andrade LE. Histopatologia e imunopatologia de glândulas salivares menores de pacientes com síndrome de Sjögren (SSj). Rev Bras Reumatol. 2005;45:215-23. [ Links ]

18. Lowe JS, Anderson PG. Stevens & Lowe’s human histology. 4nd ed. Philadelphia: Elsevier; 2015. [ Links ]

19. Aquino JL, Said MM, Leandro-Merhi VA, Ramos JP, Ichinoche L, Guimarães DM. Esophagocardioplasty as surgical treatment in relapsed non advanced megaesophagus. Arq Bras Cir Dig. 2012;25:20-4. [ Links ]

20. Pinheiro SW, Rua AM, Etchebehere RM, Cançado CG, Chica JE, Lopes ER, et al. Morphometric study of the fibrosis and mast cell count in the circular colon musculature of chronic Chagas patients with and without megacolon. Rev Soc Bras Med Trop. 2003;36:461-6. [ Links ]

21. Lima Pereira SA, Santos VM, Rodrigues DB, Cunha Castro EC, Reis MA, Paula Antunes Teixeira V. Quantitative analysis of fibrosis and mast cells in the tongue of chronic chagasic patients: autopsy study. Med Mal Infect. 2007;37:229-33. [ Links ]

22. Farahani SS, Navabazam A, Ashkevari FS. Comparison of mast cells count in oral reactive lesions. Pathol Res Pract. 2010;206:151-5. [ Links ]

23. Theoharides TC, Conti P. Mast cells: the Jekyll and Hyde of tumor growth. Trends Immunol. 2004;25:235-41. [ Links ]

24. Metz M, Grimbaldeston MA, Nakae S, Piliponsky AM, Tsai M, Galli SJ. Mast cells in the promotion and limitation of chronic inflammation. Immunol Rev. 2007;217:304-28. [ Links ]

25. Metz M, Siebenhaar F, Maurer M. Mast cell functions in the innate skin immune system. Immunobiology. 2008;213:251-60. [ Links ]

26. Bilate AM, Cunha-Neto E. Chagas disease cardiomyopathy: current concepts of an old disease. Rev Inst Med Trop Sao Paulo. 2008;50:67-74. [ Links ]

27. Silveira AB, Adad SJ, Correa-Oliveira R, Furness JB, D’Avila Reis D. Morphometric study of eosinophils, mast cells, macrophages and fibrosis in the colon of chronic chagasic patients with and without megacolon. Parasitology. 2007;134:789-96. [ Links ]


This work was funded by the University of Uberaba, process PIBIC-CNPq Nº 2017-026, by Cefores/Universidade Federal do Triângulo Mineiro and by Programa de Pós-Graduação em Ciências da Saúde/Universidade Federal do Triângulo Mineiro , Uberaba, Minas Gerais, Brazil.

Recebido: 14 de Agosto de 2019; Aceito: 13 de Novembro de 2019

Correspondence to: Sanívia Aparecida de Lima Pereira Universidade de Uberaba, Avenida Nenê Sabino, 1801, CEP 38055-500, Uberaba, MG, Brazil Tel: +55 34 33198815 E-mail:


All authors contributed to the study conception and design, data acquisition and interpretation, writing of the paper, critical review of intellectual content, reading of the paper and approval of the final version. Barbara Bellocchio Bertoldo attended and selected the patients, elaborated the figures, performed the statistical analysis and conducted the review of the paper; Renata Margarida Etchebehere conducted the histochemical and immunohistochemical analysis; Taíssa Cássia de Souza Furtado and Juliana Barbosa de Faria performed the submission and modification of the paper; Camilla Beatriz Silva performed the histochemical processing; Márcia Fernandes de Araújo performed the immunohistochemical technique; Denise Bertulucci Rocha Rodrigues contributed to the review of the paper; Sanivia Aparecida de Lima Pereira contributed to the conception and planning of the study, writing, submission and review of the paper.

Creative Commons License  This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.