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PubMed2006

Outcome for children infected with congenital toxoplasmosis in the first trimester and with normal ultrasound findings: a study of 36 cases.

OBJECTIVE: We wished to investigate the prognosis of children infected with Toxoplasma gondii during the first trimester of pregnancy and whose ultrasound findings were entirely normal, in order to find out whether congenital toxoplasmosis did or did not justify termination of pregnancy if there was no fetal abnormality on ultrasound. STUDY DESIGN: A prospective and retrospective study was carried out by 12 French centers who enrolled 36 children infected with T. gondii during the first trimester of pregnancy and whose ultrasound examinations showed no anomaly. The outcome of these children after the age of 12 months (mean 50 months, range 12-144 months) was analyzed. RESULTS: Of the 36 infected children, 28 (78%) presented subclinical toxoplasmosis. Only specific IgG antibodies persisted after 1 year. The principal manifestation in 7 children (19%) was chorioretinitis without major vision loss. Their intellectual development was entirely normal. One child (3%) developed severe congenital toxoplasmosis. CONCLUSION: Since 97% of children infected with toxoplasmosis during the first trimester of pregnancy are asymptomatic or only slightly affected, we believe that in such circumstances termination of pregnancy is not indicated. However, appropriate treatment is essential and prenatal ultrasound examinations should be free of any anomaly.

Animals↗
PubMed2002

Ocular toxoplasmosis after the fifth decade.

PURPOSE: To describe the clinical features in patients presenting with ocular toxoplasmosis after the fifth decade and to analyze laboratory findings in comparison to uveitis history and clinical data. DESIGN: Prospective consecutive observational case series. METHODS: A prospective clinical analysis of 27 consecutive patients older than 50 years of age with primary or recurrent ocular toxoplasmosis was performed during a period of 8 years. These cases account for 12% of all ocular toxoplasmosis cases irrespective of age indexed in our institution during the same period. Paired serum and aqueous humor samples were tested for anti-Toxoplasma gondii IgG, IgM, and IgA antibodies. The presence of T. gondii DNA in aqueous humor was determined by polymerase chain reaction followed by DNA hydridization method. RESULTS: Although similar in age, two groups were distinguished clinically: 12 patients (44%) presented with usual forms of retinochoroiditis (mean +/- SD, 1.6 +/- 0.5 disk areas [DA] in size); 15 patients (56%) presented with atypical lesions, greater than 3 DA in size (mean +/- SD, 5.0 +/- 2.0 DA). The second group showed a higher rate of complications (P =.028) and a poorer visual outcome (P =.015). Twenty-four patients (89%) had intraocular IgG production, 17 (63%) had intraocular IgA production, 3 (11%) had intraocular IgM production, and 12 (44%) had a positive T. gondii DNA detection. CONCLUSIONS: After the fifth decade, ocular toxoplasmosis remains an important cause of posterior uveitis. The combination of antibody detection by immunocapture tests with T. gondii DNA detection, both in aqueous humor, allowed the diagnosis of toxoplasmic infection in the atypical cases with large ocular lesions.

Age Factors↗
PubMed1993

Progressive ocular toxoplasmosis in patients with acquired immunodeficiency syndrome.

We studied two patients, a 43-year-old Hispanic man with a one-year history of acquired immunodeficiency syndrome (AIDS) and a 34-year-old Hispanic man with newly diagnosed AIDS. Both had necrotizing retinitis that progressed to panophthalmitis and orbital cellulitis. Toxoplasmosis was not diagnosed in the first patient early in the course of the disease. The second patient had a history of toxoplasmic retinochoroiditis. Despite anti-toxoplasmosis therapy, visual acuity deteriorated to no light perception in both patients. Diagnostic biopsy of the eye wall was performed on the first patient and enucleation of the globe on the second. Toxoplasmic panophthalmitis and orbital cellulitis were diagnosed in each patient by light microscopy and confirmed by electron microscopy. When patients with AIDS develop necrotizing retinitis, toxoplasmosis must be considered in the differential diagnosis, along with cytomegalovirus retinitis, progressive outer retinal necrosis, and syphilitic retinitis. Unlike cytomegalovirus retinitis, progressive outer retinal necrosis, and syphilitic retinitis, however, toxoplasmosis can cause a progressive intraocular infection, panophthalmitis, and orbital cellulitis in patients with AIDS.

AIDS-Related Opportunistic Infections↗
PubMed1992

Ocular toxoplasmosis in human immunodeficiency virus-infected patients.

The files of 45 human immunodeficiency virus-infected patients with ocular toxoplasmosis were reviewed, with a median follow-up of eight months. The condition was unilateral in 37 of the 45 patients (82%) and was bilateral in eight (18%). Inflammation of the anterior chamber and the vitreous was present in 32 of 53 eyes (60%) and 38 of 53 eyes (72%), respectively. Cytomegalovirus retinitis developed during the follow-up period in nine patients (20%). Cerebral toxoplasmosis was concurrently diagnosed with the ocular toxoplasmosis in 13 patients (29%). The efficacy of the combination of pyrimethamine and sulfadiazine or clindamycin was assessed in 42 patients for the induction therapy and in 38 patients for the maintenance therapy. Induction therapy was always effective within a median period of six weeks. During maintenance treatment, the 24-month relapse rates were 0.20 and 0.18 for the 50-mg/day and 25-mg/day dosage of pyrimethamine, respectively. The overall 12-month survival rate was 0.72. Our results suggested that ocular toxoplasmosis has a better ocular prognosis than cytomegalovirus retinitis, but that it requires appropriate treatment because life-threatening cerebral involvement is often associated.

Adult↗
PubMed1999

Toxoplasmosis and iodine deficiency in Angora goats.

Toxoplasmosis was diagnosed in two goat herds in the Czech Republic. The 1996 outbreak in the herd of Angora goats was associated with abortions and births of weak kids. No apparent signs of toxoplasmosis were observed in the herd of White Short-Haired (WSH) goats reared under similar conditions. Seroprevalences of 60% and 66% tested by complement fixation and indirect fluorescent antibody tests, respectively, were found in the herd of Angora goats during the outbreak of clinical toxoplasmosis. Significantly lower values were recorded in this herd in years 1994 and 1997 and in the herd of WSH goats between years 1994-1996. Iodine deficiency was also demonstrated in the herd of Angora goats in 1996. Goitre was detected by clinical examination in 39% of animals and mean urinary iodine concentration was 8.0+/-4.65 microg per 11. This concentration rose significantly to 15.7+/-5.02 microg per 11 in the subsequent year. Effects of iodine deficiency on clinical manifestation of toxoplasmosis in Angora goats were discussed.

Abortion, Veterinary↗
PubMed2004

[Toxoplasmosis seroconversion in pregnant women. The differing attitudes in France].

INTRODUCTION: Since 1992 France has been running a toxoplasmosis prevention program based on the serological detection of infections during pregnancy. In the absence of a consensus, the seroconversions discovered are managed in different ways, varying from one centre to another. OBJECTIVE: To describe the habits of the specialised centres in France and propose means to reduce the heterogeneity. METHODS: A survey using a questionnaire mailed to the centres of parasitology in France specialised in the management of toxoplasmosis seroconversion during pregnancy. RESULTS: All the 30 centres surveyed replied. Five of them do not provide recommendations for treatment and were excluded from analysis. The attitudes of the 25 other centres varied greatly with regard to the indications for therapeutic abortion and amniocentesis, treatment protocols with pyrimethamine and sulfamides, as well as in the frequency of sonographical monitoring. CONCLUSION: In the absence of National guidelines, the management of seroconversions discovered during the prenatal prevention of congenital toxoplasmosis program is left to the discretion of the specialised centre. This results in variations from one town to the next. This heterogeneity underlines the lack of knowledge on the most efficient and acceptable means of preventing and treating congenital toxoplasmosis. In order to improve this situation, the French parasitologists have launched a program of consensual meetings aimed at harmonising the treatment protocols and identifying the points that require further studies.

Adult↗
PubMed2002

A theoretical analysis of the relations between the risk of congenital toxoplasmosis and the annual infection rates with a convincing argument for better public intervention.

In a theoretical analysis of the present study, we quantitatively indicate a potential threat of congenital toxoplasmosis to Japanese young women by the use of a simple mathematical model or a special case of the well-known catalytic infection model. For introducing a risk function of congenital toxoplasmosis, an annual infection rate, r, was divided into r(1), the rate before age a(0 < a < 15), and r(2), the rate after age a. Presuming the values of r(1), r(2) and a on the basis of the current situation of Toxoplasma infection in Japan, simulation analyses were performed with the mathematical model. As the simulation clearly demonstrated, Japanese young women are potentially facing a threat of congenital toxoplasmosis, although the current risk of it is relatively lower. From the viewpoint of risk management, public intervention programs are required. Based on our analyses, public intervention programs can be classified into two groups: group 1 for women before age a and group 2 for those after age a, and each group is expected to give a different kind of effect to the risk of congenital toxoplasmosis. The present study implies that a certain public intervention program could augment the risk, inadvertently.

Adolescent↗
PubMedDate not supplied

Maternal serologic screening for toxoplasmosis.

Congenital toxoplasmosis is a rare, but potentially serious, problem during pregnancy. Toxoplasmosis is caused by a protozoal parasite that can be found in warm-blooded animals (including humans); dried cat feces, contaminated soil, or contaminated water; and raw or undercooked meat containing infective tissue cysts. Although cats play a role in the epidemiology of the disease, there is no statistical correlation between toxoplasmosis infection and cat ownership. Toxoplasmosis can be transmitted to the fetus in utero through transplacental transmission. Both the incidence of placental transmission and severity of congenital disease depend on gestational age at which maternal seroconversion occurs. Although transmission rates from mother to fetus tend to be low early in pregnancy, fetal disease severity is highest when the fetus is infected early in gestation. Serological tests to determine maternal seroconversion are available, but their use can pose ethical and practical dilemmas. Universal maternal screening is not currently warranted in the United States because disease prevalence is low.

Animals↗
PubMed1999

The relationship between ocular toxoplasmosis and levels of specific toxoplasma antibodies.

The relationship between ocular toxoplasmosis and levels of toxoplasma specific antibodies was examined in 195 patients. Using clinical information collected by questionnaires, patients were divided into: 97 with ocular toxoplasmosis (group 1) and 98 with ocular lesions not due to toxoplasma (group 2). The geometric mean of dye test titres (+/-S.D. natural log titre) in group 1 was 53.2 (+/-0.95) compared with 24.6 (+/-1.11) in group 2 (P < 0.001). Young females tended to have more active lesions compared with young males (P < 0.05). There was an age-dependent difference in dye test titres between the groups (P < 0.001). Group 1 showed a decline in titre with age compared with an increase in group 2. Ocular toxoplasmosis was diagnosed most frequently among 21-30 year olds. More group 1 patients had dye test titres > or = 65 iu/ml than group 2 (P < 0.05). Dye test titres > or = 65 iu/ml support a diagnosis of ocular toxoplasmosis whereas lower titres suggest other causes for eye lesions.

Adolescent↗
PubMed1997

Disseminated toxoplasmosis in marrow recipients: a report of three cases and a review of the literature. Bone Marrow Transplant Team.

Toxoplasma infection following bone marrow transplantation (BMT) is infrequently reported. We report three cases of disseminated toxoplasmosis in BMT recipients documented during an 8-year period at our institution: one after an unrelated marrow transplant in a toxoplasma-seronegative patient, the second complicating syngeneic marrow transplantation, and the third following allogeneic, related BMT. The disease is extremely rare in seronegative patients and has not been previously reported in syngeneic recipients. Toxoplasmosis was diagnosed at autopsy in two of the three cases. We also present a review of all reported cases of toxoplasmosis in marrow recipients from North American and other BMT centers. Heightened awareness of the occurrence of toxoplasmosis in marrow recipients and early diagnostic/therapeutic measures are needed for a better outcome.

Adolescent↗
PubMed2000

Disseminated toxoplasmosis following T cell-depleted related and unrelated bone marrow transplantation.

More than 95% of reported cases of disseminated toxoplasmosis following BMT have occurred following an unmodified transplant. Most have been fatal, diagnosed at autopsy and without antemortem institution of specific therapy. From 1989 to 1999, we identified 10 cases of disseminated toxoplasmosis, in 463 consecutive recipients of a T cell-depleted (TCD) BMT. Transplants were from an unrelated donor (n = 5), an HLA-matched sibling (n = 4) or an HLA-mismatched father (n = 1). In 40%, both the donor and recipient had positive IgG titers against T. gondii pre-transplant; in 30%, only the recipient was sero-positive. Three recipients of an unrelated TCD BMT developed toxoplasmosis despite both donor and host testing negative pretransplant. All 10 patients presented with high grade fever. CNS involvement ultimately occurred in seven patients, with refractory respiratory failure and hypotension developing in nine. Eight of 10 cases were found only at autopsy, involving the lungs (n = 7), heart (n = 5), GI tract (n = 5), brain (n = 8), liver and/or spleen (n = 5). The only survivor, treated on the day of presentation with fever and headache, was diagnosed by detection of T. gondii DNA by polymerase chain reaction (PCR) performed on the blood and spinal fluid. This study demonstrates the similar incidence of toxoplasmosis following TCD BMT and that reported post T cell-replete BMT, and underscores the need for rapid diagnostic tests in an effort to improve outcome.

Adult↗
PubMed1999

A switch towards Th2 during serological rebound in children with congenital toxoplasmosis.

Serological rebounds occur frequently in patients with congenital toxoplasmosis, but remain poorly understood. A link between Th1 and Th2 cytokines and the pathophysiology of infectious diseases has been reported. Production of interferon-gamma (IFN-gamma) and IL-4 in supernatants of whole blood after in vitro specific Toxoplasma gondii stimulation and serum-specific IgE levels were studied in 31 congenitally infected children. IFN-gamma was produced at higher levels by lymphocytes from children with stable congenital toxoplasmosis (n = 18) than from children showing serological rebound (n = 13) (P < 0.04). Conversely, supernatants from children with serological rebound showed higher levels of IL-4 than those from children with stable congenital toxoplasmosis (P < 0.03). The polarized Th2 response was confirmed by a greater (IL-4:IFN-gamma) x 100 ratio (P < 0.0001) and production of T. gondii-specific IgE in six out of 13 children showing serological rebound. These results suggest a role of Th2 cytokines in destabilization of congenital toxoplasmosis and perhaps in local reactivation of the parasite.

Adult↗
PubMed2004

[Strategies for the diagnosis and treatment of prenatal toxoplasmosis - a survey].

Today, a decreasing number of infants with prenatal toxoplasmosis present with clinical signs of severe, generalised infection and cerebral involvement. The favourable clinical outcome - mild or subclinical infection - is considered to be an effect of early maternofetal treatment with spiramycin and pyrimethamine/sulfadiazine (PS). However, a Cochrane Review and a recently published European multicentre study on congenital toxoplasmosis did not only question this positive effect but also the efficiency of a postnatal long-term therapy. Both studies caused much confusion among neonatologists and paediatricians. The new setting requires an update of the diagnostic possibilities and different therapeutic strategies for prenatal toxoplasmosis. Only few prospective studies are available to compare the efficiency of different drug regimens in infected infants. However, clinical data demonstrate that the available therapeutics are not curative and cannot prevent late sequelae. Follow-up studies in pregnant women and their offspring show that prenatal parasite detection does not predict an unfavourable clinical outcome when treatment is initiated early after diagnosis. In Germany, prenatal screening is not obligatory. In case of primary maternal infection, materno-fetal therapy is recommended. A combination therapy consisting of PS is considered more effective than a spiramycin monotherapy. Treatment is recommended for all infected newborns with different strategies for infants with or without clinical symptoms. The treatment strategies of different European countries are discussed. This paper provides recommendations for the diagnosis and treatment of newborn toxoplasmosis and materno-fetal infection as well as recommendations for the clinical management of infected neonates and their follow-up, including drug monitoring.

Coccidiostats↗
PubMed1993

[Screening for toxoplasmosis in pregnancy--a pilot program in Northeast Germany].

A general serological screening of pregnant women for toxoplasmosis was carried out by means of an IgG-ELISA in Greifswald and its surroundings from October 1986 to the end of 1990. Anti-toxoplasma gondii antibodies were detected in 72.8% of 4355 pregnant women. Since 1987, the prevalence of antibodies has decreased from 76% to 68%. The incidence of acquired toxoplasmosis in pregnancy was 2.53 per 1000. Seroconversion occurred in 11 women, but only 8 of them were treated with combined pyrimethamine and sulphamerazine. Despite treatment we observed 3 connatal infections. No newborn infant had clinical symptoms. With regard to the epidemiological situation, a toxoplasmosis screening is recommendable, at least in our area, from an ethical, moral, medical and economical point of view. To ensure, that toxoplasmosis screening is adequately effective, treatment of the pregnant women and their infants must be guaranteed both organisationally and professionally. It must also comprise health education measures, especially for non-immunised women to avoid the well-known main sources of infection.

Adult↗
PubMed1995

[Treatment of toxoplasmosis retinochoroiditis with atovaquone in an AIDS patient].

BACKGROUND: Treatment of ocular toxoplasmosis in HIV-infected patients with standard drug regimens (Pyrimethamine, Clindamycine, Sulfonamides) is very often complicated by side-effects and adverse reactions. On the other hand, maintenance therapy must be continued life long, because of the high recurrence rates. Atovaquone (Hydroxynaphthoquinon) is tolerated excellently and is very effective against tachyzoits of toxoplasma gondii and its cysts. PATIENT HISTORY AND CLINICAL FINDINGS: A 49-year-old homosexual man with AIDS developed an allergic rash after being treated with a course of Pyrimethamine and Clindamycine for unilateral, bifocal ocular toxoplasmosis for 13 days. Therapy with Atovaquone 3 x 750 mg/d was instituted and within 8 days the infiltrates healed leaving retinochorioidal scars. THERAPY AND CLINICAL COURSE: During maintenance therapy with Atovaquone (3 x 750 mg/d) two relapses occurred, the first after 2 months and the second after 8 months. The recurrences were successfully treated by increasing the dosage of Atovaquone to 4 x 750 mg/d and the addition of Trimethoprime/Sulfamethoxazol and Clindamycine/Pyrimethamine respectively. Reexposition was tolerated without an allergic reaction. Under maintenance therapy with Pyrimethamine the patient was free of recurrences for another 4 months until he died. CONCLUSIONS: Atovaquone is an effective and well tolerated substance for the treatment of ocular toxoplasmosis. In contrast to earlier reports, two recurrences occurred under maintenance therapy. It cannot be excluded that the patient was incomplient and did not take the tablets according to our prescription. Future clinical investigations have to control the efficacy of Atovaquone in the therapy of ocular toxoplasmosis.

AIDS-Related Opportunistic Infections↗
PubMed1999

Three children with congenital toxoplasmosis: early report from a Swedish prospective screening study.

The aim of this prospective study was to define the incidence of congenital toxoplasmosis in Sweden. Blood eluates collected on filter papers, Guthrie cards, from 40978 newborn babies were analysed for specific immunoglobulin M (IgM) and IgG antitoxoplasma antibodies. This is a preliminary report of three children with congenital toxoplasmosis, defined by the occurrence of antitoxoplasma-specific IgM antibodies. Two children were asymptomatic at birth. They were both normally developed at the age of 12 and 15 months, respectively. The third child had unidentified but uncomplicated symptoms of infection in the neonatal period. As a result of the screening congenital toxoplasmosis was confirmed and treatment instituted. Microphthalmus and peripheral chorioretinitis were detected in one eye. In spite of the chemotherapeutic treatment he developed hydrocephalus needing neurosurgical intervention at the age of 3 months. His development at 14 months was normal. The incidence in Sweden of congenital toxoplasmosis detected by specific IgM antitoxoplasma antibodies in blood from filter papers is less than 1:10000.

Anti-Bacterial Agents↗
PubMedDate not supplied

Toxoplasmosis.

Toxoplasmosis is the most common cause of posterior uveitis in immunocompetent subjects. The infection can be congenital or acquired. Ocular symptoms are variable according to the age of the subject. For instance, young children present with reduced visual acuity, strabismus, nystagmus, and leucocoria, while teenagers and adults complain of decreased vision, floaters, photophobia, pain, and hyperemia. Toxoplasmic retinochoroiditis typically affects the posterior pole, and the lesions can be solitary, multiple or satellite to a pigmented retinal scar. Active lesions present as grey-white focus of retinal necrosis with adjacent choroiditis, vasculitis, hemorrhage and vitreitis. Cicatrization occurs from the periphery towards the center, with variable pigmentary hyperplasia. Anterior uveitis is a common finding, with mutton-fat keratic precipitates, fibrine, cells and flare, iris nodules and posterior synechiae. Atypical presentations include punctate outer retinitis, neuroretinitis, papillitis, pseudo-multiple retinochoroiditis, intraocular inflammation without retinochoroiditis, unilateral pigmentary retinopathy, Fuchs'-like anterior uveitis, scleritis and multifocal or diffuse necrotizing retinitis. The laboratory diagnosis of toxoplasmosis is based on detection of antibodies and T. gondii DNA using polymerase chain reaction (PCR). Toxoplasmosis therapy includes specific medication and corticosteroids. There are several regimens, with different drug combinations. Medications include pirimetamine, sulfadiazine, clindamycin, trimethoprime-sulphamethoxazol, spiramycin, azithromycin, atovaquone, tetracycline and minocycline. The prognosis of ocular toxoplasmosis is usually good in immunocompetent individuals, as long as the central macula is not directly involved.

Animals↗
PubMed2004

Socioeconomic conditions as determining factors in the prevalence of systemic and ocular toxoplasmosis in Northeastern Brazil.

OBJECTIVE: To determine the prevalence of systemic and ocular toxoplasmosis among 1024 students in the city of Natal, Northeastern Brazil, and correlate it with demographic, socioeconomic and epidemiological risk factors. METHODS: The study population was randomly selected, asked to fill out a questionnaire, provide a blood sample for IgG and IgM (MEIA) serology and a hemogram, and undergo an eye examination. RESULTS: The seroprevalence for IgG was 46% (95% CI = 42.9-49.2%) and that for IgM was 1.4% (95% CI = 0.8-2.4%). The prevalence of ocular lesions was 1.15% (95% CI = 0.6-2.0%). In the univariate analyses, confirmed by multivariate analysis, the socioeconomic conditions were determinants in the prevalence of systemic and ocular toxoplasmosis (mother's schooling = literacy/OR = 2.9 and p < 0.001). CONCLUSIONS: The prevalence of systemic toxoplasmosis, although high, was lower than that found in studies performed in the South and Southeast of Brazil, and the incidence of ocular lesions was totally different, being lower by a factor varying from 5 to 17. Although important epidemiological variables, such as owning a cat, drinking unfiltered water or having had contact with lakes or rivers, were found to be correlated with toxoplasmosis in the preliminary analysis, they lost their influence when included in the logistic model. However, further studies must be undertaken to identify the reasons for these findings, including the determination of the strains of Toxoplasma gondii encountered in different regions of the country and the sources of the water utilized by these populations.

Adolescent↗