Toxoplasmosis and lupus. A review of the literature apropos of 4 cases

The authors report 4 cases of toxoplasmosis in patients with acute disseminated lupus erythematosus (ADLE). In one case, a pregnant patient with serology indicative of chronic infection, infected the neonate who died of subacute toxoplasmosis. Although ADLE is a classical cause of immunodepression, toxoplasmosis is a rare complication; only 5 cases were found in a review of the literature. Toxoplasmosis infection may resemble an exacerbation of lupus; an accurate diagnosis is essential as the treatment of the two conditions is radically different. The problems of diagnosis of toxoplasmosis in immunodepressed patients are reviewed and the therapeutic approach, especially in pregnant patients, is discussed. In ADLE, the authors recommend checking toxoplasmosis serology before starting and during treatment with corticosteroids. Special attention should be paid to pregnant women with apparently chronic serological changes as neonatal infection may occur.     

绵羊新孢子虫病和弓形虫病血清流行病学调查及风险因素分析

目的 调查河南、江苏和浙江省绵羊的新孢子虫病和弓形虫病的感染状况并进行风险因素分析,为绵羊寄生虫病防控和羊肉肉品安全监测提供基础依据。方法 采用间接免疫荧光(IFAT)和改良凝集实验法(MAT)分别检测绵羊血清中的新孢子虫和弓形虫的抗体。统计分析风险因素的OR值及P值。结果 绵羊新孢子虫的感染率为11.88%(62/522),弓形虫抗体的阳性率为17.81%(93/522)。地域和流产史是绵羊感染弓形虫的风险因素(P<0.05),但与新孢子虫的感染不相关(P>0.05);年龄和性别均与这两种原虫的感染不相关(P>0.05)。结论 河南、江苏和浙江省绵羊新孢子虫病和弓形虫病的阳性率均较高,羊肉肉品安全现状堪忧。该地域绵羊的新孢子虫病流行情况首次报道。     

Epidemiological and clinicoimmunological monitoring of toxoplasmosis in the Omsk Region

The toxoplasmosis epidemiological surveillance system is being improved in the Omsk Region. The prevalence of toxoplasmosis has been analyzed among 31475 inhabitants from the Omsk Region over 15 years (from 1992 to 2006). There was a 1.7-2.5-fold increase in the rates of infection in the normal and abnormal pregnancy women. IgM was detected in 7% of the adult patients with suspected toxoplasmosis, 5.2% of the physiological pregnancy women, and 2.2 times more frequently (p < 0.01) in the pregnant women with threatening interruption. The study of avidity showed that in pregnant females, primary infection occurred in 4.2% of cases; the signs of subacute toxoplasmosis were noted in 6.09%. The IgA detection rate was 33%. IgM was found in 7.2% of children, 7.8% having low-avidity antibodies. Subacute toxoplasmosis was established in 10.4% of the patients with central nervous system and eye lesions or hepatitis. In 38.1% of cases, toxoplasmosis was concurrent with active cytomegalovirus infection. The authors show it expedient to determine IgA and its avidity and to detect Toxoplasma antigens, as well as antibodies to different Toxoplasma antigens.     

Toxoplasma gondii serology in HIV-infected patients: the development of central nervous system toxoplasmosis in AIDS

Central nervous system (CNS) toxoplasmosis is an important infectious complication of AIDS which requires prolonged treatment. Most cases occur in patients with serologic evidence of prior exposure and therefore appear to result from reactivation of a previously acquired infection. Antibody to Toxoplasma gondii was found in 130 out of 411 patients with AIDS (32%). Of these, CNS toxoplasmosis developed in 31 (24%). By survival analysis, the estimated probability of ever developing CNS infection in antibody-positive individuals was 28%, occurring in 26% of patients within 2 years of the onset of AIDS. All patients with HIV infection should be tested for antibody to T. gondii and monitored for any neurologic change. Methods of prophylaxis for CNS toxoplasmosis in these high-risk patients need to be developed.     

Toxoplasmosis in bone marrow transplantation: a report of two cases and systematic review of the literature

Toxoplasma infection represents a rare but often fatal complication in bone marrow transplant (BMT) recipients. We report two cases of toxoplasmosis: one of successfully treated cerebral toxoplasmosis after peripheral blood stem cell transplantation, and a fatal case of pulmonary toxoplasmosis in a BMT recipient. We have systematically reviewed the 110 published cases of toxoplasmosis following BMT. We analyzed the pre-transplant and clinical features of BMT recipients developing toxoplasmosis, together with the diagnostic procedures used and treatment given. By univariate and multivariate statistical analysis we analyzed the risk factors for diagnosis (during life vs post-mortem) and Toxoplasma-related mortality. Ante-mortem diagnosis was made in 47% of cases. Site of infection (P = 0.02; odds ratio 10.8), presence of symptoms at onset (P = 0.01) and conditioning regimen (P = 0.04) were factors influencing whether the diagnosis was made before or after death. Overall mortality rate was 80% and that attributed to toxoplasmosis was 66%. Variables influencing outcome were: site of infection (P = 0.02; odds ratio 5.28), day of onset (P = 0.04) and conditioning regimen (P = 0.04). Underlying disease (P = 0.02; odds ratio 9.45), among patients diagnosed before death, was the most significant factor influencing outcome.     

A possible novel mechanism of opportunistic infection in systemic lupus erythematosus,based on a case of toxoplasmic encephalopathy

SIR, Opportunistic infection is common in patients with systemiclupus erythematosus (SLE). In some patients, it is difficultto distinguish between the effect of infection and exacerbationof SLE because both can produce similar symptoms [1]. Toxoplasmainfection (toxoplasmosis) is generally benign in healthy persons,with a tendency to chronic latency. However, activation of toxoplasmosisin patients with human immunodeficiency virus (HIV) infectionor organ transplantation may have serious consequences. Therehave been many reports of toxoplasmosis in     

新疆居民弓形体感染的血清流行病学调查

在新疆各有代表性的地区,用弓形体间接血凝试验对居民进行了弓形体感染的血清流行病学调查。在5321名“健康”人群中检出抗体者191人,阳性率3.5％。各不同地区居民的阳性率在1.21％～13.75％之间。阳性血清抗体滴度的几何均值与各地居民抗体阳性率的高低相一致(r=0.69)。191份阳性血清抗体摘度>256者76份,占37.79％。调查结果表明人类弓形体感染广泛存在于新疆各地。在抗体阳性者中,三分之一以上为近期感染者,提示这种疾病在居民中处于活跃传播状态。     

Toxoplasmic chorioretinitis and antitumor necrosis factor treatment in rheumatoid arthritis

OBJECTIVES: To present the data supporting the possible relationship of ocular toxoplasmosis to antitumor necrosis factor-alpha (TNF-alpha) therapy in patients with rheumatoid arthritis (RA). METHODS: A Medline search was performed using the words "toxoplasmosis, anti-TNF-alpha antagonists, chorioretinitis." We report 2 RA patients who developed ocular toxoplasmosis while receiving anti-TNF-alpha therapy. RESULTS: In addition to our patients with toxoplasmic chorioretinitis, there are 2 published cases of cerebral toxoplasmosis during treatment with anti-TNF-alpha agents. CONCLUSION: The risk of serious toxoplasmic infection during anti-TNF-alpha therapy for RA should be recognized.     

Toxoplasmosis with hemophagocytic syndrome after bone marrow transplantation: diagnosis at autopsy

Abstract: Toxoplasmosis is a rare but well recognized opportunistic infection that can occur after allogeneic hematopoietic stem cell transplantation (allo‐HSCT). Besides encephalitis, other common presentations of Toxoplasma gondii infection are interstitial pneumonitis and myocarditis. Because of its non‐specific clinical and biological signs and its lethal outcome, toxoplasmosis is often misdiagnosed and only revealed at autopsy. We report a case of a postmortem diagnosis of disseminated toxoplasmosis associated with hemophagocytic syndrome, which underlines the value of necropsy in cases of death after transplantation. We also discuss clinical presentations and risk factors that lead to toxoplasmosis in allo‐HSCT recipients.     

Toxoplasmosis in non‐cardiac solid organ transplant recipients: A case series and review of literature

The risk of toxoplasmosis in high‐risk cardiac transplant recipients is well recognized prompting universal donor and candidate screening with administration of targeted post‐transplant chemoprophylaxis in high‐risk (D+/R?) cardiac transplant patients. In contrast, until recently, there have been neither well‐defined recommendations nor consensus regarding toxoplasmosis preventive strategies among non‐cardiac solid organ transplant recipients. We report 3 cases of post‐transplant toxoplasmosis in non‐cardiac transplant recipients (one lung and two liver); all 3 infections presumed to be donor‐derived. Not surprisingly, pre‐transplant Toxoplasma serology was negative in all the patients. None of the patients were on trimethoprim‐sulfamethoxazole (TMP‐SMX) prophylaxis at the time of diagnosis of toxoplasmosis. The median time from transplant to onset of infection was 90 days (range: 30‐120 days). Clinical presentations included cerebral (n = 1) and disseminated infections (n = 2). Two of the 3 patients, both with disseminated infection died (mortality ~ 67%).     

Outbreak of toxoplasmosis in a family and documentation of acquired retinochoroiditis

An outbreak of toxoplasmosis in one household is described. It demonstrates the potential for a common source infection with Toxoplasma gondii to cause multiple cases. Six of seven members of a household investigated for toxoplasmosis demonstrated high antibody titers consistent with recent infection; five of these members (83%) were symptomatic. The most common manifestations were fever and lymphadenopathy, which developed from seven to 18 days (mean 11 days) after a common source ingestion of infected meat. Since inadequately cooked lamb, pork and beef are probably the most common sources of infection in the United States, outbreaks of multiple cases may occur more frequently than is generally appreciated. As more outbreaks of febrile illnesses are examined, especially in families and closed communities, it is likely that more common source epidemics of toxoplasmosis will be recognized. Retinochoroiditis is an unusual manifestation of adult acquired toxoplasmosis. In the index case in this epidemic the patient manifested vision threatening retinochoroiditis 129 days after infection with toxoplasmosis. He represents the ninth well-documented case of toxoplasma retinochoroiditis associated with adult acquired disease.     

艾滋病合并弓形虫感染

目的　探讨弓形虫病并发于艾滋病时的临床病理学特征。方法　回顾性研究 17例艾滋病合并弓形虫病的常规尸检材料 ,总结其临床表现与病变特点。结果　 17例患者均有神经系统受累的病理改变与相应临床症状 ,多数有呼吸系统症状但仅 4例查见弓形虫 ,8例心肌有弓形虫感染但无明显临床表现 ,8例为播散性感染 ,5例合并巨细胞病毒感染 ,10例血清弓形虫抗体效价升高 ,17例均在尸检组织中查到弓形虫 ,9例死于脑或肺弓形虫病。结论　弓形虫病与艾滋病有密切关系 ,并有一些重要的临床病理学特征 ,如潜在感染的复活 ,播散性感染 ,显著的脑部病变 ,合并其他机会性感染 ,血清抗体效价低下等。     

Tuberculosis/toxoplasmosis co-infection in Egyptian patients:A reciprocal impact

Objective:To assess the concurrent toxoplasmosis infection in Egyptian TB patients and the impact of each infection on the other in terms of increased severity of TB or reactivation of latent Toxoplasma infection.Methods:Three hundred suspected pulmonary TB cases were initially screened for TB using direct Ziehl Neelsen staining and Lowenstein Jensen culture of their sputa.Rifampicin resistance was detected by Xpert MTB/RIF assay.Control group of 30 age and sex-matched healthy individuals negative for TB was included for comparison.All subjects were further assessed for serum levels of anti-Toxoplasma Ig G antibodies and malondialdehyde(MDA).Results:Forty three confirmed TB-infected patients including 10(23.3%)rifampicin-resistant patients were detected.Associated toxoplasmosis was found to be significantly higher among TB patients(OR=2.709;95%CI:1.034-7.099;P0.05)and among rifampicin sensitive than rifampicin resistant TB patients(OR=0.213;95%CI:0.048-0.951);P0.05).Serum levels of anti-Toxoplasma IgG antibodies and MDA were significantly higher among TB patients than the control group.Furthermore,serum level of MDA was significantly higher among TB/Toxoplasma co-infected patients as compared to toxoplasmosis free-TB patients.Strong positive correlation was detected between serum levels of anti-Toxoplasma Ig G and MDA in TB patients(r=0.75,P=0.001).Conclusions:Among pulmonary TB Egyptian patients,there is a considerable prevalence of toxoplasmosis.Severity of pulmonary tuberculosis could be increased by Toxoplasma co-infection.     

Toxoplasmosis in cord blood transplantation recipients

Toxoplasmosis is a devastating opportunistic infection that can affect immunocompromised patients such as cord blood transplantation (CBT) recipients. The clinical characteristics of 4 toxoplasmosis CBT patients treated at our institution are reviewed, together with 5 cases collected from the literature. The rate of toxoplasmosis in our hospital was 6% in CBT recipients and 0.2% in other types of allogeneic hematopoietic stem cell transplantation (P < 0.001). Five patients (56%) presented disseminated toxoplasmosis and 4 patients (44%) had localized infection in the central nervous system. In 5 of the 9 patients considered (56%), cytomegalovirus viral replication had been detected before the clinical onset of toxoplasmosis. Seven patients (78%) had previously developed graft‐versus‐host disease. All patients who exhibited disseminated disease died due to Toxoplasma infection. Pre‐transplant serology was positive in 1 patient, negative in 3 patients, and not performed in another. Only 1 of these 5 patients with disseminated disease had received Toxoplasma prophylaxis with cotrimoxazole. It could be concluded that mortality in CBT patients with disseminated toxoplasmosis is unacceptably high. The negative results of serology in the majority of these cases, and its unspecific clinical presentation, makes diagnosis exceedingly difficult. Better diagnostic tests and prophylaxis strategy are needed in CBT recipients.     

Toxoplasma gondii antibody profile in HIV-1-infected and uninfected pregnant women and the impact on congenital toxoplasmosis diagnosis in Rio de Janeiro, Brazil

ObjectiveCompare the anti-T. gondii IgG titer between HIV-1 infected and non HIV-1 infected pregnant women and report three cases of congenital toxoplasmosis resulting from reactivation of infection during pregnancy of HIV-1 infected women.MethodsThis study was conducted among 2,270 pregnant women with chronic Toxoplasma gondii infection (absence of IgM and presence of IgG), including 82 HIV-1 infected and 2,188 non-infected women.ResultsThe average anti-T. gondii IgG titer was 127 for the 2,188 non-HIV-1 infected women, and 227 for the 82 HIV-1-infected women (p = 0,007). These results suggested that higher anti-T. gondii IgG titers in HIV-1-infected pregnant women may not be indicative of an elevated risk for fetal infection. In this study three cases of congenital toxoplasmosis that resulted from infection reactivation during pregnancy of HIV-1-infected women were manifested by fetal death, symptomatic infection, and infant without symptoms, respectively. In two of these women, a ten-fold increase in IgG levels above used cutoff was observed (2,320 UI/mL and 3,613 UI/mL, respectively). In the third pregnant women anti-T. gondii IgG titers during pregnancy did not rise despite the occurrence of congenital toxoplasmosis (204; 198; 172 UI/mL).ConclusionsCongenital toxoplasmosis resulting reactivation of infection during pregnancy in the studied group leads us to believe that it is a public health problem, especially in our population, in which seroprevalence of T. gondii infections is high. These findings also suggest that special attention is necessary during pregnancy, because the serologic diagnosis may not be indicative of toxoplasmosis reactivation.     

Detection of the foci of familial toxoplasmosis in rural environment

In order to detect centres of family toxoplasmosis in rural environment 24,546 patients, suspected of invasion of T. gondii, 504 healthy persons coming from villages and 1,681 live stock were examined. Among persons suspected of infection of T. gondii, 65 cases of congenital family toxoplasmosis and 19 cases of environment family toxoplasmosis, involving several members of the family were detected. In animals a comparatively high percentage with positive reaction in the direct agglutination test (cattle 55.5%, swine 27.9%, sheep 23.4%) was detected. The following serological tests were applied to humans: complement-binding test (OWD), indirect immunofluorescence test (OIF), direct agglutination test with 2-mercaptoethanol (CA), ELISA IgM and, selectively, immunoperoxidase test IgM (OIP). The results suggest that the environment conditions can play an important role in the occurrence of family toxoplasmosis in our country, especially in the countryside. Detecting active toxoplasmosis in a family member should be a signal to start serological-epidemiological examination of the remaining family members and live stock.     

Association of symptomatic human infection with Toxoplasma gondii with imbalance of monocytes and antigen-specific T cell subsets

During recent symptomatic toxoplasmosis, alterations in quantity and function of mononuclear cells in peripheral blood were observed. Flow cytofluorometric analysis and differential leukocyte counts revealed increased absolute numbers of T8+ cells, Leu 7+ (natural killer/killer) cells, and monocytes. T4+ cells and HLA-DR+ cells were not significantly changed. T4/T8 cell ratios were reversed in symptomatic toxoplasmosis (0.7 +/- 0.3) and normal in chronic infection (1.7 +/- 0.5). Toxoplasma antigen induced higher numbers of T8+ and TQ1+ cells in four T cell lines from two individuals with symptomatic infection than in five T cell lines from three individuals with asymptomatic infection. Eight cloned T cell lines produced gamma interferon in an antigen-specific fashion and in higher amounts when they originated from an asymptomatic subject than from a symptomatic subject. These results indicate that marked alterations in properties of immunoregulatory cells are characteristic of recent symptomatic toxoplasmosis. The transient immune dysfunction may be a major part of the observed disease and/or a feature of successful parasitism.     

Cerebral toxoplasmosis - a late complication of allogeneic haematopoietic stem cell transplantation

Toxoplasma gondii infection reactivation predominantly occurs among patients after allogeneic haematopoietic stem cell transplantation. Mostly, reactivation occurs during first 3 months after transplant, especially when risk factors are present. We report a case of late cerebral toxoplasmosis reactivation, which was probably triggered by a brief course of corticosteroids, administered for chronic graft-versus-host disease (cGVHD). In the presence of risk factors, such as cGVHD, prophylactic treatment for toxoplasmosis should be reinstituted; Trimethoprim-sulfamethoxasole most probably prevented earlier reactivation of toxoplasmosis in our patient.     

The epizootology of feline toxoplasmosis in the town of Perm

The study was undertaken to determine the rates of infection with acute and chronic toxoplasmosis among cats in the town of Perm. Fecal tests established the infection of domestic animals with different intestinal parasites: Toxocara cati, Toxascaris leonine, Uncinaria stenocephala, Oslerus osleri, Hydatigera taeniaformis, Blastocystisfelis, and Toxoplasma gondii. Serum tests revealed antibodies to the pathogen of toxoplasmosis in 80% of samples. The highest infection rate was observed among the cats going into the street and having a chance of catching. About 1% of seropositive cats discharged fecal oocysts, i.e. they had acute toxoplasmosis.     

Cytomegalovirus infections and toxoplasmosis in heart transplant recipients in Sweden.

The morbidity of cytomegalovirus (CMV) infection and toxoplasmosis was evaluated in 75 heart transplant recipients. Among the 73 patients who survived more than one week after transplantation, 16 (22%) acquired primary CMV infection and 30 (41%) had evidence of secondary infection. All CMV seronegative recipients receiving hearts from seropositive donors developed CMV infection. The majority of infections (42/46) occurred during the first 4 months after transplantation. Overall, the incidence of symptomatic CMV disease was 44%. The infections were generally mild and only 1 death was attributed to primary CMV disease complicated by bacterial septicaemia and multiple organ failure. The severity of CMV disease was greatest among those with primary infection. There were 3 cases of toxoplasmosis. Two patients were toxoplasma seronegative before transplantation and developed clinical and serological signs of infection 2-3 months after transplantation despite receiving organs from seronegative donors. Of toxoplasma seronegative recipients receiving allografts from seropositive donors 3/4 were prophylactically treated with pyrimethamine for 6 weeks. None developed clinical or serological signs of toxoplasmosis while one patient who received trimethoprim-sulfamethoxazole had a subclinical infection.