Abstract
Toxoplasmosis is one of the most common infections in humans. Due to the prevalence of coinfection with HIV, it carries a high impact on health systems. Humans can become infected with toxoplasma by consuming undercooked lamb or pork meat that contains tissue cysts, or by consuming water or food contaminated with cat feces. Once present in humans, T. gondii multiplies in enterocytes and spreads through the blood or lymphatic stream, parasitizing muscle cells, the retina, and frequently the Central Nervous System. The most used technique for the detection of IgG or IgM against toxoplasma is the ELISA technique. IgG antibodies can be elevated without having an active infection, so diagnosis with IgM and later with avidity test is essential. Cerebrospinal fluid shows mild pleocytosis and hyperprotein spinal cord. Neuroimaging is highly useful, since lumbar puncture can usually be contraindicated due to lesions that produce a mass effect. Ideally, patients should be evaluated with magnetic resonance imaging, which typically shows eccentric lesions in the basal ganglia with ring enhancement after the application of contrast. Central Nervous System lymphoma should be considered as a differential diagnosis. Treatment is usually started empirically with pyrimethamine, sulfadiazine, and folinic acid, with evaluation of imaging improvement at 10-14 days. If not available, treatment with trimethoprine-sulfamethoxazole is possible. The early initiation of antibiotic treatment is essential for a good prognosis, in 4 months complete neurological recovery is observed in less than 20 % of cases and after 3 years of follow-up in approximately 30 % of patients.
References
Vidal JE. HIV-Related cerebral toxoplasmosis revisited: current concepts and controversies of an old disease. J Int Assoc Provid AIDS Care. 2019;18:1-20. doi: 10.1177/2325958219867315.
Elsheikha HM, Marra CM, Quan Zhu X. Epidemiology, pathophysiology, diagnosis and Magment of cerebral toxoplasmosis. Clin Microbiol Rev 2020, 34 (1) e0011519.doi:10.1128/CMR.00115-19
Marra CM. Central nervous system infection with Toxoplasma gondii. Handb Clin Neurol. 2018;152:117-22. doi: 10.1016/B978-0-444-63849-6.00009-8.
Schlüter D, Barragan A. Advances and challenges in understanding cerebral toxoplasmosis. Front Immunol. 2019;10:242. doi: 10.3389/fimmu.2019.00242.
Elsheikha HM, Marra CM, Zhu XQ. Epidemiology, pathophysiology, diagnosis, and management of cerebral toxoplasmosis. Clin Microbiol Rev 2021;34(1):1-28. doi: 10.1128/CMR.00115-19.
Montoya J, Liesenfeld O. Toxoplasmosis. Lancet. 2004;363:1965-76. doi: 10.1016/S0140-6736(04)16412-X.
Subauste CS, Ajzenberg D, Kijlstra A. Review of the series "disease of the year 2011: Toxoplasmosis" pathophysiology of toxoplasmosis. Ocul Immunol Inflamm. 2011;19(5):297-306. doi: 10.3109/09273948.2010.605198.
Mendez OA, Koshy AA. Toxoplasma gondii: Entry, association, and physiological influence on the central nervous system. PLoS Pathog. 2017;13(7):1-12. doi: 10.1371/journal.ppat.1006351.
Martín-Hernández I, García-Izquierdo DSM. Toxoplasmosis en el hombre. Bioquimia. 2003;28(3):19-27.
Reiter-Owona I, Petersen E, Joynson D, Aspóck H, Dardé ML, Disko R, et al. The past and present role of the Sabin-Feldman dye test in the serodiagnosis of toxoplasmosis. Bull World Health Organ. 1999;77(11):929-35.
Berger JR. Mass lesions of the brain in AIDS: the dilemmas of distinguishing toxoplasmosis from primary CNS lymphoma. Am J Neuroradiol. 2003;24(4):555.
Lappalainen M, Koskela P, Koskiniemi M, Ammálá P, Hiilesmaa V, Teramo K, et al. Toxoplasmosis acquired during pregnancy: Improved serodiagnosis based on avidity of IgG. J Infect Dis. 1993;167(3):691-7. doi: 10.1093/infdis/167.3.691.
Mauhin W, Demoule A, Leclercq D, Gasnault J, Paris L, Katlama C, et al. Toxoplasmic ventriculitis. Med Mai Infect. 2016;46(2):100-3. doi: 10.1016/j.medmal.2015.11.005.
Kumar GGS, Mahadevan A, Guruprasad AS, Kovoor JME, Satishchandra P, Nath A, et al. Eccentric target sign in cerebral toxoplasmosis: Neuropathological correlate to the imaging feature. J Magn Reson Imaging. 2010;31(6):1469-72. doi: 10.1002/jmri.22192.
Marra CM, Krone MR, Koutsky LA, Holmes KK. Diagnostic accuracy of HIV-associated central nervous system toxoplasmosis. Int J STD AIDS. 1998;9(12):761-4. doi: 10.1258/0956462981921378.
Antinori A, Ammassari A, Luca D, Cingolani A, Fortini M, Tartaglione T. Diagnosis of AIDS-related focal brain lesions: A decision-making analysis based on clinical and neuroradiologic characteristics combined with polymerase chain reaction assays in CSF. Neurology. 1997;687-94. doi: 10.1212/wnl.48.3.687.
Bannoura S, El Hajj R, KhaKfeh I, El Hajj H. Acute disseminated encephalomyelitis and reactivation of cerebral toxoplas-mosis in a child: Case report. IDCases. 2018;13(2018):e00434. doi: 10.1016/j.idcr.2018.e00434.
Derouin F. Anti-toxoplasmosis drugs. Curr Opin Investig Drugs. 2001;2(10):1368-74.
Konstantinovic N, Guegan H, Stajner T, Belaz S, Robert-Gangneux F. Treatment of toxoplasmosis: Current options and future perspectives. Food Waterborne Parasitol. 2019;15. doi: 10.1016/j.fawpar.2019.e00036.
Centers for Disease Control and Prevention (CDC). Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV recommendations from the Centers for Disease Control and Prevention. MMWR Recomm Rep. 2019;424.
Van Delden C, Hirschel B. Folinic acid supplements to pyrimethamine-sulfadiazine for Toxoplasma encephalitis are associated with better outcome. J Infect Dis. 1996;173(5):1294-5. doi: 10.1093/infdis/173.5.1294.
Ben-Harari RR, Goodwin E, Casoy J. Adverse event profile of pyrimethamine-based therapy in toxoplasmosis: a systematic review. Drugs R D. 2017;17(4):523-44. doi: 10.1007/s40268-017-0206-8.
Laissy JP, Soyer P, Parlier C, Lariven S, Benmelha Z, Servois V, et al. Persistent enhancement after treatment for cerebral toxoplasmosis in patients with AIDS: Predictive value for subsequent recurrence. Am J Neuroradiol. 1994;15(9):1773-8.
Connolly MP, Goodwin E, Schey C, Zummo J. Toxoplasmic encephalitis relapse rates with pyrimethamine-based therapy: systematic review and meta-analysis. Pathog Glob Health. 2017;111(1):31-44. doi: 10.1080/20477724.2016.1273597.
Antinori A, Larussa D, Cingolani A, Lorenzini P, Bossolasco S, Finazzi MG, et al. Prevalence, associated factors, and prognostic determinants of AIDS-related toxoplasmic encephalitis in the era of advanced highly active antiretroviral therapy. Clin Infect Dis. 2004;39(11):1681-91. doi: 10.1086/424877.
Sonneville R, Schmidt M, Messika J, Hssain AA, Da Silva D, Klein IF, et al. Neurologic outcomes and adjunctive steroids in HIV patients with severe cerebral toxoplasmosis. Neurology. 2012;79(17):1762-6. doi: 10.1212/WNL.0b013e3182704040.
Sonneville R, Ferrand H, Tubach F, Roy C, Bouadma L, Klein IF, et al. Neurological complications of HIV infection in critically ill patients: Clinical features and outcomes. J Infect. 2011;62(4):301-8. doi: 10.1016/j.jinf.2011.02.003.
Martin-Iguacel R, Ahlstrõm MG, Tourna M, Engsig FN, Starke NB, Stœrkind M, et al. Incidence, presentation and outcome of toxoplasmosis in HIV infected in the combination antiretroviral therapy era. J Infect. 2017;75(3):263-73. doi: 10.1016/j.jinf.2017.05.018.
Robert-Gangneux F, Meroni V, Dupont D, Botterel F, Garcia JMA, Brenier-Pinchart MP, et al. Toxoplasmosis in transplant recipients, Europe, 2010-2014. Emerg Infect Dis. 2018;24(8):1497-504. doi: 10.3201/eid2408.180045.
Schmidt M, Sonneville R, Schnell D, Bigé N, Hamidfar R, Mongardon N, et al. Clinical features and outcomes in patients with disseminated toxoplasmosis admitted to intensive care: A multicenter study. Clin Infect Dis. 2013;57(11):1535-41. doi:10.1093/cid/cit557.
Azovtseva OV, Viktorova EA, Bakulina CG, Shelomov AS, Trofimova TN. Cerebral toxoplasmosis in HIV-infected patients over 2015-2018 (a case study of Russia). Epidemiol Infect. 2020;2018:1-6. doi: 10.1017/S0950268820000928.
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