1
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De Santis M, Tartaglia S, Apicella M, Visconti D, Noia G, Valentini P, Lanzone A, Santangelo R, Masini L. The prevention of congenital toxoplasmosis using a combination of Spiramycin and Cotrimoxazole: The long-time experience of a tertiary referral centre. Trop Med Int Health 2024. [PMID: 38842439 DOI: 10.1111/tmi.14021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
BACKGROUND Toxoplasmosis is a parasitic infection caused by Toxoplasma gondii and is responsible for gestational and congenital infections worldwide. The current standard therapy is based on the administration of Spiramycin to prevent trans-placental transmission. Other therapies are being studied to reduce the rates of foetal transmission and symptomatic congenital infection. OBJECTIVES We report our long-standing experience in maternal toxoplasmosis infection treatment using a combination of Spiramycin-Cotrimoxazole, assessing its effectiveness in preventing vertical transmission compared to the expected incidence of congenital infection. METHODS We retrospectively collected cases of pregnant women referred to our centre for suspected toxoplasmosis infection according to Lebech criteria, treated with Spiramycin-Cotrimoxazole. RESULTS Of 1364 women referred to our centre, postnatal follow-up of primary toxoplasmosis was available in 562 cases (73.9%). The overall vertical transmission rate was 3.4% in women treated immediately with Spiramycin-Cotrimoxazole after the diagnosis of infection. In comparison, it was 7.7% in women undergoing the same therapy but late or with poor compliance. The foetal transmission rate was 71.4% in untreated cases. All the infected newborns of mother treated adequately with Spiramycin-Cotrimoxazole were asymptomatic afterbirth, while 6/21 infected infants of the inadequate Spiramycin-Cotrimoxazole therapy group had postnatal sequelae (28.5%). The incidence of transmission after appropriate Spiramycin-Cotrimoxazole therapy was significantly lower than the expected rate reported in literature. CONCLUSIONS A combination of Spiramycin and Cotrimoxazole is safe and effective in preventing foetal congenital toxoplasmosis and reducing sequelae in case of in-utero infection. The timing and adherence to the therapy are crucial to lowering the risk of congenital infection and neonatal morbidity.
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Affiliation(s)
- Marco De Santis
- Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Ostetricia e Patologia Ostetrica, Rome, Italy
- Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Silvio Tartaglia
- Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Ostetricia e Patologia Ostetrica, Rome, Italy
| | | | - Daniela Visconti
- Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Ostetricia e Patologia Ostetrica, Rome, Italy
| | - Giuseppe Noia
- Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Ostetricia e Patologia Ostetrica, Rome, Italy
- Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Piero Valentini
- Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Pediatria, Rome, Italy
- Istituto di Clinica Pediatrica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio Lanzone
- Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Ostetricia e Patologia Ostetrica, Rome, Italy
- Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Rosaria Santangelo
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC di Microbiologia, Rome, Italy
- Istituto di Microbiologia, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Lucia Masini
- Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Ostetricia e Patologia Ostetrica, Rome, Italy
- Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, Rome, Italy
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2
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Garweg JG, Kieffer F, Mandelbrot L, Peyron F, Wallon M. Long-Term Outcomes in Children with Congenital Toxoplasmosis-A Systematic Review. Pathogens 2022; 11:pathogens11101187. [PMID: 36297244 PMCID: PMC9610672 DOI: 10.3390/pathogens11101187] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 10/10/2022] [Accepted: 10/11/2022] [Indexed: 11/07/2022] Open
Abstract
Even in the absence of manifestations at birth, children with congenital toxoplasmosis (CT) may develop serious long-term sequelae later in life. This systematic review aims to present the current state of knowledge to base an informed decision on how to optimally manage these pregnancies and children. For this, a systematic literature search was performed on 28 July 2022 in PubMed, CENTRAL, ClinicalTrials.gov, Google Scholar and Scopus to identify all prospective and retrospective studies on congenital toxoplasmosis and its long-term outcomes that were evaluated by the authors. We included 31 research papers from several countries. Virulent parasite strains, low socioeconomic status and any delay of treatment seem to contribute to a worse outcome, whereas an early diagnosis of CT as a consequence of prenatal screening may be beneficial. The rate of ocular lesions in treated children increases over time to 30% in European and over 70% in South American children and can be considerably reduced by early treatment in the first year of life. After treatment, new neurological manifestations are not reported, while ocular recurrences are observed in more than 50% of patients, with a mild to moderate impact on quality of life in European cohorts when compared to a significantly reduced quality of life in the more severely affected South American children. Though CT is rare and less severe in Europe when compared with South America, antenatal screening is the only effective way to diagnose and treat affected individuals at the earliest possible time in order to reduce the burden of disease and achieve satisfying outcomes.
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Affiliation(s)
- Justus G. Garweg
- Swiss Eye Institute, Rotkreuz, and Uveitis Clinic, Berner Augenklinik, Zieglerstrasse 29, 3007 Bern, Switzerland
- Department of Ophthalmology, Inselspital, University Hospital, 3010 Bern, Switzerland
- Correspondence:
| | - François Kieffer
- Assistance Publique-Hôpitaux de Paris, Hôpital Armand Trousseau, Service de Néonatologie, 75012 Paris, France
| | - Laurent Mandelbrot
- Assistance Publique-Hôpitaux de Paris, Hôpital Louis-Mourier Service de Gynécologie-Obstétrique, 178 rue des Renouillers, 92700 Colombes, France
- Inserm IAME-U1137, 75000 Paris, France
| | - François Peyron
- Hospices Civils de Lyon, Hôpital de la Croix Rousse, Department of Parasitology and Medical Mycology, 69004 Lyon, France
| | - Martine Wallon
- Hospices Civils de Lyon, Hôpital de la Croix Rousse, Department of Parasitology and Medical Mycology, 69004 Lyon, France
- Walking Team, Centre for Research in Neuroscience in Lyon, 69500 Bron, France
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3
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Cheng A, Zhang H, Chen B, Zheng S, Wang H, Shi Y, You S, Li M, Jiang L. Modulation of autophagy as a therapeutic strategy for Toxoplasma gondii infection. Front Cell Infect Microbiol 2022; 12:902428. [PMID: 36093185 PMCID: PMC9448867 DOI: 10.3389/fcimb.2022.902428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 08/05/2022] [Indexed: 12/05/2022] Open
Abstract
Toxoplasma gondii infection is a severe health threat that endangers billions of people worldwide. T. gondii utilizes the host cell membrane to form a parasitophorous vacuole (PV), thereby fully isolating itself from the host cell cytoplasm and making intracellular clearance difficult. PV can be targeted and destroyed by autophagy. Autophagic targeting results in T. gondii killing via the fusion of autophagosomes and lysosomes. However, T. gondii has developed many strategies to suppress autophagic targeting. Accordingly, the interplay between host cell autophagy and T. gondii is an emerging area with important practical implications. By promoting the canonical autophagy pathway or attenuating the suppression of autophagic targeting, autophagy can be effectively utilized in the development of novel therapeutic strategies against T gondii. Here, we have illustrated the complex interplay between host cell mediated autophagy and T. gondii. Different strategies to promote autophagy in order to target the parasite have been elucidated. Besides, we have analyzed some potential new drug molecules from the DrugBank database using bioinformatics tools, which can modulate autophagy. Various challenges and opportunities focusing autophagy mediated T. gondii clearance have been discussed, which will provide new insights for the development of novel drugs against the parasite.
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Affiliation(s)
- Ao Cheng
- Department of Parasitology, Xiangya School of Medicine, Central South University, Changsha, China
| | - Huanan Zhang
- Department of Parasitology, Xiangya School of Medicine, Central South University, Changsha, China
| | - Baike Chen
- Department of Parasitology, Xiangya School of Medicine, Central South University, Changsha, China
| | - Shengyao Zheng
- Department of Parasitology, Xiangya School of Medicine, Central South University, Changsha, China
| | - Hongyi Wang
- Department of Parasitology, Xiangya School of Medicine, Central South University, Changsha, China
| | - Yijia Shi
- Department of Parasitology, Xiangya School of Medicine, Central South University, Changsha, China
| | - Siyao You
- Department of Parasitology, Xiangya School of Medicine, Central South University, Changsha, China
| | - Ming Li
- Department of Immunology, Xiangya School of Medicine, Central South University, Changsha, China
- *Correspondence: Liping Jiang, ; Ming Li,
| | - Liping Jiang
- Department of Parasitology, Xiangya School of Medicine, Central South University, Changsha, China
- China-Africa Research Center of Infectious Diseases, Xiangya School of Medicine, Central South University, Changsha, China
- *Correspondence: Liping Jiang, ; Ming Li,
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Khademi SZ, Ghaffarifar F, Dalimi A, Davoodian P, Abdoli A. Spontaneous abortion among Toxoplasma gondii IgG seropositive women: Molecular detection, genotype identification, and serological assessment with conventional ELISA and avidity ELISA. J Obstet Gynaecol Res 2022; 48:2479-2485. [PMID: 35793814 DOI: 10.1111/jog.15349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 06/14/2022] [Accepted: 06/21/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVES It has been generally believed that women who exposed to Toxoplasma gondii before pregnancy and have anti-T. gondii IgG antibody are immunized and their newborns will be protected from congenital infection. This study is aimed to investigate the role of T. gondii infection in spontaneous abortion through serological and molecular methods in southern Iran. STUDY DESIGN Blood samples were taken from 50 spontaneously aborted mothers and anti-T. gondii antibodies were assessed using conventional enzyme-linked immunosorbent assay (ELISA) and avidity ELISA methods. The placenta and blood samples of aborted women were used for detection of the parasite's DNA by polymerase chain reaction (PCR) method targeting the RE gene. The parasite genotypes were determined by PCR-restriction fragment length polymorphism (RFLP) method using SAG3 and GRA6 genes. RESULTS IgG antibody was detected in 28% (14/50) of mothers, but all samples were negative for IgM antibody. In the avidity ELISA test, 26% (13/50) of the samples had a high avidity index, suggesting chronic infection, while a low avidity index was detected in one case (2%), which suggests acute infection. The parasite's DNA was detected in 18% (9/50) and 14% (7/50) of blood and placenta samples, respectively. All DNA positive samples were IgG positive. All isolates were belonged to the T. gondii type III genotype. CONCLUSION The results suggest that T. gondii seropositive women are not protected from congenital transmission. However, the results should be interpreted cautiously until further studies will be confirmed these results.
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Affiliation(s)
| | - Fatemeh Ghaffarifar
- Department of Parasitology, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | - Abdolhossein Dalimi
- Department of Parasitology, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | - Parivash Davoodian
- Department of infectious Disease, Hormozgan University of Medical Sciences, Hormozgan, Iran
| | - Amir Abdoli
- Zoonoses Research Center, Jahrom University of Medical Sciences, Jahrom, Iran.,Department of Parasitology and Mycology, Jahrom University of Medical Sciences, Jahrom, Iran
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5
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Ardabili S, Kohl J, Gül G, Hodel M. Republished: What obstetricians should be aware of - serious side effects of antibiotic toxoplasmosis treatment in pregnancy. Drug Ther Bull 2022; 60:92-95. [PMID: 35351681 DOI: 10.1136/dtb.2022.240809rep] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Sara Ardabili
- Department of Obstetrics and Gynecology, Cantonal Hospital Lucerne, Luzern, Switzerland
| | - Joachim Kohl
- Department of Obstetrics and Gynecology, Cantonal Hospital Lucerne, Luzern, Switzerland
| | - Gülseven Gül
- Department of Obstetrics and Gynecology, Cantonal Hospital Lucerne, Luzern, Switzerland
| | - Markus Hodel
- Department of Obstetrics and Gynecology, Cantonal Hospital Lucerne, Luzern, Switzerland
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6
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Petersen E, Meroni V, Vasconcelos-Santos DV, Mandelbrot L, Peyron F. Congenital toxoplasmosis: Should we still care about screening? Food Waterborne Parasitol 2022; 27:e00162. [PMID: 35782022 PMCID: PMC9249550 DOI: 10.1016/j.fawpar.2022.e00162] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 05/02/2022] [Accepted: 05/06/2022] [Indexed: 11/18/2022] Open
Abstract
Prenatal systematic screening for congenital toxoplasmosis has been performed in Austria and France since 1975 and neonatal screening for congenital toxoplasmosis has been part of the New England Newborn screening program since 1986. In this narrative review we review the data leading up to the systematic screening programs in Austria and France, highlighting the main finding of the European Union funded research in the 1990s and early 2000s. Different descriptive studies of the effect of pre- or postnatal treatment are discussed. Toxoplasma gondii has different genetic lineages with different pathogenicity in humans. This means that results in areas with a low pathogenic lineage cannot be extrapolated to an area with highly pathogenic lineages. The importance of meat as a source of infection is discussed in the light of an increased prevalence of T.gondii in organic livestock production .
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Affiliation(s)
- Eskild Petersen
- Institute for Clinical Medicine, Faculty of Health Science, University of Aarhus, Denmark
- European Society for Clinical Microbiology and Infectious Diseases, Emerging Infections Task Force, Basel, Switzerland
- Correspondong author at: Institute for Clinical Medicine, University of Aarhus, Denmark.
| | - Valeria Meroni
- Molecular Medicine Department, University of Pavia, Pavia, Italy
| | | | - Laurent Mandelbrot
- Assistance Publique-Hôpitaux de Paris, Service de Gynécologie-Obstétrique, Hôpital Louis Mourier, Colombes, France; Université de Paris; Inserm IAME-U1137, Paris, France; FHU PREMA, Paris, France
| | - Francois Peyron
- Institut de Parasitologie et de Mycologie Médicale Hôpital de la Croix Rousse, Lyon, France
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7
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Montoya JG, Laessig K, Fazeli MS, Siliman G, Yoon SS, Drake-Shanahan E, Zhu C, Akbary A, McLeod R. A fresh look at the role of spiramycin in preventing a neglected disease: meta-analyses of observational studies. Eur J Med Res 2021; 26:143. [PMID: 34895348 PMCID: PMC8665510 DOI: 10.1186/s40001-021-00606-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 11/14/2021] [Indexed: 12/18/2022] Open
Abstract
PURPOSE We aimed to investigate the effect of antepartum treatment with spiramycin with or without subsequent pyrimethamine-sulfonamide-folinic acid, compared to no treatment, on the rate of mother-to-child transmission (MTCT) of Toxoplasma gondii (T. gondii) and incidence/severity of sequelae in the offspring. METHODS Embase and PubMed were searched for literature on spiramycin in pregnant women suspected/diagnosed with T. gondii infection. Meta-analyses were performed using random-effects model. RESULTS Thirty-three studies (32 cohorts and 1 cross-sectional study), with a total of 15,406 mothers and 15,250 offspring, were pooled for analyses. The MTCT rate for all treated patients was significantly lower than the untreated [19.5% (95% CI 14-25.5%) versus 50.7% (95% CI 31.2-70%), p < 0.001]. The transmission rate in patients on spiramycin monotherapy was also significantly lower than untreated [17.6% (95% CI 9.9-26.8%) versus 50.7% (95% CI 31.2-70%), p < 0.001]. CONCLUSION Results indicate significant reduction in MTCT rates following spiramycin treatment of suspected/diagnosed maternal T. gondii infection.
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Affiliation(s)
- Jose G Montoya
- Jack S. Remington Laboratory for Specialty Diagnostics, Palo Alto, CA, USA
| | | | | | | | | | | | - Chengyue Zhu
- Department of General Medicines, Sanofi S.A, Bridgewater, NJ, USA
| | - Akbar Akbary
- Department of General Medicines, Sanofi S.A, Bridgewater, NJ, USA
| | - Rima McLeod
- Division of Biologic Sciences, Departments of Pediatrics (Infectious Diseases) and Ophthalmology and Visual Sciences, University of Chicago, Chicago, IL, USA.
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8
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da Silva M, Teixeira C, Gomes P, Borges M. Promising Drug Targets and Compounds with Anti- Toxoplasma gondii Activity. Microorganisms 2021; 9:1960. [PMID: 34576854 PMCID: PMC8471693 DOI: 10.3390/microorganisms9091960] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 09/09/2021] [Accepted: 09/10/2021] [Indexed: 12/25/2022] Open
Abstract
Toxoplasmosis is a parasitic disease caused by the globally distributed protozoan parasite Toxoplasma gondii, which infects around one-third of the world population. This disease may result in serious complications for fetuses, newborns, and immunocompromised individuals. Current treatment options are old, limited, and possess toxic side effects. Long treatment durations are required since the current therapeutic system lacks efficiency against T. gondii tissue cysts, promoting the establishment of latent infection. This review highlights the most promising drug targets involved in anti-T. gondii drug discovery, including the mitochondrial electron transport chain, microneme secretion pathway, type II fatty acid synthesis, DNA synthesis and replication and, DNA expression as well as others. A description of some of the most promising compounds demonstrating antiparasitic activity, developed over the last decade through drug discovery and drug repurposing, is provided as a means of giving new perspectives for future research in this field.
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Affiliation(s)
- Marco da Silva
- Departamento de Ciências Biológicas, Faculdade de Farmácia da Universidade do Porto, 4050-313 Porto, Portugal;
| | - Cátia Teixeira
- LAQV-REQUIMTE, Departamento de Química e Bioquímica, Faculdade de Ciências da Universidade do Porto, 4169-007 Porto, Portugal; (C.T.); (P.G.)
| | - Paula Gomes
- LAQV-REQUIMTE, Departamento de Química e Bioquímica, Faculdade de Ciências da Universidade do Porto, 4169-007 Porto, Portugal; (C.T.); (P.G.)
| | - Margarida Borges
- Associate Laboratory i4HB—Institute for Health and Bioeconomy, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal
- UCIBIO/REQUIMTE, Laboratory of Toxicology, Department of Biological Sciences, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal
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9
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Shmeleva EV, Colucci F. Maternal natural killer cells at the intersection between reproduction and mucosal immunity. Mucosal Immunol 2021; 14:991-1005. [PMID: 33903735 PMCID: PMC8071844 DOI: 10.1038/s41385-020-00374-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 11/24/2020] [Accepted: 12/02/2020] [Indexed: 02/07/2023]
Abstract
Many maternal immune cells populate the decidua, which is the mucosal lining of the uterus transformed during pregnancy. Here, abundant natural killer (NK) cells and macrophages help the uterine vasculature adapt to fetal demands for gas and nutrients, thereby supporting fetal growth. Fetal trophoblast cells budding off the forming placenta and invading deep into maternal tissues come into contact with these and other immune cells. Besides their homeostatic functions, decidual NK cells can respond to pathogens during infection, but in doing so, they may become conflicted between destroying the invader and sustaining fetoplacental growth. We review how maternal NK cells balance their double duty both in the local microenvironment of the uterus and systemically, during toxoplasmosis, influenza, cytomegalovirus, malaria and other infections that threat pregnancy. We also discuss recent developments in the understanding of NK-cell responses to SARS-Cov-2 infection and the possible dangers of COVID-19 during pregnancy.
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Affiliation(s)
- Evgeniya V Shmeleva
- Department of Obstetrics & Gynaecology, University of Cambridge, National Institute for Health Research Cambridge Biomedical Research Centre, Cambridge, CB2 0SW, UK
- Centre for Trophoblast Research, University of Cambridge, Cambridge, UK
| | - Francesco Colucci
- Department of Obstetrics & Gynaecology, University of Cambridge, National Institute for Health Research Cambridge Biomedical Research Centre, Cambridge, CB2 0SW, UK.
- Centre for Trophoblast Research, University of Cambridge, Cambridge, UK.
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10
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Donadono V, Saccone G, Sarno L, Esposito G, Mazzarelli LL, Sirico A, Guida M, Martinelli P, Zullo F, Maruotti GM. Association between lymphadenopathy after toxoplasmosis seroconversion in pregnancy and risk of congenital infection. Eur J Clin Microbiol Infect Dis 2021; 41:45-51. [PMID: 34458947 DOI: 10.1007/s10096-021-04337-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 08/16/2021] [Indexed: 12/19/2022]
Abstract
The aim of the study was to describe the pregnancy outcome of a large cohort of women with toxoplasmosis seroconversion in pregnancy and to investigate the relation between maternal lymphadenopathy and risk of congenital toxoplasmosis (CT). This was a retrospective study involving women with confirmed toxoplasmosis seroconversion in pregnancy between 2001 and 2017. Women were clinically evaluated for lymphadenopathy and classified as follows: lymphadenopathy absent (L-) or lymphadenopathy present (L+). The mothers were treated and followed-up according to local protocol, and neonates were monitored at least for 1 year in order to diagnose CT. A total of 218 women (one twin pregnancy) were included in the analysis. Pregnancy outcome was as follows: 149 (68%) of children not infected, 62 (28.3%) infected, 4 (1.8%) first trimester termination of pregnancy, 2 (0.9%) first trimester miscarriages, and 3 (1.4%) stillbirths (of which one already counted in the infected cohort). 13.8% of women were L+ , and they were nearly three times more likely to have a child with CT compared to L- women (aOR, 2.90; 95%CI, 1.28-6.58). Moreover, the result was still statistically significant when the analysis was restricted to 81 children whose mothers were clinically examined and received treatment within 5 weeks from estimated time of infection. In conclusion, there is a positive association between L+ status in pregnant women, and risk of CT also confirmed when restricting the analysis to women with early diagnosis of seroconversion and treatment. This data could be very useful in counselling pregnant women with toxoplasmosis seroconversion and lead to direct a more specific therapeutic and diagnostic protocol.
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MESH Headings
- Adult
- Antibodies, Protozoan/blood
- Female
- Humans
- Infant
- Infant, Newborn
- Infant, Newborn, Diseases/diagnosis
- Infant, Newborn, Diseases/parasitology
- Infectious Disease Transmission, Vertical
- Lymphadenopathy/blood
- Lymphadenopathy/diagnosis
- Lymphadenopathy/parasitology
- Male
- Pregnancy
- Pregnancy Complications, Infectious/blood
- Pregnancy Complications, Infectious/diagnosis
- Pregnancy Complications, Infectious/parasitology
- Pregnancy Outcome
- Prenatal Exposure Delayed Effects/diagnosis
- Prenatal Exposure Delayed Effects/parasitology
- Retrospective Studies
- Seroconversion
- Toxoplasmosis/blood
- Toxoplasmosis/diagnosis
- Toxoplasmosis/parasitology
- Toxoplasmosis/transmission
- Toxoplasmosis, Congenital/diagnosis
- Toxoplasmosis, Congenital/parasitology
- Young Adult
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Affiliation(s)
- Vera Donadono
- Department of Neuroscience, Reproductive Sciences and Dentistry , University of Naples Federico II, Via Pansini 5, 80131, Naples, Italy.
| | - Gabriele Saccone
- Department of Neuroscience, Reproductive Sciences and Dentistry , University of Naples Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Laura Sarno
- Department of Neuroscience, Reproductive Sciences and Dentistry , University of Naples Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Giuseppina Esposito
- Department of Neuroscience, Reproductive Sciences and Dentistry , University of Naples Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Laura L Mazzarelli
- Department of Neuroscience, Reproductive Sciences and Dentistry , University of Naples Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Angelo Sirico
- Department of Neuroscience, Reproductive Sciences and Dentistry , University of Naples Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Maurizio Guida
- Department of Neuroscience, Reproductive Sciences and Dentistry , University of Naples Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Pasquale Martinelli
- Department of Neuroscience, Reproductive Sciences and Dentistry , University of Naples Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Fulvio Zullo
- Department of Neuroscience, Reproductive Sciences and Dentistry , University of Naples Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Giuseppe M Maruotti
- Department of Neuroscience, Reproductive Sciences and Dentistry , University of Naples Federico II, Via Pansini 5, 80131, Naples, Italy
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11
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Mandelbrot L, Kieffer F, Wallon M, Winer N, Massardier J, Picone O, Fuchs F, Benoist G, Garcia-Meric P, L'Ollivier C, Paris L, Piarroux R, Villena I, Peyron F. [Toxoplasmosis in pregnancy: Practical Management]. ACTA ACUST UNITED AC 2021; 49:782-791. [PMID: 33677120 DOI: 10.1016/j.gofs.2021.03.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Indexed: 11/28/2022]
Abstract
The burden of congenital toxoplasmosis has become small in France today, in particular as a result of timely therapy for pregnant women, fetuses and newborns. Thus, the French screening and prevention program has been evaluated and recently confirmed despite a decline over time in the incidence of toxoplasmosis. Serological diagnosis of maternal seroconversion is usually simple but can be difficult when the first trimester test shows the presence of IgM, requiring referral to an expert laboratory. Woman with confirmed seroconversion should be referred quickly to an expert center, which will decide with her on treatment and antenatal diagnosis. Although the level of proof is moderate, there is a body of evidence in favor of active prophylactic prenatal treatment started as early as possible (ideally within 3 weeks of seroconversion) to reduce the risk of maternal-fetal transmission, as well as symptoms in children. The recommended therapies to prevent maternal-fetal transmission are: (1) spiramycin in case of maternal infection before 14 gestational weeks; (2) pyrimethamine and sulfadiazine (P-S) with folinic acid in case of maternal infection at 14 WG or more. Amniocentesis is recommended to guide prenatal and neonatal care. If fetal infection is diagnosed by PCR on amniotic fluid, therapy with P-S should be initiated as early as possible or continued in order reduce the risk of damage to the brain or eyes. Further research is required to validate new approaches to preventing congenital toxoplasmosis.
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Affiliation(s)
- L Mandelbrot
- AP-HP hôpital Louis-Mourier service de gynécologie-obstétrique, 178, rue des Renouillers, 92700 Colombes France; Université de Paris, Paris, France; Inserm IAME-U1137, Paris, France; FHU PREMA, Paris, France.
| | - F Kieffer
- FHU PREMA, Paris, France; Assistance Publique-hôpitaux de Paris, hôpital Armand Trousseau, Service de néonatologie, Paris, France
| | - M Wallon
- Hospices Civils de Lyon, hôpital de la Croix-Rousse, service de parasitologie-Mycologie Médicale, Lyon, France; INSERM U1028-CNRS UMR 5292, université Claude-Bernard, université Lyon-1, Bron, France
| | - N Winer
- Centre hospitalier universitaire de Nantes, service de gynécologie-obstétrique, et NUN, INRA, UMR 1280, Phan Université de Nantes, 44000 Nantes, France
| | - J Massardier
- INSERM U1028-CNRS UMR 5292, université Claude-Bernard, université Lyon-1, Bron, France; Hospices civils de Lyon, hôpital de la Croix-Rousse, service de gynécologie-obstétrique, Lyon, France
| | - O Picone
- AP-HP hôpital Louis-Mourier service de gynécologie-obstétrique, 178, rue des Renouillers, 92700 Colombes France; Université de Paris, Paris, France; Inserm IAME-U1137, Paris, France; FHU PREMA, Paris, France
| | - F Fuchs
- Service de gynécologie obstétrique CHU de Montpellier, Hopital Arnaud de Villeneuve, 371, avenue du Doyen Gaston-Giraud, 34295 Montpellier Cedex 5, France; Inserm, CESP Centre de recherche en Epidémiologie et Santé des Populations, U1018, Reproduction et Développement de l'enfant, 94807 Villejuif, France; Institut Desbrest d'epidemiologie et de santé publique, UMR inserm - université de Montpellier, Montpellier, France
| | - G Benoist
- Obstetrics and gynecology, Caen university Hospital, 14000 Caen, France
| | - P Garcia-Meric
- Assistance Publique-hôpitaux de Marseille, service de médecine néonatale, hôpital de la Conception, Marseille, France
| | - C L'Ollivier
- Aix Marseille Université, IRD, AP-HM, SSA, VITROME, IHU Méditerranée Infection, Marseille, France
| | - L Paris
- Assistance Publique-hôpitaux de Paris, hôpital Pitié-Salpêtrière, service de Parasitologie, Paris, France
| | - R Piarroux
- Assistance Publique-hôpitaux de Paris, hôpital Pitié-Salpêtrière, service de Parasitologie, Paris, France; Sorbonne Université, IPLESP UMR 1136, inserm, Paris, France
| | - I Villena
- Service de parasitologie-mycologie, centre national de référence de la toxoplasmose, centre de ressources biologiques toxoplasma, CHU Reims, Reims, France; EA 7510, laboratoire parasitologie-mycologie, université Reims Champagne -Ardenne, Reims, France
| | - F Peyron
- Hospices Civils de Lyon, hôpital de la Croix-Rousse, service de parasitologie-Mycologie Médicale, Lyon, France; INSERM U1028-CNRS UMR 5292, université Claude-Bernard, université Lyon-1, Bron, France
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Ardabili S, Kohl J, Gül G, Hodel M. What obstetricians should be aware of: serious side effects of antibiotic toxoplasmosis treatment in pregnancy. BMJ Case Rep 2021; 14:e240809. [PMID: 33649030 PMCID: PMC7929819 DOI: 10.1136/bcr-2020-240809] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2021] [Indexed: 11/04/2022] Open
Abstract
Infection with Toxoplasma gondii is usually an asymptomatic or oligosymptomatic, self-limiting disease in immunocompetent individuals. However, during the pregnancy, primary infection can lead to transplacental vertical transmission resulting in congenital toxoplasmosis with possible severe sequelae. The efficacy of systematic screening remains controversial and the effect of antibiotic treatment is unclear. Although main side effects of antibiotic drugs used for toxoplasmosis are well known, mostly from malaria treatment, there is a lack of information about occurrence in pregnant woman treated for toxoplasmosis. We report a case of a healthy pregnant woman with primary toxoplasmosis infection in the second trimester, who developed a severe adverse reaction in form of hypersensitivity pneumonia after antibiotic treatment with pyrimethamine and sulfadiazine and discuss the literature.
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Affiliation(s)
- Sara Ardabili
- Department of Obstetrics and Gynecology, Cantonal Hospital Lucerne, Luzern, Switzerland
| | - Joachim Kohl
- Department of Obstetrics and Gynecology, Cantonal Hospital Lucerne, Luzern, Switzerland
| | - Gülseven Gül
- Department of Obstetrics and Gynecology, Cantonal Hospital Lucerne, Luzern, Switzerland
| | - Markus Hodel
- Department of Obstetrics and Gynecology, Cantonal Hospital Lucerne, Luzern, Switzerland
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Huang DB. The activity of the diaminopyrimidine dihydrofolate reducatase inhibitor, iclaprim, against Toxoplasma gondii in an in vitro model: a pilot study. Diagn Microbiol Infect Dis 2020; 99:115296. [PMID: 33387894 DOI: 10.1016/j.diagmicrobio.2020.115296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 12/08/2020] [Accepted: 12/12/2020] [Indexed: 11/29/2022]
Abstract
The objective of this pilot study was to examine the activity of iclaprim, a diaminopyrimidine dihydrofolate reducatase inhibitor, in an in vitro infection model of infection with Toxoplasma gondii. Toxoplasma growth was assessed by enzyme linked immunoassay (ELISA) performed directly on the fixed cultures using a peroxidase labeled monoclonal antibody directed against the SAG-l surface protein of T. gondii. For each well, the results were expressed as optical density (OD) values. Iclaprim inhibited T. gondii growth at concentrations between 0.1 and 10 mg/L; the IC50 was estimated at 0.26 mg/L (95% confidence interval 0.22-0.33). Iclaprim was about 10 times more active than trimethoprim, which had an IC50 of 2.3 mg/L. Iclaprim demonstrated synergistic effects at concentrations of 0.02, 0.05 and 0.1 mg/L when combined with subinhibitory concentrations of sulfamethoxazole (0.1 or 0.02 mg/L). These results show that iclaprim is a potent inhibitor of T. gondii growth in vitro. In addition, iclaprim exhibited synergy in vitro when tested in the presence of sulfamethoxazole. Iclaprim should be further investigated as an agent for the treatment or prophylaxis of toxoplasmosis.
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Affiliation(s)
- David B Huang
- Motif BioSciences, New York, NY, USA; Rutgers New Jersey Medical School, Newark, NJ, USA.
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Mandelbrot L. Congenital toxoplasmosis: What is the evidence for chemoprophylaxis to prevent fetal infection? Prenat Diagn 2020; 40:1693-1702. [PMID: 32453454 DOI: 10.1002/pd.5758] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 05/02/2020] [Accepted: 05/23/2020] [Indexed: 12/25/2022]
Abstract
Although prenatal diagnosis and prenatal and neonatal therapy of congenital toxoplasmosis are available, there is controversy concerning the effectiveness of prophylaxis to prevent placental transmission. Experimental, parasitological, and clinical data suggest a "window of opportunity" following maternal infection. Among medications active against Toxoplasma gondii, mainly spiramycin (Spy) and pyrimethamine + sulfonamide combinations (P-S) have been evaluated. Results from observational studies suffered treatment bias, since prescriptions differed according to the gestational age at seroconversion, which is the major risk factor for transmission, and many lacked precise timing. Some large retrospective studies found no difference in transmission according to prophylactic treatment, but transmission was lower when treatment started promptly after maternal seroconversion. A few recent studies adjusting for timing of infection observed lower transmission in case of P-S than other or no prophylaxis. In the only randomized controlled trial, transmission was lower with P-S than S (18.5% vs 30%, P = .147); this association was strengthened when the treatment was started within 3 weeks of seroconversion, and the incidence of fetal cerebral ultrasound signs was significantly reduced in the P-S group. Rapid initiation of prophylactic therapy following maternal infection, which is usually asymptomatic, requires systematic screening for maternal seroconversion during pregnancy.
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Affiliation(s)
- Laurent Mandelbrot
- Service de Gynécologie-Obstétrique, Assistance Publique-Hôpitaux de Paris Nord Université de Paris, Hôpital Louis Mourier, Colombes, France.,Inserm IAME 1137, Université de Paris, Paris, France
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Picone O, Fuchs F, Benoist G, Binquet C, Kieffer F, Wallon M, Wehbe K, Mandelbrot L, Villena I. Toxoplasmosis screening during pregnancy in France: Opinion of an expert panel for the CNGOF. J Gynecol Obstet Hum Reprod 2020; 49:101814. [PMID: 32428782 DOI: 10.1016/j.jogoh.2020.101814] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 05/12/2020] [Indexed: 11/15/2022]
Abstract
Prenatal screening to prevent congenital toxoplasmosis as performed in France for several decades has been questioned in view of the decreasing incidence of this infection and the cost of testing. The French College of Obstetrics and Gynecology mandated a multidisciplinary panel of experts to perform a reassessment of the screening program in accordance with international good practice. In France, about 70% of pregnant women are not immune to T. gondii, and 0.2-0.25% become infected during pregnancy. The risk of maternal-fetal transmission of infection is on average 25-29% and depends greatly on the gestational age at seroconversion. In case of fetal transmission, the outcome is livebirth in 95% of cases, with latent congenital toxoplasmosis in 90% of cases and symptomatic forms in 10% of cases, of which 1/3 are severe and 2/3 moderate. Biological techniques have satisfactory performance regarding serologies for the diagnosis of maternal infections and PCR on amniotic fluid for the prenatal diagnosis of congenital toxoplasmosis. Primary prevention of toxoplasmosis is based on hygiene measures that are relatively simple, but poorly implemented. In case of maternal seroconversion, there is a strong case for prenatal prophylactic treatment as soon as possible (ideally within 3 weeks of seroconversion), spiramycin before 14 weeks of gestation (WG), and with a tendency to superiority of the pyrimethamine/sulfadiazine association over spiramycin beyond 14 W G, in order to reduce the risk of symptomatic congenital toxoplasmosis. In case of congenital toxoplasmosis, prompt initiation of treatment reduces the occurrence of cerebral signs and symptoms, as well as retinal lesions. Several medico-economic evaluations of the French toxoplasmosis screening program have been conducted including an individual cost-effectiveness approach with decision analysis which concluded on the profitability of prenatal screening as carried out in France (monthly surveillance of seronegative women, prenatal treatment in case of seroconversion, termination of pregnancy in severe forms). Though most international societies do not recommend systematic screening for mainly financial reasons, if congenital toxoplasmosis appears benign in France today, it is probably thanks to screening and the possibility of early treatment of fetuses and/or newborns. Thus, the panel recommends continuing for now the program in France for prevention of congenital toxoplasmosis.
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Affiliation(s)
- Olivier Picone
- Assistance Publique-Hôpitaux de Paris, Service de Gynécologie-Obstétrique, Hôpital Louis Mourier, Colombes, France; Université de Paris; Inserm IAME-U1137, Paris, France; FHU PREMA; Groupe de Recherche sur les Infections pendant la grossesse (GRIG)
| | - Florent Fuchs
- Service de Gynécologie Obstétrique CHU de Montpellier, Hopital Arnaud de Villeneuve, Montpellier, France; Inserm, CESP Centre de recherche en Epidémiologie et Santé des Populations, U1018, Reproduction et Développement de l'enfant, 94807 Villejuif, France; EA2415: Aide à la décision médicale Personnalisée, Axe B: Méthode en épidémiologie Clinique, Université de Montpellier
| | | | - Christine Binquet
- Inserm, CIC1432, module Epidémiologie Clinique, Dijon, France; CHU Dijon-Bourgogne, Centre d'Investigation Clinique, Module Epidémiologie Clinique/Essais Cliniques, Dijon, France
| | - François Kieffer
- Assistance Publique-Hôpitaux de Paris, Service de néonatologie, Hôpital Armand Trousseau, Paris, France
| | - Martine Wallon
- Hospices Civils de Lyon, Hôpital de la Croix-Rousse, Service de Parasitologie - Mycologie Médicale, Lyon, France; Université Lyon-1, Equipe Waking, Physiologie Intégrée du Système d'éveil, Centre de Recherche en Neurosciences de Lyon (INSERM U1028 - CNRS UMR 5292), Bron, France
| | - Karl Wehbe
- Centre Hospitalier Universitaire de Strasbourg, Service de Gynécologie-Obstétrique, Strasbourg, France
| | - Laurent Mandelbrot
- Assistance Publique-Hôpitaux de Paris, Service de Gynécologie-Obstétrique, Hôpital Louis Mourier, Colombes, France; Université de Paris; Inserm IAME-U1137, Paris, France; FHU PREMA; Groupe de Recherche sur les Infections pendant la grossesse (GRIG)
| | - Isabelle Villena
- Université Reims Champagne -Ardenne, EA7510 et Centre National de Référence de la Toxoplasmose, Centre de Ressources Biologiques Toxoplasma, Service de Parasitologie-Mycologie, Centre Hospitalier Universitaire de Reims, Reims, France
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The cost-effectiveness of neonatal versus prenatal screening for congenital toxoplasmosis. PLoS One 2019; 14:e0221709. [PMID: 31532766 PMCID: PMC6750576 DOI: 10.1371/journal.pone.0221709] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Accepted: 08/13/2019] [Indexed: 01/27/2023] Open
Abstract
Background Congenital Toxoplasmosis (CT) can have severe consequences. France, Austria, and Slovenia have prenatal screening programs whereas some other countries are considering universal screening to reduce congenital transmission and severity of infection in children. The efficiency of such programs is debated increasingly as seroprevalence among pregnant women and incidence of congenital toxoplasmosis show a steady decrease. In addition, uncertainty remains regarding the effectiveness of pre- and postnatal treatments. Method To identify cost-effective strategies, prenatal and neonatal screenings were compared using a decision-analytic model based on French guidelines and current knowledge of long-term evolution of the disease in treated children. Epidemiological data were extracted from the scientific literature and clinical data from the French Lyon cohort. Strategies were compared at one year of age, when infection can be definitively evaluated, and at 15 years of age, after which validated outcome data become scarce. The analysis was performed from the French Health Insurance System perspective and included direct medical costs for pregnant women and their children. Results The 1-year Incremental Cost-Effectiveness Ratio showed that prenatal screening would require investing €14,826 to avoid one adverse event (liveborn with CT, fetal loss, neonatal death or pregnancy termination) compared to neonatal screening. Extra investment increased up to €21,472 when considering the 15-year endpoint. Conclusions Prenatal screening is cost-effective as compared to neonatal screening in moderate prevalence areas with predominant Type II strains. In addition, prenatal screening, by providing closer follow-up of women at risk increases the number of occasions for education avoiding toxoplasmosis.
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de Wit LA, Croll DA, Tershy B, Correa D, Luna-Pasten H, Quadri P, Kilpatrick AM. Potential public health benefits from cat eradications on islands. PLoS Negl Trop Dis 2019; 13:e0007040. [PMID: 30763304 PMCID: PMC6392314 DOI: 10.1371/journal.pntd.0007040] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 02/27/2019] [Accepted: 11/29/2018] [Indexed: 11/18/2022] Open
Abstract
Cats (Felis catus) are reservoirs of several pathogens that affect humans, including Toxoplasma gondii. Infection of pregnant women with T. gondii can cause ocular and neurological lesions in newborns, and congenital toxoplasmosis has been associated with schizophrenia, epilepsy, movement disorders, and Alzheimer's disease. We compared seroprevalence of T. gondii and risk factors in people on seven islands in Mexico with and without introduced cats to determine the effect of cat eradication and cat density on exposure to T. gondii. Seroprevalence was zero on an island that never had cats and 1.8% on an island where cats were eradicated in 2000. Seroprevalence was significantly higher (12-26%) on the five islands with cats, yet it did not increase across a five-fold range of cat density. Having cats near households, being male and spending time on the mainland were significant risk factors for T. gondii seroprevalence among individuals, whereas eating shellfish was protective. Our results suggest that cats are an important source of T. gondii on islands, and eradicating, but not controlling, introduced cats from islands could benefit human health.
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Affiliation(s)
- Luz A. de Wit
- Department of Ecology and Evolutionary Biology, University of California Santa Cruz, Santa Cruz, California, United States of America
- * E-mail:
| | - Donald A. Croll
- Department of Ecology and Evolutionary Biology, University of California Santa Cruz, Santa Cruz, California, United States of America
| | - Bernie Tershy
- Department of Ecology and Evolutionary Biology, University of California Santa Cruz, Santa Cruz, California, United States of America
| | - Dolores Correa
- Laboratorio de Inmunología Experimental, Instituto Nacional de Pediatría, Ciudad de México, México
| | - Hector Luna-Pasten
- Laboratorio de Inmunología Experimental, Instituto Nacional de Pediatría, Ciudad de México, México
| | - Paulo Quadri
- Department of Environmental Studies, University of California Santa Cruz, Santa Cruz, California, United States of America
| | - A. Marm Kilpatrick
- Department of Ecology and Evolutionary Biology, University of California Santa Cruz, Santa Cruz, California, United States of America
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Paul E, Kiwelu I, Mmbaga B, Nazareth R, Sabuni E, Maro A, Ndaro A, Halliday JEB, Chilongola J. Toxoplasma gondii seroprevalence among pregnant women attending antenatal clinic in Northern Tanzania. Trop Med Health 2018; 46:39. [PMID: 30479556 PMCID: PMC6245905 DOI: 10.1186/s41182-018-0122-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 11/08/2018] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Acute Toxoplasma gondii infection during pregnancy represents a risk for congenital disease, especially among women without previous exposure to infection. There is, however, a paucity of information about the epidemiology of T. gondii infection in pregnant women in Tanzania. This study aimed to determine the seroprevalence of T. gondii infection and associated demographic, clinical, and behavioral risk factors in pregnant women attending ante-natal clinic (ANC) at Kilimanjaro Christian Medical Center (KCMC), a referral medical center in Northern Tanzania. METHODS A hospital-based cross-sectional study was carried out from 1 February to 30 April 2017. Data on maternal demographic characteristics, obstetric history, knowledge, and practices related to T. gondii infection were collected from 254 pregnant women attending antenatal care at KCMC. A sample of 4 mL of blood was collected from each participant and sera prepared from each sample. Serum samples were tested for the presence of specific T. gondii IgG and IgM antibodies by indirect Enzyme-Linked Immunosorbent Assay (ELISA). DNA was extracted from whole blood for polymerase chain reaction (PCR) testing, targeting the DNA sequence coding for the Internal Transcribed Spacer 1 (ITS1). RESULTS The overall T. gondii seroprevalence, including both IgM- and IgG-positive individuals, was 44.5%. Of the 254 tested women, 102 and 23 were seropositive for T. gondii-specific IgG and IgM antibodies respectively and 113 individuals had antibodies of either or both classes. All IgM-positive samples were also tested by PCR, and all were negative. The majority (90%) of the women surveyed had never heard about toxoplasmosis. Consumption of raw vegetables [aOR = 0. 344; 95% CI 0.151-0.784; p = 0.011] and having regular contact with soil [aOR = 0.482; 95% CI 0.268-0.8681; p = 0.015] were both associated with T. gondii antibody status. Inverse relationships with probability of T. gondii exposure were observed, such that these practices were associated with reduced probability of antibody detection. CONCLUSION Based on serology results, we report widespread exposure to T. gondii infection among pregnant women attending ANC in KCMC. The complex interaction of risk factors for T. gondii infection needs to be studied in larger longitudinal studies.
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Affiliation(s)
- Eliakimu Paul
- Kilimanjaro Christian Medical University College, P.O. Box 2240, Moshi, Tanzania
| | - Ireen Kiwelu
- Kilimanjaro Clinical Research Institute, P.O. Box 2236, Moshi, Tanzania
- Kilimanjaro Christian Medical Center, P.O. Box 3010, Moshi, Tanzania
| | - Blandina Mmbaga
- Kilimanjaro Clinical Research Institute, P.O. Box 2236, Moshi, Tanzania
- Kilimanjaro Christian Medical Center, P.O. Box 3010, Moshi, Tanzania
| | - Rebeka Nazareth
- Kilimanjaro Christian Medical University College, P.O. Box 2240, Moshi, Tanzania
| | - Elias Sabuni
- Kilimanjaro Christian Medical University College, P.O. Box 2240, Moshi, Tanzania
| | - Athanasia Maro
- Kilimanjaro Clinical Research Institute, P.O. Box 2236, Moshi, Tanzania
| | - Arnold Ndaro
- Kilimanjaro Clinical Research Institute, P.O. Box 2236, Moshi, Tanzania
- Kilimanjaro Christian Medical Center, P.O. Box 3010, Moshi, Tanzania
| | - Jo E. B. Halliday
- Boyd Orr Center for Population and Ecosystem Health, Institute of Biodiversity, Animal Health and Comparative Medicine, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, G12 8QQ UK
| | - Jaffu Chilongola
- Kilimanjaro Christian Medical University College, P.O. Box 2240, Moshi, Tanzania
- Kilimanjaro Clinical Research Institute, P.O. Box 2236, Moshi, Tanzania
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Montoya JG. Systematic screening and treatment of toxoplasmosis during pregnancy: is the glass half full or half empty? Am J Obstet Gynecol 2018; 219:315-319. [PMID: 30269768 DOI: 10.1016/j.ajog.2018.08.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 08/01/2018] [Indexed: 12/20/2022]
Affiliation(s)
- Jose G Montoya
- Department of Medicine, Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA; Palo Alto Medical Foundation Toxoplasma Serology Laboratory, National Reference Center for the Study and Diagnosis of Toxoplasmosis, Palo Alto, CA.
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Prenatal therapy with pyrimethamine + sulfadiazine vs spiramycin to reduce placental transmission of toxoplasmosis: a multicenter, randomized trial. Am J Obstet Gynecol 2018; 219:386.e1-386.e9. [PMID: 29870736 DOI: 10.1016/j.ajog.2018.05.031] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 05/15/2018] [Accepted: 05/24/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND The efficacy of prophylaxis to prevent prenatal toxoplasmosis transmission is controversial, without any previous randomized clinical trial. In France, spiramycin is usually prescribed for maternal seroconversions. A more potent pyrimethamine + sulfadiazine regimen is used to treat congenital toxoplasmosis and is offered in some countries as prophylaxis. OBJECTIVE We sought to compare the efficacy and tolerance of pyrimethamine + sulfadiazine vs spiramycin to reduce placental transmission. STUDY DESIGN This was a randomized, open-label trial in 36 French centers, comparing pyrimethamine (50 mg qd) + sulfadiazine (1 g tid) with folinic acid vs spiramycin (1 g tid) following toxoplasmosis seroconversion. RESULTS In all, 143 women were randomized from November 2010 through January 2014. An amniocentesis was later performed in 131 cases, with a positive Toxoplasma gondii polymerase chain reaction in 7/67 (10.4%) in the pyrimethamine + sulfadiazine group vs 13/64 (20.3%) in the spiramycin group. Cerebral ultrasound anomalies appeared in 0/73 fetuses in the pyrimethamine + sulfadiazine group, vs 6/70 in the spiramycin group (P = .01). Two of these pregnancies were terminated. Transmission rates, excluding 18 children with undefined status, were 12/65 in the pyrimethamine + sulfadiazine group (18.5%), vs 18/60 in the spiramycin group (30%, P = .147), equivalent to an odds ratio of 0.53 (95% confidence interval, 0.23-1.22) and which after adjustment tended to be stronger (P = .03 for interaction) when treatment started within 3 weeks of seroconversion (95% confidence interval, 0.00-1.63). Two women had severe rashes, both with pyrimethamine + sulfadiazine. CONCLUSION There was a trend toward lower transmission with pyrimethamine + sulfadiazine, but it did not reach statistical significance, possibly for lack of statistical power because enrollment was discontinued. There were also no fetal cerebral toxoplasmosis lesions in the pyrimethamine + sulfadiazine group. These promising results encourage further research on chemoprophylaxis to prevent congenital toxoplasmosis.
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Abstract
Prevention and management of opportunistic infections in children is particularly relevant in an era demonstrating an increased prevalence of immunocompromising conditions. The presence of an unusual organism which results in serious infection in a child should therefore always raise the consideration of immune compromise. The more common opportunistic infections have become easier to recognize in recent times due to improved awareness and more refined diagnostic testing. Targeted treatment is usually followed by long-term prophylactic medication. The impact of these conditions on patient outcome is of clear significance and certainly warrants further discussion.
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Zhou Q, Wang Q, Shen H, Zhang Y, Zhang S, Li X, Acharya G. Seroepidemiological map of Toxoplasma gondii infection and associated risk factors in preconception period in China: A nationwide cross-sectional study. J Obstet Gynaecol Res 2018; 44:1134-1139. [PMID: 29673005 DOI: 10.1111/jog.13638] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 02/17/2018] [Indexed: 11/29/2022]
Abstract
AIM The aims of this study were to investigate the regional differences in seroepidemiology of toxoplasmosis in preconception period among Chinese women of reproductive age and to evaluate associated risk factors. METHODS This national, population-based, cross-sectional serosurvey covered all 31 provinces and province-level municipalities in Mainland China. Married women intending to get pregnant within 6 months between 2010 and 2012 were recruited. Information on demographic characteristics (age, place of residence, occupation, dietary habits and exposure to cat) was obtained using interviews, and venous blood samples were collected to screen for Toxoplasma gondii infection. RESULTS Of 2 008 561 women recruited to the study, 45 405 (2.3%) were Toxoplasma gondii IgG positive, and 6884 (0.3%) were IgM positive. Geographical variation for seropositivity ranged from 0.2% in Heilongjiang to 11.2% in Tianjing for IgG and from 0% in Tibet to 0.9% in Anhui for IgM. Advanced maternal age, occupation of a farmer, vegetarian diet and exposure to cat was significantly associated with Toxoplasma gondii IgM seropositivity, and its association with occupation of farmer and exposure to cat was significant after adjusting for province of residence (P < 0.05). CONCLUSION There were significant regional variations in Toxoplasma gondii seropositivity and associated risk factors among Chinese women of reproductive age during preconception period. This calls for a targeted primary prevention strategy. Screening and treatment before conception and preconception health education may have potential for reducing congenital Toxoplasmosis in China.
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Affiliation(s)
- Qiongjie Zhou
- Department of Obstetrics, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China.,Women's Health and Perinatology Research Group, Department of Clinical Medicine, UiT - The Arctic University of Norway, Tromsø, Norway
| | - Qiaomei Wang
- Department of Maternal and Child Health, National Health and Family Planning Commission of the People's Republic of China, Beijing, China
| | - Haiping Shen
- Department of Maternal and Child Health, National Health and Family Planning Commission of the People's Republic of China, Beijing, China
| | - Yiping Zhang
- Department of Maternal and Child Health, National Health and Family Planning Commission of the People's Republic of China, Beijing, China
| | - Shikun Zhang
- Department of Maternal and Child Health, National Health and Family Planning Commission of the People's Republic of China, Beijing, China
| | - Xiaotian Li
- Department of Obstetrics, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China.,Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, China
| | - Ganesh Acharya
- Women's Health and Perinatology Research Group, Department of Clinical Medicine, UiT - The Arctic University of Norway, Tromsø, Norway.,Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Obstetrics and Gynecology, Karolinska Institute, Stockholm, Sweden
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Dalmartello M, Parazzini F, Pedron M, Pertile R, Collini L, La Vecchia C, Piffer S. Coverage and outcomes of antenatal tests for infections: a population based survey in the Province of Trento, Italy. J Matern Fetal Neonatal Med 2018; 32:2049-2055. [PMID: 29343192 DOI: 10.1080/14767058.2018.1424822] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Rubella, syphilis, toxoplasmosis, cytomegalovirus (CMV), hepatitis B (HBV) and C (HCV), HIV, and Group B Streptococcus (GBS) infections may have very severe outcomes during pregnancy, and for this reason, monitoring of infections in pregnant women is a requirement of prenatal assistance. AIMS To describe coverage and outcome of the screening for rubella, syphilis, toxoplasmosis, CMV, HBV, HCV, HIV, and Group B Streptococcus in pregnancy in the Autonomous Province of Trento, Northern Italy (538,600 inhabitants). METHODS We analysed the coverage and outcome of the above-mentioned screenings among women who delivered in the hospitals of the Province of Trento between 2007 and 2014 (N = 38,712). Screenings were grouped according to characteristics such as recommendation by national and local guidelines, scheduling of the tests, operating methods, and charge. We also estimated odds ratios (ORs) for missing screening for selected infections through multiple logistic regression. RESULTS Estimated uptake of antenatal screening was 99.7% for rubella, 99.3% for syphilis, 99.7% for toxoplasmosis, 98.1% for HIV infection, 99.0% for HBV, 98.9% for HCV, 94.0% for GBS infection, and 75.4% for CMV infection. The overall prevalence of immunity was 94.1% for rubella, 24.2% for toxoplasmosis, and 64.2% for CMV. The rate of seroconversion in pregnant women was 0.02% for rubella, 0.29% for toxoplasmosis, and 0.75% for CMV. The overall prevalence of infection was 0.94% for HBV, 0.53% for HCV, 22.3% for GBS, 0.29% for syphilis, and 0.13% for HIV. We found a significant positive association for all screening tests, between lack of testing and late first medical examination in pregnancy (ORs ranging from 1.20 to 1.66 for the first medical visit in the second trimester and ORs ranging from 1.60 to 5.88 for the first medical visit in third trimester, compared to early medical visit in the first trimester). Compared to Italian citizenship, foreign citizenship of the mother was also positively associated with absence of screening (ORs ranging from 1.30 to 1.53). A significant inverse association was observed for calendar year of delivery (ORs ranging from 0.71 to 0.97, for 1 year increment). Less educated mothers and pluriparae were also at higher risks of not being tested. Analysis of the association with mother age showed different heterogeneous effects. CONCLUSIONS Our study indicates that the attention to screening and detecting infected cases is growing over the time. In addition, care delivered during pregnancy has a leading role in determining coverage of the examinations. Immigrant, pluriparous and less educated women need particular attention.
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Affiliation(s)
- Michela Dalmartello
- a Department of Clinical Sciences and Community Health , University of Milan , Milan , Italy
| | - Fabio Parazzini
- a Department of Clinical Sciences and Community Health , University of Milan , Milan , Italy.,b Department of Obstetrics, Gynecology, and Neonatology , University of Milan, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico , Milan , Italy
| | - Mariangela Pedron
- c Clinical and Evaluative Epidemiology Department , Trento Health Service , Trento , Italy
| | - Riccardo Pertile
- c Clinical and Evaluative Epidemiology Department , Trento Health Service , Trento , Italy
| | - Lucia Collini
- d O.U. Microbiology and Virology , Trento Health Service , Trento , Italy
| | - Carlo La Vecchia
- a Department of Clinical Sciences and Community Health , University of Milan , Milan , Italy
| | - Silvano Piffer
- c Clinical and Evaluative Epidemiology Department , Trento Health Service , Trento , Italy
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Prusa AR, Kasper DC, Sawers L, Walter E, Hayde M, Stillwaggon E. Congenital toxoplasmosis in Austria: Prenatal screening for prevention is cost-saving. PLoS Negl Trop Dis 2017; 11:e0005648. [PMID: 28692640 PMCID: PMC5503164 DOI: 10.1371/journal.pntd.0005648] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 05/17/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Primary infection of Toxoplasma gondii during pregnancy can be transmitted to the unborn child and may have serious consequences, including retinochoroiditis, hydrocephaly, cerebral calcifications, encephalitis, splenomegaly, hearing loss, blindness, and death. Austria, a country with moderate seroprevalence, instituted mandatory prenatal screening for toxoplasma infection to minimize the effects of congenital transmission. This work compares the societal costs of congenital toxoplasmosis under the Austrian national prenatal screening program with the societal costs that would have occurred in a No-Screening scenario. METHODOLOGY/PRINCIPAL FINDINGS We retrospectively investigated data from the Austrian Toxoplasmosis Register for birth cohorts from 1992 to 2008, including pediatric long-term follow-up until May 2013. We constructed a decision-analytic model to compare lifetime societal costs of prenatal screening with lifetime societal costs estimated in a No-Screening scenario. We included costs of treatment, lifetime care, accommodation of injuries, loss of life, and lost earnings that would have occurred in a No-Screening scenario and compared them with the actual costs of screening, treatment, lifetime care, accommodation, loss of life, and lost earnings. We replicated that analysis excluding loss of life and lost earnings to estimate the budgetary impact alone. Our model calculated total lifetime costs of €103 per birth under prenatal screening as carried out in Austria, saving €323 per birth compared with No-Screening. Without screening and treatment, lifetime societal costs for all affected children would have been €35 million per year; the implementation costs of the Austrian program are less than €2 million per year. Calculating only the budgetary impact, the national program was still cost-saving by more than €15 million per year and saved €258 million in 17 years. CONCLUSIONS/SIGNIFICANCE Cost savings under a national program of prenatal screening for toxoplasma infection and treatment are outstanding. Our results are of relevance for health care providers by supplying economic data based on a unique national dataset including long-term follow-up of affected infants.
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Affiliation(s)
- Andrea-Romana Prusa
- Department of Pediatrics and Adolescent Medicine, Toxoplasmosis Reference Laboratory, Medical University of Vienna, Vienna, Austria
| | - David C. Kasper
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Larry Sawers
- Department of Economics, American University, Washington DC, United States of America
| | - Evelyn Walter
- Institute for Pharmaeconomic Research, Vienna, Austria
| | - Michael Hayde
- Department of Pediatrics and Adolescent Medicine, Toxoplasmosis Reference Laboratory, Medical University of Vienna, Vienna, Austria
| | - Eileen Stillwaggon
- Department of Economics, Gettysburg College, Gettysburg, Pennsylvania, United States of America
- * E-mail:
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Kwofie KD, Ghansah A, Osei JHN, Frempong KK, Obed S, Frimpong EH, Boakye DA, Suzuki T, Ohta N, Ayi I. Indication of Risk of Mother-to-Child Toxoplasma gondii Transmission in the Greater Accra Region of Ghana. Matern Child Health J 2016; 20:2581-2588. [DOI: 10.1007/s10995-016-2084-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Panchaud A, Stojanov M, Ammerdorffer A, Vouga M, Baud D. Emerging Role of Zika Virus in Adverse Fetal and Neonatal Outcomes. Clin Microbiol Rev 2016; 29:659-94. [PMID: 27281741 PMCID: PMC4978612 DOI: 10.1128/cmr.00014-16] [Citation(s) in RCA: 117] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The rapid spread of the Zika virus (ZIKV) in the Americas and its potential association with thousands of suspected cases of microcephaly in Brazil and higher rates of Guillain-Barré syndrome meet the conditions for a Public Health Emergency of International Concern, as stated by the World Health Organization in February 2016. Two months later, the Centers for Disease Control and Prevention (CDC) announced that the current available evidence supports the existence of a causal relationship between prenatal Zika virus infection and microcephaly and other serious brain anomalies. Microcephaly can be caused by several factors, and its clinical course and prognosis are difficult to predict. Other pathogens with proven teratogenicity have been identified long before the current ZIKV epidemic. Despite the growing number of cases with maternal signs of infection and/or presence of ZIKV in tissues of affected newborns or fetuses, it is currently difficult to assess the magnitude of increase of microcephaly prevalence in Brazil, as well as the role of other factors in the development of congenital neurological conditions. Meanwhile, health agencies and medical organizations have issued cautious guidelines advising health care practitioners and expectant couples traveling to, returning from, or living in affected areas. Analogous to dengue virus (DENV) epidemics, ZIKV has the potential to become endemic in all countries infested by Aedes mosquitoes, while new mutations could impact viral replication in humans, leading to increased virulence and consequently heightened chances of viral transmission to additional naive mosquito vectors. Studies are urgently needed to answer the questions surrounding ZIKV and its role in congenital neurological conditions.
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Affiliation(s)
- Alice Panchaud
- School of Pharmaceutical Sciences, University of Geneva and University of Lausanne, Geneva, Switzerland Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA Swiss Teratogen Information Service and Division of Clinical Pharmacology, University of Lausanne and University Hospital, Lausanne, Switzerland
| | - Miloš Stojanov
- Institute of Microbiology, Faculty of Biology and Medicine, University of Lausanne and University Hospital, Lausanne, Switzerland Materno-fetal and Obstetrics Research Unit, Department Femme-Mère-Enfant, University of Lausanne and University Hospital, Lausanne, Switzerland
| | - Anne Ammerdorffer
- Institute of Microbiology, Faculty of Biology and Medicine, University of Lausanne and University Hospital, Lausanne, Switzerland Materno-fetal and Obstetrics Research Unit, Department Femme-Mère-Enfant, University of Lausanne and University Hospital, Lausanne, Switzerland
| | - Manon Vouga
- Institute of Microbiology, Faculty of Biology and Medicine, University of Lausanne and University Hospital, Lausanne, Switzerland Materno-fetal and Obstetrics Research Unit, Department Femme-Mère-Enfant, University of Lausanne and University Hospital, Lausanne, Switzerland
| | - David Baud
- Institute of Microbiology, Faculty of Biology and Medicine, University of Lausanne and University Hospital, Lausanne, Switzerland Materno-fetal and Obstetrics Research Unit, Department Femme-Mère-Enfant, University of Lausanne and University Hospital, Lausanne, Switzerland
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de Oliveira Azevedo CT, do Brasil PEAA, Guida L, Lopes Moreira ME. Performance of Polymerase Chain Reaction Analysis of the Amniotic Fluid of Pregnant Women for Diagnosis of Congenital Toxoplasmosis: A Systematic Review and Meta-Analysis. PLoS One 2016; 11:e0149938. [PMID: 27055272 PMCID: PMC4824461 DOI: 10.1371/journal.pone.0149938] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 02/07/2016] [Indexed: 11/19/2022] Open
Abstract
Introduction Congenital infection caused by Toxoplasma gondii can cause serious damage that can be diagnosed in utero or at birth, although most infants are asymptomatic at birth. Prenatal diagnosis of congenital toxoplasmosis considerably improves the prognosis and outcome for infected infants. For this reason, an assay for the quick, sensitive, and safe diagnosis of fetal toxoplasmosis is desirable. Goal To systematically review the performance of polymerase chain reaction (PCR) analysis of the amniotic fluid of pregnant women with recent serological toxoplasmosis diagnoses for the diagnosis of fetal toxoplasmosis. Method A systematic literature review was conducted via a search of electronic databases; the literature included primary studies of the diagnostic accuracy of PCR analysis of amniotic fluid from pregnant women who seroconverted during pregnancy. The PCR test was compared to a gold standard for diagnosis. Results A total of 1.269 summaries were obtained from the electronic database and reviewed, and 20 studies, comprising 4.171 samples, met the established inclusion criteria and were included in the review. The following results were obtained: studies about PCR assays for fetal toxoplasmosis are generally susceptible to bias; reports of the tests’ use lack critical information; the protocols varied among studies; the heterogeneity among studies was concentrated in the tests’ sensitivity; there was evidence that the sensitivity of the tests increases with time, as represented by the trimester; and there was more heterogeneity among studies in which there was more time between maternal diagnosis and fetal testing. The sensitivity of the method, if performed up to five weeks after maternal diagnosis, was 87% and specificity was 99%. Conclusion The global sensitivity heterogeneity of the PCR test in this review was 66.5% (I2). The tests show low evidence of heterogeneity with a sensitivity of 87% and specificity of 99% when performed up to five weeks after maternal diagnosis. The test has a known performance and could be recommended for use up to five weeks after maternal diagnosis, when there is suspicion of fetal toxoplasmosis.
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Affiliation(s)
| | | | - Letícia Guida
- Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira (IFF/Fiocruz)
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Petersen EE. [Risk in pregnancy by infections]. MMW Fortschr Med 2016; 158:54-60. [PMID: 28924802 DOI: 10.1007/s15006-015-3304-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
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Di Mario S, Basevi V, Gagliotti C, Spettoli D, Gori G, D'Amico R, Magrini N. Prenatal education for congenital toxoplasmosis. Cochrane Database Syst Rev 2015; 2015:CD006171. [PMID: 26493047 PMCID: PMC9272404 DOI: 10.1002/14651858.cd006171.pub4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Congenital toxoplasmosis is considered a rare but potentially severe infection. Prenatal education about congenital toxoplasmosis could be the most efficient and least harmful intervention, yet its effectiveness is uncertain. OBJECTIVES To assess the effects of prenatal education for preventing congenital toxoplasmosis. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2015), and reference lists of relevant papers, reviews and websites. SELECTION CRITERIA Randomized and quasi-randomized controlled trials of all types of prenatal education on toxoplasmosis infection during pregnancy. Cluster-randomized trials were eligible for inclusion. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. MAIN RESULTS Two cluster-randomized controlled trials (RCTs) (involving a total of 5455 women) met the inclusion criteria. The two included trials measured the effectiveness of the intervention in different ways, which meant that meta-analysis of the results was not possible. The overall quality of the two studies, as assessed using the GRADE approach, was low, with high risk of detection and attrition bias in both included trials.One trial (432 women enrolled) conducted in Canada was judged of low methodological quality. This trial did not report on any of the review's pre-specified primary outcomes and the secondary outcomes reported results only as P values. Moreover, losses to follow-up were high (34%, 147 out of 432 women initially enrolled). The authors concluded that prenatal education can effectively change pregnant women's behavior as it increased pet, personal and food hygiene. The second trial conducted in France was also judged of low methodological quality. Losses to follow-up were also high (44.5%, 2233 out of 5023 women initially enrolled) and differential (40% in the intervention group and 52% in the control group). The authors concluded that prenatal education for congenital toxoplasmoses has a significant effect on improving women's knowledge, whereas it has no effect on changing women's behavior. In this trial 17/3949 pregnant women seroconverted for toxoplasmosis: 13/2591 (0.5%) in the intervention group and 4/1358 (0.3%) in the control group. The rate of seroconversion detected during the study did not differ between groups (risk ratio (RR) 1.70, 95% confidence interval (CI) 0.56 to 5.21; participants = 3949; studies = one, low quality evidence). The number of events was too small to reach conclusions about the effect of prenatal education on seroconversion rate during pregnancy.No other randomized trials on the effect of prenatal education on congenital toxoplasmosis rate, or toxoplasmosis seroconversion rate during pregnancy were detected. AUTHORS' CONCLUSIONS Even though primary prevention of congenital toxoplasmosis is considered a desirable intervention, given the lack of related risks compared to secondary and tertiary prevention, its effectiveness has not been adequately evaluated. There is very little evidence from RCTs that prenatal education is effective in reducing congenital toxoplasmosis even though evidence from observational studies suggests it is. Given the lack of good evidence supporting prenatal education for congenital toxoplasmosis prevention, further RCTs are needed to confirm any potential benefits and to further quantify the impact of different sets of educational intervention.
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Affiliation(s)
- Simona Di Mario
- Regional health authority of Emilia‐RomagnaSaPeRiDoc, Primary health care, general medicine, planning and development of health servicesBolognaItaly
| | - Vittorio Basevi
- Emilia‐Romagna Regional health authoritySaPeRiDoc, Primary health care, general medicine, planning and development of health servicesBolognaItaly
| | - Carlo Gagliotti
- Regional agency for health and social care of Emilia‐RomagnaControl of infectious disease UnitBolognaItaly
| | - Daniela Spettoli
- Regional health authority of Emilia‐RomagnaSaPeRiDoc, Primary health care, general medicine, planning and development of health servicesBolognaItaly
| | - Gianfranco Gori
- Regional health authority of Emilia‐RomagnaSaPeRiDoc, Primary health care, general medicine, planning and development of health servicesBolognaItaly
| | - Roberto D'Amico
- University of Modena and Reggio EmiliaItalian Cochrane Centre, Department of Diagnostic, Clinical and Public Health MedicineVia del Pozzo 71ModenaItaly41124
| | - Nicola Magrini
- World Health OrganisationPolicy, Access and Use (PAU), Department of Essential Medicines and Health ProductsAvenue Appia 20GenevaSwitzerland1211 GENEVA 27
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A Systematic Review and Meta-Analysis of the Efficacy of Anti-Toxoplasma gondii Medicines in Humans. PLoS One 2015; 10:e0138204. [PMID: 26394212 PMCID: PMC4578932 DOI: 10.1371/journal.pone.0138204] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 07/20/2015] [Indexed: 11/19/2022] Open
Abstract
No effective drug and definitive "gold standard" treatment for Toxoplasma gondii (T. gondii) infection has been available so far, though some medicines have been commonly used in the treatment of T. gondii infection, such as spiramycin, azithromycin, traditional Chinese medicine (TCM), pyrimethamine- sulfadiazine (P-S), trimethoprim-sulfamethoxazole (TMP-SMX), and pyrimethamine-clindamycin (P-C). A systematic review and meta-analysis were performed to compare the efficacies of these conventional medicines in the treatment. Cohort studies for the treatment of acute T. gondii infection were searched from PubMed, Google Scholar, ect. All the cases number for different group extracted from each included literature were input to meta-analysis 3.13 software to calculate the pooled negative conversion rate (NCR), cure rate (CR) or vertical transmission rate based on their sample size and weight. The pooled NCR with 95% confidence intervals (CI) was used to evaluate the overall rate of a diagnosis positive result conversion to a negative result after treatment, which of spiramycin, azithromycin and TCM were 83.4% (95%CI, 72.1%-90.8%), 82.5% (95%CI, 75.9%-87.6%), and 85.5% (95%CI, 71.3%-93.3%) respectively, with no statistical difference between them. The pooled CR with 95% CI was used to evaluate the overall rate of complete disappearance of clinical symptoms for toxoplasmic encephalitis after therapy, which of P-S, TMP-SMX, and P-C were 49.8% (95%CI, 38. 8% -60.8%), 59.9% (95%CI, 48.9%-70.0%), and 47.6% (95%CI, 24.8%-71.4%) respectively, with no statistical difference between them. Primary T. gondii infection in pregnancy was treated mainly with spiramycin alone or combined with other drugs, and the pooled rate of vertical transmission was about 9.9% (95%CI, 5.9%-16.2%) after therapy. Toxoplasmic encephalitis in AIDS patients was usually treated with sulfonamides combined with other drugs and the pooled CR was 49.4% (95%CI, 37.9%-60.9%).
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Avci ME, Arslan F, Çiftçi Ş, Ekiz A, Tüten A, Yildirim G, Madazli R. Role of spiramycin in prevention of fetal toxoplasmosis. J Matern Fetal Neonatal Med 2015; 29:2073-6. [PMID: 26365472 DOI: 10.3109/14767058.2015.1074998] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The aim of this study is to evaluate the efficacy of spiramycin in prevention of mother-to-child transmission of Toxoplasma gondii infection. METHODS Patients within first trimester of their pregnancy with Toxoplasma IgM positivity (>0.65 index, ELISA, VIDAS) and IgG positivity (>8 IU/ml), who had low IgG avidity (<0.50 index, ELISA, Architet) were considered as having acute toxoplasmosis. These patients who had amniocentesis at the 19th-21st week of pregnancy were examined for the detection of Toxoplasma DNA. Detailed ultrasonographic examinations performed between the 20th and 24th gestational weeks and the mothers and babies were followed for at least one year. RESULTS Out of 61 patients, 55 (90.2%) had received Spy prophylaxis while 6 (9.8%) cases refused Spy prophylaxis. Toxoplasma PCR test was found to be positive in amniotic fluid of 4 (6.6%) patients obtained by amniocentesis at the 19th-21st week of pregnancy. All four of these patients had refused Spy prophylaxis had positive Toxoplasma PCR in amniotic fluid (p < 0.01). CONCLUSION Our results seem to encourage the use of spiramycin in women with toxoplasmosis during pregnancy.
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Affiliation(s)
- Muhittin Eftal Avci
- a Department of Perinatology , Kanuni Sultan Suleyman Education and Research Hospital , Istanbul , Turkey
| | - Ferhat Arslan
- b Department of Infectious Diseases and Clinical Microbiology , İstanbul Medipol University Hospital , Istanbul , Turkey , and
| | - Şinasi Çiftçi
- a Department of Perinatology , Kanuni Sultan Suleyman Education and Research Hospital , Istanbul , Turkey
| | - Ali Ekiz
- a Department of Perinatology , Kanuni Sultan Suleyman Education and Research Hospital , Istanbul , Turkey
| | - Abdullah Tüten
- c Department of Perinatology , Cerrahpasa Medicine Faculty, Istanbul University , Istanbul , Turkey
| | - Gökhan Yildirim
- a Department of Perinatology , Kanuni Sultan Suleyman Education and Research Hospital , Istanbul , Turkey
| | - Rıza Madazli
- c Department of Perinatology , Cerrahpasa Medicine Faculty, Istanbul University , Istanbul , Turkey
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Davis SM, Anderson BL, Schulkin J, Jones K, Vanden Eng J, Jones JL. Survey of obstetrician-gynecologists in the United States about toxoplasmosis: 2012 update. Arch Gynecol Obstet 2015; 291:545-55. [PMID: 25205181 PMCID: PMC4720129 DOI: 10.1007/s00404-014-3450-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 08/26/2014] [Indexed: 11/26/2022]
Abstract
PURPOSE Toxoplasmosis, caused by the parasite Toxoplasma gondii, can have serious impacts on fetal development in the setting of acute maternal primary infection. The American College of Obstetricians and Gynecologists (ACOG) sought to determine current knowledge, practices, opinions, and educational preferences regarding T. gondii infection in pregnancy among ACOG members practicing prenatal care. METHODS ACOG sent a survey to 1,056 members chosen by stratified random sampling from membership lists, including 370 participants and 686 non-participants in the Collaborative Ambulatory Research Network (CARN). Mailings were sent up to four times to nonresponders. RESULTS Survey minimum response rates were 40.3% (CARN) and 19.7% (non-CARN); response rates adjusted for imputed non-eligibility were 59.7% (CARN) and 22.6% (non-CARN). Among providers, 80.2% had diagnosed no acute maternal T. gondii infections in the past 5 years, 12.7% correctly identified the screening role of the Toxoplasma avidity test, 42.6% performed serologic T. gondii screening for at least some asymptomatic pregnant women, and 62.1% of those who so did used appropriate approaches. Providers in the northeastern United States were 2.02 times more likely to routinely screen than those in the west (p = 0.025) and female providers were 1.48 times more likely than male providers (p = 0.047). The potential educational interventions considered useful by the most practitioners were updated ACOG guidelines on screening (81.4%) and management (71.7%) for acute T. gondii infection in pregnancy. CONCLUSIONS ACOG members would benefit from educational efforts targeted at risk factor counseling and screening approaches.
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Affiliation(s)
- Stephanie M Davis
- Division of Global HIV/AIDS, HIV Prevention Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA,
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Valentini P, Buonsenso D, Barone G, Serranti D, Calzedda R, Ceccarelli M, Speziale D, Ricci R, Masini L. Spiramycin/cotrimoxazole versus pyrimethamine/sulfonamide and spiramycin alone for the treatment of toxoplasmosis in pregnancy. J Perinatol 2015; 35:90-4. [PMID: 25211284 DOI: 10.1038/jp.2014.161] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 07/16/2014] [Accepted: 07/25/2014] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To compare the effectiviness of spiramycin/cotrimoxazole (Sp/C) versus pyrimethamine/sulfonamide (Pyr/Sul) and spiramycin alone (Spy) on mother-to-child transmission of toxoplasmosis infection in pregnancy. STUDY DESIGN Retrospective study of pregnant women evaluated for suspected toxoplasmosis between 1992 and 2011. RESULT A total of 120 mothers and their 123 newborns were included. Prenatal treatment consisted of spiramycin in 43 mothers (35%), spiramycin/cotrimoxazole in 70 (56.9%) and pyrimethamine/sulfonamide in 10 (8.1%). A trend toward reduction in toxoplasmosis transmission was found when Sp/C was compared with Pyr/Sul and particularly with Spy alone (P=0.014). In particular, Spy increased the risk of congenital infection when compared with Sp/C (odds ratio (OR) 4.368; 95% CI: 1.253 to 15.219), but there was no significant reduction when Sp/C was compared with Pyr/Sul (OR 1.83; 95% CI: 0.184 to 18.274). CONCLUSION The treatment based on Sp/C has significant efficacy in reducing maternal-fetal transmission of Toxoplasma gondii when compared with Pyr/Sul and particularly to Spy. Randomized controlled trials would be required.
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Affiliation(s)
- P Valentini
- Department of Pediatrics, Catholic University of the Sacred Heart, A. Gemelli Hospital, Rome, Italy
| | - D Buonsenso
- Department of Pediatrics, Catholic University of the Sacred Heart, A. Gemelli Hospital, Rome, Italy
| | - G Barone
- Department of Pediatrics, Catholic University of the Sacred Heart, A. Gemelli Hospital, Rome, Italy
| | - D Serranti
- Department of Pediatrics, Meyer Pediatric Hospital, Florence, Italy
| | - R Calzedda
- Department of Pediatrics, Catholic University of the Sacred Heart, A. Gemelli Hospital, Rome, Italy
| | - M Ceccarelli
- Department of Pediatrics, Catholic University of the Sacred Heart, A. Gemelli Hospital, Rome, Italy
| | - D Speziale
- Department of Microbiology, Catholic University of Sacred Heart, A. Gemelli Hospital, Rome, Italy
| | - R Ricci
- Department of Microbiology, Catholic University of Sacred Heart, A. Gemelli Hospital, Rome, Italy
| | - L Masini
- Department of Obstetrics and Gynecology, Catholic University of Sacred Heart, A. Gemelli Hospital, Rome, Italy
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Prusa AR, Kasper DC, Pollak A, Olischar M, Gleiss A, Hayde M. Amniocentesis for the detection of congenital toxoplasmosis: results from the nationwide Austrian prenatal screening program. Clin Microbiol Infect 2014; 21:191.e1-8. [PMID: 25596783 DOI: 10.1016/j.cmi.2014.09.018] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 09/18/2014] [Accepted: 09/18/2014] [Indexed: 10/24/2022]
Abstract
Prenatal diagnosis of congenital toxoplasmosis (CT) influences therapeutical management in pregnant women and their offspring. In Austria, a nationwide serological healthcare program to identify potential maternal toxoplasma infections during pregnancy exists. We assessed the clinical use of amniocentesis for toxoplasma-specific polymerase chain reaction (PCR) on amniotic fluid to detect CT. Data on serology, amniocentesis, PCR, complications, treatment, and paediatric clinical outcome were collected retrospectively among the birth cohort 1992-2008. There were 1386 women with amniocentesis, but only in 707 cases (51%) was acute maternal infection confirmed serologically. A high proportion (49%) of amniocenteses with negative PCR results in women with chronic infection or seronegativity were performed without clinical justification for the women or their foetuses. The positive and negative predictive values of PCR were 94.4% and 99.3%, respectively. Thirty-nine foetuses with CT, including four deaths, were reported. The five PCR-negative but infected infants were identified by the serological and clinical follow-up program. Thirty percent of amniocenteses were performed in the third trimester, and gestational age or treatment did not influence PCR sensitivity. Amniocentesis is indicated in women with acute maternal infection, and facilitated targeted therapies in pregnant women and their offspring. In women with late toxoplasma infection, negative amniotic fluid PCR made treatment of infants unnecessary. Serological and clinical follow-up of infants is important to confirm the infection status of the infant. Recommendations, based on our 17-year experience, to improve the current diagnostic strategies and to reduce unnecessary amniocentesis, are given.
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Affiliation(s)
- A-R Prusa
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - D C Kasper
- Research Core Unit for Pediatric Biochemistry and Analytics, Medical University of Vienna, Vienna, Austria.
| | - A Pollak
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - M Olischar
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - A Gleiss
- Centre for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - M Hayde
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
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Prusa AR, Kasper DC, Pollak A, Gleiss A, Waldhoer T, Hayde M. The Austrian Toxoplasmosis Register, 1992-2008. Clin Infect Dis 2014; 60:e4-e10. [PMID: 25216688 DOI: 10.1093/cid/ciu724] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND We aimed to determine the incidence of primary gestational infections with Toxoplasma gondii and congenital toxoplasmosis in Austria, a country with a nationwide prenatal serological screening program since 1974. METHODS We analyzed retrospective data from the Austrian Toxoplasmosis Register of pregnant women with Toxoplasma infection and their offspring with births between 1992 and 2008, identified by the prenatal mandatory screening program. Treatment was administered to women from diagnosis of a Toxoplasma infection until delivery. Infected infants were treated up to 1 year of life routinely. Clinical manifestations in infected infants were monitored at least for 1 year and documented in the register. RESULTS The Austrian Toxoplasmosis Register included 2147 pregnant women with suspected Toxoplasma infection. Annually, 8.5 per 10 000 women acquired Toxoplasma infection during pregnancy, and 1.0 per 10 000 infants had congenital toxoplasmosis (13% mean transmission rate). Our data showed that women treated according to the Austrian scheme had a 6-fold decrease in the maternofetal transmission rate compared to women without treatment. CONCLUSIONS Results from the Austrian Toxoplasmosis Register show the efficiency of the prenatal screening program. Our results are of clinical relevance for infants, healthcare systems, and policy makers to consider preventive Toxoplasma screening as a potential tool to reduce the incidence of congenital toxoplasmosis.
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Affiliation(s)
| | - David C Kasper
- Research Core Unit for Pediatric Biochemistry and Analytics
| | | | - Andreas Gleiss
- Center for Medical Statistics, Informatics and Intelligent Systems
| | - Thomas Waldhoer
- Department of Epidemiology, Center of Public Health, Medical University of Vienna, Austria
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Sato S, Nishida M, Nasu K, Narahara H, Norose K, Aosai F. Congenital toxoplasmosis from a mother with type 2 diabetes mellitus: A case report. J Obstet Gynaecol Res 2014; 40:2158-61. [DOI: 10.1111/jog.12477] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 04/18/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Shimpei Sato
- Department of Obstetrics and Gynecology; Nakatsu Municipal Hospital; Oita Japan
| | - Masakazu Nishida
- Department of Obstetrics and Gynecology; Nakatsu Municipal Hospital; Oita Japan
| | - Kaei Nasu
- Department of Obstetrics and Gynecology, Faculty of Medicine; Oita University; Oita Japan
- Department of Obstetrics and Gynecology; Department of Community Medicine; Oita University; Oita Japan
| | - Hisashi Narahara
- Department of Obstetrics and Gynecology, Faculty of Medicine; Oita University; Oita Japan
| | - Kazumi Norose
- Department of Infection and Host Defense, Graduate School of Medicine; Chiba University; Chiba Japan
| | - Fumie Aosai
- Department of Infection and Host Defense, Graduate School of Medicine; Chiba University; Chiba Japan
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Rodrigues IMX, Costa TL, Avelar JB, Amaral WN, Castro AM, Avelino MM. Assessment of laboratory methods used in the diagnosis of congenital toxoplasmosis after maternal treatment with spiramycin in pregnancy. BMC Infect Dis 2014; 14:349. [PMID: 24961630 PMCID: PMC4230641 DOI: 10.1186/1471-2334-14-349] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Accepted: 06/10/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The different laboratory methods used in the diagnosis of congenital toxoplasmosis have variable sensitivity and specificity. There is no evidence to prove that maternal treatment reduces the risk of fetal infection. The purpose of this study was to assess methods for the confirmation of congenital toxoplasmosis after maternal treatment with spiramycin during pregnancy, and to evaluate the effect of this treatment on clinical manifestations of the disease in newborns (NB). METHODS This was a community-based, cross-sectional study of acute toxoplasmosis in newborns at risk of acquiring congenital infection. Participating newborns were born in the Clinical Hospital Maternity Ward of the Federal University of Goiás. Eligible participants were divided into 2 groups: group 1 consisted of 44 newborns born to mothers treated with spiramycin during pregnancy and group 2 consisted of 24 newborns born to mothers not treated with spiramycin during pregnancy because the diagnosis of toxoplasmosis was not performed. The sensitivity and specifity of PCR for T. gondii DNA in peripheral blood and serological testing for specific anti-T. gondii IgM and IgA, and the effects of maternal spiramycin treatment on these parameters, were determined by associating test results with clinical manifestations of disease. RESULTS The sensitivity of the markers (T. gondii DNA detected by PCR, and the presence of specific anti-T. gondii IgM and IgA) for congenital toxoplasmosis was higher in group 2 than in group 1 (31.6, 68.4, 36.8% and 3.7, 25.9, 11.1% respectively). Even with a low PCR sensitivity, the group 2 results indicate the importance of developing new techniques for the diagnosis of congenital toxoplasmosis in newborns. Within group 1, 70.4% of the infected newborns were asymptomatic and, in group 2, 68.4% showed clinical manifestations of congenital toxoplasmosis. CONCLUSIONS The higher proportion of infants without clinical symptoms in group 1 (70.4%) suggests the maternal treatment with spiramycin delays fetal infection, reducing the clinical sequelae of the disease in newborns. Given the low sensitivity of the tests used, when there is suspicion of congenital transmission several serological and parasitological tests are required in order to confirm or exclude congenital toxoplasmosis in newborns.
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Affiliation(s)
- Isolina MX Rodrigues
- Laboratory studies of the host-parasite relationship (LAERPH) of Institute for Tropical Pathology and Public Health (IPTSP) of the Federal University of Goiás (UFG), Goiânia, Brazil
| | - Tatiane L Costa
- Clinical Laboratory of the University Hospital of the Federal University of Goiás (UFG), Goiânia, Brazil
| | - Juliana B Avelar
- Laboratory studies of the host-parasite relationship (LAERPH) of Institute for Tropical Pathology and Public Health (IPTSP) of the Federal University of Goiás (UFG), Goiânia, Brazil
| | - Waldemar N Amaral
- Department of Gynecology and Obstetrics of the Faculty of Medicine - FM/UFG, Goiânia, Brazil
| | - Ana M Castro
- Laboratory studies of the host-parasite relationship (LAERPH) of Institute for Tropical Pathology and Public Health (IPTSP) of the Federal University of Goiás (UFG), Goiânia, Brazil
| | - Mariza M Avelino
- Department of Pediatrics and Puericulture in the Medical School (MS) of Federal University of Goiás (UFG), Av. s/n Setor Leste Universitário, Goiânia-GO CEP: 74001-970, Brazil
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Li XL, Wei HX, Zhang H, Peng HJ, Lindsay DS. A meta analysis on risks of adverse pregnancy outcomes in Toxoplasma gondii infection. PLoS One 2014; 9:e97775. [PMID: 24830795 PMCID: PMC4022675 DOI: 10.1371/journal.pone.0097775] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2014] [Accepted: 04/22/2014] [Indexed: 11/26/2022] Open
Abstract
Objective Quantified risks of congenital Toxoplasma gondii infection and abnormal pregnancy outcomes following primary maternal infection were evaluated with meta- analysis based on published studies. Methods The related literatures were searched in multiple literature databases regardless of languages. Odds ratio (OR) and 95% confidence interval (CI) were used to evaluate the risks of vertical transmission of Toxoplasma gondii and abnormal pregnancy outcomes following primary maternal infection with meta-analysis. Results 53 of the 2632 searched literatures were included in our analysis. The incidence of abnormal pregnancy outcomes in T. gondii infected pregnant women (infected group) was significantly higher than that in the uninfected pregnant women (control group) (OR = 5.10; 95% CI, 3.85–6.75). Toxoplasma gondii infection rate in the abnormal-pregnancy-outcome group was significantly higher than in the normal-pregnancy group (OR = 3.71; 95% CI, 3.31–4.15). The pooled rate of vertical transmission was 20% (95% CI, 15%–26%) in maternal infection of T. gondii. The incidences of vertical transmission in women who were infected in the first, second or third trimester of pregnancy were 5% (95%CI, 2%–16%), 13% (95%CI, 7%–23%), and 32% (95%CI, 24%–41%), respectively. The rates of vertical transmission in women who were treated with spiramycin-only, PSF (pyrimethamine + sulfadiazine + folinic acid) or PS (pyrimethamine + sulfadiazine) combined with spiramycin, or other untypical treatments were 13% (95%CI, 7%–22%), 13%(95%CI, 7%–25%), and 24%(95%CI, 18%–32%), respectively. Conclusions Toxoplasma gondii infection can result in adverse pregnancy outcomes in pregnant women. The pooled rate of vertical transmission was 20% in maternal infection and the incidences of vertical transmission increased in the first, second or third trimester of pregnancy. The pooled rates of transmission in groups treated with spiramycin-only, PSF or PS combined with spiramycin, or other untypical treatments were not significantly different.
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Affiliation(s)
- Xue-Lan Li
- Department of Pathogen Biology, School of Public Health and Tropical Medicine, Southern Medical University, Guangzhou, Guangdong, the People's Republic of China
| | - Hai-Xia Wei
- Department of Pathogen Biology, School of Public Health and Tropical Medicine, Southern Medical University, Guangzhou, Guangdong, the People's Republic of China
| | - Hao Zhang
- Department of Pathogen Biology, School of Public Health and Tropical Medicine, Southern Medical University, Guangzhou, Guangdong, the People's Republic of China
- Department of Infectious Diseases and Hepatology Unit, Nanfang Hospital attached to Southern Medical University, Guangzhou, Guangdong, and the People's Republic of China,
| | - Hong-Juan Peng
- Department of Pathogen Biology, School of Public Health and Tropical Medicine, Southern Medical University, Guangzhou, Guangdong, the People's Republic of China
- * E-mail: (HP); (DL)
| | - David S. Lindsay
- Department of Biomedical Sciences & Pathobiology, VA-MD Regional College of Veterinary Medicine, Virginia Tech, Duck Pond Drive, Blacksburg, Virginia, United States of America
- * E-mail: (HP); (DL)
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Jones JL, Parise ME, Fiore AE. Neglected parasitic infections in the United States: toxoplasmosis. Am J Trop Med Hyg 2014; 90:794-799. [PMID: 24808246 PMCID: PMC4015566 DOI: 10.4269/ajtmh.13-0722] [Citation(s) in RCA: 101] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Accepted: 01/31/2014] [Indexed: 11/07/2022] Open
Abstract
Toxoplasma gondii is a leading cause of severe foodborne illness in the United States. Population-based studies have found T. gondii infection to be more prevalent in racial/ethnic minority and socioeconomically disadvantaged groups. Soil contaminated with cat feces, undercooked meat, and congenital transmission are the principal sources of infection. Toxoplasmosis-associated illnesses include congenital neurologic and ocular disease; acquired illness in immunocompetent persons, most notably ocular disease; and encephalitis or disseminated disease in immunosuppressed persons. The association of T. gondii infection with risk for mental illness is intriguing and requires further research. Reduction of T. gondii in meat, improvements in hygiene and food preparation practices, and reduction of environmental contamination can prevent toxoplasmosis, but more research is needed on how to implement these measures. In addition, screening and treatment may help prevent toxoplasmosis or reduce the severity of disease in some settings.
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Affiliation(s)
- Jeffrey L. Jones
- Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
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Wallon M, Garweg JG, Abrahamowicz M, Cornu C, Vinault S, Quantin C, Bonithon-Kopp C, Picot S, Peyron F, Binquet C. Ophthalmic outcomes of congenital toxoplasmosis followed until adolescence. Pediatrics 2014; 133:e601-8. [PMID: 24534412 DOI: 10.1542/peds.2013-2153] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Congenital toxoplasmosis (CT) can elicit severe damage to several organs, especially the eye, and may be manifested at birth or later. We assessed the long-term ocular prognosis in a cohort of congenitally infected children treated according to a standardized protocol and monitored for up to 22 years. METHODS This prospective study included confirmed cases of CT, which were identified by obligatory antenatal screening at the Lyon (France) reference center between 1987 and 2008. Data obtained through ocular examinations were recorded on a standardized form and confirmed by an independent external committee. Risk factors for retinochoroiditis were identified by using a multivariable Cox model and a flexible model that accounted for changes in the factor effects during follow-up. RESULTS A total of 477 of 485 infected live-born children were followed for a median of 10.5 years (75th percentile: 15.0 years). During the follow-up, 142 patients (29.8%) manifested at least 1 ocular lesion. Lesions were unilateral in 98 individuals (69.0%) and caused no vision loss in 80.6%. Lesions were first manifested at a median age of 3.1 (0.0-20.7) years. In 48 (33.8%) of the children, recurrences or new ocular lesions occurred up to 12 years after the appearance of the first lesion. Early maternal infection and confirmation of CT in children, prematurity, and nonocular CT lesions at baseline were associated with a higher risk of retinochoroiditis. CONCLUSIONS Although the consequences of CT are rarely severe in treated children, regular postnatal monitoring is nevertheless justified because of the lifelong persisting risk of new ocular manifestations.
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Affiliation(s)
- Martine Wallon
- Hospices Civils de Lyon, Institut de Parasitologie et de Mycologie Médicale, Hôpital de la Croix-Rousse, Lyon, France
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Rajapakse S, Chrishan Shivanthan M, Samaranayake N, Rodrigo C, Deepika Fernando S. Antibiotics for human toxoplasmosis: a systematic review of randomized trials. Pathog Glob Health 2014; 107:162-9. [PMID: 23816507 DOI: 10.1179/2047773213y.0000000094] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
The efficacy of different treatment regimens in clinical syndromes of toxoplasmosis were assessed by conducting a systematic review of published randomized clinical trials through extensive searches in MEDLINE, EMBASE, and SCOPUS with no date limits, as well as manual review of journals. Outcome measures varied depending on the clinical entity of toxoplasmosis. Risk of bias was evaluated and quality of evidence was graded. Fourteen randomized trials were included of which one was a non-comparative study. One well-designed trial showed that trimethoprim-sulphamethoxazole was more effective than placebo for clinical recovery of toxoplasmic lymphadenopathy in immunocompetent hosts. For toxoplasmic encephalopathy, efficacy of pyrimethamine+sulphadiazine and trimethoprim+sulphamethoxazole were similar, whereas pyrimethamine+sulphadiazine versus pyrimathamine+clindamycin showed no difference, irrespective of the outcome. Intravitreal clindamycin+dexamethasone and conventional treatment with oral pyrimethamine+sulphadiazine had similar efficacy with regard to all outcome measures in ocular toxoplasmosis, and intravitreal therapy was found to be safe. Adverse effects seemed more common with pyrimethamine+sulphadiazine. Most trials for encephalitis and ocular manifestations had a high risk of bias and were of poor methodological quality. There were no trials evaluating drugs for toxoplasmosis in pregnancy, or for congenital toxoplasmosis. Pyrimethamine+sulphadiazine is an effective therapy for treatment of toxoplasmic encephalitis; trimethoprim+sulphamethoxazole and pyrimethamine+clindamycin are possible alternatives. Treatment with either oral or intravitreal antibiotics seems reasonable for ocular toxoplasmosis. Overall, trial evidence for the efficacy of these drugs for toxoplasmosis is poor, and further well-designed trials are needed.
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Affiliation(s)
- Senaka Rajapakse
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Sri Lanka.
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Avelino MM, Amaral WN, Rodrigues IMX, Rassi AR, Gomes MBF, Costa TL, Castro AM. Congenital toxoplasmosis and prenatal care state programs. BMC Infect Dis 2014; 14:33. [PMID: 24438336 PMCID: PMC3918215 DOI: 10.1186/1471-2334-14-33] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Accepted: 01/08/2014] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Control programs have been executed in an attempt to reduce vertical transmission and the severity of congenital infection in regions with a high incidence of toxoplasmosis in pregnant women. We aimed to evaluate whether treatment of pregnant women with spiramycin associated with a lack of monitoring for toxoplasmosis seroconversion affects the prognosis of patients. METHODS We performed a prospective cohort study with 246 newborns (NB) at risk for congenital toxoplasmosis in Goiânia (Brazil) between October 2003 and October 2011. We analyzed the efficacy of maternal treatment with spiramycin. RESULTS A total of 40.7% (66/162) of the neonates were born seriously infected. Vertical transmission associated with reactivation during pregnancy occurred in 5.5% (9/162) of the NB, with one showing severe infection (systemic). The presence of specific immunoglobulins (fetal IgM and NB IgA) suggested the worst prognosis. Treatment of pregnant women by spiramycin resulted in reduced vertical transmission. When infected pregnant women did not undergo proper treatment, the risk of severe infection (neural-optical) in NB was significantly increased. Fetal IgM was associated with ocular impairment in 48.0% (12/25) of the fetuses and neonatal IgA-specific was related to the neuro-ophthalmologic and systemic forms of the disease. When acute toxoplasmosis was identified in the postpartum period, a lack of monitoring of seronegative pregnant women resulted in a higher risk of severe congenital infection. CONCLUSION Treatment of pregnant women with spiramycin reduces the possibility of transmission of infection to the fetus. However, a lack of proper treatment is associated with the onset of the neural-optical form of congenital infection. Primary preventive measures should be increased for all pregnant women during the prenatal period and secondary prophylaxis through surveillance of seroconversion in seronegative pregnant woman should be introduced to reduce the severity of congenital infection in the environment.
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Affiliation(s)
- Mariza M Avelino
- Pediatrics and Childcare Department of the Medical School of Federal University of Goiás (UFG), Goiânia, Brazil
- Department of Pediatrics and Puericulture MS/UFG and the Postgraduate Program from IPTSP/UFG, Rua 235 esq com 1a. Av. s/n Setor Leste Universitário, Goiânia-GO, Brazil
| | - Waldemar N Amaral
- Department of Gynecology and Obstetrics of the Medical School of Federal University of Goiás (UFG), Goiânia, Brazil
| | | | - Alan R Rassi
- Department of Ophthalmology of the Medical School (UFG), Goiânia, Brazil
| | | | - Tatiane L Costa
- Clinical Analyses Laboratory - Clinical Hospital of UFG, Goiânia, Brazil
| | - Ana M Castro
- Laboratory studies of the host-parasite relationship at the Institute for Tropical Pathology and Public Health (IPTSP) of the Federal University of Goiás (UFG), - LAERPH/IPTSP/UFG, Goiânia, Brazil
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It is not only the cat that did it: how to prevent and treat congenital toxoplasmosis. J Infect 2013; 68 Suppl 1:S125-33. [PMID: 24119928 DOI: 10.1016/j.jinf.2013.09.023] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2013] [Indexed: 11/22/2022]
Abstract
The apicomplexan parasite Toxoplasma gondii was discovered a little over one hundred years ago and was soon recognized as a pathogen responsible for congenital infection. But detailed understanding of its epidemiology emerged only after 1970 with the discovery of its life cycle. In the last ten years, high resolution molecular tools have allowed the characterization of various strain types with different virulence patterns, and current studies are exploring the distribution of these different genotypes. In parallel, sophisticated diagnostic tools have been developed and awareness of disease burden has led some European countries with high prevalence rates to implement screening of pregnant women. In this article, the screening options and therapies used to prevent congenital toxoplasmosis are dissected in the light of recent data from cohort studies and other epidemiological data.
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Chintapalli S, Padmaja IJ. Seroprevalence of toxoplasmosis in antenatal women with bad obstetric history. Trop Parasitol 2013; 3:62-6. [PMID: 23961444 PMCID: PMC3745674 DOI: 10.4103/2229-5070.113915] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Accepted: 06/24/2013] [Indexed: 12/03/2022] Open
Abstract
Background: The occurrence of fetal death is one of the tragedies that confront the physician providing obstetric care. Among the various agents associated with infections of pregnancy, viruses are the most important followed by bacteria and protozoa. Among protozoal infections in pregnancy, toxoplasmosis is reported to have a high incidence, sometimes causing fetal death. The study was intended to observe the seroprevalence of Toxoplasmosis in pregnant women presenting with bad obstetric history (BOH). Materials and Methods: A total of 92 antenatal women were included in the study (80 in the study group and 12 in control group). The study group comprised of antenatal women with BOH in the age group of 20-35 years. Antenatal women with Rh incompatibility, pregnancy induced hypertension, diabetes mellitus, renal disorders and syphilis were not included in the study. The control group included women in reproductive age group without BOH. All the samples were screened by enzyme linked immuno sorbent assay (ELISA) for Toxoplasma specific Immunoglobulin M (IgM) and Immunoglobulin G (IgG) antibodies. Results: Of the 80 antenatal women in the study group, 36 (45%) were seropositive for Toxoplasma specific IgG antibodies (P < 0.005), 16 (20%) were seropositive for Toxoplasma specific IgM antibodies (P < 0.005) and 8 (10%) were seropositive for both IgG and IgM antibodies (P < 0.005). Various predisposing factors for acquiring Toxoplasmosis such as contact with cats, contact with soil, food habits, illiteracy, socio-economic status and residential status were also studied. Conclusions: We conclude that toxoplasmosis during pregnancy causes congenital fetal infection with possible fetal loss. ELISA was found to be a sensitive serological test for diagnosis of Toxoplasmosis in pregnant women with BOH. Major cause of fetal loss in BOH cases in the study group was abortion.
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Abstract
Toxoplasma gondii, rubella, cytomegalovirus and herpes simplex virus have in common that they can cause congenital (TORCH) infection, leading to fetal and neonatal morbidity and mortality. During the last decades, TORCH screening, which is generally considered to be single serum testing, has been increasingly used inappropriately and questions have been raised concerning the indications and cost-effectiveness of TORCH testing. The problems of TORCH screening lie in requesting the screening for the wrong indications, wrong interpretation of the single serum results and in case there is a good indication for diagnosis of congenital infection, sending in the wrong materials. This review provides an overview of the pathogenesis, epidemiology and clinical consequences of congenital TORCH infections and discusses the indications for, and interpretation of, TORCH screens.
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Affiliation(s)
- Eveline P de Jong
- Department of Paediatrics, Juliana Children’s Hospital, HAGA Hospital, The Hague, The Netherlands
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Ferreira EC, Marchioro AA, Guedes TA, Mota DCGA, Guilherme ALF, de Araujo SM. Association between seropositivity for Toxoplasma gondii, scholastic development of children and risk factors for T. gondii infection. Trans R Soc Trop Med Hyg 2013; 107:390-6. [DOI: 10.1093/trstmh/trt026] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Di Mario S, Basevi V, Gagliotti C, Spettoli D, Gori G, D'Amico R, Magrini N. Prenatal education for congenital toxoplasmosis. Cochrane Database Syst Rev 2013:CD006171. [PMID: 23450566 DOI: 10.1002/14651858.cd006171.pub3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Congenital toxoplasmosis is considered a rare but potentially severe infection. Prenatal education about congenital toxoplasmosis could be the most efficient and least harmful intervention, yet its effectiveness is uncertain. OBJECTIVES To assess the effects of prenatal education for preventing congenital toxoplasmosis. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (15 January 2012), PubMed (1966 to 15 January 2012), EMBASE (1980 to 15 January 2012), CINAHL (1982 to 15 January 2012), LILACS (1982 to 15 January 2012), IMEMR (1984 to 15 January 2012), and reference lists of relevant papers, reviews and websites. SELECTION CRITERIA Randomized and quasi-randomized controlled trials (RCTs) of all types of prenatal education on toxoplasmosis infection during pregnancy. Cluster-randomized trials were included. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and study quality. Two review authors extracted data. Data were checked for accuracy. MAIN RESULTS Two cluster-randomized controlled trials (involving a total of 5455 women) met the inclusion criteria. The two included trials measured the effectiveness of the intervention in different ways which meant that meta-analysis of the results was not possible One trial (432 women enrolled) conducted in Canada was judged of low methodological quality. The authors did not report measure of association but only provided P values (P less than 0.05) for all outcomes. Moreover, losses to follow-up were high (34%, 147 out of 432 women initially enrolled). The authors concluded that prenatal education can effectively change pregnant women's behavior as it increased pet, personal and food hygiene. The second trial conducted in France was also judged of low methodological quality. Losses to follow-up were high (44.5%, 2233 out of 5023 women initially enrolled) and differential (40% in the intervention group and 52% in the control group). The authors concluded that prenatal education for congenital toxoplasmoses has a significant effect on improving women's knowledge whereas it has no effect on changing women's behavior. In this trial 17/3949 pregnant women seroconverted for toxoplasmosis: 13/2591 (0.5%) in the intervention group and 4/1358 (0.3%) in the control group. The number of events was too small to reach conclusions about the effect of prenatal education on seroconversion rate during pregnancy.No other randomized trials on the effect of prenatal education on congenital toxoplasmosis rate, or toxoplasmosis seroconversion rate during pregnancy were detected. AUTHORS' CONCLUSIONS Even though primary prevention of congenital toxoplasmosis is considered a desirable intervention, given the lack of related risks compared to secondary and tertiary prevention, its effectiveness has not been adequately evaluated. There is very little evidence from RCTs that prenatal education is effective in reducing congenital toxoplasmosis even though evidence from observational studies suggests it is. Given the lack of good evidence supporting prenatal education for congenital toxoplasmosis prevention, further RCTs are needed to confirm any potential benefits and to further quantify the impact of different sets of educational intervention.
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Affiliation(s)
- Simona Di Mario
- SaPeRiDoc, Primary health care, general medicine, planning and development of health services, Regional health authority of Emilia-Romagna, Bologna, Italy.
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Mandelbrot L. Prévention de la transmission mère-enfant de la toxoplasmose : perspectives. ACTA ACUST UNITED AC 2012; 40:591-8. [DOI: 10.1016/j.gyobfe.2012.07.033] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2012] [Accepted: 07/05/2012] [Indexed: 10/27/2022]
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Séroconversion toxoplasmique périconceptionnelle : à propos de 79 cas. ACTA ACUST UNITED AC 2012; 41:546-52. [DOI: 10.1016/j.jgyn.2012.03.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2011] [Revised: 03/14/2012] [Accepted: 03/19/2012] [Indexed: 11/23/2022]
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