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Aerts R, Mehra V, Groll AH, Martino R, Lagrou K, Robin C, Perruccio K, Blijlevens N, Nucci M, Slavin M, Bretagne S, Cordonnier C. Guidelines for the management of Toxoplasma gondii infection and disease in patients with haematological malignancies and after haematopoietic stem-cell transplantation: guidelines from the 9th European Conference on Infections in Leukaemia, 2022. THE LANCET. INFECTIOUS DISEASES 2024; 24:e291-e306. [PMID: 38134949 DOI: 10.1016/s1473-3099(23)00495-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 07/19/2023] [Accepted: 07/25/2023] [Indexed: 12/24/2023]
Abstract
Patients with haematological malignancies might develop life-threatening toxoplasmosis, especially after allogeneic haematopoietic stem-cell transplantation (HSCT). Reactivation of latent cysts is the primary mechanism of toxoplasmosis following HSCT; hence, patients at high risk are those who were seropositive before transplantation. The lack of trimethoprim-sulfamethoxazole prophylaxis and various immune status parameters of the patient are other associated risk factors. The mortality of toxoplasma disease-eg, with organ involvement-can be particularly high in this setting. We have developed guidelines for managing toxoplasmosis in haematology patients, through a literature review and consultation with experts. In allogeneic HSCT recipients seropositive for Toxoplasma gondii before transplant, because T gondii infection mostly precedes toxoplasma disease, we propose weekly blood screening by use of quantitative PCR (qPCR) to identify infection early as a pre-emptive strategy. As trimethoprim-sulfamethoxazole prophylaxis might fail, prophylaxis and qPCR screening should be combined. However, PCR in blood can be negative even in toxoplasma disease. The duration of prophylaxis should be a least 6 months and extended during treatment-induced immunosuppression or severe CD4 lymphopenia. If a positive qPCR test occurs, treatment with trimethoprim-sulfamethoxazole, pyrimethamine-sulfadiazine, or pyrimethamine-clindamycin should be started, and a new sample taken. If the second qPCR test is negative, clinical judgement is recommended to either continue or stop therapy and restart prophylaxis. Therapy must be continued until a minimum of two negative PCRs for infection, or for at least 6 weeks for disease. The pre-emptive approach is not indicated in seronegative HSCT recipients, after autologous transplantation, or in non-transplant haematology patients, but PCR should be performed with a high level of clinical suspicion.
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Affiliation(s)
- Robina Aerts
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium; Department of Internal Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Varun Mehra
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Andreas H Groll
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Department of Pediatric Hematology and Oncology, University Children's Hospital Münster, Münster, Germany
| | - Rodrigo Martino
- Servei d'Hematologia, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Katrien Lagrou
- Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Christine Robin
- Department of Haematology, Assistance Publique des Hôpitaux de Paris, Henri Mondor Hospital, Créteil, France
| | - Katia Perruccio
- Pediatric Oncology Hematology, Mother and Child Health Department, Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Nicole Blijlevens
- Department of Haematology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Marcio Nucci
- Department of Internal Medicine, University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Monica Slavin
- Department of Infectious Diseases and Sir Peter MacCallum Department of Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Stéphane Bretagne
- Université Paris Cité, and Parasitology and Mycology laboratory, Assistance Publique des Hôpitaux de Paris, Saint Louis Hospital, Paris, France
| | - Catherine Cordonnier
- Department of Haematology, Assistance Publique des Hôpitaux de Paris, Henri Mondor Hospital, Créteil, France; University Paris-Est-Créteil, Créteil, France.
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Yamaguchi K, Yamamoto H, Izutsu K, Yuasa M, Kaji D, Nishida A, Ishiwata K, Takagi S, Yamamoto G, Asano-Mori Y, Uchida N, Taniguchi S. Fatal outcome of BK virus encephalitis in an allogeneic stem cell transplantation recipient. J Infect Chemother 2024:S1341-321X(24)00096-5. [PMID: 38514025 DOI: 10.1016/j.jiac.2024.03.012] [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: 11/19/2023] [Revised: 03/15/2024] [Accepted: 03/18/2024] [Indexed: 03/23/2024]
Abstract
BK virus (BKV) encephalitis is a rare complication after hematopoietic stem cell transplantation (HSCT). A 43-year-old woman with recurrent follicular lymphoma after autologous HSCT received allogeneic bone marrow transplantation from a human leukocyte antigen-matched related donor. Neutrophil engraftment was achieved on post-transplant day 13. Memory loss and noncooperative attitude toward the medical staff were observed on day 16, and her mental status worsened progressively. Magnetic resonance imaging (MRI) showed nonspecific findings on day 19; however, cerebrospinal fluid (CSF) analysis including real-time polymerase chain reaction on day 20 revealed elevated levels of BKV 4.67 × 104 copy/mL. BKV encephalitis was diagnosed based on CSF findings, intravenous administration of immunoglobulin and cidofovir was started, and the immunosuppressive agent dose was reduced. Diffusion-weighted MRI on day 28 showed signal abnormalities in the bilateral periventricular white matter. Although the follow-up CSF analysis on day 35 was negative for BKV, her mental status and MRI findings did not improve, and she died on day 55 because of respiratory failure. This case emphasizes the importance of considering BKV encephalitis as a differential diagnosis of post-transplant encephalitis, considering the central nervous system-associated immune reconstitution inflammatory syndrome in patients with worsening central nervous system findings after eradication of BKV in the CSF.
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Affiliation(s)
| | | | - Koji Izutsu
- Department of Hematology, Toranomon Hospital, Tokyo, Japan
| | | | - Daisuke Kaji
- Department of Hematology, Toranomon Hospital, Tokyo, Japan
| | - Aya Nishida
- Department of Hematology, Toranomon Hospital, Tokyo, Japan
| | | | | | - Go Yamamoto
- Department of Hematology, Toranomon Hospital, Tokyo, Japan
| | | | - Naoyuki Uchida
- Department of Hematology, Toranomon Hospital, Tokyo, Japan
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Rauwolf KK, Floeth M, Kerl K, Schaumburg F, Groll AH. Toxoplasmosis after allogeneic haematopoietic cell transplantation-disease burden and approaches to diagnosis, prevention and management in adults and children. Clin Microbiol Infect 2020; 27:378-388. [PMID: 33065238 DOI: 10.1016/j.cmi.2020.10.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 10/06/2020] [Accepted: 10/10/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Toxoplasmosis is a rare but highly lethal opportunistic infection after allogeneic haematopoietic cell transplantation (HCT). Successful management depends on screening, early recognition and effective treatment. OBJECTIVES To review the current epidemiology and approaches to diagnosis, prevention and treatment of toxoplasmosis in adult and paediatric allogeneic HCT recipients. SOURCE Search of the English literature published in MEDLINE up to 30 June 2020 using combinations of broad search terms including toxoplasmosis, transplantation, diagnosis, epidemiology, prevention and treatment. Selection of articles for review and synthesis on the basis of perceived quality and relevance of content. CONTENT Toxoplasmosis continues to be a major challenge in the management of allogeneic HCT recipients. Here we provide a summary of published case series of toxoplasmosis in adult and paediatric patients post allogeneic HCT. We review and discuss the pathogenesis, epidemiology, clinical presentation, diagnosis and current recommendations for prevention and treatment. We also discuss impacts of toxoplasmosis in this setting and factors affecting outcome, emphasizing attention to neurological, neuropsychological and neurocognitive late effects in survivors. IMPLICATIONS Apart from careful adherence to established strategies of disease prevention through avoidance of primary infection, identification of seropositive patients and implementation of molecular monitoring, future perspectives to improve the control of toxoplasmosis in allogeneic HCT recipients may include the systematic investigation of pre-emptive treatment, development of immunomodulatory approaches, antimicrobial agents with activity against the cyst form and vaccines to prevent chronic infection.
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Affiliation(s)
- Kerstin K Rauwolf
- Department of Paediatric Haematology and Oncology, University Children's Hospital Münster, Münster, Germany; Centre for Bone Marrow Transplantation, University Hospital Münster, Münster, Germany
| | - Matthias Floeth
- Centre for Bone Marrow Transplantation, University Hospital Münster, Münster, Germany; Department of Medicine A, Haematology and Oncology, University Hospital Münster, Münster, Germany
| | - Kornelius Kerl
- Department of Paediatric Haematology and Oncology, University Children's Hospital Münster, Münster, Germany; Centre for Bone Marrow Transplantation, University Hospital Münster, Münster, Germany
| | - Frieder Schaumburg
- Institute of Medical Microbiology, University Hospital Münster, Münster, Germany
| | - Andreas H Groll
- Department of Paediatric Haematology and Oncology, University Children's Hospital Münster, Münster, Germany; Centre for Bone Marrow Transplantation, University Hospital Münster, Münster, Germany.
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Abbas A, Zheng C, van Nispen tot Pannerden C, Newsholme W, Hilton R. Primary toxoplasmosis complicated by possible IRIS 15 years after renal transplantation. CLINICAL INFECTION IN PRACTICE 2020. [DOI: 10.1016/j.clinpr.2020.100021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Czyzewski K, Fraczkiewicz J, Salamonowicz M, Pieczonka A, Zajac-Spychala O, Zaucha-Prazmo A, Gozdzik J, Styczynski J. Low seroprevalence and low incidence of infection with Toxoplasma gondii (Nicolle et Manceaux, 1908) in pediatric hematopoietic cell transplantation donors and recipients: Polish nationwide study. Folia Parasitol (Praha) 2019; 66. [DOI: 10.14411/fp.2019.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 08/21/2019] [Indexed: 12/24/2022]
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Abstract
Immune reconstitution inflammatory syndrome (IRIS) describes a syndrome of aberrant reconstituted immunity, often in association with HIV infection, beginning with a normalization of CD4+ T-cell counts resulting in a dysregulated immune response against an infecting opportunistic pathogen and the host. In this chapter, we discuss the unique nature of IRIS when present in the central nervous system (CNS IRIS) and the changes experienced with each host pathogen and its unique influence on the immune system. Consensus on the mechanism of action of the immune system in IRIS pathology is less clear and multiple theories have been proposed. Here we explore the early history of the term IRIS, proposed mechanisms and animal models, as well as common CNS pathogens associated with IRIS, and management strategies.
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Affiliation(s)
- Lauren Bowen
- Section of Infections of the Nervous System, National Institute for Neurologic Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States
| | - Avindra Nath
- Section of Infections of the Nervous System, National Institute for Neurologic Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States.
| | - Bryan Smith
- Section of Infections of the Nervous System, National Institute for Neurologic Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States
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