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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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Khosla A, Singhal S, Jotwani P, Kleyman R. Cerebral Toxoplasmosis As the Initial Presentation of HIV: A Case Series. Cureus 2022; 14:e23359. [PMID: 35475054 PMCID: PMC9018902 DOI: 10.7759/cureus.23359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2022] [Indexed: 11/21/2022] Open
Abstract
The HIV epidemic afflicts millions across the globe, and Sub-Saharan countries bear a disproportionately high burden. Cerebral toxoplasmosis is commonly seen as the disease progresses but is rarely ever reported as the initial manifestation of HIV. The clinical presentation, co-existing risk factors, and outcomes remain underreported. The objective of this article is to report cerebral toxoplasmosis as the initial manifestation of HIV. This is a consecutive series of three patients that presented to a community hospital in Pennsylvania, United States, with a variety of neuropsychiatric symptoms and were found to have cerebral toxoplasmosis. The findings are compared with existing literature on cerebral toxoplasmosis as the initial manifestation of HIV. Cerebral toxoplasmosis as the initial manifestation of HIV is a rarely reported phenomenon. Hyponatremia may be linked with this disease-complex, although further studies are warranted to establish a causal relationship. Co-infection with hepatitis viruses is also a common finding in these patients.
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Brewer D, MacMillan ML, Schleiss MR, Ayuthaya SIN, Young JA, Ebens CL. Detection and treatment of cerebral toxoplasmosis in an aplastic pediatric post-allogeneic hematopoietic cell transplant patient: a case report. BMC Infect Dis 2021; 21:941. [PMID: 34507535 PMCID: PMC8434744 DOI: 10.1186/s12879-021-06650-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 09/01/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cerebral toxoplasmosis infection presents with non-specific neurologic symptoms in immunocompromised patients. With lack of measurable adaptive immune responses and reluctance to sample affected brain tissue, expedient diagnosis to guide directed treatment is often delayed. CASE PRESENTATION We describe the use of cerebrospinal fluid polymerase chain reaction and plasma cell-free DNA technologies to supplement neuroimaging in the diagnosis of cerebral toxoplasmosis in an immunocompromised pediatric patient following allogeneic hematopoietic cell transplantation for idiopathic severe aplastic anemia. Successful cerebral toxoplasmosis treatment included antibiotic therapy for 1 year following restoration of cellular immunity with an allogeneic stem cell boost. CONCLUSIONS Plasma cell-free DNA technology provides a non-invasive method of rapid diagnosis, improving the likelihood of survival from often lethal opportunistic infection in a high risk, immunocompromised patient population.
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Affiliation(s)
- Danielle Brewer
- Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Margaret L MacMillan
- Department of Pediatrics, Division of Blood and Marrow Transplantation and Cellular Therapy, University of Minnesota, Minneapolis, MN, USA
| | - Mark R Schleiss
- Department of Pediatrics, Division of Infectious Diseases, University of Minnesota, Minneapolis, MN, USA
| | | | - Jo-Anne Young
- Department of Medicine, Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Christen L Ebens
- Department of Pediatrics, Division of Blood and Marrow Transplantation and Cellular Therapy, University of Minnesota, Minneapolis, MN, USA.
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Luo L, Shen N, Chen W, Luo C, Huang X, Jiang Y, Cao Q. Toxoplasma gondii infection in children after allogeneic hematopoietic stem cell transplantation: A case report and literature review. Pediatr Investig 2021; 5:239-243. [PMID: 34589678 PMCID: PMC8458717 DOI: 10.1002/ped4.12290] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/13/2021] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Toxoplasmosis is a life-threatening complication after hematopoietic stem cell transplantation (HSCT). However, for several reasons, clinicians know little about Toxoplasma infection. CASE PRESENTATION We report a case of toxoplasmosis that was diagnosed by bone marrow smear and metagenomic next-generation sequencing (mNGS) after HSCT in a boy. Additionally, we summarize the characteristics of toxoplasmosis after pediatric HSCT reported in the literature published in PubMed. CONCLUSION Clinicians should increase their awareness of toxoplasmosis in children after HSCT and implement pre-transplant screening and post-transplant monitoring and prevention in future according to the national conditions of our country.
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Affiliation(s)
- Lijuan Luo
- Department of Infectious DiseasesShanghai Children’s Medical CenterSchool of MedicineShanghai Jiao Tong UniversityShanghaiChina
| | - Nan Shen
- Department of Infectious DiseasesShanghai Children’s Medical CenterSchool of MedicineShanghai Jiao Tong UniversityShanghaiChina
| | - Wenjuan Chen
- Department of Infectious DiseasesShanghai Children’s Medical CenterSchool of MedicineShanghai Jiao Tong UniversityShanghaiChina
| | - Chengjuan Luo
- Department of Hematology and OncologyShanghai Children’s Medical CenterSchool of MedicineShanghai Jiao Tong UniversityShanghaiChina
| | - Xiaohang Huang
- Department of Hematology and OncologyShanghai Children’s Medical CenterSchool of MedicineShanghai Jiao Tong UniversityShanghaiChina
| | - Yuelian Jiang
- Department of PharmacyShanghai Children’s Medical CenterSchool of MedicineShanghai Jiao Tong UniversityShanghaiChina
| | - Qing Cao
- Department of Infectious DiseasesShanghai Children’s Medical CenterSchool of MedicineShanghai Jiao Tong UniversityShanghaiChina
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Lindell RB, Wolf MS, Alcamo AM, Silverman MA, Dulek DE, Otto WR, Olson TS, Kitko CL, Paueksakon P, Chiotos K. Case Report: Immune Dysregulation Due to Toxoplasma gondii Reactivation After Allogeneic Hematopoietic Cell Transplant. Front Pediatr 2021; 9:719679. [PMID: 34447731 PMCID: PMC8382793 DOI: 10.3389/fped.2021.719679] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 07/08/2021] [Indexed: 11/23/2022] Open
Abstract
Disseminated toxoplasmosis is an uncommon but highly lethal cause of hyperferritinemic sepsis after hematopoietic cell transplantation (HCT). We report two cases of disseminated toxoplasmosis from two centers in critically ill adolescents after HCT: a 19-year-old who developed fever and altered mental status on day +19 after HCT and a 20-year-old who developed fever and diarrhea on day +52 after HCT. Both patients developed hyperferritinemia with multiple organ dysfunction syndrome and profound immune dysregulation, which progressed to death despite maximal medical therapies. Because disseminated toxoplasmosis is both treatable and challenging to diagnose, it is imperative that intensivists maintain a high index of suspicion for Toxoplasma gondii infection when managing immunocompromised children, particularly in those with known positive T. gondii serologies.
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Affiliation(s)
- Robert B Lindell
- Department of Anesthesia and Critical Care Medicine, Division of Critical Care Medicine, Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Michael S Wolf
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt and the Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Alicia M Alcamo
- Department of Anesthesia and Critical Care Medicine, Division of Critical Care Medicine, Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Michael A Silverman
- Department of Pediatrics, Division of Infectious Diseases, Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Daniel E Dulek
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Monroe Carell Jr. Children's Hospital at Vanderbilt and the Vanderbilt University School of Medicine, Nashville, TN, United States
| | - William R Otto
- Department of Pediatrics, Division of Infectious Diseases, Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Timothy S Olson
- Department of Pediatrics, Division of Oncology, Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Carrie L Kitko
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Monroe Carell Jr. Children's Hospital at Vanderbilt and the Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Paisit Paueksakon
- Department of Pathology, Microbiology, and Immunology, Monroe Carell Jr. Children's Hospital at Vanderbilt and the Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Kathleen Chiotos
- Department of Anesthesia and Critical Care Medicine, Division of Critical Care Medicine, Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States.,Department of Pediatrics, Division of Infectious Diseases, Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
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Komitopoulou A, Goussetis E, Oikonomopoulou C, Paisiou A, Kaisari K, Ioannidou E, Sipsas NV, Kosmidis H, Vessalas G, Peristeri I, Kitra V. Toxoplasma gondii: How fatal is it in pediatric allogeneic bone marrow transplantation setting? Transpl Infect Dis 2019; 22:e13226. [PMID: 31785038 DOI: 10.1111/tid.13226] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 11/22/2019] [Accepted: 11/24/2019] [Indexed: 12/21/2022]
Abstract
Toxoplasmosis is a disease of the immunocompetent population. However, cases of toxoplasma infection associated with immunosuppression have been reported, especially the first months after transplantation. Limited data are available about toxoplasma infection, occurring even many months post-transplant in pediatric patients with nonmalignant and malignant diseases. We report the cases of three patients with early and late disseminated toxoplasmosis and review the literature.
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Affiliation(s)
- Anna Komitopoulou
- Stem Cell Transplant Unit "Agia Sofia Children's Hospital", Athens, Greece
| | - Evgenios Goussetis
- Stem Cell Transplant Unit "Agia Sofia Children's Hospital", Athens, Greece
| | | | - Anna Paisiou
- Stem Cell Transplant Unit "Agia Sofia Children's Hospital", Athens, Greece
| | - Katerina Kaisari
- Stem Cell Transplant Unit "Agia Sofia Children's Hospital", Athens, Greece
| | - Eleni Ioannidou
- Stem Cell Transplant Unit "Agia Sofia Children's Hospital", Athens, Greece
| | - Nikolaos V Sipsas
- Infectious Diseases Unit, Department of Pathophysiology, Laikon General Hospital and Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Helen Kosmidis
- Pediatric Oncology Department, MITERA HOSPITAL, Athens, Greece
| | - Georgios Vessalas
- Stem Cell Transplant Unit "Agia Sofia Children's Hospital", Athens, Greece
| | - Ioulia Peristeri
- Stem Cell Transplant Unit "Agia Sofia Children's Hospital", Athens, Greece
| | - Vassiliki Kitra
- Stem Cell Transplant Unit "Agia Sofia Children's Hospital", Athens, Greece
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Toxoplasma prophylaxis in haematopoietic cell transplant recipients: a review of the literature and recommendations. Curr Opin Infect Dis 2016; 28:283-92. [PMID: 26098500 DOI: 10.1097/qco.0000000000000169] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Toxoplasmosis in haematopoietic cell transplant (HCT) recipients is associated with high morbidity and mortality rates. Prophylaxis following HCT is recommended for high-risk pre-HCT toxoplasma-seropositive (pre-HCTSP) recipients. However, there is no agreement or consistency among programmes on whether to adopt prophylaxis or not, or if used, on the chosen antitoxoplasma prophylactic regimen. This review discusses the role of prophylaxis, and preemptive treatment, for toxoplasmosis in the setting of HCT. RECENT FINDINGS Approximately two-thirds of toxoplasmosis cases following HCT are reported in allogeneic pre-HCTSP (allo pre-HCTSP) patients. This finding confirms a major role of reactivation of latent infection in the pathogenesis of toxoplasmosis in this patient population. Toxoplasma disease-related mortality in allo pre-HCTSP patients was reported at 62%, but it can be significantly decreased with early detection and treatment of toxoplasma infection. There are no randomized trials comparing the efficacy of different prophylactic agents to prevent toxoplasmosis after HCT. Several observational studies have demonstrated the efficacy of trimethoprim-sulfamethoxazole (TMP/SMX) in decreasing the incidence of toxoplasmosis following HCT. There is limited information regarding efficacy of other prophylactic agents. Preemptive treatment using routine blood PCR monitoring seems to be beneficial in detecting infection early and preventing disease in several observational studies and has been adopted for allo pre-HCTSP HCT patients when universal prophylaxis is not possible. SUMMARY Universal prophylaxis with TMP/SMX in allo pre-HCTSP patients should be implemented by all transplant programmes. Preemptive treatment with routine blood PCR monitoring is an option if prophylaxis cannot be used.
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Kerl K, Ehlert K, Brentrup A, Schiborr M, Keyvani K, Becker K, Rossig C, Groll A. Cerebral toxoplasmosis in an adolescent post allogeneic hematopoietic stem cell transplantation: successful outcome by antiprotozoal chemotherapy and CD4+T-lymphocyte recovery. Transpl Infect Dis 2015; 17:119-24. [DOI: 10.1111/tid.12344] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Revised: 10/04/2014] [Accepted: 11/18/2014] [Indexed: 11/28/2022]
Affiliation(s)
- K. Kerl
- Department of Pediatric Hematology and Oncology; University Children's Hospital Muenster; Muenster Germany
| | - K. Ehlert
- Department of Pediatric Hematology and Oncology; University Children's Hospital Muenster; Muenster Germany
| | - A. Brentrup
- Neurosurgery Department; University Hospital Muenster; Muenster Germany
| | - M. Schiborr
- Radiology Department; University Hospital Muenster; Muenster Germany
| | - K. Keyvani
- Neuropathology Department; University Hospital Muenster; Muenster Germany
| | - K. Becker
- Medical Microbiology Department; University Hospital Muenster; Muenster Germany
| | - C. Rossig
- Department of Pediatric Hematology and Oncology; University Children's Hospital Muenster; Muenster Germany
| | - A.H. Groll
- Department of Pediatric Hematology and Oncology; University Children's Hospital Muenster; Muenster Germany
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Libório AB, Silva GB, Silva CGCH, Lima Filho FJC, Studart Neto A, Okoba W, de Bruin VMS, Araújo SMHA, Daher EF. Hyponatremia, acute kidney injury, and mortality in HIV-related toxoplasmic encephalitis. Braz J Infect Dis 2012; 16:558-63. [PMID: 23146154 DOI: 10.1016/j.bjid.2012.08.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2012] [Accepted: 08/10/2012] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND There are no reports on hyponatremia and acute kidney injury (AKI) involved in the course of HIV-related toxoplasmic encephalitis (TE). The main objective of this study was to describe the occurrence of hyponatremia and its relationship with AKI and mortality in HIV-related toxoplasmic encephalitis (TE). METHODS This was a retrospective cohort study on patients with HIV-related TE. AKI was considered only when the RIFLE (risk, injury, failure, loss, end-stage) criterion was met, after the patient was admitted. RESULTS A total of 92 patients were included, with a mean age of 36±9 years. Hyponatremia at admission was observed in 43 patients (46.7%), with AKI developing in 25 (27.1%) patients during their hospitalization. Sulfadiazine was the treatment of choice in 81% of the cases. Death occurred in 13 cases (14.1%). Low serum sodium level correlated directly with AKI and mortality. Male gender (OR 7.89, 95% CI 1.22-50.90, p = 0.03) and hyponatremia at admission (OR 4.73, 95% CI 1.22-18.30, p = 0.02) were predictors for AKI. Independent risk factors for death were AKI (OR 8.3, 95% CI 1.4-48.2, p < 0.0001) and hyponatremia (OR 9.9, 95% CI 1.2-96.3, p < 0.0001). CONCLUSION AKI and hyponatremia are frequent in TE. Hyponatremia on admission is highly associated with AKI and mortality.
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Affiliation(s)
- Alexandre B Libório
- School of Medicine, Health Sciences Center, Universidade de Fortaleza, Fortaleza, CE, Brazil
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