Severe toxoplasmosis in immunocompetent hosts: be aware of atypical strains

In vitro and in vivo activities of a trithiolato-diRuthenium complex conjugated with sulfadoxine against the apicomplexan parasite Toxoplasma gondii

Organometallic compounds, including Ruthenium complexes, have been widely developed as anti-cancer chemotherapeutics, but have also attracted much interest as potential anti-parasitic drugs. Recently hybrid drugs composed of organometallic Ruthenium moieties that were complexed to different antimicrobial agents were synthesized. One of these compounds, a trithiolato-diRuthenium complex (RU) conjugated to sulfadoxine (SDX), inhibited proliferation of Toxoplasma gondii tachyzoites grown in human foreskin fibroblast (HFF) monolayers with an IC50 < 150 nM, while SDX and the non-modified RU complex applied either individually or as an equimolar mixture were much less potent. In addition, conjugation of SDX to RU lead to decreased HFF cytotoxicity. RU-SDX did not impair the in vitro proliferation of murine splenocytes at concentrations ranging from 0.1 to 0.5 μM but had an impact at 2 μM, and induced zebrafish embryotoxicity at 20 μM, but not at 2 or 0.2 μM. RU-SDX acted parasitostatic but not parasiticidal, and induced transient ultrastructural changes in the mitochondrial matrix of tachyzoites early during treatment. While other compounds that target the mitochondrion such as the uncouplers FCCP and CCCP and another trithiolato-Ruthenium complex conjugated to adenine affected the mitochondrial membrane potential, no such effect was detected for RU-SDX. Evaluation of the in vivo efficacy of RU-SDX in a murine T. gondii oocyst infection model comprised of non-pregnant outbred CD1 mice showed no effects on the cerebral parasite burden, but reduced parasite load in the eyes and in heart tissue.

Molecular diagnosis of toxoplasmosis: recent advances and a look to the future

INTRODUCTION

Toxoplasmosis is a globally distributed parasitic infection that can be particularly severe when opportunistic or congenital. Its diagnosis requires accurate and rapid techniques that rely mainly on serology and molecular methods.

AREAS COVERED

The aim of this review was to discuss the positioning of the molecular diagnosis of toxoplasmosis according to the different clinical situations possibly resulting from infection with T. gondii, and to detail recent developments in this technique. The English and French literature were searched with the following keywords: 'Toxoplasmosis', "Molecular diagnosis" and 'PCR'.

EXPERT OPINION

Molecular techniques have revolutionized the diagnosis of toxoplasmosis, and practices have considerably evolved over the past decades. However, there is still a high degree of inter-laboratory heterogeneity which impairs comparisons between results and studies. Efforts to standardize practices are underway.

Patterns of Transmission and Sources of Infection in Outbreaks of Human Toxoplasmosis

We report on apparent temporal progression of probable sources of infection and transmission routes for global human toxoplasmosis outbreaks as described in published articles. We searched the Scientific Electronic Library Online, Web of Science, PubMed, and Scopus databases for articles on Toxoplasma, toxoplasmosis, and outbreaks. We found that transmission routes for Toxoplasma gondii varied by decade. In the 1960s and 1990s, toxoplasmosis outbreaks mainly occurred through ingestion of cysts in meat and meat derivatives; in the 1980s, through milk contaminated with tachyzoites; in 2000, due to the presence of oocysts in water, sand, and soil; and in 2010, due to oocysts in raw fruits and vegetables. Our study suggests a possible change in the epidemiology of reported toxoplasmosis outbreaks. Because of this change, we suggest that greater attention be paid to the disinfection of vegetables, as well as to the quality of water used for drinking and irrigation.

Toxoplasma gondii Seroprevalence in Horses from Ukraine: an Investigation Using Two Serological Methods

BACKGROUND

Horses are recognized as important hosts for the zoonotic parasite Toxoplasma gondii, mainly because meat of infected horses can be a source of human T. gondii infections. However, the baseline knowledge on equine T. gondii infections is limited and lacking from many countries. This seroepidemiological study was set in Ukraine, a country where little is known about T. gondii prevalence in any host species.

METHODS

We investigated 78 serum samples from horses, collected from Kyiv and Lviv regions of Ukraine, using a commercial enzyme-linked immunosorbent assay (ELISA) and a commercial modified direct agglutination test (DAT). The ELISA is intended to detect the presence of total antibodies against T. gondii, and the DAT detects specific anti-T. gondii immunoglobulin G antibodies. The cutoff titer for DAT seropositivity was a titer of 40.

RESULTS

Two horses were omitted from statistical analyses due to disagreeing ELISA results. Altogether 16 of the remaining 76 horses were seropositive with the ELISA, yielding an apparent seroprevalence estimate of 21.1% (95% confidence interval 13.0-31.3). Five horses tested positive with both ELISA and DAT, 11 horses tested positive with ELISA only, and one with DAT only. For 64 of the 76 horses, the results of ELISA and DAT agreed; the percent agreement was 84.2 and the Kappa statistic was - 1.5208, indicating poor agreement.

CONCLUSION

Our results add to the knowledge on the global epidemiology of T. gondii and exposure level of horses to the major zoonotic parasite, as well as to the discussion of challenges of applying serology to estimate exposure to T. gondii in horses.

Genetic Characterization of Toxoplasma gondii DNA Samples Isolated From Humans Living in North America: An Unexpected High Prevalence of Atypical Genotypes

Background

Whereas in Europe most of Toxoplasma gondii genotypes belong to the type II lineage, in Latin America, type II is rare and atypical strains predominate. In North America, data on T. gondii genotypes in humans are scarce.

Methods

In this study, T. gondii DNA samples from 67 patients with diagnosed toxoplasmosis in the United States were available for genotyping. Discriminant analysis of principal components was used to infer each atypical genotype to a geographic area where patients were probably infected. Associations between genotype, disease severity, immune status, and geographic region were also estimated.

Results

Of 67 DNA samples, 41 were successfully genotyped: 18 (43.9%) and 5 (12.2%) were characterized as types II and III, respectively. The remaining 18 genotypes (43.9%) were atypical and were assigned to a geographic area. Ten genotypes originated from Latin America, 7 from North America, and 1 from Asia (China). In North America, unlike in Europe, T. gondii atypical genotypes are common in humans and, unlike in Latin America, type II strains are still present with significant frequency.

Conclusions

Clinicians should be aware that atypical genotypes are common in North America and have been associated with severe ocular and systemic disease and unusual presentations of toxoplasmosis in immunocompetent patients.

Seroprevalence and risk factors of Toxoplasma gondii infection in horses in Jilin Province and Inner Mongolia Autonomous Region, northern China

Toxoplasmosis is caused by the protozoon Toxoplasma gondii that can infect almost all warm-blooded hosts including horses and humans. Horse meat is one of the most important meat products for human consumption. However, data on seroprevalence of T. gondii in horses intended for human consumption in Northern China is scarce. Thus, a total of 614 serum samples were collected from Jilin Province and Inner Mongolia Autonomous Region (IMAR) between 2015 and 2017, and were detected the seroprevalence for T. gondii by indirect hemagglutination assay test. In the prevalence study, the overall seroprevalence of T. gondii in horses was 17.92% (110/614) by IHA test, at the cut- off 1:64. Horses collected from Changchun (13.58%, P = 0.02) has a significantly lower seroprevalence than those from Meihekou City (21.72%) and Tongliao City (22.81%). Moreover, a significant difference of T. gondii seroprevalence was found between horses ages at less than 12 months (22.75%) and ≥12 months or higher (16.42%, P = 0.002). To our knowledge, this is the first report of seroprevalence of T. gondii in horses in Jilin and IMAR, Northern China. Logistic regression suggested that age and geographical location of horses were identified as risk factors. These findings will provide the useful data for controlling and preventing toxoplasmosis in horses and/or other hosts in China.

Toxoplasmosis aguda diseminada fatal en una paciente adulta inmunocompetente proveniente del Pacífico colombiano

Se presenta el caso de una paciente inmunocompetente de 72 años de edad, proveniente del departamento del Chocó, con un cuadro clínico de 12 días de fiebre, cefalea, deterioro neurológico progresivo y rápida evolución a falla orgánica múltiple y muerte.En el estudio histopatológico de los tejidos obtenidos en la necropsia, se identificaron quistes tisulares morfológicamente sugestivos de ser bradizoítos de Toxoplasma gondii, lo que se confirmó mediante inmunohistoquímica en corazón, cerebro y músculo estriado.

Direct genetic characterization of Toxoplasma gondii from clinical samples from Denmark: not only genotypes II and III

Genetic variation within Toxoplasma gondii can have both clinical and epidemiological significance, while the genotypes circulating in many parts of the world, including the Nordic country Denmark, are still unknown. We genetically characterized T. gondii strains that had been detected in human clinical samples in Denmark in 2011-2016. Samples that had tested positive for T. gondii DNA and had a quantification cycle value <33 were included in this study and subjected to direct genetic characterization of T. gondii based on length-polymorphism of 15 microsatellite markers. A total of 23 DNA samples from 22 individual patients were analyzed. The results were consistent with genotype II with 15/15 markers amplified from seven samples from the central nervous system (CNS) including two samples from one patient, four ocular samples, and one unspecified sample; with genotype III with 15/15 markers amplified from two ocular samples; with genotype Africa 1 with 15/15 markers amplified from one amniotic fluid sample and from one CNS-sample; with atypical genotype with 15/15 markers amplified from one CNS-sample and with 11/15 markers amplified from one CNS-sample; and with HG12-like genotype with 9/15 markers amplified from one CNS-sample. Genotype II, which is endemic in Europe, was predominant, but more than a third of the successfully genotyped strains were non-type-II. The possibility that clinical toxoplasmosis is caused by a strain that is not considered endemic to the region is definitely not negligible.

A more sensitive, efficient and ISO 17025 validated Magnetic Capture real time PCR method for the detection of archetypal Toxoplasma gondii strains in meat

Toxoplasma gondii is a globally prevalent, zoonotic parasite of major importance to public health. Various indirect and direct methods can be used for the diagnosis of toxoplasmosis. Whereas serological tests are useful to prove contact with the parasite has occurred, the actual presence of the parasite in the tissues of a seropositive animal is not demonstrated. For this, a bioassay is still the reference method. As an alternative, various PCR methods have been developed, but due to the limited amount of sample that can be tested, combined with a low tissue cyst density, those have proved to be insufficiently sensitive. A major improvement of the sensitivity was achieved with magnetic capture-based DNA extraction. By combining the hybridization of specific, biotinylated probes with the capture of those probes with streptavidin-coated paramagnetic beads, T. gondii DNA can selectively be "fished out" from a large volume of meat lysate. Still, several studies showed an insufficient sensitivity compared with the mouse bioassay. Here we present a method that is more sensitive (99% limit of detection: 65.4 tachyzoites per 100g of meat), economical and reliable (ISO 17025 validated) by adding a non-competitive PCR inhibition control (co-capture of cellular r18S) and making the release of the target DNA from the streptavidin-coated paramagnetic beads UV-dependent. The presented results demonstrate the potential of the modified Magnetic Capture real time PCR as a full alternative to the mouse bioassay for the screening of various types of tissues and meat, with the additional advantage of being quantitative.

Recurrent seizures during acute acquired toxoplasmosis in an immunocompetent traveller returning from Africa

INTRODUCTION

We report an unusual case of acute acquired toxoplasmosis (AAT) presenting as lymphadenopathy and recurrent seizures in an immunocompetent 15-year-old boy.

MATERIALS AND METHODS

The patient reported an 18-day vacation to Africa (Ethiopia), 39 days prior to the first seizure. Electroencephalogram (EEG) showed sporadic single-spike or sharp-wave paroxysms and the magnetic resonance imaging (RMI) of the brain was negative. The serology for T. gondii was compatible with an acute infection defined as positive for both toxoplasma-specific IgG and IgM and a low avidity (6 %), confirmed by a reference laboratory. The patient reported other two episodes of seizures, occurring 7 days apart. He was treated with pyrimethamine plus sulfadiazine and leucovorin for 4 weeks, with an improvement of lymphadenitis and normalization of EEG. After 5 months, new seizures were reported and a diagnosis of epilepsy was done. Toxoplasma polymerase chain reaction (PCR) of cerebrospinal fluid (CSF) and blood were negative. A treatment with valproic acid was started, obtaining control of the neurological disease.

CONCLUSION

Awareness of this neurologic manifestation by clinicians is required, also in immunocompetent patients. The relationship between toxoplasmosis and recurrent seizure needs to be investigated by new studies.

Strain hypothesis of Toxoplasma gondii infection on the outcome of human diseases

The intracellular protozoan Toxoplasma gondii is an exceptionally successful food and waterborne parasite that infects approximately 1 billion people worldwide. Genotyping of T. gondii isolates from all continents revealed a complex population structure. Recent research supports the notion that T. gondii genotype may be associated with disease severity. Here, we (1) discuss molecular and serological approaches for designation of T. gondii strain type, (2) overview the literatures on the association of T. gondii strain type and the outcome of human disease and (3) explore possible mechanisms underlying these strain-specific pathology and severity of human toxoplasmosis. Although no final conclusions can be drawn, it is clear that virulent strains (e.g. strains containing type I or atypical alleles) are significantly more often associated with increased frequency and severity of human toxoplasmosis. The significance of highly virulent strains can cause severe diseases in immunocompetent patients and might implicated in brain disorders such as schizophrenia should led to reconsideration of toxoplasmosis. Further studies that combine parasite strain typing and human factor analysis (e.g. immune status and genetic background) are required for better understanding of human susceptibility or resistance to toxoplasmosis.

Detection of Toxoplasma gondii DNA in horse meat from supermarkets in France and performance evaluation of two serological tests

In France, some cases of severe toxoplasmosis have been linked to the consumption of horse meat that had been imported from the American continent where atypical strains of Toxoplasma gondii are more common than in Europe. Many seroprevalence studies are presented in the literature but risk assessment of T. gondii infection after horse meat consumption is not possible in the absence of validated serological tests and the unknown correlation between detection of antibodies against T. gondii and presence of tissue cysts. We performed magnetic-capture polymerase chain reaction (MC-PCR) to detect T. gondii DNA in 231 horse meat samples purchased in supermarkets in France and evaluated the performance and level of agreement of the modified agglutination test (MAT) and enzyme-linked immunosorbent assay (ELISA) in the meat juices. The serological tests lacked sensitivity, specificity, and agreement between them, and there was no correlation with the presence of T. gondii DNA in horse meat, raising concerns about the reliability of T. gondii seroprevalence data in horses from the literature. T. gondii DNA was detected in 43% of horse meat samples but the absence of strain isolation in mice following inoculation of more than 100 horse meat samples suggests a low distribution of cysts in skeletal muscles and a low risk of T. gondii infection associated with horse meat consumption. However, to avoid any risk of toxoplasmosis, thorough cooking of horse meat is recommended.

Toxoplasma gondii infection in interstate truck drivers: a case-control seroprevalence study

Background

Infection with Toxoplasma gondii can be acquired via the ingestion of undercooked or raw meat containing tissue cysts, or via ingestion of water contaminated with oocysts. Professional long distance truck driving may have epidemiological importance for food-borne infections since drivers eat out of home and in places where hygiene and cooking practices are uncertain. We aimed to determine whether interstate truck drivers in Durango, Mexico have an increased risk of infection with T. gondii as indicated by seropositivity; and to determine the socio-demographic, work, clinical, and behavioral characteristics associated with T. gondii seropositivity in interstate truck drivers.

Methods

Through a case–control study design, 192 truck drivers and 192 controls from the general population of the same region matched by gender and age were examined with enzyme-linked immunoassays for the presence of anti-Toxoplasma IgG and IgM antibodies. Socio-demographic, work, clinical and behavioral characteristics from the truck drivers were obtained.

Results

Anti-T. gondii IgG antibodies were found in 23 (12.0%) of 192 truck drivers and in 13 (6.8%) of 192 controls (OR = 21.0; 95% CI: 1.23-358.38; P = 0.002). Anti-T. gondii IgM antibodies were found in 7 (3.6%) cases and in 7 (3.6%) controls (P = 1.00). The seroprevalence of T. gondii infection was higher in drivers with reflex impairment than in those without this impairment (4/13, 30.8% vs 19/179, 10.6%, respectively; P = 0.05), and in drivers with hearing impairment than in those without this impairment (3/7, 42.9% vs 20/185, 10.8%, respectively; P = 0.03). Multivariate analysis of work and behavioral characteristics of truck drives showed positive associations of T. gondii exposure with trips to the south of Mexico (OR = 3.11; 95% CI: 1.02-9.44; P = 0.04) and consumption of horse meat (OR = 5.18; 95% CI: 1.62-16.55; P = 0.005).

Conclusions

Results suggest that interstate truck drivers may have an increased risk for T. gondii infection, and that T. gondii exposure may be impacting neurological functions in truck drivers. Contributing factors for T. gondii exposure should be taken into account for the design of optimal prevention measures against T. gondii infection.

Prevalence of Toxoplasma gondii antibodies in domestic donkeys (Equus asinus) in Durango, Mexico slaughtered for human consumption

Background

Nothing is known about Toxoplasma gondii prevalence in donkeys in Mexico. Meat from donkey is consumed by humans in Mexico and also exported to other countries. We sought to determine the presence of antibodies against T. gondii in 239 domestic donkeys (Equus asinus) for slaughter in Durango, Mexico using the modified agglutination test (MAT). Donkeys were sampled in four premises (trade centers) where donkeys were gather for shipment to abattoirs in other Mexican states.

Results

Antibodies to T. gondii were found in 26 (10.9%) of 239 donkeys, with MAT titers of 1:25 in 7, 1:50 in 11, 1:100 in 6, and 1:200 in 2. Seropositive donkeys were found in three (75%) of the four gathering premises studied. Seroprevalence in donkeys varied from 0% to 23.1% among gathering premises. The seroprevalence of T. gondii infection was comparable among donkeys regardless their age, sex or health status. Seropositivity to T. gondii was found in donkeys between 1 to 12 years old. Multivariate analysis showed that seropositivity to T. gondii was associated with the gathering premises (OR = 1.58; 95% CI: 1.11-2.24; P = 0.009).

Conclusions

This is the first report of T. gondii infection in donkeys in Mexico. Results indicate that consumption of undercooked or raw meat from T. gondii-infected donkeys is potentially a source of T. gondii infection for humans.

Tomographic findings of acute pulmonary toxoplasmosis in immunocompetent patients

Background

Toxoplasmosis is one of the most common human zoonosis, and is generally benign in most of the individuals. Pulmonary involvement is common in immunocompromised subjects, but very rare in immunocompetents and there are scarce reports of tomographic findings in the literature. The aim of the study is to describe three immunocompetent patients diagnosed with acute pulmonary toxoplasmosis and their respective thoracic tomographic findings. Acute toxoplasmosis was diagnosed according to the results of serological tests suggestive of recent primary infection and the absence of an alternative etiology.

Case presentation

From 2009 to 2013, three patients were diagnosed with acute respiratory failure secondary to acute toxoplasmosis. The patients were two female and one male, and were 38, 56 and 36 years old. Similarly they presented a two-week febrile illness and progressive dyspnea before admission. Laboratory tests demonstrated lymphocytosis, slight changes in liver enzymes and high inflammatory markers. Tomographic findings were bilateral smooth septal and peribronchovascular thickening (100%), ground-glass opacities (100%), atelectasis (33%), random nodules (33%), lymph node enlargement (33%) and pleural effusion (66%). All the patients improved their symptoms after treatment, and complete resolution of tomographic findings were found in the followup.

Conclusion

These cases provide a unique description of the presentation and evolution of pulmonary tomographic manifestations of toxoplasmosis in immunocompetent patients. Toxoplasma pneumonia manifests with fever, dyspnea and a non-productive cough that may result in respiratory failure. In animal models, changes were described as interstitial pneumonitis with focal infiltrates of neutrophils that can finally evolve into a pattern of diffuse alveolar damage with focal necrosis. The tomographic findings are characterized as ground glass opacities, smooth septal and marked peribronchovascular thickening; and may mimic pulmonary congestion, lymphangitis, atypical pneumonia and pneumocystosis. This is the largest series of CT findings of acute toxoplasmosis in immunocompetent hosts, and the diagnosis should be considered as patients that present with acute respiratory failure in the context of a subacute febrile illness with bilateral and diffuse interstitial infiltrates with marked peribronchovascular thickening. If promptly treated, pulmonary toxoplasmosis can result in complete clinical and radiological recovery in immunocompetent hosts.

Animals are key to human toxoplasmosis

Toxoplasma gondii is an extremely sucessfull protozoal parasite which infects almost all mamalian species including humans. Approximately 30% of the human population worldwide is chronically infected with T. gondii. In general, human infection is asymptomatic but the parasite may induce severe disease in fetuses and immunocompromised patients. In addition, T. gondii may cause sight-threatening posterior uveitis in immunocompetent patients. Apart from few exceptions, humans acquire T. gondii from animals. Both, the oral uptake of T. gondii oocysts released by specific hosts, i.e. felidae, and of cysts persisting in muscle cells of animals result in human toxoplasmosis. In the present review, we discuss recent new data on the cell biology of T. gondii and parasite diversity in animals. In addition, we focus on the impact of these various parasite strains and their different virulence on the clinical outcome of human congenital toxoplasmosis and T. gondii uveitis.

Genotyping Toxoplasma gondii from wildlife in Pennsylvania and identification of natural recombinants virulent to mice

Recent studies indicated the predominance of Toxoplasma gondii haplogroup 12 in wildlife in the USA. However, still little is known of the genetic diversity of this parasite circulating in wildlife. In the present study, we tested coyotes (Canis latrans), red foxes (Vulpes vulpes), white-tailed deer (Odocoileus virginianus), and geese (Branta canadensis) from the state of Pennsylvania for T. gondii infection. Antibodies to T. gondii were found in 160 of 367 animals, including 92 (34.5%) of 266 coyotes, 49 (62.0%) of 79 white-tailed deer, 17 (85.0%) of 20 red fox, and two of two Canada geese tested by the modified agglutination test (cut off titer 1:25). Tissues from 105 seropositive animals were bioassayed in mice, and viable T. gondii was isolated from 29 animals, including 10 of 53 coyotes, 11 of 16 foxes, 7 of 49 deer, and one of one goose. DNA isolated from culture-derived tachyzoites of these isolates was characterized initially using multilocus PCR-RFLP markers. Nine genotypes were revealed, including ToxoDB PCR-RFLP #1 (4 isolates), #2 (2 isolates), #3 (4 isolates), #4 (6 isolates), #5 (4 isolates), #54 (1 isolate), #141 (1 isolate), #143 (1 isolate), and #216 (6 isolates), indicating high genetic diversity of T. gondii in wildlife in Pennsylvania. Pathogenicity of six T. gondii isolates (5 of #216 and #141) was determined in outbred Swiss Webster mice. Three of #216 and the #141 isolates were acute virulent to mice, and the other 2 #216 isolates were intermediate virulent. To determine the extent of genetic variation of these as well as a few recently reported virulent isolates from wildlife in North America, intron sequences were generated. Analysis of intron sequences and PCR-RFLP genotyping results indicated that the #216 isolates are likely derived from recombination of the clonal type I and III lineages. To determine if T. gondii virulence can be predicted by typing, we genotyped a collection of strains using PCR-RFLP markers for polymorphic genes ROP5, ROP16, ROP18 and GRA15, which are known to interact with host immune response. The results showed that there is an association of genotypes of ROP5 and ROP18 with mouse-virulence, however, additional gene(s) may also contribute to virulence in distinct T. gondii genotypes.