[Congenital transmission of Trypanosoma cruzi in Brazil: estimation of prevalence based on preliminary data of national serological surveys in children under 5 years old and other sources]

A prevalence estimation of congenital transmission in Brazil is performed, based on several sources of recent data. From a serological survey conducted now in Brazil, with children below 5 years old, preliminary data from the state of Minas Gerais only 19/9,556 children did have antibodies against Trypanosoma cruzi. All 19 mothers were infected, but only one child persisted with antibodies on a second blood collection, hence diagnosed as congenital. The other were just passive transference of maternal antibodies. From a recent publication, 278 children born from 145 infected mothers were studied. Two cases (0.7%) were congenital. In other source, from 1,348 blood donors, 35 were born in non endemic areas. When 10 of them were called, 8 were born from infected mothers and five may be congenital. Finally, no infection was detected in 93 children born from 78 infected mothers. The reasons for this low prevalence are discussed, are lower than in other countries of the South Cone, that harbor also T. cruzi 2, but are unrecognized up to now.

[Factors and mechanisms involved in the transmission and development of congenital infection with Trypanosoma cruzi]

This paper synthesizes the results obtained from multidisciplinary studies of Bolivian cases of congenital infection with T. cruzi. Congenital infection and congenital Chagas disease do not result from transmission of a particular strain of parasite, but from an equilibrium between complex phenomena, such as a weak maternal type 1 adaptative immune response associated with high maternal parasitemia, an invasion of placental chorion and umbilical cord by parasites, in front of a fetal T. cruzi-specific immune response characterized by an activation of cytotoxic CD8 T cells producing IFN-gamma and able to limit parasite multiplication and morbi-mortality of congenital Chagas disease.

[Congenital Chagas disease in Córdoba, Argentina: epidemiological, clinical, diagnostic, and therapeutic aspects. Experience of 30 years of follow up]

Chagas'disease has a great epidemiological relevance. Most of infected children are asymptomatics, with low mortality rate. The most frequent clinical findings are hepatomegaly and splenomegaly Parasitological methods: fresh smears, microStrout and Hemoculture, sequentially performed, detect the parasite in almost 100% of infected children. The gold standard for immunodiagnosis are serological curves, due to the interference of maternal IgG. Infected children maintain their antibody levels , whereas non infected became negatives. IgM test show false positive and false negative results. In children acutely infected during the first year of life and in cases of congenital infection, we observed high serum levels of soluble receptors of TNFalpha, IL-2 and sCD8, with significantly post treatment decrease. In a prospective 30 years research, we observed high therapeutic efficacy when children were treated before 3 years of life with benznidazol or nifurtimox, with good clinical evolution, together with parasitological and serological negativization.

[Endemic level of congenital Trypanosoma cruzi infection in the areas of maternal residence and the development of congenital Chagas disease in Bolivia]

In Bolivia, the prevalence of infection by T. cruzi in women in fertile age can vary between 20 and 60%. The present study made in the Maternity Germin Urquidi of Cochabamba - Bolivia, it has demonstrated, that 19.9% of the mothers who go to this hospitable center to be taken care of in the childbirth, they are carrying of the infection and that 4,6% of them, they are going to transmit, by transplacentaria route, the infection to its babies. Of the 71 children born with congenital Chagas, only 47,8 % present/display some type of alteration or of development(Apgar to 1 minute low, BPN, prematuridad, pathological dismadurez) or signs (SDR, hepatomegalia, esplenomegalia, neurological signs, cardiomegalia, anasarca, petequias). When investigating the effect of the differences in the vectorial density (low, medium and high) of the zone of maternal residence, on the transmission of the infection of the mother infected to the fetus, we concluded that the rate of transmission of the congenital infection of T. cruzi is not modified by the level of endemicidad of the zone of maternal residence. By another infected new born sides whose mothers reside in zones of high endemicidad present/display, most frequently and of significant way, Apgar to 1 minute < to 7, low weight when being born and prematuridad or an association of these alterations with respiratory syndrome of distress or anasarca, when one compares them with new born of resident mothers in the zones of loss or medium endemicidad, mortality in this group is greater. These results suggest calls to account it of the mothers, in areas of high endemicidad, she is associate with a serious increase in the risk of Disease of newborn severe and mortal congenital Chagas in.

[Effects of acute and chronic Trypanosoma cruzi infection in pregnant mice]

Pathogens may impair reproduction in association or not with congenital infections. We have investigated the effect of acute infection with Trypanosoma cruzi, the protozoan agent of Chagas disease, on reproduction of female mice. In the acute, parasitemic, phase of the infection, female mice were totally unable to reproduce. Most of them (80%) were infertiles and did not develop any gestation. In the few gravid infected mice, implantation numbers were as in uninfected control mice. However, their fetuses presented a weight meanly reduced by 40% as compared to those of uninfected females, and all of them died during the gestation or whithin 48 h after birth. Such massive mortality did not result from congenital infection, which did not occur. The infertility and the fetal mortality occuring early in gestation (resorptions) were significantly correlated with a high maternal parasitemia, whereas later fetal mortality was associated with the presence of intracellular parasites in the utero-placental unit. The decidua was particularly receptive to T. cruzi multiplication, since this tissue harboured 125 fold more amastigotes than the maternal heart or other placental tissues. In addition, placentas of dead fetuses presented histopathological lesions (inflammatory infiltrates, fibrine deposits and ischemic necrosis). Such harmfull effects of acute infection were not observed when female mice were in the chronic phase of the infection, since these reproduce normally. Their fetuses only suffered from moderate and reversible growth retardation. These results indicate that, following the maternal parasite burden, T. cruzi infection may induce very deleterious effects on gestation.

Association between congenital toxoplasmosis and preterm birth, low birthweight and small for gestational age birth

OBJECTIVE

To determine the association between congenital toxoplasmosis and preterm birth, low birthweight and small for gestational age birth.

DESIGN

Multicentre prospective cohort study.

SETTING

Ten European centres offering prenatal screening for toxoplasmosis.

POPULATION

Deliveries after 23 weeks of gestation in 386 women with singleton pregnancies who seroconverted to toxoplasma infection before 20 weeks of gestation. Deliveries after 36 weeks in 234 women who seroconverted at 20 weeks or later, and tested positive before 37 weeks.

METHODS

Comparison of infected and uninfected births, adjusted for parity and country of birth.

MAIN OUTCOME MEASURES

Differences in gestational age at birth, birthweight and birthweight centile.

RESULTS

Infected babies were born or delivered earlier than uninfected babies: the mean difference for seroconverters before 20 weeks was -5.4 days (95% CI: -1.4, -9.4), and at 20 weeks or more, -2.6 days (95% CI: -0.5, -4.7). Congenital infection was associated with an increased risk of preterm delivery when seroconversion occurred before 20 weeks (OR 4.71; 95% CI: 2.03, 10.9). No significant differences were detected for birthweight or birthweight centile.

CONCLUSION

Babies with congenital toxoplasmosis were born earlier than uninfected babies but the mechanism leading to shorter length of gestation is unknown. Congenital infection could precipitate early delivery or prompt caesarean section or induction of delivery. We found no evidence for a significant association between congenital toxoplasmosis and reduced birthweight or small for gestational age birth.

[Real-time quantitative PCR for toxoplasmosis diagnosis]

Congenital toxoplasmosis results from foetus contamination by Toxoplasma gondii during pregnancy. It is a frequent and severe condition calling for close monitoring of mothers at risk. During the last decades, numerous advances have been made specially in the antenatal diagnosis. The congenital toxoplasmosis diagnosis relies currently on PCR test of amniotic fluid, with a sensitivity of 80%. More recently, real-time quantitative PCR has been developed to improve toxoplasmosis diagnosis. We therefore compared the diagnosis value of quantitative real-time PCR with our conventional PCR-hybridization for the diagnosis of congenital toxoplasmosis.

Busca retrospectiva da transmissão maternal da infecção chagásica em pacientes na fase crônica

Avaliamos a transmissão maternal do Trypanosoma cruzi em 278 filhos de 145 mães com a doença crônica causada por esse protozoário, nascidos após o estabelecimento do diagnóstico materno. Usamos, nas mães e nos filhos, provas sorológicas como base do objetivo do estudo. Verificamos que ocorreram apenas duas veiculações pela modalidade citada (2/278 = 0,7%). Como houve amamentação, não foi possível diferenciar, nesses casos, a transmissão congênita da adquirida pelo leite, mas, de qualquer forma, processou-se transmissão maternal, que constitui uma das modalidades alternativas de infecção pelo Trypanosoma cruzi. A metodologia empregada é mais uma dentre as diversas propostas para aquilatar a prevalência desse tipo de propagação do Trypanosoma cruzi. Ao lado da constatação fundamental, registramos fatos relacionados com a gestação, parto, puerpério, abortamento, prematuridade, nati-neomortalidade e aleitamento materno, que podem representar subsídios para melhores interpretações sobre o assunto.

Severe neonatal toxoplasmosis after third trimester maternal infection

We report an unusual case of neonatal toxoplasmosis. After a late third trimester maternal infection, the infant developed severe disseminated intravascular coagulopathy with thrombocytopenia, hepatitis, jaundice and severe pneumonitis. Clinicians that manage infants with severe unexplained systemic disease should consider the possibility of congenital toxoplasmosis.

Polymorphism of Fc receptor IIa for immunoglobulin G is associated with placental malaria in HIV-1-positive women in western Kenya

BACKGROUND

Genetic polymorphism of the Fc receptor IIa for immunoglobulin (Ig) G (Fc gamma RIIa) determines IgG subclass binding. Previous studies have shown that individuals with the IgG1/3-binding Fc gamma RIIa-Arg/Arg131 genotype are relatively protected against high-density malaria, whereas individuals with the IgG2-binding Fc gamma RIIa-His/His131 genotype are at increased risk for developing cerebral malaria. The present study was undertaken to examine the relationship between Fc gamma RIIa polymorphism and placental malaria (PM) in pregnant women of known human immunodeficiency virus (HIV)-1 status.

METHODS

Fc gamma RIIa genotype was determined in 903 pregnant women who had participated in a study designed to assess the effect that PM has on vertical transmission of HIV-1. Fc gamma RIIa polymorphism was assessed in relation to PM.

RESULTS

Among HIV-negative women, there was no difference in the distribution of the Fc gamma RIIa polymorphism by PM status. However, among HIV-positive women, the frequency of the Fc gamma RIIa-His/His131 genotype was significantly higher in women with PM than in women without PM (31% vs. 22%, respectively [P=.032]). In multivariate analysis, the adjusted odds ratio for PM in HIV-positive women with the Fc gamma RIIa-His/His131 genotype versus women in the Fc gamma RIIa-His/Arg131 reference group was 1.72 (95% confidence interval, 1.11-2.69 [P=.016]).

CONCLUSIONS

The present study suggests that the IgG2-binding Fc gamma RIIa-His/His131 genotype is associated with enhanced susceptibility to PM in HIV-positive women but not in HIV-negative women.

Pregnancy complicated by malaria, precipitate labor and uterine rupture

A case of Plasmodium falciparum malaria is reported in a 25-year-old pregnant woman with a history of three previous cesarean sections. She developed premature precipitate labor which was complicated by stillbirth, uterine rupture, bladder and vaginal tears necessitating hysterectomy.

Mass spectrometric analysis ofPlasmodium falciparum erythrocyte membrane protein-1 variants expressed by placental malaria parasites

Surface proteins from Plasmodium falciparum are important malaria vaccine targets. However, the surface proteins previously identified are highly variant and difficult to study. We used tandem mass spectrometry to characterize the variant antigens (Plasmodium falciparum erythrocyte membrane protein 1 (PfEMP1)) expressed on the surface of malaria-infected erythrocytes that bind to chondroitin sulfate A (CSA) in the placenta. Whereas PfEMP1 variants previously implicated as CSA ligands were detected, in unselected parasites four novel variants were detected in CSA-binding or placental parasites but not in unselected parasites. These novel PfEMP1 variants require further study to confirm whether they play a role in placental malaria.

Syncytiotrophoblast Degradation and the Pathophysiology of the Malaria-infected Placenta

Malaria is associated with excessive parasitic infection of the placenta and a reduction in neonatal birthweight. This study has investigated placental cell death in women with active and past malarial infection. Term placentae, with and without malarial pathology, were obtained from women in The Gambia. Active and past malaria infections were identified in placental sections and histological examination was used to determine the number of villi, the incidence of apoptosis, syncytial degradation, fibrinoid deposition and the frequency of syncytial knots. Placentae with active malaria infection showed erythrocyte adhesion of infected cells to syncytiotrophoblast, syncytial degradation, increased syncytial knotting and, in rare cases, localized destruction of the villi. Past malarial infection was characterized by syncytiotrophoblast disruption and fibrin-type fibrinoid (FTF) deposition. Perivillous FTF deposition was consistent with increased syncytial lesions and both increased lesions and syncytial knots were associated with birthweight reductions. Active malaria infection produced no alteration in placental apoptosis. The numbers of chorionic villi remained unchanged and infiltration of inflammatory cells, although not measured directly, appeared to be non-pervasive within the infected tissue. These observations establish a direct link between malaria parasitic infection and syncytiotrophoblast damage. The placental rejection of parasite-affected syncytia may invoke structural changes to compensate for inadequate placental exchange. Syncytial destruction could have serious implications; impairing fetal growth and in some rare cases, providing a previously unrecognized pathway to congenital infection.

Vertical transmission of toxoplasmosis from a chronically infected immunocompetent woman

We report the vertical transmission of congenital toxoplasmosis from a chronically infected immunocompetent woman to her child. On the background of published knowledge in this field, vertical transmission must have developed after maternal reinfection or reactivation of the preexisting disease.

Survey of ovine and caprine toxoplasmosis by IFAT and PCR assays in Sardinia, Italy

During the period 1999-2002, we have analyzed 9639 serum samples and 815 aborted samples (670 fetuses and 145 placenta) from 964 ovine and caprine farms distributed over all Sardinia island. After abortion notification, sera collected at random from adult animals were examined to detect simultaneously IgG and IgM antibodies specific to Toxoplasma gondii by indirect immunofluorescence assay, whereas fetuses and placenta were analyzed by a single tube nested PCR assay. Specific IgG antibodies were detected in 2048 (28.4%) sheep and 302 (12.3%) goats, specific IgM antibodies were found in 652 (9%) sheep and 139 (5.6%) goats. From a total of 2471 ovine and 362 caprine fetal samples including muscle, liver, abomasum, spleen, brain and placenta, 271 (11.1%) ovine and 23 (6.4%) caprine samples were T. gondii PCR-positive. Although T. gondii DNA was amplified from different types of tissues, placenta was the tissue with the highest detection rate. On the one hand, these results indicate that the seroprevalence of T. gondii infection in sheep and goats is relatively high, on the other PCR results demonstrate that T. gondii has a significant role in ovine and caprine abortion. Adequate management might be useful and essential to control the toxoplasmosis in the sheep and goats herds of Sardinia.

Immunodiagnosis of primary Toxoplasma gondii infection in sheep by the use of a P30 IgG avidity ELISA

Toxoplasma gondii is a protozoan parasite with a worldwide distribution. In both sheep and humans, if the parasite is encountered during pregnancy, fetal infection and abortion can occur. Therefore, Toxoplasma infection in sheep has a major economic impact upon sheep farming. Clinically, there is a need to distinguish recent (acute) infections from longstanding (chronic) infections. However, current serological techniques, such as detection of anti-T. gondii IgG, cannot discriminate between acute and chronic infections. Increasing immunoglobulin avidity is a good determining factor of how recent an infection is. In this study, we describe the application and validation of a T. gondii IgG avidity ELISA, based on the use of an affinity-purified, native T. gondii P30 antigen. The assay was used to examine sera from eight sheep experimentally infected with T. gondii and found that all seroconverted within 21 days post-infection (p.i.), beginning with avidities that were initially low but that increased over time, with all sheep reaching high IgG avidity within 10 weeks p.i. In addition, sera from clinically healthy but T. gondii-seropositive lambs and ewes and seropositive ewes with a history of abortion were also subjected to a preliminary serological investigation. High IgG avidities were found in 80% of the seropositive lambs, in 90% of the clinically healthy ewes and in 97% of the ewes with abortion problems. These findings indicate that the animals had most likely contacted the parasite a longer time ago.

Trypanosoma cruzi infection induces microfilament depletion in human placenta syncytiotrophoblast

Congenital Chagas disease, endemic in Latin America, is associated with premature labour, miscarriage, and placentitis. Metacyclic trypomastigotes adhere to specific receptors on the outer membrane of host cells as a prelude to intracellular invasion, causing calcium ion mobilization, rearrangement of host cell microfilaments, recruitment of lysosomes and parasite internalization. The actin cytoskeleton plays an important role in many cellular processes including the parasite invasion into mammalian cells. In order to observe if placental cytoskeleton is altered in the process of parasite invasion into placental villi, actin microfilaments were studied. Using immunohistochemical techniques, it was observed that the presence of actin in the syncytiotrophoblast was intense throughout the brush border in control placentae belonging to non-chagasic women. But after culture with the trypomastigote, this labelling disappeared, indicating that the parasite induced disassembly of the cortical actin cytoskeleton when the placenta was infected. As a control, placentae from chagasic women were studied, and no actin was found. The same results were obtained by the electron microscope. We confirmed that cortical actin rearrangements may be an early step in the Trypanosoma cruzi invasion mechanism into placental cells, in order to allow lysosomes access to the plasma membrane, and formation of the parasitophorous vacuole. The recruitment of lysosomes occurs directly beneath the invasion site, and this process is required for parasite internalization.

Parasite load in guinea pig foetus with real time PCR after maternofoetal transmission of Toxoplasma gondii

Parasite loads of different tissues were assessed in guinea pig foetus after maternal infection. Twelve female guinea pigs were infected with 100 cysts of the 76 K strain of Toxoplasma gondii by the oral route. Inoculation was performed 20 +/- 5 days (G20) or 40 +/- 5 days (G40) after the beginning of gestation. Gestational age was determined by progesterone assay. Maternal and foetal organ samples were taken 60 days after the beginning of gestation. Parasite loads (from placenta, amniotic fluid (AF), cord blood (CB), foetal brain, liver, lung and spleen) were assessed by a real-time PCR quantification using fluorescence resonance energy transfer (FRET) hybridization probes on the Light Cycler. Congenital transmission was proven by the presence of parasites in blood or tissue samples of the foetus in 84.6% (11/13) and 100% (16/16) of cases after inoculation on G20 and G40, respectively. The quantitative analysis of our results after inoculation at G20 and G40 has allowed us to determinate the positive parasitic loads as a function of the origin of the sample and the period of inoculation. The parasite loads expressed as log (parasite/g) were low in AF and CB samples: 1.49 +/- 0.50 and 1.05 +/- 0.10 at G20 and 1.21 +/- 0.36 and 1.20 +/- 0.42 at G40 respectively. In contrast the placenta and the different foetal tissues had higher parasite burdens: 2.89 +/- 0.54 to 5.30 +/- 0.51 at G20 and 2.81 +/- 0.71 to 3.65 +/- 0.59 at G40. All the placentae were positive for parasites even in the two cases with no proven transmission. Real time quantitative PCR using the hybridization probe was a very sensitive and reproducible technique to study the kinetics of congenital toxoplasmosis in the guinea pig model wich is close to that of humans.

The effect of dual infection with HIV and malaria on pregnancy outcome in western Kenya

OBJECTIVE

To determine the effect of dual infection with HIV and malaria on birth outcomes and maternal anaemia among women delivering at a large public hospital in Kisumu, western Kenya.

SUBJECTS AND METHODS

Data on obstetric and neonatal characteristics, maternal and placental parasitaemia, and postpartum haemoglobin levels were collected from women enrolled in a cohort study of the interaction between malaria and HIV during pregnancy.

RESULTS

Between 1996 and 1999, data were available from 2466 singleton deliveries. The maternal HIV seroprevalence was 24.3%, and at delivery 22.0% of the women had evidence of malaria. Low birthweight, preterm delivery (PTD), intrauterine growth retardation (IUGR) and maternal anaemia (haemoglobin < 8 g/dl) occurred in 4.6, 6.7, 9.8 and 13.8% of deliveries, respectively. Maternal HIV, in the absence of malaria, was associated with a 99 g (95% CI 52-145) reduction in mean birthweight among all gravidae. Malaria was associated with both IUGR and PTD, resulting in a reduction in mean birthweight of 145 g (95% CI 82-209) among HIV-seronegative and 206 g (95% CI 115-298) among HIV-seropositive primigravidae, but not among multigravidae. Both HIV and malaria were significant risk factors for postpartum maternal anaemia, and HIV-seropositive women with malaria were twice as likely to have anaemia than HIV-seronegative women with or without malaria.

CONCLUSION

Women with dual infection are at particular risk of adverse birth outcomes. In areas with a moderate or high prevalence of HIV and malaria, all pregnant women should be the focus of malaria and anaemia control efforts to improve birth outcomes.

HIV increases the risk of malaria in women of all gravidities in Kisumu, Kenya

OBJECTIVE

To study the importance of HIV infection for malaria in pregnancy in Kisumu, Kenya.

SUBJECTS AND METHODS

Healthy women with an uncomplicated pregnancy of 32 weeks or more attending the prenatal clinic in the Provincial Hospital between June 1996 and March 1999 were tested for HIV and malaria after consent had been obtained. For participating women who delivered in the same hospital, a blood smear of the mother and the placenta were obtained.

RESULTS

In the third trimester, 5093 women consented to testing: the prevalence of malaria and HIV was 20.1 and 24.9%, respectively. Among the 2502 screened women who delivered in the hospital, the prevalence of HIV, peripheral parasitaemia and placental malaria was 24.5, 15.2, and 19.0%, respectively. Compared with HIV-seronegative women, HIV-seropositive women were more likely to be parasitaemic, to have higher parasite densities, and to be febrile when parasitaemic. Placental infections in HIV-seropositive women were more likely to be chronic, as indicated by the presence of moderate to heavy pigment depositions. When adjusted by age, the typical gravidity-specific pattern of malaria in pregnancy disappeared in HIV-seropositive women; HIV-seropositive primigravidae had a similar risk of malaria as HIV-seropositive multigravidae. The excess malaria attributable to HIV in the third trimester increased from 34.6% among HIV-seropositive primigravidae, to 41.5% among HIV-seropositive secundigravidae, and 50.7% among HIV-seropositive gravidae with three or more pregnancies.

CONCLUSION

HIV infection alters patterns of malaria in pregnant women; in areas with both infections, all pregnant women should use malaria prevention.

Urinary tract infection with Trichomonas vaginalis in a premature newborn infant and the development of chronic lung disease

We report a case of a low-birth-weight infant with an infection of the urinary tract with Trichomonas vaginalis, who later developed cystic chronic lung disease suggestive of Wilson-Mikity syndrome. Although she had mild respiratory distress syndrome at birth, the extent of the chronic lung disease was out of proportion to the initial illness. We speculate that maternal infection with this organism may have resulted in an inflammatory response that led to its development.

Placental tumor necrosis factor alpha but not gamma interferon is associated with placental malaria and low birth weight in Malawian women

Malaria in pregnancy predisposes to maternal anemia and low birth weight (LBW). We examined the possible roles of the cytokines tumor necrosis factor alpha (TNF-alpha) and gamma interferon (IFN-gamma) in these adverse outcomes. We measured cytokine concentrations in placental, peripheral, and cord blood plasma in relation to malaria parasitemia and placental monocyte accumulation in 276 Malawian women. Maternal hemoglobin concentration, human immunodeficiency virus status, and infant birth weight were determined. Concentrations of TNF-alpha in placental blood were correlated with densities of Plasmodium falciparum-infected erythrocytes (P < 0.0001) and of intervillous monocyte infiltrates (P < 0.0001) on placental histology. Peripheral blood TNF-alpha concentrations were relatively low and were weakly associated with malaria. TNF-alpha concentrations were higher in placental blood, where they were strongly associated with malaria. Placental plasma TNF-alpha levels were higher in women who had LBW babies (P = 0.0027), women with febrile symptoms (P < 0.0001), and teenage mothers (P = 0.04) than in other women. The presence of TNF-alpha in cord blood was not associated with malaria infection. IFN-gamma levels were infrequently elevated, and elevated IFN-gamma levels were not associated with poor pregnancy outcomes. Placental production of TNF-alpha, but not of IFN-gamma, may be implicated in impaired fetal growth in Malawian women.