Ultrasound features of fetal toxoplasmosis: A contemporary multicenter survey in 88 fetuses

Associations between Fetal Symptoms during Pregnancy and Neonatal Clinical Complications with Toxoplasmosis

INTRODUCTION

Toxoplasmosis is a parasitism transmitted by Toxoplasma gondii, part of the TORCH complex, the most prevalent parasitism worldwide. It is asymptomatic in immunocompetent individuals but causes severe infections and developmental abnormalities in pregnant women, mainly affecting the central nervous system and the gastrointestinal system.

METHODS

In our prospective study, we analyzed cases of recent maternal Toxoplasma infections confirmed by serological testing between 1996 and 2020 at the Department of Obstetrics and Gynecology, Semmelweis University. Amniocentesis, followed by PCR, was performed in cases of recent infection confirmed by serological testing during pregnancy. After birth, a neonatological, microbiological, pediatric neurological and ophthalmological examination and a follow-up was carried out.

RESULTS

During the study period, a total of 238 cases of amniotic fluid Toxoplasma PCR testing due to Toxoplasma recent infection were performed. In terms of pregnancies, there were 219 deliveries and seven abortions. Twelve cases had no data available on the outcome of the pregnancy. In total, 133 cases of ultrasound abnormalities were detected during pregnancy, while in 105 cases, no abnormalities were detected on ultrasound examination. During amniocentesis, eight cases of Toxoplasma infection were revealed in amniotic fluid samples by PCR, and in 230 cases, the result was negative. Neonatal follow-up was performed in 139 cases, with no abnormalities during follow-up in 117 cases, and in 22 cases, there was a detectable complication that was likely to be related to Toxoplasma infection. In all 22 cases, amniotic fluid PCR Toxoplasma testing was negative.

CONCLUSIONS

The most common ultrasound abnormalities involve the nervous system and the gastrointestinal system. In cases of suspicion, it is recommended to perform amniocentesis Toxoplasma PCR testing besides the indirect methods to help the pregnant woman decide whether to carry the pregnancy to term. During follow-up, a multidisciplinary team experienced in pregnancies complicated by toxoplasmosis must carry out the follow-up, care and subsequent development.

A Rare Case of Unilateral Fetal Cataract and Coincidental Polydactyly in Congenital Toxoplasmosis

Congenital toxoplasmosis is caused by transplacental infection of Toxoplasma gondii during pregnancy. We present a case of a congenital toxoplasma with intracranial calcifications, microcephaly, growth restriction, a unilateral cataract that developed in the third trimester, and a coincidental post-axial-polydactyly. Antenatal imaging findings are important to guide further testing and confirmation of diagnosis, it is important to know all possible associations and prognoses for timely counseling, testing, and intervention. To our knowledge, no case has been published with findings of unilateral cataract in congenital toxoplasmosis and associated coincidental polydactyly. Therefore, we wish to add this case to the current scientific literature.

Pediatric Posterior Infectious Uveitis

PURPOSE

To describe the most important cause of infectious posterior uveitis in pediatric patients.

METHODS

Review of the literature.

RESULTS

The most important causes of infectious uveitis in pediatric patients are: cat-scratch disease, toxocariasis, tuberculosis, viral diseases and toxoplasmosis. Ocular manifestations include retinitis, neuroretinitis, choroidal granulomas, peripheral granulomas and posterior pole granulomas.

CONCLUSION

Infectious posterior uveitis is a challenging subject and should be considered in the differential diagnosis of any posterior uveitis in children. Infectious uveitis must be excluded before initiating immunosuppressive therapy.

Toxoplasma gondii Infection in Pregnancy - Recommendations of the Working Group on Obstetrics and Prenatal Medicine (AGG - Section on Maternal Disorders)

Aim The AGG (Working Group for Obstetrics and Prenatal Diagnostics, Section Maternal Diseases) has issued these recommendations to improve the detection and management of Toxoplasma gondii infection in pregnancy. Methods Members of the Task Force developed the recommendations and statements presented here using recently published literature. The recommendations were adopted after a consensus process by members of the working group. Recommendations This article focuses on the epidemiology and pathophysiology of Toxoplasma gondii infection in pregnancy and includes recommendations for maternal and fetal diagnosis, transmission prophylaxis, therapy, prevention, screening, and peripartum management.

Prevention of congenital toxoplasmosis in France using prenatal screening: A decision-analytic economic model

Background

Toxoplasma gondii is one of the world’s most common parasites. Primary infection of the mother during pregnancy can lead to transmission to the fetus with risks of brain and eye lesions, which may cause lifelong disabilities. France instituted a national program based on monthly retesting of susceptible pregnant women to reduce the number of severe cases through prompt antenatal and postnatal treatment and follow-up.

Objective

To evaluate the ability of the French prenatal retesting program to reduce the lifetime costs of congenital toxoplasmosis.

Methods

We measured and then compared the costs and benefits of screening vs. not screening using decision-tree modelling. It included direct and indirect costs to society of treatment and care, and the lifetime lost earnings of children and caregivers. A probabilistic sensitivity analysis was carried out.

Findings

Total lifetime costs per live born child identified as congenitally infected were estimated to be €444 for those identified through prenatal screening vs €656 for those who were not screened. Estimates were robust to changes in all costs of diagnosis, treatment, and sequelae.

Interpretation

Screening for the prevention of the congenital T. gondii infection in France is cost saving at €212 per birth. Compared with no screening, screening every pregnant woman in France for toxoplasmosis in 2020 would have saved the country €148 million in addition to reducing or eliminating the devastating physical and emotional suffering caused by T. gondii. Our findings reinforce the conclusions of other decision-analytic modelling of prenatal toxoplasmosis screening.

A systematic review of maternal TORCH serology as a screen for suspected fetal infection

BACKGROUND

The acronym 'TORCH' refers to well-recognised causes of perinatal infections: toxoplasmosis, rubella, cytomegalovirus (CMV) and herpes simplex virus (HSV). A TORCH serology panel is often used to test for maternal primary infection following detection of ultrasound abnormalities in pregnancy.

AIM

This review aims to estimate the diagnostic yield of maternal TORCH serology in pregnancy following fetal ultrasound abnormalities.

MATERIALS AND METHODS

Primary studies published since 2000 that assessed maternal TORCH serology for suspected fetal infection and included information on indications for testing, definition of positive TORCH serology results, and perinatal outcomes were included.

RESULTS

Eight studies with a total of 2538 pregnancies were included. The main indications for testing were polyhydramnios, fetal growth restriction and hyperechogenic bowel. There were 26 confirmed cases of congenital CMV, of which 15 had multiple ultrasound abnormalities. There were no cases of congenital toxoplasmosis, rubella or HSV confirmed in any of the eight studies.

CONCLUSIONS

The clinical utility of TORCH serology for non-specific ultrasound abnormalities such as isolated fetal growth restriction or isolated polyhydramnios is low. It is time to retire the TORCH acronym and the reflex ordering of 'TORCH' panels, as their continued use obscures, rather than illuminates, appropriate investigation for fetal ultrasound abnormalities.

Primary toxoplasmosis acquired during early pregnancy: Is it currently overestimated?

OBJECTIVE

Toxoplasmosis acquired in early pregnancy is a potentially severe complication for the fetus. Evaluating the risk of transplacental infection in pregnant women accessing the Tuscany Reference Center for Infectious Diseases in Pregnancy during the last 20 years with suspected or confirmed toxoplasmosis acquired in early pregnancy was the aim of the study.

STUDY DESIGN

We retrospectively enrolled all pregnant women undergoing amniocentesis for toxoplasmosis acquired in the first 16 gestational weeks in the period 1999-2019, comparing patients with certain acute infection (seroconversion occurred in pregnancy, CAIP) with those with suspected acute infection (IgG positive with low/intermediate IgG avidity index, SAIP).

RESULTS

237 patients were enrolled, 187 (78.9%) with SAIP and 50 (21.1%) with CAIP. Specific IgM was detected in 47.5% and 76.7% (p-value 0.001), and the mean IgG avidity index was 22.7% and 7.1% (p-value < 0.001) in the SAIP and in the CAIP group, respectively. The mean delay from diagnosis to antibiotic initiation was 14.6 in SAIP and 11 days in CAIP group. Toxoplasma DNA was detected in the amniotic fluid in one case in a patient with CAIP. Excluding 24 newborns with not available data, prevalence of congenital infection was 0.47% [1/213 (95% CI 0.08%-2.61%)], 0% [0/178 (95% CI 0%-2.11%)] in SAIP and 2.8% [1/35 (95% CI 0.51%-14.53%)] in CAIP group.

CONCLUSIONS

Toxoplasmosis acquired in early pregnancy has a low risk of fetal infection. Actively discussing case-by-case amniocentesis indication with patients, especially when a recent toxoplasmosis is not properly confirmed, is desirable.

Congenital toxoplasmosis in humans: an update of worldwide rate of congenital infections

The morbidity due to congenital toxoplasmosis in humans is very high. Most of these infected children are likely to develop symptoms of clinical toxoplasmosis. Sequelae in fetus resulting from Toxoplasma gondii infections in women who become infected with this parasite during pregnancy can be devastating and enormous efforts are directed in some countries to prevent these consequences. Here, an update on congenital toxoplasmosis in humans, especially the rate of congenital infections in humans worldwide, is provided. Although several countries have surveillance programmes, most information on the rate of congenital transmission is from France and Brazil. Because of compulsory national screening programme in France to detect and treat women with recently acquired T. gondii infection with anti-toxoplasma therapy, the rate of congenital transmission and the severity of disease in children are declining. Infections by this parasite are widely prevalent in Brazil. The severity of clinical toxoplasmosis in Brazilian children is very high and may be associated with the genetic characteristics of T. gondii isolates prevailing in animals and humans in Brazil. Virtually little or no information is available on this topic from China, India and other countries in Asia.

Congenital Toxoplasmosis: Findings in Fetal MRI

Toxoplasma gondii infection, when acquired as an acute infection during pregnancy, can have substantial adverse effects on fetuses. We present the case of a 19-year-old pregnant woman with no previous relevant medical history. The ultrasound in the third trimester showed brain and abdominal abnormalities such as congenital hydrocephalus, volume loss of the brain parenchyma, and hepatosplenomegaly. The laboratory test showed positive IgM for Toxoplasma gondii. MRI was performed for better assessment and it shows the lesions in the central nervous system and other organs with more details.

Evaluation of the impact of the first evidence-based guidelines for congenital toxoplasmosis in Armenia (Quindío) Colombia: An observational retrospective analysis

Background

Colombia implemented the world's first evidence-based guidelines for congenital toxoplasmosis in 2013, no evaluation of its impact has been reported.

Methods

We reviewed the clinical charts of cases referred to the specialized consultation of the health care centre at Universidad del Quindío during an 18-year period (2001-2019), where the diagnosis criteria and the correlation between prenatal treatment and symptoms at birth were analysed. Additionally, we described the diagnosis criteria and treatment for mothers during pregnancy at a primary prenatal care centre in the city of Armenia during 2018. Institutional consent was obtained to review clinical charts.

Findings

At the referral centre, we found that before the implementation, 27.3% did not have prenatal diagnosis but after implementing the clinical practice guidelines, all mothers were diagnosed during pregnancy. In addition, we observed that prenatal treatment was associated with fewer symptoms and this improved significantly over time after implementing the guidelines. At the primary health care centre in 2018, we found that all mothers were diagnosed and treated, as recommended by the national guideline.

Interpretation

The national guideline has had a positive impact by improving early diagnosis and treatment of prenatal toxoplasmosis and reducing severe forms, as observed at the referral centre.

Funding

Colombian Ministry of Science.

Association between lymphadenopathy after toxoplasmosis seroconversion in pregnancy and risk of congenital infection

The aim of the study was to describe the pregnancy outcome of a large cohort of women with toxoplasmosis seroconversion in pregnancy and to investigate the relation between maternal lymphadenopathy and risk of congenital toxoplasmosis (CT). This was a retrospective study involving women with confirmed toxoplasmosis seroconversion in pregnancy between 2001 and 2017. Women were clinically evaluated for lymphadenopathy and classified as follows: lymphadenopathy absent (L-) or lymphadenopathy present (L+). The mothers were treated and followed-up according to local protocol, and neonates were monitored at least for 1 year in order to diagnose CT. A total of 218 women (one twin pregnancy) were included in the analysis. Pregnancy outcome was as follows: 149 (68%) of children not infected, 62 (28.3%) infected, 4 (1.8%) first trimester termination of pregnancy, 2 (0.9%) first trimester miscarriages, and 3 (1.4%) stillbirths (of which one already counted in the infected cohort). 13.8% of women were L+ , and they were nearly three times more likely to have a child with CT compared to L- women (aOR, 2.90; 95%CI, 1.28-6.58). Moreover, the result was still statistically significant when the analysis was restricted to 81 children whose mothers were clinically examined and received treatment within 5 weeks from estimated time of infection. In conclusion, there is a positive association between L+ status in pregnant women, and risk of CT also confirmed when restricting the analysis to women with early diagnosis of seroconversion and treatment. This data could be very useful in counselling pregnant women with toxoplasmosis seroconversion and lead to direct a more specific therapeutic and diagnostic protocol.

[Toxoplasmosis in pregnancy: Practical Management]

The burden of congenital toxoplasmosis has become small in France today, in particular as a result of timely therapy for pregnant women, fetuses and newborns. Thus, the French screening and prevention program has been evaluated and recently confirmed despite a decline over time in the incidence of toxoplasmosis. Serological diagnosis of maternal seroconversion is usually simple but can be difficult when the first trimester test shows the presence of IgM, requiring referral to an expert laboratory. Woman with confirmed seroconversion should be referred quickly to an expert center, which will decide with her on treatment and antenatal diagnosis. Although the level of proof is moderate, there is a body of evidence in favor of active prophylactic prenatal treatment started as early as possible (ideally within 3 weeks of seroconversion) to reduce the risk of maternal-fetal transmission, as well as symptoms in children. The recommended therapies to prevent maternal-fetal transmission are: (1) spiramycin in case of maternal infection before 14 gestational weeks; (2) pyrimethamine and sulfadiazine (P-S) with folinic acid in case of maternal infection at 14 WG or more. Amniocentesis is recommended to guide prenatal and neonatal care. If fetal infection is diagnosed by PCR on amniotic fluid, therapy with P-S should be initiated as early as possible or continued in order reduce the risk of damage to the brain or eyes. Further research is required to validate new approaches to preventing congenital toxoplasmosis.

Seroprevalence of Toxoplasma gondii infection among women of childbearing age in an endemic region of Romania, 2016-2018

Toxoplasmosis is an important worldwide zoonosis caused by the protozoan parasite Toxoplasma gondii. This parasitic infection is often asymptomatic in immunocompetent people. However, if the infection occurs in pregnant women, it can have serious consequences for the foetus. In this study, we evaluated the seroprevalence of T. gondii in women of childbearing age in Arad County, Western Romania. Serum samples from 2626 women were analysed using a Siemens ADVIA Centaur XP Immunoassay System. Toxoplasma gondii IgG antibodies were demonstrated in 1081 women (41%) and prevalence tended to increase with age, from 32% in women aged 15–19 years to 62% in women aged 40–45 years. There was a higher prevalence in rural areas (46%) than in urban areas (36%). This study provides new data on T. gondii seroprevalence in women of childbearing age from Western Romania.