Toxoplasmic encephalitis in AIDS-patients before and after the introduction of highly active antiretroviral therapy (HAART)

Toxoplasmosis Encephalitis: A Cross-Sectional Analysis at a U.S. Safety-Net Hospital in the Late cART Era

Despite decreasing incidence of toxoplasmosis encephalitis(TE) among people living with HIV(PLWH) in the late antiretroviral era, U.S. safety-net hospitals still see significant numbers of admissions for TE. Little is known about this population, their healthcare utilization and long-term outcomes. We conducted an 8-year retrospective review of PLWH with TE at a safety-net hospital. Demographics, clinical characteristics, treatments, readmissions, and outcomes were collected. We used chi-squared test to evaluate 6-month all-cause readmission and demographic/clinical characteristics. Of 38 patients identified, 79% and 40% had a new diagnosis of TE and HIV respectively. 59% had 6-month all-cause readmission. Social factors were associated with readmission (uninsured (p = 0.036), Spanish as primary language (p = 0.017), non-adherence (p = 0.030)) and not markers of clinical severity (ICU admission, steroid-use, concomitant infections, therapeutic adverse events). Despite high readmission rates, at follow-up, 60% had a complete response, 30% had a partial response. Improving TE outcomes requires focus on culturally competent, coordinated care.

Toxoplasma gondii in South America: a differentiated pattern of spread, population structure and clinical manifestations

Toxoplasma gondii is an obligate intracellular parasite belonging to the phylum Apicomplexa. It has a worldwide distribution and can infect a wide variety of intermediate hosts, including humans. In South America, toxoplasmosis shows high health impacts, and the incidence of the disease is frequently reported and more severe than in other regions, such as Europe. Although most T. gondii infections are asymptomatic, severe manifestations can occur in cases of congenital toxoplasmosis and immunocompromised individuals. In South America, the ocular disease in immunocompetent individuals is also frequently reported. Treatment for any clinical manifestation of toxoplasmosis consists of the combination of sulfadiazine (SDZ) and pyrimethamine (PYR). However, failures in the treatment of toxoplasmosis have been reported, especially in South America, suggesting the acquisition of resistance against SDZ and PYR. Another paradigm present in the literature is that once infected with T. gondii, the host is immunologically protected from further reinfections. However, some studies indicate cases of congenital transmission of T. gondii from immunocompetent pregnant women with chronic infection, suggesting the possibility of reinfection in humans. Thus, in this review, we will cover several aspects of South American T. gondii isolates, such as genetic characterization, disease manifestation, host reinfection and drug resistance.

Effect of combination antiretroviral therapy on the clinical manifestations, radiological characteristics, and disease severity of HIV-associated Talaromyces marneffei infection

The objective of this study was to evaluate whether combination antiretroviral therapy (cART) has an effect on the clinical manifestations, radiological characteristics, and disease severity of human immunodeficiency virus (HIV)-associated Talaromyces marneffei infection. The clinical manifestations, chest computed tomography (CT) images, and disease severity were compared between 14 patients with culture-confirmed T. marneffei infections who received cART and 38 patients who did not receive cART. Clinical manifestations included high fever (>38°C), cough, shortness of breath, chills, and skin rash. Chest CT scans were evaluated for the presence of ground-glass opacities, consolidation, miliary nodules, nodules, masses, cavitation, pericardial effusion, pleural effusion, mediastinal lymphadenitis, and the distribution of parenchymal abnormalities. Disease severity was estimated by clinical manifestations and chest CT findings. Fever (>38°C), cough, shortness of breath, and chills were significantly less frequent in patients who received cART than in those who did not receive cART (P < 0.05). The frequencies of miliary nodules, mediastinal lymphadenitis, and the proportion of diffuse lesions were significantly lower in patients who received cART than in those who did not receive cART (P < 0.05). The disease severity was significantly decreased in patients who received cART compared with patients who did not receive cART (P < 0.001). T. marneffei-infected patients who received cART had fewer clinical manifestations and decreased disease severity compared with those who did not receive this treatment. The use of cART is associated with modified chest CT characteristics in HIV-associated T. marneffei infections.

Epidemiology, Pathophysiology, Diagnosis, and Management of Cerebral Toxoplasmosis

Toxoplasma gondii is known to infect a considerable number of mammalian and avian species and a substantial proportion of the world's human population. The parasite has an impressive ability to disseminate within the host's body and employs various tactics to overcome the highly regulatory blood-brain barrier and reside in the brain. In healthy individuals, T. gondii infection is largely tolerated without any obvious ill effects. However, primary infection in immunosuppressed patients can result in acute cerebral or systemic disease, and reactivation of latent tissue cysts can lead to a deadly outcome. It is imperative that treatment of life-threatening toxoplasmic encephalitis is timely and effective. Several therapeutic and prophylactic regimens have been used in clinical practice. Current approaches can control infection caused by the invasive and highly proliferative tachyzoites but cannot eliminate the dormant tissue cysts. Adverse events and other limitations are associated with the standard pyrimethamine-based therapy, and effective vaccines are unavailable. In this review, the epidemiology, economic impact, pathophysiology, diagnosis, and management of cerebral toxoplasmosis are discussed, and critical areas for future research are highlighted.

The Neurotropic Parasite Toxoplasma gondii Induces Astrocyte Polarization Through NFκB Pathway

Background:Toxoplasma gondii is a protozoan parasite that chronically infects nearly one-third of the world's human population. In immunosuppressed individuals and fetus, infection with T. gondii contributes to a series of devastating conditions, including toxoplasmic encephalitis (TE), which is characterized by neuron damage in the central nervous system (CNS). Astrocyte polarization is currently found in some neurodegenerative diseases, and A1 subtype of astrocyte leads to neuron apoptosis. However, little information has been available on the role of astrocyte polarization in TE.

Methods: In the present study, we established a mouse model to study TE and detected A1 astrocyte in the brains of mice with TE. Expression level of A1 astrocyte-specific marker C3 was evaluated using indirect fluorescent assay (IFA) and Western blotting. Primary mouse astrocytes were incubated with different concentrations of T. gondii excreted-secreted antigens (TgESAs) in vitro. Expression level of C3 and A1 astrocyte-specific transcription levels were assessed using Western blotting and qRT-PCR, respectively. Bay11-7082 was used to study nuclear factor (NF) κB pathway in TgESA-induced astrocyte polarization.

Results: In mice with TE, the proportion of A1 astrocyte (GFAP⁺C3⁺) increased significantly. The results of in vitro study showed that TgESAs induced astrocyte polarization to A1 subtype. Blocking of NFκB pathway by Bay11-7082 inhibited TgESA-induced astrocyte polarization.

Conclusions: Our preliminary study showed the involvement of A1 astrocyte in the process of TE in mice, and TgESAs could trigger astrocyte to polarize to A1 subtype. These findings suggest a new mechanism underlying the neuropathogenesis induced by T. gondii infection.

Central nervous system infection with Toxoplasma gondii

Central nervous system infection by Toxoplasma gondii, or Toxoplasma encephalitis, is the most common cause of brain mass lesions in human immunodeficiency virus (HIV)-infected patients. It usually presents as one or more brain abscesses, but it can also cause a diffuse encephalitis or ventriculitis. Individuals who are Toxoplasma immunoglobulin G-seropositive, who have peripheral blood CD4+ T-cell concentrations below 200/μL, are not on antiretroviral therapy, and are not taking trimethoprim-sulfamethoxazole to prevent Pneumocystis pneumonia, are at particular risk for Toxoplasma encephalitis. Neuroimaging typically shows round, isodense or hyperdense lesions in the hemispheric gray-white junction, deep white matter, or basal ganglia that enhance with contrast in a ring, nodular, or homogeneous pattern. In appropriate patients, response to an empiric treatment trial can establish the diagnosis. Immune reconstitution inflammatory syndrome is uncommon in HIV-infected patients treated for Toxoplasma encephalitis and combination antiretroviral therapy is an integral part of toxoplasmosis treatment.

Inhibition of Calcium Dependent Protein Kinase 1 (CDPK1) by Pyrazolopyrimidine Analogs Decreases Establishment and Reoccurrence of Central Nervous System Disease by Toxoplasma gondii

Calcium dependent protein kinase 1 (CDPK1) is an essential enzyme in the opportunistic pathogen Toxoplasma gondii. CDPK1 controls multiple processes that are critical to the intracellular replicative cycle of T. gondii including secretion of adhesins, motility, invasion, and egress. Remarkably, CDPK1 contains a small glycine gatekeeper residue in the ATP binding pocket making it sensitive to ATP-competitive inhibitors with bulky substituents that complement this expanded binding pocket. Here we explored structure-activity relationships of a series of pyrazolopyrimidine inhibitors of CDPK1 with the goal of increasing selectivity over host enzymes, improving antiparasite potency, and improving metabolic stability. The resulting lead compound 24 exhibited excellent enzyme inhibition and selectivity for CDPK1 and potently inhibited parasite growth in vitro. Compound 24 was also effective at treating acute toxoplasmosis in the mouse, reducing dissemination to the central nervous system, and decreasing reactivation of chronic infection in severely immunocompromised mice. These findings provide proof of concept for the development of small molecule inhibitors of CDPK1 for treatment of CNS toxoplasmosis.

Incidence, presentation and outcome of toxoplasmosis in HIV infected in the combination antiretroviral therapy era

BACKGROUND

HIV-associated incidence and prognosis of cerebral toxoplasmosis (CTX) is not well established during later years.

METHODS

From the Danish HIV Cohort Study, we identified 6325 HIV-infected individuals. We assessed incidence, mortality, predictive and prognostic factors of CTX during the pre-combination antiretroviral therapy (pre-cART; 1995-1996) and cART-era (1997-2014). Adjusted incidence rate ratios (aIRR), mortality rate ratios (aMRR) and 95% confidence intervals (CI) were assessed using Poisson regression analysis.

RESULTS

CTX IR was 1.17/1000 PYR (95% CI 0.93-1.47). We observed no change in CTX-risk in the first year after HIV-diagnosis, but a substantial reduction in mortality in the first 3 months after CTX diagnosis when comparing the cART-era to the pre-cART-era; {(aIRR: 0.79; 95% CI: 0.37-1.72) (aMRR: 0.15; 95% CI: 0.06-0.38)}. For individuals surviving the first year after HIV-diagnosis or the first 3 months after CTX-diagnosis, IRR and MRR had declined to minimal levels {(aIRR: 0.06; 95% CI: 0.03-0.10); (aMRR: 0.02; 95% CI: 0.01-0.05)}. Three years after CTX-diagnosis 30% of the patients still had neurological deficits.

CONCLUSION

Although, CTX remains an important cause of morbidity and mortality in the cART-era, with high prevalence of neurological sequelae, incidence and mortality has largely declined, especially among those surviving the first year after diagnosis.

Relevance of and New Developments in Serology for Toxoplasmosis

Toxoplasmosis is a widespread parasitic disease caused by the intracellular parasite Toxoplasma gondii with a wide spectrum of clinical outcomes. The biological diagnosis of toxoplasmosis is often difficult and of paramount importance because clinical features are not sufficient to discriminate between toxoplasmosis and other illnesses. Serological tests are the most widely used biological tools for the diagnosis of toxoplasmosis worldwide. This review focuses on the crucial role of serology in providing answers to the most important questions related to the epidemiology and diagnosis of toxoplasmosis in human pathology. Notwithstanding their undeniable importance, serological tools need to be continuously improved and the interpretation of the ensuing results remains complex in many circumstances.

Neurons are the Primary Target Cell for the Brain-Tropic Intracellular Parasite Toxoplasma gondii

Toxoplasma gondii, a common brain-tropic parasite, is capable of infecting most nucleated cells, including astrocytes and neurons, in vitro. Yet, in vivo, Toxoplasma is primarily found in neurons. In vitro data showing that interferon-γ-stimulated astrocytes, but not neurons, clear intracellular parasites suggest that neurons alone are persistently infected in vivo because they lack the ability to clear intracellular parasites. Here we test this theory by using a novel Toxoplasma-mouse model capable of marking and tracking host cells that directly interact with parasites, even if the interaction is transient. Remarkably, we find that Toxoplasma shows a strong predilection for interacting with neurons throughout CNS infection. This predilection remains in the setting of IFN-γ depletion; infection with parasites resistant to the major mechanism by which murine astrocytes clear parasites; or when directly injecting parasites into the brain. These findings, in combination with prior work, strongly suggest that neurons are not incidentally infected, but rather they are Toxoplasma's primary in vivo target.

Toxoplasma gondii: the effect of fluconazole combined with sulfadiazine and pyrimethamine against acute toxoplasmosis in murine model

Toxoplasma gondii is an important opportunistic pathogen for immunocompromised patients and responsible for toxoplasmic encephalitis, which is often lethal. Treatment for this infection is limited to a restricted therapeutic arsenal. In this work we tested the combination of fluconazole with the current treatment for acute toxoplasmosis on the murine model in vivo. Different experimental groups were treated with combinations of sulfadiazine plus pyrimethamine with fluconazole and pyrimethamine with fluconazole. Fluconazole is an important antifungal triazole used against others CNS related opportunistic pathogens such as Cryptococcus neoformans and Candida spp. The combinations of fluconazole plus sulfadiazine and pyrimethamine or fluconazole plus pyrimethamine were remarkably effective against T. gondii in vivo. The 10-day treatment with 10mg/kg/day of fluconazole combined with 40/1mg/kg/day sulfadiazine and pyrimethamine resulted in 93% survival of CF1 mice acutely infected with the highly virulent T. gondii RH strain, versus 36% of mice treated with just sulfadiazine and pyrimethamine. Combinations of fluconazole with lower doses of sulfadiazine and pyrimethamine or with just pyrimethamine were also efficient in reducing the mortality of mice compared with the treatment without fluconazole. The results obtained are promising for the treatment of human toxoplasmosis and point to the need to extend these studies to other murine models.