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Lipsitt A, Hijano DR, Ferrolino JA, Dallas R, Sharma A, Maron G. Variance in Pneumocystis jirovecii prophylaxis practice for pediatric patients undergoing hematopoietic cell transplantation. Pediatr Blood Cancer 2024; 71:e31201. [PMID: 39010649 DOI: 10.1002/pbc.31201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Revised: 06/17/2024] [Accepted: 07/03/2024] [Indexed: 07/17/2024]
Abstract
Pneumocystis jirovecii pneumonia (PJP) in hematopoietic cell transplant (HCT) recipients can be prevented by efficient prophylaxis. We surveyed HCT centers in North America to assess their PJP prophylaxis practices. Most institutions used intravenous (IV) pentamidine (29.6%) or inhaled pentamidine (14.8%); 37% institutions changed from trimethoprim/sulfamethoxazole (TMP-SMX) to another medication after conditioning; and 44% administered no PJP prophylaxis during the pre-engraftment period. Most institutions avoided using TMP-SMX during the pre-engraftment period, mainly because of concerns about myelotoxicity, despite this being the preferred PJP prophylaxis agent. There is a need to evaluate the effects of TMP-SMX on engraftment.
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Affiliation(s)
- Amanda Lipsitt
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Diego R Hijano
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Jose A Ferrolino
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Ronald Dallas
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Akshay Sharma
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Gabriela Maron
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
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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: 2] [Impact Index Per Article: 2.0] [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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Heald-Sargent T, Michaels MG, Ardura MI. Pre-Transplantation Strategies for Infectious Disease Mitigation and Prevention. J Pediatric Infect Dis Soc 2024; 13:S3-S13. [PMID: 38417081 DOI: 10.1093/jpids/piad075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 09/22/2023] [Indexed: 03/01/2024]
Abstract
Pediatric Infectious Disease (ID) clinicians play a critical role in helping prevent and mitigate infectious risks in children peri- and post-transplantation. Prevention starts during the pre-transplant evaluation and persists throughout the solid organ transplant and hematopoietic cell transplant continuum. The pre-transplant evaluation is an opportunity to screen for latent infections, plan preventative strategies, optimize immunizations, and discuss risk mitigation practices. An ideal pre-transplant evaluation establishes a relationship with the family that further promotes post-transplant infectious risk reduction. This manuscript builds on shared pediatric ID prevention strategies, introduces updated ID testing recommendations for transplant donors/candidates, highlights emerging data, and identifies ongoing knowledge gaps that are potential areas of research.
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Affiliation(s)
- Taylor Heald-Sargent
- Department of Pediatrics, Division of Infectious Diseases, Northwestern University, Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois, USA
| | - Marian G Michaels
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Monica I Ardura
- Division of Pediatric Infectious Diseases & Host Defense Program, Nationwide Children's Hospital and Department of Pediatrics, The Ohio University College of Medicine, Columbus, Ohio, USA
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Lv Q, Cao Y, Wang J, Meng L, Wang G. Metagenomic Next-generation Sequencing May be a Tool for Timely Diagnosis of Seronegative and Primary Toxoplasma Infection After Allogeneic Hematopoietic Stem Cell Transplantation: A Case Report and Literature Review. Pediatr Infect Dis J 2024; 43:155-159. [PMID: 38190489 DOI: 10.1097/inf.0000000000004170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
We report a case of Toxoplasma gondii ( T. gondii ) antibody seronegativity in a 14-year-old boy with a primary infection of T. gondii after allogeneic hematopoietic stem cell transplantation for acute T-cell lymphoblastic leukemia who was rapidly diagnosed through metagenomic next-generation sequencing of peripheral blood as well as clinical manifestations. He was successfully cured with timely administration of trimethoprim-sulfamethoxazole due to early diagnosis.
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Affiliation(s)
- Qiuxia Lv
- From the Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
- Department of Hematology, The Peoples Hospital of Guangxi Zhuang Autonomous Region, Guangxi Academy of Medical Sciences, Nanning, People's Republic of China
| | - Yang Cao
- From the Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Jue Wang
- From the Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Li Meng
- From the Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Gaoxiang Wang
- From the Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
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Caceres A, Caceres-Alan A, Caceres-Alan T. Toxoplasma gondii infections in pediatric neurosurgery. Childs Nerv Syst 2024; 40:295-301. [PMID: 36943435 DOI: 10.1007/s00381-023-05915-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 03/12/2023] [Indexed: 03/23/2023]
Abstract
Toxoplasma gondii is a parasite that is estimated to infect one-third of the world's population. It is acquired by ingesting contaminated water and food specially undercooked meat, contact with domestic or wild feline feces, and during pregnancy by transplacental transmission.Immunocompetent hosts are usually asymptomatic, and infection will be self-limited, while those patients whose immune system is debilitated by HIV infection, immunosuppressive therapy, long-term steroid treatment, and fetuses infected during gestation will show evidence of systemic activity which is more severe in the central nervous system and eyes due to insufficient immune response caused by their respective blood barriers. Congenital toxoplasmosis has an estimated incidence of 8% in mothers who were seronegative at the beginning of their pregnancy. Infection in the first trimester may result in spontaneous abortion or stillbirth; however, it is estimated that the highest risk for vertical transmission is during the second and third trimesters when blood flow and placenta thickness favor parasitic transmission.Congenital toxoplasmosis can be detected with periodic surveillance in endemic areas, and with appropriate treatment, the risk of vertical transmission can be reduced, and the severity of the disease can be reversed in infected fetuses.While most infected newborns will show no evidence of the disease, those who suffer active intrauterine complications will present with cerebral calcifications in 8-12% of cases, hydrocephalus in 4-30%, and chorioretinitis in 12-15%. Also, seizure disorders, spasticity, and varying degrees of neurocognitive deficits can be found in 12%.Four distinct patterns of hydrocephalus have been described: aqueductal stenosis with lateral and third ventricle dilatation, periforaminal calcifications leading to foramen of Monro stenosis with associated asymmetrical ventricle dilatation, a mix of aqueductal and foramen of Monro stenosis, and overt hydrocephalus without clear evidence of obstruction with predominant dilatation of occipital horns (colpocephaly).While all patients diagnosed with congenital toxoplasmosis should undergo pharmacological treatment, those presenting with hydrocephalus have traditionally been managed with CSF shunting; however, there are reports of at least 50% success when selected cases are treated with endoscopic third ventriculostomy. Successful hydrocephalus management with appropriate treatment leads to better intellectual outcomes.
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Affiliation(s)
- Adrian Caceres
- Pediatric Neurosurgery Department, Hospital Nacional de Niños "Dr. Carlos Sáenz Herrera", CCSS, San José, Costa Rica.
| | - Ariadnna Caceres-Alan
- Pediatric Neurosurgery Department, Hospital Nacional de Niños "Dr. Carlos Sáenz Herrera", CCSS, San José, Costa Rica
- Universidad de Ciencias Médicas, UCIMED, San José, Costa Rica
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Cunningham KT, Mills KHG. Modulation of haematopoiesis by protozoal and helminth parasites. Parasite Immunol 2023; 45:e12975. [PMID: 36797216 PMCID: PMC10909493 DOI: 10.1111/pim.12975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 02/07/2023] [Accepted: 02/13/2023] [Indexed: 02/18/2023]
Abstract
During inflammation, haematopoietic stem cells (HSCs) in the bone marrow (BM) and periphery rapidly expand and preferentially differentiate into myeloid cells that mediate innate immune responses. HSCs can be directed into quiescence or differentiation by sensing alterations to the haematopoietic niche, including cytokines, chemokines, and pathogen-derived products. Most studies attempting to identify the mechanisms of haematopoiesis have focused on bacterial and viral infections. From intracellular protozoan infections to large multicellular worms, parasites are a global health burden and represent major immunological challenges that remain poorly defined in the context of haematopoiesis. Immune responses to parasites vary drastically, and parasites have developed sophisticated immunomodulatory mechanisms that allow development of chronic infections. Recent advances in imaging, genomic sequencing, and mouse models have shed new light on how parasites induce unique forms of emergency haematopoiesis. In addition, parasites can modify the haematopoiesis in the BM and periphery to improve their survival in the host. Parasites can also induce long-lasting modifications to HSCs, altering future immune responses to infection, inflammation or transplantation, a term sometimes referred to as central trained immunity. In this review, we highlight the current understanding of parasite-induced haematopoiesis and how parasites target this process to promote chronic infections.
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Affiliation(s)
- Kyle T. Cunningham
- Wellcome Centre for Integrative ParasitologyInstitute of Infection and Immunity, University of GlasgowGlasgowUK
| | - Kingston H. G. Mills
- Immune Regulation Research GroupTrinity Biomedical Sciences Institute, Trinity College DublinDublinIreland
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Haque E, Muhsen IN, Rasheed W, Fakih RE, Aljurf M. Parasitic infections in hematopoietic stem cell transplant recipients. Transpl Infect Dis 2023; 25 Suppl 1:e14160. [PMID: 37793057 DOI: 10.1111/tid.14160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 09/16/2023] [Indexed: 10/06/2023]
Abstract
INTRODUCTION Hematopoietic stem cell transplantation (HSCT) is a vital treatment for various hematological disorders. However, HSCT recipients face increased risks of infectious complications due to immunosuppression. Parasitic infections are a significant concern in this vulnerable population and can lead to substantial morbidity and mortality. This review examines parasitic infections in HSCT recipients, focusing on major infections affecting different organ systems, including intestinal parasites (Giardia spp., Entamoeba histolytica, and Cryptosporidium spp.), hematologic parasites (Plasmodium spp. and Babesia spp.), and tissue/visceral parasites (Toxoplasma gondii, Leishmania spp., and Trypanosoma cruzi). METHODS A systematic search of relevant literature was conducted and included studies up to August 2023. Databases included PubMed, Google Scholar, were queried using specific keywords related to parasitic infections in HSCT patients. The epidemiology, risk factors, clinical presentation, diagnostic methods, and treatment approaches for each infection were evaluated. RESULTS AND CONCLUSION Knowing the epidemiology, risk factors, and clinical presentations are crucial for timely intervention and successful management. By emphasizing early detection, effective therapies, and the unique challenges posed by each of these infections, this review highlights the importance of tailored strategies for HSCT recipients. Future research can further refine management protocols to enhance care and outcomes for these patients.
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Affiliation(s)
- Emaan Haque
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Ibrahim N Muhsen
- Department of Medicine, Section of Hematology and Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - Walid Rasheed
- Department of Adult Hematology and Stem Cell Transplant, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Riad El Fakih
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
- Department of Adult Hematology and Stem Cell Transplant, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mahmoud Aljurf
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
- Department of Adult Hematology and Stem Cell Transplant, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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Contopoulos‐Ioannidis DG, Gianniki M, Ai‐Nhi Truong A, Montoya JG. Toxoplasmosis and Schizophrenia: A Systematic Review and Meta‐Analysis of Prevalence and Associations and Future Directions. PSYCHIATRIC RESEARCH AND CLINICAL PRACTICE 2022; 4:48-60. [PMID: 36254187 PMCID: PMC9558922 DOI: 10.1176/appi.prcp.20210041] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 02/22/2022] [Accepted: 02/23/2022] [Indexed: 12/15/2022] Open
Affiliation(s)
- Despina G. Contopoulos‐Ioannidis
- Department of Pediatrics, Division of Infectious Diseases, Stanford University School of Medicine, Stanford, California, USA (D. G. Contopoulos‐Ioannidis); Department of Pediatrics, University Hospital, Athens, Greece (M. Gianniki); Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, California, USA (A. Ai‐Nhi Truong); Dr. Jack S. Remington Laboratory for Specialty Diagnostics, National Reference Center for the Study and Diagnosis of Toxoplasmosis Palo Alto Medical
| | - Maria Gianniki
- Department of Pediatrics, Division of Infectious Diseases, Stanford University School of Medicine, Stanford, California, USA (D. G. Contopoulos‐Ioannidis); Department of Pediatrics, University Hospital, Athens, Greece (M. Gianniki); Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, California, USA (A. Ai‐Nhi Truong); Dr. Jack S. Remington Laboratory for Specialty Diagnostics, National Reference Center for the Study and Diagnosis of Toxoplasmosis Palo Alto Medical
| | - Angeline Ai‐Nhi Truong
- Department of Pediatrics, Division of Infectious Diseases, Stanford University School of Medicine, Stanford, California, USA (D. G. Contopoulos‐Ioannidis); Department of Pediatrics, University Hospital, Athens, Greece (M. Gianniki); Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, California, USA (A. Ai‐Nhi Truong); Dr. Jack S. Remington Laboratory for Specialty Diagnostics, National Reference Center for the Study and Diagnosis of Toxoplasmosis Palo Alto Medical
| | - Jose G. Montoya
- Department of Pediatrics, Division of Infectious Diseases, Stanford University School of Medicine, Stanford, California, USA (D. G. Contopoulos‐Ioannidis); Department of Pediatrics, University Hospital, Athens, Greece (M. Gianniki); Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, California, USA (A. Ai‐Nhi Truong); Dr. Jack S. Remington Laboratory for Specialty Diagnostics, National Reference Center for the Study and Diagnosis of Toxoplasmosis Palo Alto Medical
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Toxoplasmosis Among 38,751 Hematopoietic Stem Cell Transplant Recipients: A Systematic Review of Disease Prevalence and a Compilation of Imaging and Autopsy Findings. Transplantation 2021; 105:e375-e386. [PMID: 33654004 DOI: 10.1097/tp.0000000000003662] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Toxoplasmosis in hematopoietic stem cell transplant-recipients (HSCT) can be life threatening if not promptly diagnosed and treated. METHODS We performed a systematic review (PubMed last search 03/29/2020) of toxoplasmosis among HSCT-recipients and calculated the toxoplasmosis prevalence across studies. We also created a compilation list of brain imaging, chest imaging and autopsy findings of toxoplasmosis among HSCT-recipients. RESULTS We identified 46 eligible studies (47 datasets) with 399 toxoplasmosis cases among 38751 HSCT-recipients. There was large heterogeneity in the reported toxoplasmosis prevalence across studies, thus formal meta-analysis was not attempted. The median toxoplasmosis prevalence among 38751 HSCT-recipients was 2.14% (range 0-66.67%). Data on toxoplasmosis among at-risk R+HSCT-recipients were more limited (25 studies; 2404 R+HSCT-recipients [6.2% of all HSCT-recipients]) although the median number of R+HSCT-recipients was 56.79% across all HSCT-recipients. Median toxoplasmosis prevalence across studies among 2404 R+HSCT was 7.51% (range 0-80%) vs 0% (range 0-1.23%) among 7438 R-HSCT. There were limited data to allow meaningful analyses of toxoplasmosis prevalence according to prophylaxis-status of R+HSCT-recipients. CONCLUSION Toxoplasmosis prevalence among HSCT-recipients is underestimated. The majority of studies report toxoplasmosis prevalence among all HSCT-recipients rather than only among the at-risk R+HSCT-recipients. In fact, the median toxoplasmosis prevalence among all R+/R- HSCT-recipients is 3.5-fold lower compared to the prevalence among only the at-risk R+HSCT-recipients and the median prevalence among R+HSCT-recipients is 7.51-fold higher than among R-HSCT-recipients. The imaging findings of toxoplasmosis among HSCT-recipients can be atypical. High-index of suspicion is needed in R+HSCT-recipients with fever, pneumonia or encephalitis.
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