Vertical transmission of toxoplasma by human immunodeficiency virus-infected women

A novel DNA vaccine encoding the SRS13 protein administered by electroporation confers protection against chronic toxoplasmosis

Toxoplasma gondii is an obligate intracellular parasite that can infect a variety of mammals including humans and causes toxoplasmosis. Unfortunately, a protective and safe vaccine against toxoplasmosis hasn't been developed yet. In this study, we developed a DNA vaccine encoding the SRS13 protein and immunized BALB/c mice thrice with pVAX1-SRS13 through the intramuscular route (IM) or intradermally using an electroporation device (ID + EP). The immunogenicity of pVAX1-SRS13 was analyzed by ELISA, Western blot, cytokine ELISA, and flow cytometry. The protective efficacy of the pVAX1-SRS13 was investigated by challenging mice orally with T. gondii PRU strain tissue cysts. The results revealed that pVAX1-SRS13 administered through IM or ID + EP routes induced high level of anti-SRS13 IgG antibody responses (P = 0.0037 and P < 0.0001). The IFN-γ level elicited by the pVAX1-SRS13 (ID + EP) was significantly higher compared to the control group (P = 0.00159). In mice administered with pVAX1-SRS13 (ID + EP), CD8+ cells secreting IFN-γ was significantly higher compared to pVAX1-SRS13 (IM) (P = 0.0035) and the control group (P = 0.0068). Mice vaccinated with the SRS13 DNA vaccine did not induce significant IL-4 level. Moreover, a significant reduction in the number of tissue cysts and the load of T. gondii DNA was detected in brains of mice administered with pVAX1-SRS13 through ID + EP and IM routes compared to controls. In conclusion, the SRS13 DNA vaccine was found to be highly immunogenic and confers strong protection against chronic toxoplasmosis.

Serological Responses to Toxoplasma gondii and Matrix Antigen 1 Predict the Risk of Subsequent Toxoplasmic Encephalitis in People Living with HIV

BACKGROUND

Clinically useful predictors for fatal toxoplasmosis are lacking. We investigated the value of serological assays for antibodies to whole Toxoplasma antigens and to peptide antigens of the Toxoplasma cyst protein MAG1, for predicting incident toxoplasmic encephalitis (TE) in people living with HIV (PLWH).

METHODS

We performed a nested case control study, conducted within the Multicenter AIDS Cohort Study (MACS), using serum samples obtained 2 years prior to diagnosis of TE from 28 cases, and 37 HIV disease-matched Toxoplasma seropositive controls at matched time-points. Sera were tested for Toxoplasma antibodies using a commercial assay and for antibodies to MAG1_4.2 and MAG1_5.2 peptides in ELISA.

RESULTS

Two years prior to clinical diagnosis, 68% of TE cases were MAG1_4.2 seropositive compared with 16% of controls (OR 25.0, 95% CI 3.14-199.18). Corresponding results for MAG1_5.2 seropositivity were 36% and 14% (OR 3.6, 95% CI 0.95-13.42). Higher levels of antibody to MAG1_4.2 (OR 18.5 per doubling of the OD value, 95% CI 1.41-242) and to Toxoplasma (OR 2.91 for each OD unit increase, 95% CI 1.48-5.72) were also associated with the risk of TE. When seropositivity was defined as the presence of MAG1 antibody or relatively high levels of Toxoplasma antibody, the sensitivity was 89% and specificity was 68% for subsequent TE.

CONCLUSIONS

Antibodies to MAG1 showed predictive value on the occurrence of TE in PLWH, and the predictive performance was further improved by adding the levels of Toxoplasma antibody. These measures could be clinically useful for predicting subsequent diseases in multiple at-risk populations.

Toxoplasmosis in pregnancy

Toxoplasmosis is one of the common chronic infections caused by the parasite Toxoplasma gondii. Even though its infection in healthy non-pregnant women is self-limited and largely asymptomatic, the main concern is the risk to the fetus by vertical transmission in pregnancy. Congenital toxoplasmosis can result in permanent neurological damage and even serious morbidity such as blindness. Screening programs are implemented in various countries depending on the prevalence and virulence of the parasite in the respective regions. Upon diagnosis of infection, appropriate antibiotic therapy should be initiated as it has been proven to reduce the risk of fetal transmission. Primary prevention remains the key intervention to avoid the infection and hence patient education is an important aspect of the management.

An updated literature review on maternal-fetal and reproductive disorders of Toxoplasma gondii infection

BACKGROUND

Toxoplasma gondii infection is one of the most prevalent infectious disease with worldwide distribution. Congenital toxoplasmosis is annually responsible for 1.20 million disability-adjusted life years around the world, but often it is overlooked many countries.

METHODS

We performed an updated review to summarize the current researches on fetal, neonatal and maternal consequences of T. gondii infection and also adverse effects of toxoplasmosis on women reproductive organs.

RESULTS

T. gondii infection could be cause of several abnormalities from hydrocephalus, microcephaly, deafness, abortion and still birth in fetal to psychomotor retardation, intellectual disability, hearing loss, slower postnatal motor development during the first year of life; and chorioretinitis, cryptogenic epilepsy and autism spectrum disorders in newborns. Moreover, this infection is related with neuropsychiatric disorders such as anxiety, schizophrenia spectrum disorders, depression, decreased weight, autoimmune thyroid diseases, self-directed violence, violent suicide attempts in mothers. This literature review emphasized that toxoplasmosis could be an important neglected factor endometritis, ovarian dysfunction, impaired folliculogenesis, ovarian and uterine atrophy, decrease in reproductive organs weight and reproductive performance in women. We reviewed role of the immunological profile such as pro-infiammatory cytokines and hormonal changes as main potential mechanisms related to this infection and development of maternal-fetal and reproductive disorders.

CONCLUSION

T. gondii is associated with several brain related disorders in both mothers and newborns, and also it is cause of several abnormalities in reproductive organs. Early diagnosis and treatment of the infection could be effective to significantly improve the clinical outcome.

In vitro activity of the interaction between taxifolin (dihydroquercetin) and pyrimethamine against Toxoplasma gondii

Toxoplasmosis is one of the most neglected zoonotic foodborne parasitic diseases that cause public health and socioeconomic concern worldwide. The current drugs used for the treatment of toxoplasmosis have been identified to have clinical limitations. Hence, new drugs are urgently needed to eradicate T.gondii infections globally. Here, an in vitro anti-Toxoplasma gondii activity of taxifolin (dihydroquercetin) and dihydrofolate inhibitor (pyrimethamine) alone and in combination with a fixed concentration of pyrimethamine were investigated against the rapidly proliferating T.gondii RH strain at 48 hr using colorimetric assay. Pyrimethamine showed the highest anti-T. gondii activity with IC_50P of 0.84 μg/ml (p > .05), respectively. The combination of pyrimethamine with dihydroquercetin gave a significant inhibitory activity against tachyzoites in in vitro with IC_50p of 1.39 μg/ml (p < .05). The IC_50p ranges obtained for the individual and the combination of taxifolin with pyrimethamine inhibition of parasite growth were not cytotoxic to the infected HFF and Hek-293 cell lines used. These compounds combination should be investigated further using in vivo model of toxoplasmosis.

Toxoplasmosis seroprevalence in Iranian women and risk factors of the disease: a systematic review and meta-analysis

BACKGROUND

Toxoplasmosis is caused by an intracellular obligatory parasite, Toxoplasma gondii, and it has global distribution. The purposes of this systematic review and meta-analysis were to evaluate the seroprevalence of toxoplasmosis in Iranian pregnant women, and girls and women of childbearing age, and identify potentially preventable risk factors.

METHODS

Between November 2014 and February 2017, nine electronic databases that reported data on the T. gondii seroprevalence in Iranian women were searched. Our search resulted in 83 reports published from 1994 to 2017.

RESULTS

The results showed that the pooled estimation for the prevalence of T. gondii using a random-effect model was 43% (95% confidence interval (CI) = 38-48%) in pregnant women and 33% (95% CI = 23-43%) in girls and the childbearing age groups. There was a significant association between the T. gondii seroprevalence with age and the gestational age of conception in pregnant women and those who had contact with cats in both groups.

CONCLUSIONS

This is the first comprehensive systematic review of T. gondii infection seroprevalence in Iranian women, which showed a high prevalence of Toxoplasma infection. Around 57% of pregnant women and 67% of girls and the childbearing age groups were seronegative and thus were susceptible to infection and should be monitored.

[Good's syndrome and congenital toxoplasmosis due to maternal reactivation during pregnancy]

INTRODUCTION

Good syndrome is a rare condition in which thymoma is associated with hypogammaglobulinemia. It is characterized by an increased susceptibility to infections.

CASE REPORT

We report a woman with Good's syndrome diagnosed after severe congenital toxoplasmosis in her daughter, even though she was immunized against this infection during pregnancy.

CONCLUSION

This presentation is very unusual by its early diagnosis and to our knowledge is the first report of parasitic infection in this syndrome.

Parasites

Parasites are an important cause of human disease worldwide. The clinical severity and outcome of parasitic disease is often dependent on the immune status of the host. Specific parasitic diseases discussed in this chapter are amebiasis, giardiasis, cryptosporidiosis, cyclosporiasis, cystoisosporiasis, microsporidosis, granulomatous amebic encephalitis, toxoplasmosis, leishmaniasis, Chagas disease, malaria, babesiosis, strongyloidiasis, and scabies.

Toxoplasmosis in HIV infection: An overview

Toxoplasma gondii is an obligate intracellular protozoan parasite presenting as a zoonotic infection distributed worldwide. In HIV-positive individuals, it causes severe opportunistic infections, which is of major public health concern as it results in physical and psychological disabilities. In healthy immunocompetent individuals, it causes asymptomatic chronic persistent infections, but in immunosuppressed patients, there is reactivation of the parasite if the CD4 counts fall below 200 cells/μl. The seroprevalence rates are variable in different geographic areas. The tissue cyst or oocyst is the infective form which enters by ingestion of contaminated meat and transform into tachyzoites and disseminate into blood stream. In immunocompetent persons due to cell-mediated immunity the parasite is transformed into tissue cyst resulting in life long chronic infection. In HIV-infected people opportunistic infection by T. gondii occurs due to depletion of CD4 cells, decreased production of cytokines and interferon gamma and impaired cytotoxic T-lymphocyte activity resulting in reactivation of latent infection. The diagnosis can be done by clinical, serological, radiological, histological or molecular methods, or by the combination of these. There is various treatment regimen including acute treatment, maintenance therapy should be given as the current anti T. gondii therapy cannot eradicate tissue cysts. In HIV patients, CD4 counts <100; cotrimoxazole, alternately dapsone + pyrimethamine can be given for 6 months. Hence, early diagnosis of T. gondii antibodies is important in all HIV-positive individuals to prevent complications of cerebral toxoplasmosis.

Dual congenital transmission of Toxoplasma gondii and Sarcocystis neurona in a late-term aborted pup from a chronically infected southern sea otter (Enhydra lutris nereis)

Toxoplasma gondii and Sarcocystis neurona are protozoan parasites with terrestrial definitive hosts, and both pathogens can cause fatal disease in a wide range of marine animals. Close monitoring of threatened southern sea otters (Enhydra lutris nereis) in California allowed for the diagnosis of dual transplacental transmission of T. gondii and S. neurona in a wild female otter that was chronically infected with both parasites. Congenital infection resulted in late-term abortion due to disseminated toxoplasmosis. Toxoplasma gondii and S. neurona DNA was amplified from placental tissue culture, as well as from fetal lung tissue. Molecular characterization of T. gondii revealed a Type X genotype in isolates derived from placenta and fetal brain, as well as in all tested fetal organs (brain, lung, spleen, liver and thymus). This report provides the first evidence for transplacental transmission of T. gondii in a chronically infected wild sea otter, and the first molecular and immunohistochemical confirmation of concurrent transplacental transmission of T. gondii and S. neurona in any species. Repeated fetal and/or neonatal losses in the sea otter dam also suggested that T. gondii has the potential to reduce fecundity in chronically infected marine mammals through parasite recrudescence and repeated fetal infection.

[Severe congenital toxoplasmosis secondary to toxoplasma reactivation in an HIV-infected mother]

Congenital toxoplasmosis is a potentially serious fetal infection associated with maternal seroconversion or a reactivation of toxoplasmosis during pregnancy. We report the case of congenital toxoplasmosis with severe neurological injury with normal prenatal obstetric ultrasounds in a mother infected with HIV at the AIDS stage and previously immunized against toxoplasmosis.

Incidence of congenital toxoplasmosis among infants born to HIV-coinfected mothers: case series and literature review

INTRODUCTION

There is a paucity of data on the occurrence of congenital toxoplasmosis in children born to mothers dually infected with HIV and Toxoplasma gondii.

OBJECTIVE

To evaluate aspects of the mother-infant pairs associated with vertical transmission of toxoplasmosis in women co-infected with HIV in a referral center for perinatally acquired infections in Belo Horizonte, Brazil.

METHODS

Descriptive study of HIV vertically exposed children, with congenital toxoplasmosis, followed at a referral center (cohort/Belo Horizonte). Prenatal and post-natal variables for the mother-infant pairs were evaluated. A literature review with no filtering for time and language was performed to identify reports of congenital toxoplasmosis in HIV vertically exposed children.

RESULTS

Among 2007 HIV vertically exposed children evaluated in the period from 1998 to 2011, 10 cases of congenital toxoplasmosis were identified (incidence: 0.5%, 95% confidence interval: 0.24-0.91). In searching the literature 22 additional cases in 17 reports were found. Combining the findings of our cohort with other reported cases, 50% (16/32) of congenital toxoplasmosis in HIV vertically exposed children were from Brazil. The cases of congenital toxoplasmosis in HIV vertically exposed children identified in Brazil occurred mainly in the post-Highly Active Antiretroviral Therapy era (p=0.002) and presented a lower death rate (p=0.003) than those from other countries. In the cohort/Belo Horizonte, HIV infection was identified mainly during gestation; T. gondii vertical transmission was observed in pregnant women with CD4(+)>500 cells/mm(3) and latent toxoplasmosis. High rates of ocular lesions (87.5%) and central nervous system involvement (70%) were detected.

CONCLUSIONS

The risk of vertical transmission of T. gondii in HIV-infected women is low and has been usually associated with maternal immunosuppression and elevated viral load. However, our findings of congenital toxoplasmosis in children born to HIV-infected mothers with latent toxoplasmosis and not immunosuppressed emphasize the need for careful follow-up in these cases.

Immunopathogenesis of toxoplasmosis in pregnancy

The immunopathogenesis of toxoplasmosis during pregnancy is not completely understood. This paper will try to discuss the most frequently asked questions about the immunopathogeny of congenital toxoplasmosis: differential virulence of Toxoplasma isolates, genetic susceptibility to infection, facilitation of placental transfer, models of congenital toxoplasmosis, and transmission in seropositive hosts. Most published data suggest a role of the genetic background of the host and of the parasite. Models of congenital toxoplasmosis have been evaluated, but it appears that the conclusion drawn would be barely appropriate to understand the pathogenesis in pregnant women.

Mother-to-child transmission of human immunodeficiency virus in aten years period

Objectives

to evaluate mother-to-child transmission (MTCT) rates and related factors in HIV-infected pregnant women from a tertiary hospital between 2000 and 2009.

Subjects and method

cohort of 452 HIV-infected pregnant women and their newborns. Data was collected from recorded files and undiagnosed children were enrolled for investigation. Statistical analysis: qui-square test, Fisher exact test, Student t test, Mann-Whitney test, ANOVA, risk ratio and confidence intervals.

Results

MTCT occurred in 3.74%. The study population displayed a mean age of 27 years; 86.5% were found to have acquired HIV through sexual contact; 55% were aware of the diagnosis prior to the pregnancy; 62% were not using HAART. Mean CD4 cell-count was 474 cells/ml and 70.3% had undetectable viral loads in the third trimester. HAART included nevirapine in 35% of cases and protease inhibitors in 55%; Zidovudine monotherapy was used in 7.3%. Mean gestational age at delivery was 37.2 weeks and in 92% by caesarian section; 97.2% received intravenous zidovudine. Use of AZT to newborn occurred in 100% of them. Factors identified as associated to MTCT were: low CD4 cell counts, elevated viral loads, maternal AIDS, shorter periods receiving HAART, other conditions (anemia, IUGR (intra uterine growth restriction), oligohydramnium), coinfecctions (CMV and toxoplasmosis) and the occurrence of labor. Use of HAART for longer periods, caesarian and oral zidovudine for the newborns were associated with a decreased risk. Poor adhesion to treatment was present in 13 of the 15 cases of transmission; in 7, coinfecctions were diagnosed (CMV and toxoplasmosis).

Conclusion

Use of HAART and caesarian delivery are protective factors for mother-to-child transmission of HIV. Maternal coinfecctions and other conditions were risk factors for MTCT.

Evaluation of vertical transmission of Toxoplasma gondii in Calomys callosus model after reinfection with heterologous and virulent strain

Toxoplasma gondii is an obligate intracellular protozoan parasite that causes a variety of clinical syndromes, but the infection is severe in immunocompromised individuals and during pregnancy due to the possibility of transplacental transmission of the parasite causing congenital toxoplasmosis. Vertical transmission of the parasite usually occurs when females are primarily infected during pregnancy. Calomys callosus is resistant to T. gondii ME49 strain, which presents a moderate virulence and congenital disease occurs only during the acute phase of infection. The aim of this study was to determine whether vertical transmission occurs when females of C. callosus chronically infected with ME49 strain of T. gondii are reinfected with a highly virulent strain (RH, type I). Females were infected with cysts of the ME49 strain. On the 1st day of pregnancy, animals were reinfected with tachyzoites of the RH strain. In the 19th day of pregnancy, placentas and embryos were processed for morphological analysis, immunohistochemistry and for detection of the parasite by PCR and mouse bioassay. Morphological and immunohistochemical analyses revealed the presence of parasites only in placental tissues. Mouse bioassay results showed seroconversion only in mice that were inoculated with placental tissues. Also, T. gondii DNA was detected only in placental samples. Congenital toxoplasmosis does not occur in C. callosus females chronically infected with the moderately virulent ME49 strain of T. gondii and reinfected with the highly virulent RH strain, thus indicating that primary T. gondii infection before pregnancy leads to an effective long-term immunity preventing transplacental transmission to the fetus.

Fetal death as a result of placental immune reconstitution inflammatory syndrome

A 26-year-old woman was HIV-1 diagnosed at 11 weeks of pregnancy (CD4 = 7/mm(3), HIV-1 RNA = 108,000 copies/mL) with immunity against toxoplasmosis (Toxoplasma IgG = 1800 UI/mL). A fetal death was diagnosed 7 weeks after starting HAART (CD4 = 185/mm(3), HIV-1 RNA = 391 copies/mL) with a positive Toxoplasma PCR on fetal tissues and amniotic fluid. The absence of severe toxoplasmic foetopathy, the very exaggerated and atypical placental inflammation and the immune restoration context led to the diagnosis of placental IRIS associated with Toxoplasma gondii reactivation. This outcome remains undescribed and could represent an issue in resource-limited settings where HIV-pregnant patients are often severely immunodeficient and infected with opportunistic pathogens.

Congenital transmission of human immunodeficiency virus, cytomegalovirus, and toxoplasmosis in a premature infant

We report a preterm infant with congenital HIV-1, CMV, and toxoplasmosis coinfection, whose mother succumbed to probable cerebral toxoplasmosis. Despite repeated neuroimaging, retinal examinations and infant serologic tests, during the first 36 days of life, there was no evidence of congenital toxoplasmosis. However, subsequent tests showed cerebral calcifications, bilateral chorioretinitis, antitoxoplasma IgM antibody, and Toxoplasma gondii DNA in the cerebrospinal fluid by polymerase chain reaction.

Toxoplasmosis: A history of clinical observations

It has been 100 years since Toxoplasma gondii was initially described in Tunis by Nicolle and Manceaux (1908) in the tissues of the gundi (Ctenodoactylus gundi) and in Brazil by Splendore (1908) in the tissues of a rabbit. Toxoplasma gondii is a ubiquitous, Apicomplexan parasite of warm-blooded animals that can cause several clinical syndromes including encephalitis, chorioretinitis, congenital infection and neonatal mortality. Fifteen years after the description of T. gondii by Nicolle and Manceaux a fatal case of toxoplasmosis in a child was reported by Janků. In 1939 Wolf, Cowen and Paige were the first to conclusively identify T. gondii as a cause of human disease. This review examines the clinical manifestations of infection with T. gondii and the history of the discovery of these manifestations.

Cellular and molecular physiopathology of congenital toxoplasmosis: the dual role of IFN-gamma

Toxoplasma gondii is one of the few pathogens that can cross the placenta. Frequency and severity of transmission vary with gestational age. While the control of acquired toxoplasmosis is already well explored, the control of materno-foetal transmission of the parasite remains almost unknown. This is partly due to the lack of an animal model to study this process. This review summarises the studies which have been undertaken and shows that the mouse is a valuable model despite obvious differences to the human case. The paramount role of the cellular immune response has been shown by several experiments. However, IFN-gamma has a dual role in this process. While its beneficial effects in the control of toxoplasmosis are well known, it also seems to have transmission-enhancing effects and can also directly harm the developing foetus. The ultimate goal of these studies is to develop a vaccine which protects both mother and foetus. Therefore, it is useful to study the mechanisms of natural resistance against transmission during a secondary infection. In this setting, the process is more complicated, involving both cellular and also humoral components of the immune system. In summary, even if the whole process is far from being elucidated, important insights have been gained so far which will help us to undertake rational vaccine research.

First isolate of Toxoplasma gondii from arctic fox (Vulpes lagopus) from Svalbard

Cats are considered essential for the maintenance of Toxoplasma gondii in nature. However, T. gondii infection has been reported in arctic fox (Vulpes lagopus) from the Svalbard high arctic archipelago where felids are virtually absent. To identify the potential source of T. gondii, we attempted to isolate and genetically characterize the parasite from arctic foxes in Svalbard. Eleven foxes were trapped live in Grumant (78 degrees 11'N, 15 degrees 09'E), Svalbard, in September 2005 and 2006. One of the foxes was found to be seropositive to T. gondii by the modified agglutination test (MAT). The fox was euthanized and its heart and brain were bioassayed in mice for the isolation of T. gondii. All 10 mice inoculated with brain tissue and one of the five inoculated with heart developed MAT antibodies, and tissue cysts were found in the brains of seropositive mice. Two cats fed tissues from infected mice shed T. gondii oocysts. Genotyping using 10 PCR-RFLP markers and DNA sequencing of gene loci BSR4, GRA6, UPRT1 and UPRT2 determined the isolate to be Type II strain, the predominant T. gondii lineage in the world.

Congenital toxoplasmosis from an HIV-infected woman as a result of reactivation

Congenital toxoplasmosis usually results from acquired infection in non-immune pregnant women. However, severely HIV-infected women with a latent Toxoplasma infection can transmit the parasite as a result of reactivation. We report a case of toxoplasmic reactivation in an HIV-infected woman with moderate immunosuppression resulting in a severe congenital toxoplasmosis.

Previous maternal infection with Toxoplasma gondii and the risk of fetal death

OBJECTIVE

The purpose of this study was to assess the association between previous maternal Toxoplasma gondii (T gondii) infection and risk of fetal death.

STUDY DESIGN

This was a population-based prospective cohort of 29,912 pregnant women without acute T gondii infection in Norway.

RESULTS

In the study population, 2937 (9.8%) women had evidence of previous maternal T gondii infection, and 299 (1.0%) had fetal deaths. We found no association between previous T gondii infection and risk of fetal death at > or = 20 weeks of gestation. We did find a trend for an increased risk of fetal death at > or = 16 and <20 weeks of gestation. However, we noted no association between previous T gondii infection and risk of fetal death at all birth weight categories (> or = 1000, > or = 500 and <1000, and <500 g).

CONCLUSION

These data do not indicate an increased risk of fetal death at > or = 20 weeks of gestation in women with previous maternal T gondii infection.

Toxoplasmosis

Toxoplasma gondii is a protozoan parasite that infects up to a third of the world's population. Infection is mainly acquired by ingestion of food or water that is contaminated with oocysts shed by cats or by eating undercooked or raw meat containing tissue cysts. Primary infection is usually subclinical but in some patients cervical lymphadenopathy or ocular disease can be present. Infection acquired during pregnancy may cause severe damage to the fetus. In immunocompromised patients, reactivation of latent disease can cause life-threatening encephalitis. Diagnosis of toxoplasmosis can be established by direct detection of the parasite or by serological techniques. The most commonly used therapeutic regimen, and probably the most effective, is the combination of pyrimethamine with sulfadiazine and folinic acid. This Seminar provides an overview and update on management of patients with acute infection, pregnant women who acquire infection during gestation, fetuses or infants who are congenitally infected, those with ocular disease, and immunocompromised individuals. Controversy about the effectiveness of primary and secondary prevention in pregnant women is discussed. Important topics of current and future research are presented.

Prevalence and predictors of Toxoplasma seropositivity in women with and at risk for human immunodeficiency virus infection

We assessed the prevalence and predictors of latent Toxoplasma infection in a large group of human immunodeficiency virus (HIV)-infected and HIV-uninfected at-risk US women. The prevalence of latent Toxoplasma infection was 15% (380 of 2525 persons) and did not differ by HIV infection status. HIV-infected women aged > or =50 years and those born outside of the United States were more likely to have latent Toxoplasma infection, with prevalences of 32% and 41%, respectively.

Primary Toxoplasma gondii infection in a pregnant human immunodeficiency virus-infected woman

We report a 36-year-old HIV-infected woman who developed primary Toxoplasma gondii infection during pregnancy that was treated with spiramycin and antiretroviral drugs. There was no vertical transmission of toxoplasmosis and HIV.

Congenital toxoplasmosis: a review

Toxoplasmosis is caused by infection with the protozoan parasite Toxoplasma gondii. In the United States, approximately 85% of women of childbearing age are susceptible to acute infection with T. gondii. Acute infections in pregnant women may cause serious health problems when the organism is transmitted to the fetus (congenital toxoplasmosis), including mental retardation, seizures, blindness, and death. An estimated 400 to 4000 cases of congenital toxoplasmosis occur in the U.S. each year. Manifestations of congenital toxoplasmosis may not become apparent until the second or third decade of life. Serologic tests are used to diagnose acute infection in pregnant women, but false-positive tests occur frequently, therefore, serologic diagnosis must be confirmed at a reference laboratory before treatment with potentially toxic drugs should be considered. Much of congenital toxoplasmosis can be prevented by educating women of childbearing age and pregnant women to avoid eating raw or undercooked meat, to avoid cross-contamination of other foods with raw or undercooked meat, and to use proper cat-litter and soil-related hygiene.

Prevalence and incidence of gynecologic disorders among women infected with human immunodeficiency virus

OBJECTIVE

Our purpose was to ascertain the prevalence, incidence, and predictors of gynecologic disorders among women infected with human immunodeficiency virus.

STUDY DESIGN

We serially assessed 292 women infected with human immunodeficiency virus and 681 uninfected women. Outcomes were incidence and prevalence of sexually transmitted diseases, viral shedding, findings of Papanicolaou smears, fungal infections, and menstrual disorders.

RESULTS

Women infected with the virus were more likely to have prevalent vulvovaginal candidiasis (odds ratio 1.80, 95% confidence interval 1. 0-3.25, P =.05), oncogenic human papillomavirus (odds ratio 3.79, 95% confidence interval 2.43-5.91, P =.001), abnormal Papanicolaou smears (odds ratio 5.40, 95% confidence interval 3.35-8.78, P =.001), amenorrhea (4.8% vs 0%, P =.05), positive results on Treponema pallidum hemagglutination assay (odds ratio 1.83, 95% confidence interval 1.16-2.88, P =.01), infection with cytomegalovirus (odds ratio 4.2, 95% confidence interval 1.82-10.62, P =.001), and genital warts (odds ratio 6.93, 95% confidence interval 3.16-16.30, P =.001) but were less likely to have Chlamydia trachomatis infection (odds ratio 0.28, 95% confidence interval 0.10-0.66, P =.01). Annual incidence rates among women infected with human immunodeficiency virus were 4.0% for candidiasis, 22.0% for oncogenic human papillomavirus, 11.4% for genital warts, 1.7% for infection with C trachomatis, 1.7% for infection with Neisseria gonorrhoeae, 10.3% for Trichomonas vaginalis, 1.1% for positive results on T pallidum hemagglutination assay, 7.4% for an abnormal Papanicolaou smear, and 10.9% for infection with herpes simplex virus. Overall, 46.9% had at least 1 incident condition. Women infected with human immunodeficiency virus were more likely to have incident oncogenic human papillomavirus infection (odds ratio 2.0, 95% confidence interval 1.01-3.8), abnormal Papanicolaou smears (odds ratio 7.76, 95% confidence interval 2.08-42.8), and genital warts (odds ratio 9. 32, 95% confidence interval 3.04-38.0). Incidence and prevalence of sexually transmitted diseases and oncogenic human papillomavirus infection increased with increased CD4(+) cell counts.

CONCLUSIONS

Women infected with the human immunodeficiency virus are significantly more likely to have prevalent and incident gynecologic disorders but not disorders related to risk taking (eg, incident sexually transmitted diseases). The latter disorders increased in women with CD4(+) cell counts >500 cells/mm3. Clinicians should be aware of these patterns so that they can provide appropriate evaluation and treatment of gynecologic disorders.

TORCH testing in HIV-infected women

The issue of TORCH testing in pregnant women infected with the HIV virus remains confusing, even more so than it is in the non-HIV-infected gravida. Unfortunately, the data presented in this article make the recommendations of how to test for these various infections in pregnancy that much more difficult. Patients who are newly diagnosed as being HIV-infected and referred for prenatal care or who have not had TORCH testing probably should be tested. Thus, the prenatal patient with newly diagnosed HIV infection should be tested for T. gondii IgG antibodies. If positive for IgG antibodies, IgM antibodies should be obtained in an attempt to rule out acute T. gondii infection. Patients who test negative do not require any further testing until after the pregnancy unless they are severely immunocompromised and show signs and symptoms of toxoplasmosis. Antibodies (IgG) to CMV should be obtained in the HIV-infected gravida who is at high risk for CMV disease, i.e., patients with CD4+ T cell counts less than 100/mm3. Unfortunately, the previously described problems with antibody detection make this testing less than ideal; thus, it is not routinely recommended in the HIV-infected pregnant patient who presents for prenatal care except for those at risk of disease reactivation. As for herpes simplex virus testing, there is no value in routinely testing patients prenatally for evidence of the disease. Finally, syphilis testing in the HIV-infected gravida is of major importance. Once tested, the patient who tests negative and who remains at risk for infection should probably be retested in the third trimester. Patients who are found to have the disease and who are treated need to be tested serially to rule out re-infection or treatment failure.