1
|
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.
Collapse
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.
| |
Collapse
|
2
|
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.
Collapse
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
| |
Collapse
|
3
|
Prosty C, Hanula R, Levin Y, Bogoch II, McDonald EG, Lee TC. Revisiting the Evidence Base for Modern-Day Practice of the Treatment of Toxoplasmic Encephalitis: A Systematic Review and Meta-Analysis. Clin Infect Dis 2023; 76:e1302-e1319. [PMID: 35944134 DOI: 10.1093/cid/ciac645] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 07/29/2022] [Accepted: 08/05/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Toxoplasmic encephalitis (TE) is an opportunistic infection of people with human immunodeficiency virus (HIV) or other causes of immunosuppression. Guideline-recommended treatments for TE are pyrimethamine and sulfadiazine (P-S) or pyrimethamine and clindamycin (P-C); however, a substantial price increase has limited access to pyrimethamine. Consequently, some centers have transitioned to trimethoprim-sulfamethoxazole (TMP-SMX), an inexpensive alternative treatment. We aimed to review the evidence on the efficacy and safety of pyrimethamine-containing therapies vs TMP-SMX. METHODS We searched for and included randomized controlled trials (RCTs) and observational studies of TE treatments, regardless of HIV status. Data for each therapy were pooled by meta-analysis to assess the proportions of patients who experienced clinical and radiologic responses to treatment, all-cause mortality, and discontinuation due to toxicity. Sensitivity analyses limited to RCTs directly compared therapies. RESULTS We identified 6 RCTs/dose-escalation studies and 26 single-arm/observational studies. Identified studies included only persons with HIV, and most predated modern antiretroviral treatment. Pooled proportions of clinical and radiologic response and mortality were not significantly different between TMP-SMX and pyrimethamine-containing regimens (P > .05). Treatment discontinuation due to toxicity was significantly lower in TMP-SMX (7.3%; 95% confidence interval [CI], 4.7-11.4; I2 = 0.0%) vs P-S (30.5%; 95% CI, 27.1-34.2; I2 = 0.0%; P < .01) or P-C (13.7%; 95% CI, 9.8-18.8; I2 = 32.0%; P = .031). These results were consistent in analyses restricted to RCT data. CONCLUSIONS TMP-SMX appears to be as effective and safer than pyrimethamine-containing regimens for TE. These findings support modern RCTs comparing TMP-SMX to pyrimethamine-based therapies and a revisiting of the guidelines.
Collapse
Affiliation(s)
- Connor Prosty
- Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Ryan Hanula
- Division of Experimental Medicine, Department of Medicine, McGill University, Montréal, Québec, Canada
| | - Yossef Levin
- Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Isaac I Bogoch
- Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Emily G McDonald
- Division of Experimental Medicine, Department of Medicine, McGill University, Montréal, Québec, Canada.,Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada.,Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada
| | - Todd C Lee
- Division of Experimental Medicine, Department of Medicine, McGill University, Montréal, Québec, Canada.,Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada.,Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Québec, Montréal, Canada
| |
Collapse
|
4
|
Baluch A, Handley G, Ludlow S, Morrison A, Velez A, Rojas MC, Pasikhova Y. Disseminated Toxoplasmosis in an Allogeneic Hematopoietic Stem Cell Transplant Recipient: A Case Report and Review of the Current Literature. Cureus 2022; 14:e29185. [PMID: 36259018 PMCID: PMC9569131 DOI: 10.7759/cureus.29185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2022] [Indexed: 11/23/2022] Open
Abstract
Reactivation infections in hematopoietic stem cell transplants are mitigated by prophylactic regimens. Despite high rates of exposure, morbidity and mortality secondary to toxoplasmosis are limited to subsets of patients such as immunocompromised persons. We describe the first case of disseminated toxoplasmosis in a double umbilical cord blood transplant recipient.
Collapse
|
5
|
Qu Y, Ding W, Liu S, Wang X, Wang P, Liu H, Xia H, Chen Y, Jiang H. Metagenomic Next-Generation Sequencing vs. Traditional Pathogen Detection in the Diagnosis of Infection After Allogeneic Hematopoietic Stem Cell Transplantation in Children. Front Microbiol 2022; 13:868160. [PMID: 35509305 PMCID: PMC9058167 DOI: 10.3389/fmicb.2022.868160] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 03/21/2022] [Indexed: 11/23/2022] Open
Abstract
Infection is a severe complication of allo-HSCT in children, however, the accurate detection of the infection is hard. In this study, we traced the records of 101 pediatric recipients with allo-HSCT to investigate the pathogens of infection, and collected 54 bronchoalveolar lavage fluid, 32 blood, and 15 cerebrospinal fluid samples. In these samples, 87 was with post-transplant infection and 14 without infection. Using the metagenomic next-generation sequencing (mNGS) and traditional pathogen detection, we compared their sensitivity and specificity to detect pathogens of infection. Our results showed that mNGS was more sensitive (89.7%) than conventional pathogen detection (21.8%), with a difference of 67.9% (P < 0.001), However, mNGS was less specific (78.5%) than traditional methods (92.9%), with a difference of 14.4% (P = 0.596). The sensitivity of mNGS for diagnosing pulmonary infections, bloodstream infections or viremia, and CNS infections post-transplant were 91.7, 85.7, and 90.9%, respectively. In contrast, the sensitivity of conventional testing for diagnosing pulmonary infections, bloodstream infections or viremia, and CNS infections post-transplant were 22.9, 21.4, and 18.2%, respectively. There were significant differences in the sensitivity of mNGS and conventional testing in BALF, blood, and CSF samples, with P values of 0.000, 0.000, and 0.002 respectively. Among the patients with pulmonary infection, 11 pathogens were both identified by mNGS and conventional testing, and 33 by mNGS only. The percentage with the mNGS-positive result was 44/48 (91.7%), including viruses (n = 12), bacteria (n = 17), fungi (n = 9) and mixed infections (n = 6). Among the patients diagnosed with fungal pneumonia (n = 9), the most prevalent pathogenic fungi were Pneumocystis jiroveci (n = 6), which were also detected in 4 patients with mixed infectious pneumonia. In the 28 blood specimens of patients with bloodstream infections or viremia, five patients were positive by both mNGS and conventional testing, 19 were positive by mNGS, and 1 was positive by traditional testing only. The percentage with the mNGS-positive results was 24/28 (85.7%), including viruses (n = 12), bacteria (n = 4), fungi (n = 3), and mixed infections (n = 5). Of the 15 CSF specimens enrolled, 11 patients were eventually diagnosed with CNS infections. Ten pathogens were identified by mNGS in the 11 patients, including viruses (n = 8), bacteria (n = 1), and fungi (n = 1). These results suggest that mNGS is more sensitive than conventional pathogen detection for diagnosing infections post HSCT in children which may help the clinic diagnosis. Pneumocystis jiroveci was the most frequent pathogen of pulmonary infections post-transplant, while viruses were the most common pathogens of CNS infections in allo-HSCT recipients.
Collapse
Affiliation(s)
- Yuhua Qu
- Department of Hematology and Oncology, Guangzhou Women and Children’s Medical Center, Guangzhou, China
| | - Wenjiao Ding
- Department of Hematology and Oncology, Guangzhou Women and Children’s Medical Center, Guangzhou, China
| | - Sha Liu
- Department of Hematology and Oncology, Guangzhou Women and Children’s Medical Center, Guangzhou, China
| | - Xiaojing Wang
- Department of Hematology and Oncology, Guangzhou Women and Children’s Medical Center, Guangzhou, China
| | - Pengfei Wang
- Department of Hematology and Oncology, Guangzhou Women and Children’s Medical Center, Guangzhou, China
| | - Haiyan Liu
- Department of Hematology and Oncology, Guangzhou Women and Children’s Medical Center, Guangzhou, China
| | - Han Xia
- Department of Scientific Affairs, Hugobiotech Co., Ltd., Beijing, China
| | - Yong Chen
- Department of Scientific Affairs, BGI PathoGenesis Pharmaceutical Technology Co., Ltd., Shenzhen, China
| | - Hua Jiang
- Department of Hematology and Oncology, Guangzhou Women and Children’s Medical Center, Guangzhou, China
| |
Collapse
|
6
|
Štajner T, Vujić D, Srbljanović J, Bauman N, Zečević Ž, Simić M, Djurković-Djaković O. Risk of reactivated toxoplasmosis in haematopoietic stem cell transplant recipients: a prospective cohort study in a setting withholding prophylaxis. Clin Microbiol Infect 2021; 28:733.e1-733.e5. [PMID: 34555535 DOI: 10.1016/j.cmi.2021.09.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 09/01/2021] [Accepted: 09/08/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Reactivation of latent toxoplasmosis may be life-threatening in haematopoietic stem cell transplant (HSCT) recipients. We conducted an 8-year-long prospective study on the diagnosis and monitoring of reactivated toxoplasmosis in paediatric HSCT recipients. The primary objective was to determine the incidence of reactivated toxoplasmosis in a setting that withholds prophylaxis until engraftment. The second objective was to identify the subgroups of HSCT recipients particularly prone to reactivation who may benefit the most from regular PCR follow-up. METHODS Serological and qPCR screening targeting the Toxoplasma 529 bp gene was performed before HSCT, and continued by weekly monitoring after HSCT for a median time of 104 days. RESULTS Reactivated toxoplasmosis was diagnosed in 21/104 (20.2%), predominantly in allo- (19/75) and rarely in auto-HSCT (2/29) recipients. Over 50% (14/21) of cases were diagnosed during the first month after HSCT, while awaiting engraftment without prophylaxis. Toxoplasma disease evolved in only three (14.3%, 3/21) patients, all treated by allo-HSCT. Reactivation was more frequent in patients treated for acute lymphoblastic leukaemia (3/27, p 0.03) and especially, in recipients of haploidentical stem cells (10/20, p 0.005). Seronegative status of the donor (where was known) contributed to 75% (12/16) cases of reactivated toxoplasmosis after allo-HSCT. DISCUSSION The presented results show that peripheral blood-based qPCR, both before and after HSCT, is a valuable asset for the diagnosis of reactivated toxoplasmosis, whereas the results of serology in recipients should be interpreted with caution. Weekly qPCR monitoring, at least until successful engraftment and administration of prophylaxis, allows for prompt introduction of specific treatment.
Collapse
Affiliation(s)
- Tijana Štajner
- National Reference Laboratory for Toxoplasmosis, Group for Microbiology with Parasitology, Centre of Excellence for Food- and Vector-borne Zoonoses, Institute for Medical Research, National Institute of Republic of Serbia, University of Belgrade, Belgrade, Serbia
| | - Dragana Vujić
- Faculty of Medicine, University of Belgrade, Serbia; Mother and Child Health Care Institute of Serbia "Dr Vukan Čupić", Belgrade, Serbia
| | - Jelena Srbljanović
- National Reference Laboratory for Toxoplasmosis, Group for Microbiology with Parasitology, Centre of Excellence for Food- and Vector-borne Zoonoses, Institute for Medical Research, National Institute of Republic of Serbia, University of Belgrade, Belgrade, Serbia
| | - Neda Bauman
- National Reference Laboratory for Toxoplasmosis, Group for Microbiology with Parasitology, Centre of Excellence for Food- and Vector-borne Zoonoses, Institute for Medical Research, National Institute of Republic of Serbia, University of Belgrade, Belgrade, Serbia
| | - Željko Zečević
- Mother and Child Health Care Institute of Serbia "Dr Vukan Čupić", Belgrade, Serbia
| | - Marija Simić
- Mother and Child Health Care Institute of Serbia "Dr Vukan Čupić", Belgrade, Serbia
| | - Olgica Djurković-Djaković
- National Reference Laboratory for Toxoplasmosis, Group for Microbiology with Parasitology, Centre of Excellence for Food- and Vector-borne Zoonoses, Institute for Medical Research, National Institute of Republic of Serbia, University of Belgrade, Belgrade, Serbia.
| |
Collapse
|
7
|
Nawej Tshikung O, Porto V, Nabergoj M, Deffert C, Masouridi-Levrat S, Chalandon Y, Van Delden C, Neofytos D. Intracellular Pathogen in the Cerebrospinal Fluid of an Allogeneic Hematopoietic Cell Transplant Recipient With Graft-Versus-Host Disease and Brain Lesions. Clin Infect Dis 2021; 71:3005-3008. [PMID: 33386855 DOI: 10.1093/cid/ciaa235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Violaine Porto
- Division of Hematology, Bone Marrow Unit, University Hospital of Geneva and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Mitja Nabergoj
- Division of Hematology, Bone Marrow Unit, University Hospital of Geneva and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Christine Deffert
- Division of Laboratory, University Hospital of Geneva, Geneva, Switzerland
| | - Stavroula Masouridi-Levrat
- Division of Hematology, Bone Marrow Unit, University Hospital of Geneva and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Yves Chalandon
- Division of Hematology, Bone Marrow Unit, University Hospital of Geneva and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Christian Van Delden
- Division of Infectious Diseases, University Hospital of Geneva, Geneva, Switzerland
| | - Dionysios Neofytos
- Division of Infectious Diseases, University Hospital of Geneva, Geneva, Switzerland
| |
Collapse
|
8
|
Bodilsen J, Dalager-Pedersen M, van de Beek D, Brouwer MC, Nielsen H. Risk Factors for Brain Abscess: A Nationwide, Population-Based, Nested Case-Control Study. Clin Infect Dis 2021; 71:1040-1046. [PMID: 31641757 DOI: 10.1093/cid/ciz890] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 09/05/2019] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Knowledge on risk factors for brain abscess is limited and relies on single-center cohort studies. METHODS We accessed nationwide medical registries to conduct a population-based, nested case-control study of risk factors for brain abscess. We applied risk-set sampling for the selection of population controls (1:10), who were individually matched by age, sex, and area of residence. Conditional logistic regression was used to compute adjusted odds ratios (aOR) with 95% confidence intervals (CIs). Population-attributable fractions were calculated. RESULTS We identified 1384 brain abscess patients in Denmark from 1982 through 2016, and 13 839 matched population controls. The median age of patients was 50 years (interquartile range 33-63) and 37% were female. Cases often had Charlson comorbidity scores >2 (16%), compared with controls (3%). Our calculated aORs were 2.15 (95% CI 1.72-2.70) for head trauma; 19.3 (95% CI 14.3-26.0) for neurosurgery; 4.61 (95% CI 3.39-6.26) for dental infections; 2.57 (95% CI 1.71-3.84) for dental surgery; 3.81 (95% CI 3.11-4.67) for ear, nose, and throat infection; 2.85 (95% CI 2.21-3.70) for ear, nose, and throat surgery; 15.6 (95% CI 9.57-25.4) for congenital heart disease; 1.74 (95% CI 1.33-2.29) for diabetes mellitus; 2.22 (95% CI 1.58-3.11) for alcohol abuse; 2.37 (95% CI 1.53-3.68) for liver disease; 2.04 (95% CI 1.30-3.20) for kidney disease and 8.15 (95% CI 3.59-18.5) for lung abscess or bronchiectasis. The aORs were 4.12 (95% CI 3.37-5.04) for solid cancer; 8.77 (95% CI 5.66-13.6) for hematological cancer; 12.0 (95% CI 6.13-23.7) for human immunodeficiency virus; and 5.71 (95% CI 4.22-7.75) for immunomodulating treatments. Population-attributable fractions showed were substantial contributors to the occurrence of brain abscess neurosurgery (12%); solid cancer (11%); ear, nose, and throat infections (7%); and immunomodulating treatments (5%). CONCLUSIONS Important risk factors included neurosurgery; cancer; ear, nose, and throat infections; and immunomodulating treatments.
Collapse
Affiliation(s)
| | - Michael Dalager-Pedersen
- Department Infectious Diseases, Aalborg, Denmark.,Department Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Diederik van de Beek
- Amsterdam University Medical Centers, University of Amsterdam, Department of Neurology, Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Matthijs C Brouwer
- Amsterdam University Medical Centers, University of Amsterdam, Department of Neurology, Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Henrik Nielsen
- Department Infectious Diseases, Aalborg, Denmark.,Department Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
| |
Collapse
|
9
|
Liu W, Fan Z, Zhang Y, Huang F, Xu N, Xuan L, Liu H, Shi P, Wang Z, Xu J, Li X, Sun J, Liu Q, Lin R. Metagenomic next-generation sequencing for identifying pathogens in central nervous system complications after allogeneic hematopoietic stem cell transplantation. Bone Marrow Transplant 2021; 56:1978-1983. [PMID: 33824437 PMCID: PMC8023769 DOI: 10.1038/s41409-021-01243-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 01/26/2021] [Accepted: 02/12/2021] [Indexed: 11/09/2022]
Abstract
A prospective study was conducted to compare metagenomic next-generation sequencing (mNGS) and conventional testing in investigating the pathogens of central nervous system (CNS) infections in allogeneic hematopoietic stem cell transplantation (allo-HSCT) recipients. A total of 53 patients with CNS disorders after allo-HSCT were enrolled in this study. A total of 35 patients were diagnosed as CNS infections, including 28 viral, 2 bacterial, 1 fungal, 3 mixed infections, and 1 infection with unknown pathogen. Among these 35 patients with CNS infections, mNGS identified 5 patients who were not identified by conventional testing. For the remaining 30 infections, mNGS made concurrent diagnoses with conventional testing in 29, while 1 was diagnosed according to the good response to the antimicrobial treatment without etiological evidence. The presence of Aspergillus detected by mNGS only in one patient was considered false positive due to lack of validation. The sensitivity of mNGS and conventional testing for diagnosing CNS infections post transplant were 97.1% and 82.9%, respectively (P = 0.106), while the specificity of mNGS and conventional testing were 94.4% and 100%, respectively (P = 1.000). These results suggest that mNGS might be a promising technology for diagnosis of CNS infections post transplant. Viruses were the most common pathogens of CNS infections in allo-HSCT recipients.
Collapse
Affiliation(s)
- Wenjun Liu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhiping Fan
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yan Zhang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Fen Huang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Na Xu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Li Xuan
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Hui Liu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Pengcheng Shi
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhixiang Wang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jun Xu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xiaofang Li
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jing Sun
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qifa Liu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China.
| | - Ren Lin
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China.
| |
Collapse
|
10
|
Schwenk HT, Khan A, Kohlman K, Bertaina A, Cho S, Montoya JG, Contopoulos-Ioannidis DG. Toxoplasmosis in Pediatric Hematopoietic Stem Cell Transplantation Patients. Transplant Cell Ther 2020; 27:292-300. [PMID: 33840441 DOI: 10.1016/j.jtct.2020.11.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 10/05/2020] [Accepted: 11/02/2020] [Indexed: 11/18/2022]
Abstract
Infection due to the protozoa Toxoplasma gondii can be life-threatening in hematopoietic stem cell transplantation (HSCT) recipients. Most cases of toxoplasmosis in HSCT recipients result from reactivation of latent infection in individuals who were Toxoplasma-seropositive before transplantation and did not receive appropriate prophylaxis. Pretransplantation screening with Toxoplasma IgG and IgM antibodies is suggested for all allogeneic HSCT recipients and their donors and all autologous HSCT recipients. Prevention of toxoplasmosis in T. gondii-seropositive HSCT recipients requires primary prophylaxis, preemptive screening, or both. Trimethoprim-sulfamethoxazole (TMP-SMX) is the preferred agent for Toxoplasma prophylaxis and should be continued for 6 months or until the patient is no longer receiving immunosuppression, whichever is longer, assuming that immune reconstitution has occurred. Preemptive weekly screening with whole blood Toxoplasma PCR should be considered for seropositive HSCT recipients if prophylaxis cannot be given or if prophylaxis other than TMP-SMX is used. The signs, symptoms, and radiographic findings of toxoplasmosis in HSCT recipients can be nonspecific, and the diagnosis requires a high degree of suspicion. Common presentations include fever, encephalopathy with mental status changes or seizures, and pneumonia. A Toxoplasma PCR analysis from whole blood (and other body fluids/tissues according to clinical symptoms) should be obtained in patients in whom there is a concern for toxoplasmosis. Treatment with oral pyrimethamine, sulfadiazine, and leucovorin for at least 6 weeks is the first-line therapy and should be followed by secondary prophylaxis. In this article, we review the published literature regarding the epidemiology, clinical presentation, treatment, and prevention of toxoplasmosis in HSCT recipients.
Collapse
Affiliation(s)
- Hayden T Schwenk
- Lucile Packard Children's Hospital Stanford, Palo Alto, California; Division of Infectious Diseases, Department of Pediatrics, Stanford University School of Medicine, Stanford, California.
| | - Aslam Khan
- Lucile Packard Children's Hospital Stanford, Palo Alto, California; Division of Infectious Diseases, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Krystal Kohlman
- Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Alice Bertaina
- Lucile Packard Children's Hospital Stanford, Palo Alto, California; Division of Stem Cell Transplantation and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Stephanie Cho
- Community Health and Prevention Research Master's Graduate Program, Stanford University School of Medicine, Stanford, California
| | - Jose G Montoya
- Dr Jack S. Remington Laboratory for Specialty Diagnostics, Palo Alto Medical Foundation, Palo Alto, California
| | - Despina G Contopoulos-Ioannidis
- Lucile Packard Children's Hospital Stanford, Palo Alto, California; Division of Infectious Diseases, Department of Pediatrics, Stanford University School of Medicine, Stanford, California; Dr Jack S. Remington Laboratory for Specialty Diagnostics, Palo Alto Medical Foundation, Palo Alto, California
| |
Collapse
|
11
|
Rauwolf KK, Floeth M, Kerl K, Schaumburg F, Groll AH. Toxoplasmosis after allogeneic haematopoietic cell transplantation-disease burden and approaches to diagnosis, prevention and management in adults and children. Clin Microbiol Infect 2020; 27:378-388. [PMID: 33065238 DOI: 10.1016/j.cmi.2020.10.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 10/06/2020] [Accepted: 10/10/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Toxoplasmosis is a rare but highly lethal opportunistic infection after allogeneic haematopoietic cell transplantation (HCT). Successful management depends on screening, early recognition and effective treatment. OBJECTIVES To review the current epidemiology and approaches to diagnosis, prevention and treatment of toxoplasmosis in adult and paediatric allogeneic HCT recipients. SOURCE Search of the English literature published in MEDLINE up to 30 June 2020 using combinations of broad search terms including toxoplasmosis, transplantation, diagnosis, epidemiology, prevention and treatment. Selection of articles for review and synthesis on the basis of perceived quality and relevance of content. CONTENT Toxoplasmosis continues to be a major challenge in the management of allogeneic HCT recipients. Here we provide a summary of published case series of toxoplasmosis in adult and paediatric patients post allogeneic HCT. We review and discuss the pathogenesis, epidemiology, clinical presentation, diagnosis and current recommendations for prevention and treatment. We also discuss impacts of toxoplasmosis in this setting and factors affecting outcome, emphasizing attention to neurological, neuropsychological and neurocognitive late effects in survivors. IMPLICATIONS Apart from careful adherence to established strategies of disease prevention through avoidance of primary infection, identification of seropositive patients and implementation of molecular monitoring, future perspectives to improve the control of toxoplasmosis in allogeneic HCT recipients may include the systematic investigation of pre-emptive treatment, development of immunomodulatory approaches, antimicrobial agents with activity against the cyst form and vaccines to prevent chronic infection.
Collapse
Affiliation(s)
- Kerstin K Rauwolf
- Department of Paediatric Haematology and Oncology, University Children's Hospital Münster, Münster, Germany; Centre for Bone Marrow Transplantation, University Hospital Münster, Münster, Germany
| | - Matthias Floeth
- Centre for Bone Marrow Transplantation, University Hospital Münster, Münster, Germany; Department of Medicine A, Haematology and Oncology, University Hospital Münster, Münster, Germany
| | - Kornelius Kerl
- Department of Paediatric Haematology and Oncology, University Children's Hospital Münster, Münster, Germany; Centre for Bone Marrow Transplantation, University Hospital Münster, Münster, Germany
| | - Frieder Schaumburg
- Institute of Medical Microbiology, University Hospital Münster, Münster, Germany
| | - Andreas H Groll
- Department of Paediatric Haematology and Oncology, University Children's Hospital Münster, Münster, Germany; Centre for Bone Marrow Transplantation, University Hospital Münster, Münster, Germany.
| |
Collapse
|
12
|
Sanchez-Petitto G, Holtzman NG, Bukhari A, Brown M, Morales MK, Koka M, Yared JA, Dahiya S, Rapoport AP, Hardy NM. Toxoplasma-induced hemophagocytic lymphohistiocytosis after haploidentical allogeneic stem cell transplantation. Transpl Infect Dis 2020; 22:e13242. [PMID: 31895492 DOI: 10.1111/tid.13242] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 12/25/2019] [Indexed: 12/11/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a disorder of immune regulation, manifested by fever, pancytopenia, hyperferritiniemia, hypertriglyceridemia, and extensive hemophagocytosis involving the bone marrow and spleen. HLH can occur in adults with an underlying hematopoietic malignancy, or with systemic infections. HLH following hematopoietic stem cell transplantation (HSCT) is unusual, and the diagnosis may be challenging particularly because the diagnostic criteria in the HLH-2004 guidelines overlap with common post-transplant complications such as engraftment syndrome, graft-vs-host disease, and infections. HLH is commonly triggered by viral, bacterial and, less commonly, parasitic infections. Following HSCT, patients with latent Toxoplasma infection may develop systemic disease secondary to reactivation, and rarely this may lead to a HLH physiology, with a very high mortality rate. Herein we describe the successful management of disseminated toxoplasmosis associated with life-threatening HLH using tocilizumab and antimicrobial therapy.
Collapse
Affiliation(s)
- Gabriela Sanchez-Petitto
- Division of Hematology and Oncology, Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD
| | - Noa G Holtzman
- Division of Hematology and Oncology, National Institutes of Health, Bethesda, MD
| | - Ali Bukhari
- Division of Hematology and Oncology, Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD
| | - Matthew Brown
- Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, MD
| | - Megan K Morales
- Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, MD
| | - Madhurima Koka
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD
| | - Jean A Yared
- Division of Hematology and Oncology, Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD
| | - Saurabh Dahiya
- Division of Hematology and Oncology, Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD
| | - Aaron P Rapoport
- Division of Hematology and Oncology, Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD
| | - Nancy M Hardy
- Division of Hematology and Oncology, Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD
| |
Collapse
|
13
|
Chueng TA, Moroz IV, Anderson AD, Morris MI, Komanduri KV, Camargo JF. Failure of atovaquone prophylaxis for prevention of toxoplasmosis in hematopoietic cell transplant recipients. Transpl Infect Dis 2019; 22:e13198. [DOI: 10.1111/tid.13198] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 09/29/2019] [Indexed: 11/30/2022]
Affiliation(s)
| | - Ilona V. Moroz
- Division of Infectious Diseases Department of Medicine University of Miami Miller School of Medicine Miami FL USA
| | - Anthony D. Anderson
- Department of Pharmacy Sylvester Comprehensive Cancer Center University of Miami Miller School of Medicine Miami FL USA
| | - Michele I. Morris
- Division of Infectious Diseases Department of Medicine University of Miami Miller School of Medicine Miami FL USA
| | - Krishna V. Komanduri
- Division of Transplantation and Cellular Therapy Department of Medicine Sylvester Comprehensive Cancer Center University of Miami Miller School of Medicine Miami FL USA
| | - Jose F. Camargo
- Division of Infectious Diseases Department of Medicine University of Miami Miller School of Medicine Miami FL USA
| |
Collapse
|
14
|
Safdar A. Respiratory Tract Infections: Sinusitis, Bronchitis, and Pneumonia. PRINCIPLES AND PRACTICE OF TRANSPLANT INFECTIOUS DISEASES 2019. [PMCID: PMC7120972 DOI: 10.1007/978-1-4939-9034-4_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Solid organ and hematopoietic stem cell transplant recipients are at increased risk of upper and lower respiratory tract infections. While these infections are frequently encountered in the general population, the spectrum of their clinical presentation including morbidity and mortality is increased in patients undergoing transplantation procedures. Impaired innate and adaptive immunity, potential anatomical abnormalities resulting from extensive surgical procedures, presences of indwelling medical devices, and increased healthcare exposure put transplant recipients at particularly high risk for respiratory tract disease. Infections of the respiratory tract can be divided into those affecting the paranasal sinuses, the upper airways such as bronchitis and tracheobronchitis, and the lower airways like pneumonia. Each of these clinical syndromes can further be classified based on their chronicity, acute vs. chronic; their setting, community vs. nosocomial; and the etiology such as bacteria, viruses, fungi, and rarely parasites. It is also important to realize that such immunologically vulnerable patients are at risk for polymicrobial infection that may present concurrently or in a sequential, consecutive fashion. This chapter reviews the common respiratory tract infections affecting transplant recipients with particular attention directed toward epidemiological risk factors, clinical presentations, diagnostic strategies, and common pathogens. Specific causes of opportunistic pneumonias are also reviewed.
Collapse
Affiliation(s)
- Amar Safdar
- Clinical Associate Professor of Medicine, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX USA
| |
Collapse
|
15
|
Toxoplasma Encephalitis following Tandem Autologous Hematopoietic Stem Cell Transplantation: A Case Report and Review of the Literature. Case Rep Infect Dis 2018; 2018:9409121. [PMID: 30534451 PMCID: PMC6252224 DOI: 10.1155/2018/9409121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 09/24/2018] [Indexed: 11/17/2022] Open
Abstract
Infection with Toxoplasma gondii is a rare but often fatal complication in hematopoietic stem cell transplantation (HSCT) recipients. Most cases have been reported in allogeneic (allo-) HSCT recipients, with only narrative reports following autologous HSCT (ASCT). We report the case of a 58-year-old Caucasian male presenting with toxoplasma encephalitis following tandem ASCT for myeloma and successfully treated with diagnosis by polymerase chain reaction analysis of cerebrospinal fluid. He was treated with sulfadiazine and pyrimethamine (with leucovorin) followed by pyrimethamine and atovaquone as secondary prophylaxis while receiving subsequent therapy for progressive multiple myeloma. Toxoplasmosis is a potential complication in allo-HSCT as well as ASCT recipients and should be considered in any post-HSCT patient with neurological dysfunction. Rapid diagnosis and immediate antimicrobial treatment are essential to avoid morbidity and mortality.
Collapse
|
16
|
Dard C, Marty P, Brenier-Pinchart MP, Garnaud C, Fricker-Hidalgo H, Pelloux H, Pomares C. Management of toxoplasmosis in transplant recipients: an update. Expert Rev Anti Infect Ther 2018; 16:447-460. [DOI: 10.1080/14787210.2018.1483721] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Céline Dard
- Laboratoire de Parasitologie-Mycologie, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble Cedex France
- Institute for Advanced Biosciences (IAB), Team Host-Pathogen Interactions and Immunity to Infection, INSERM U1209 - CNRS UMR5309, Université Grenoble Alpes, Grenoble France
| | - Pierre Marty
- Faculté de Médecine, Laboratoire de Parasitologie-Mycologie, Centre Hospitalier Universitaire de Nice, 06202 Nice, France Université de la Côte d’Azur, Nice, France
- 38043, INSERM U1065, Centre Méditerranéen de Médecine Moléculaire, C3M, Nice, France
| | - Marie-Pierre Brenier-Pinchart
- Laboratoire de Parasitologie-Mycologie, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble Cedex France
- Institute for Advanced Biosciences (IAB), Team Host-Pathogen Interactions and Immunity to Infection, INSERM U1209 - CNRS UMR5309, Université Grenoble Alpes, Grenoble France
| | - Cécile Garnaud
- Laboratoire de Parasitologie-Mycologie, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble Cedex France
| | - Hélène Fricker-Hidalgo
- Laboratoire de Parasitologie-Mycologie, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble Cedex France
| | - Hervé Pelloux
- Laboratoire de Parasitologie-Mycologie, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble Cedex France
- Institute for Advanced Biosciences (IAB), Team Host-Pathogen Interactions and Immunity to Infection, INSERM U1209 - CNRS UMR5309, Université Grenoble Alpes, Grenoble France
| | - Christelle Pomares
- Faculté de Médecine, Laboratoire de Parasitologie-Mycologie, Centre Hospitalier Universitaire de Nice, 06202 Nice, France Université de la Côte d’Azur, Nice, France
- 38043, INSERM U1065, Centre Méditerranéen de Médecine Moléculaire, C3M, Nice, France
| |
Collapse
|
17
|
Hashiguchi J, Onozawa M, Naka T, Hatanaka KC, Shiratori S, Sugita J, Fujimoto K, Matsuno Y, Teshima T. Re-infection of Toxoplasma gondii
after HSCT presenting lymphadenopathy resembling recurrence of lymphoma. Transpl Infect Dis 2018; 20:e12892. [DOI: 10.1111/tid.12892] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 03/01/2018] [Accepted: 03/11/2018] [Indexed: 12/01/2022]
Affiliation(s)
| | - Masahiro Onozawa
- Department of Hematology; Hokkaido University Hospital; Sapporo Japan
| | - Tomoaki Naka
- Department of Surgical Pathology; Hokkaido University Hospital; Sapporo Japan
| | - Kanako C. Hatanaka
- Department of Surgical Pathology; Hokkaido University Hospital; Sapporo Japan
| | - Souichi Shiratori
- Department of Hematology; Hokkaido University Hospital; Sapporo Japan
| | - Junichi Sugita
- Department of Hematology; Hokkaido University Hospital; Sapporo Japan
| | - Katsuya Fujimoto
- Department of Hematology; Hokkaido University Hospital; Sapporo Japan
| | - Yoshihiro Matsuno
- Department of Surgical Pathology; Hokkaido University Hospital; Sapporo Japan
| | - Takanori Teshima
- Department of Hematology; Hokkaido University Hospital; Sapporo Japan
| |
Collapse
|
18
|
Chaudhary RK, Dhakal P, Aryal A, Bhatt VR. Central nervous system complications after allogeneic hematopoietic stem cell transplantation. Future Oncol 2017; 13:2297-2312. [PMID: 28984145 DOI: 10.2217/fon-2017-0274] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Allogenic hematopoietic stem cell transplant (alloSCT) is a potentially curative modality of treatment for patients with hematological malignancies. However, CNS complications following transplant pose a risk to survival of the patients. Early recognition and management of these complications are crucial to reduce morbidity and mortality of patients following transplant. Early CNS complications associated with alloSCT are infection, cerebrovascular events, chemotherapy and radiation-induced toxicities while late complications include post-transplant lymphoproliferative disorder, CNS relapse of underlying malignancy and viral and fungal infections. Development of graft-versus-host disease can further increase the risk of CNS complications and outcomes after alloSCT. Strategies aimed to reduce the risk of CNS complications and early management may ameliorate the morbidity and mortality in transplant recipients.
Collapse
Affiliation(s)
- Ranjit Kumar Chaudhary
- Department of Radiodiagnosis & Imaging, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | - Prajwal Dhakal
- Department of Medicine, Michigan State University, East Lansing, MI 48824, USA
| | - Aashrayata Aryal
- Department of Neurology, University of Nebraska Medical Center; Omaha, NE 68198, USA
| | - Vijaya Raj Bhatt
- Department of Internal Medicine, Division of Hematology & Oncology, University of Nebraska Medical Center; Omaha, NE 68198, USA
| |
Collapse
|
19
|
Tateno T, Onozawa M, Hashiguchi J, Ishio T, Yuzawa S, Matsuoka S, Kosugi-Kanaya M, Okada K, Shiratori S, Goto H, Kimura T, Sugita J, Nakagawa M, Hashimoto D, Kahata K, Fujimoto K, Endo T, Kondo T, Tanaka S, Hashino S, Teshima T. Disseminated toxoplasmosis after hematopoietic stem cell transplantation showing unusual magnetic resonance images. Transpl Infect Dis 2017; 19. [DOI: 10.1111/tid.12720] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 01/26/2017] [Accepted: 02/16/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Takahiro Tateno
- Department of Hematology; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Masahiro Onozawa
- Department of Hematology; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Junichi Hashiguchi
- Department of Hematology; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Takashi Ishio
- Department of Hematology; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Sayaka Yuzawa
- Department of Cancer Pathology; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Satomi Matsuoka
- Department of Hematology; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Mizuha Kosugi-Kanaya
- Department of Hematology; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Kohei Okada
- Department of Hematology; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Souichi Shiratori
- Department of Hematology; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Hideki Goto
- Department of Hematology; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Taichi Kimura
- Department of Cancer Pathology; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Junichi Sugita
- Department of Hematology; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Masao Nakagawa
- Department of Hematology; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Daigo Hashimoto
- Department of Hematology; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Kaoru Kahata
- Department of Hematology; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Katsuya Fujimoto
- Department of Hematology; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Tomoyuki Endo
- Department of Hematology; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Takeshi Kondo
- Department of Hematology; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Shinya Tanaka
- Department of Cancer Pathology; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Satoshi Hashino
- Department of Hematology; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Takanori Teshima
- Department of Hematology; Hokkaido University Graduate School of Medicine; Sapporo Japan
| |
Collapse
|
20
|
Abolghasemi H, Shahverdi E, Jafari R, Dolatimehr F, Khandani A. Central Nervous System Toxoplasmosis in Relapsed Hodgkin's Lymphoma: A Case Report. IRANIAN JOURNAL OF CANCER PREVENTION 2016; 9:e5810. [PMID: 27822344 PMCID: PMC5098589 DOI: 10.17795/ijcp-5810] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Revised: 04/10/2016] [Accepted: 06/05/2016] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Patients with immunosuppression have an increased incidence of toxoplasmosis characterized by involvement of the central nervous system. Only a few cases of toxoplasmosis associated with immunosuppressive agents have been reported. Such cases have been reported in immune suppressed patients outside the Iran, but a search of the literature has not revealed any previous reports from this country. CASE PRESENTATION We described a 17- year -old male, a known case of Hodgkin's lymphoma with the diagnosis of central nervous system (CNS) toxoplasmosis. CONCLUSIONS As a conclusion, CNS toxoplasmosis should be considered in the differential diagnosis of immunosuppressed patients who present with neurological manifestations.
Collapse
Affiliation(s)
- Hassan Abolghasemi
- Department of Pediatrics, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
| | - Ehsan Shahverdi
- Blood Transfusion Research Center/High Institute for Research Center & Education in Transfusion Medicine, Immunohematology Department, Tehran, IR Iran
| | - Ramezan Jafari
- Department of Radiology, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
| | - Fardin Dolatimehr
- Blood Transfusion Research Center/High Institute for Research Center & Education in Transfusion Medicine, Immunohematology Department, Tehran, IR Iran
| | - Azam Khandani
- Students’ Research Committee (SRC), Baqiyatallah University of Medical Sciences, Tehran, IR Iran
| |
Collapse
|
21
|
Gajurel K, Gomez C, Dhakal R, Vogel H, Montoya J. Failure of primary atovaquone prophylaxis for prevention of toxoplasmosis in hematopoietic cell transplant recipients. Transpl Infect Dis 2016; 18:446-452. [DOI: 10.1111/tid.12532] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2015] [Revised: 11/10/2015] [Accepted: 01/31/2016] [Indexed: 11/29/2022]
Affiliation(s)
- K. Gajurel
- Division of Infectious Diseases and Geographic Medicine; School of Medicine; Stanford University; Stanford California USA
| | - C.A. Gomez
- Division of Infectious Diseases and Geographic Medicine; School of Medicine; Stanford University; Stanford California USA
| | - R. Dhakal
- Toxoplasma Serology Laboratory; National Reference Center for the Study and Diagnosis of Toxoplasmosis; Palo Alto California USA
| | - H. Vogel
- Department of Pathology; School of Medicine; Stanford University; Stanford California USA
| | - J.G. Montoya
- Division of Infectious Diseases and Geographic Medicine; School of Medicine; Stanford University; Stanford California USA
- Toxoplasma Serology Laboratory; National Reference Center for the Study and Diagnosis of Toxoplasmosis; Palo Alto California USA
| |
Collapse
|
22
|
Schmidt-Hieber M, Silling G, Schalk E, Heinz W, Panse J, Penack O, Christopeit M, Buchheidt D, Meyding-Lamadé U, Hähnel S, Wolf HH, Ruhnke M, Schwartz S, Maschmeyer G. CNS infections in patients with hematological disorders (including allogeneic stem-cell transplantation)-Guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO). Ann Oncol 2016; 27:1207-25. [PMID: 27052648 PMCID: PMC4922317 DOI: 10.1093/annonc/mdw155] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 03/24/2016] [Indexed: 12/22/2022] Open
Abstract
Diagnosis of CNS infections remains a great challenge in patients with hematological disorders since symptoms might both be masked and be mimicked by other conditions such as metabolic disturbances or consequences from antineoplastic treatment. Thus, awareness of this complication is crucial and any suspicion of a CNS infection should lead to timely and adequate diagnostics and treatment to improve the outcome in this population. Infections of the central nervous system (CNS) are infrequently diagnosed in immunocompetent patients, but they do occur in a significant proportion of patients with hematological disorders. In particular, patients undergoing allogeneic hematopoietic stem-cell transplantation carry a high risk for CNS infections of up to 15%. Fungi and Toxoplasma gondii are the predominant causative agents. The diagnosis of CNS infections is based on neuroimaging, cerebrospinal fluid examination and biopsy of suspicious lesions in selected patients. However, identification of CNS infections in immunocompromised patients could represent a major challenge since metabolic disturbances, side-effects of antineoplastic or immunosuppressive drugs and CNS involvement of the underlying hematological disorder may mimic symptoms of a CNS infection. The prognosis of CNS infections is generally poor in these patients, albeit the introduction of novel substances (e.g. voriconazole) has improved the outcome in distinct patient subgroups. This guideline has been developed by the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO) with the contribution of a panel of 14 experts certified in internal medicine, hematology/oncology, infectious diseases, intensive care, neurology and neuroradiology. Grades of recommendation and levels of evidence were categorized by using novel criteria, as recently published by the European Society of Clinical Microbiology and Infectious Diseases.
Collapse
Affiliation(s)
- M Schmidt-Hieber
- Department of Hematology, Oncology and Tumor Immunology, HELIOS Clinic Berlin-Buch, Berlin
| | - G Silling
- Department of Hematology, Oncology and Stem Cell Transplantation, University Hospital, Aachen, Medical Faculty, RWTH Aachen, Aachen
| | - E Schalk
- Department of Hematology and Oncology, Otto-von-Guericke University Hospital Magdeburg, Magdeburg
| | - W Heinz
- Department of Internal Medicine II, University Hospital Würzburg, Center of Internal Medicine, Würzburg
| | - J Panse
- Department of Hematology, Oncology and Stem Cell Transplantation, University Hospital, Aachen, Medical Faculty, RWTH Aachen, Aachen
| | - O Penack
- Department of Hematology, Oncology and Tumor Immunology, Charité University Medicine, Campus Virchow Clinic, Berlin
| | - M Christopeit
- Department of Stem Cell Transplantation, University Medical Center Hamburg Eppendorf, Hamburg
| | - D Buchheidt
- Department of Hematology and Oncology, Mannheim University Hospital, University of Heidelberg, Mannheim
| | - U Meyding-Lamadé
- Department of Neurology, Hospital Nordwest Frankfurt, Frankfurt/M., Germany Brunei Neuroscience Stroke and Rehabilitation Centre, Jerudong, Brunei Darussalam Department of Neuroinfectiology, Otto-Meyerhof-Centre, University of Heidelberg, Heidelberg
| | - S Hähnel
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg
| | - H H Wolf
- Department of Hematology and Oncology, University Hospital Halle, Halle
| | - M Ruhnke
- Paracelsus Clinic Osnabrück, Osnabrück
| | - S Schwartz
- Department of Hematology and Oncology, Charité University Medicine, Campus Benjamin Franklin, Berlin
| | - G Maschmeyer
- Department of Hematology, Oncology and Palliative Care, Ernst von Bergmann Clinic, Potsdam, Germany
| |
Collapse
|
23
|
Morjaria S, Epstein DJ, Romero FA, Taur Y, Seo SK, Papanicolaou GA, Hatzoglou V, Rosenblum M, Perales MA, Scordo M, Kaltsas A. Toxoplasma Encephalitis in Atypical Hosts at an Academic Cancer Center. Open Forum Infect Dis 2016; 3:ofw070. [PMID: 27096140 PMCID: PMC4834739 DOI: 10.1093/ofid/ofw070] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 03/28/2016] [Indexed: 11/29/2022] Open
Abstract
Toxoplasma encephalitis is a well recognized complication of acquired immune deficiency syndrome, solid organ transplantation, and allogeneic hematopoietic stem cell transplantation (HSCT). However, patients with hematologic malignancies not treated with allogeneic HSCT may also develop this condition, which requires high clinical suspicion and consideration for prophylactic therapy.
Collapse
Affiliation(s)
| | - David J Epstein
- Division of Infectious Diseases and Immunology, Department of Medicine , New York University School of Medicine
| | | | - Ying Taur
- Infectious Disease Service, Department of Medicine; Departments ofMedicine
| | - Susan K Seo
- Infectious Disease Service, Department of Medicine; Departments ofMedicine
| | | | - Vaios Hatzoglou
- Neuroradiology Service, Department of Radiology; Radiology, Weill Cornell Medical College, New York
| | | | - Miguel-Angel Perales
- Bone Marrow Transplant Service, Memorial Sloan-Kettering Cancer Center, New York; Departments ofMedicine
| | - Michael Scordo
- Bone Marrow Transplant Service , Memorial Sloan-Kettering Cancer Center , New York
| | - Anna Kaltsas
- Infectious Disease Service, Department of Medicine; Departments ofMedicine
| |
Collapse
|
24
|
Toxoplasma prophylaxis in haematopoietic cell transplant recipients: a review of the literature and recommendations. Curr Opin Infect Dis 2016; 28:283-92. [PMID: 26098500 DOI: 10.1097/qco.0000000000000169] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Toxoplasmosis in haematopoietic cell transplant (HCT) recipients is associated with high morbidity and mortality rates. Prophylaxis following HCT is recommended for high-risk pre-HCT toxoplasma-seropositive (pre-HCTSP) recipients. However, there is no agreement or consistency among programmes on whether to adopt prophylaxis or not, or if used, on the chosen antitoxoplasma prophylactic regimen. This review discusses the role of prophylaxis, and preemptive treatment, for toxoplasmosis in the setting of HCT. RECENT FINDINGS Approximately two-thirds of toxoplasmosis cases following HCT are reported in allogeneic pre-HCTSP (allo pre-HCTSP) patients. This finding confirms a major role of reactivation of latent infection in the pathogenesis of toxoplasmosis in this patient population. Toxoplasma disease-related mortality in allo pre-HCTSP patients was reported at 62%, but it can be significantly decreased with early detection and treatment of toxoplasma infection. There are no randomized trials comparing the efficacy of different prophylactic agents to prevent toxoplasmosis after HCT. Several observational studies have demonstrated the efficacy of trimethoprim-sulfamethoxazole (TMP/SMX) in decreasing the incidence of toxoplasmosis following HCT. There is limited information regarding efficacy of other prophylactic agents. Preemptive treatment using routine blood PCR monitoring seems to be beneficial in detecting infection early and preventing disease in several observational studies and has been adopted for allo pre-HCTSP HCT patients when universal prophylaxis is not possible. SUMMARY Universal prophylaxis with TMP/SMX in allo pre-HCTSP patients should be implemented by all transplant programmes. Preemptive treatment with routine blood PCR monitoring is an option if prophylaxis cannot be used.
Collapse
|
25
|
Miyagi T, Itonaga H, Aosai F, Taguchi J, Norose K, Mochizuki K, Fujii H, Furumoto A, Ohama M, Karimata K, Yamanoha A, Taniguchi H, Sato S, Taira N, Moriuchi Y, Fukushima T, Masuzaki H, Miyazaki Y. Successful treatment of toxoplasmic encephalitis diagnosed early by polymerase chain reaction after allogeneic hematopoietic stem cell transplantation: two case reports and review of the literature. Transpl Infect Dis 2015; 17:593-8. [PMID: 25970830 DOI: 10.1111/tid.12401] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 03/31/2015] [Accepted: 04/17/2015] [Indexed: 11/26/2022]
Abstract
Toxoplasmic encephalitis represents a rare, but often fatal infection after allogeneic hematopoietic stem cell transplantation. Polymerase chain reaction (PCR)-based preemptive therapy is considered promising for this disease, but is not routinely applied, especially in low seroprevalence countries including Japan. We encountered 2 cases of toxoplasmic encephalitis after transplantation that were successfully treated. The diagnosis of toxoplasmic encephalitis in these cases was confirmed by PCR testing when neurological symptoms were observed. Both patients received pyrimethamine and sulfadiazine treatments within 2 weeks of the development of neurological symptoms, and remained free of recurrence for 32 and 12 months. These results emphasized the importance of the PCR test and immediate treatment after diagnosis for the management of toxoplasmic encephalitis.
Collapse
Affiliation(s)
- T Miyagi
- Department of Hematology, Heartlife Hospital, Okinawa, Japan
| | - H Itonaga
- Department of Hematology, Sasebo City General Hospital, Sasebo, Japan
| | - F Aosai
- Department of Infection and Host Defense, Graduate School of Medicine, Chiba University, Chiba, Japan.,Department of Infection and Host Defense, Graduate School of Medicine, Shinshu University, Matsumoto, Japan
| | - J Taguchi
- Department of Hematology, Atomic Bomb Disease and Hibakusha Medicine Unit, Atomic Bomb Disease Institute, Nagasaki University, Nagasaki City, Japan
| | - K Norose
- Department of Infection and Host Defense, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - K Mochizuki
- Department of Infectious Disease, Nagasaki University Hospital, Nagasaki, Japan
| | - H Fujii
- Department of Infectious Disease, Nagasaki University Hospital, Nagasaki, Japan
| | - A Furumoto
- Department of Infectious Disease, Nagasaki University Hospital, Nagasaki, Japan
| | - M Ohama
- Department of Hematology, Heartlife Hospital, Okinawa, Japan
| | - K Karimata
- Department of Hematology, Heartlife Hospital, Okinawa, Japan
| | - A Yamanoha
- Department of Hematology, Heartlife Hospital, Okinawa, Japan
| | - H Taniguchi
- Department of Hematology, Sasebo City General Hospital, Sasebo, Japan
| | - S Sato
- Department of Hematology, Sasebo City General Hospital, Sasebo, Japan
| | - N Taira
- Department of Hematology, Heartlife Hospital, Okinawa, Japan
| | - Y Moriuchi
- Department of Hematology, Sasebo City General Hospital, Sasebo, Japan
| | - T Fukushima
- Laboratory of Hematoimmunology, Department of Clinical Laboratory Sciences, School of Health Sciences, Faculty of Medicine, University of the Ryukyus, Okinawa, Japan
| | - H Masuzaki
- Division of Endocrinology, Diabetes and Metabolism, Hematology, Rheumatology (Second Department of Medicine), Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Y Miyazaki
- Department of Hematology, Atomic Bomb Disease and Hibakusha Medicine Unit, Atomic Bomb Disease Institute, Nagasaki University, Nagasaki City, Japan
| |
Collapse
|
26
|
Molecular diagnosis of toxoplasmosis in immunocompromised patients: a 3-year multicenter retrospective study. J Clin Microbiol 2015; 53:1677-84. [PMID: 25762774 DOI: 10.1128/jcm.03282-14] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 03/07/2015] [Indexed: 11/20/2022] Open
Abstract
Toxoplasmosis is a life-threatening infection in immunocompromised patients (ICPs). The definitive diagnosis relies on parasite DNA detection, but little is known about the incidence and burden of disease in HIV-negative patients. A 3-year retrospective study was conducted in 15 reference laboratories from the network of the French National Reference Center for Toxoplasmosis, in order to record the frequency of Toxoplasma gondii DNA detection in ICPs and to review the molecular methods used for diagnosis and the prevention measures implemented in transplant patients. During the study period, of 31,640 PCRs performed on samples from ICPs, 610 were positive (323 patients). Blood (n = 337 samples), cerebrospinal fluid (n = 101 samples), and aqueous humor (n = 100 samples) were more frequently positive. Chemoprophylaxis schemes in transplant patients differed between centers. PCR follow-up of allogeneic hematopoietic stem cell transplant (allo-HSCT) patients was implemented in 8/15 centers. Data from 180 patients (13 centers) were further analyzed regarding clinical setting and outcome. Only 68/180 (38%) patients were HIV(+); the remaining 62% consisted of 72 HSCT, 14 solid organ transplant, and 26 miscellaneous immunodeficiency patients. Cerebral toxoplasmosis and disseminated toxoplasmosis were most frequently observed in HIV and transplant patients, respectively. Of 72 allo-HSCT patients with a positive PCR result, 23 were asymptomatic; all were diagnosed in centers performing systematic blood PCR follow-up, and they received specific treatment. Overall survival of allo-HSCT patients at 2 months was better in centers with PCR follow-up than in other centers (P < 0.01). This study provides updated data on the frequency of toxoplasmosis in HIV-negative ICPs and suggests that regular PCR follow-up of allo-HSCT patients could guide preemptive treatment and improve outcome.
Collapse
|
27
|
Kerl K, Ehlert K, Brentrup A, Schiborr M, Keyvani K, Becker K, Rossig C, Groll A. Cerebral toxoplasmosis in an adolescent post allogeneic hematopoietic stem cell transplantation: successful outcome by antiprotozoal chemotherapy and CD4+T-lymphocyte recovery. Transpl Infect Dis 2015; 17:119-24. [DOI: 10.1111/tid.12344] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Revised: 10/04/2014] [Accepted: 11/18/2014] [Indexed: 11/28/2022]
Affiliation(s)
- K. Kerl
- Department of Pediatric Hematology and Oncology; University Children's Hospital Muenster; Muenster Germany
| | - K. Ehlert
- Department of Pediatric Hematology and Oncology; University Children's Hospital Muenster; Muenster Germany
| | - A. Brentrup
- Neurosurgery Department; University Hospital Muenster; Muenster Germany
| | - M. Schiborr
- Radiology Department; University Hospital Muenster; Muenster Germany
| | - K. Keyvani
- Neuropathology Department; University Hospital Muenster; Muenster Germany
| | - K. Becker
- Medical Microbiology Department; University Hospital Muenster; Muenster Germany
| | - C. Rossig
- Department of Pediatric Hematology and Oncology; University Children's Hospital Muenster; Muenster Germany
| | - A.H. Groll
- Department of Pediatric Hematology and Oncology; University Children's Hospital Muenster; Muenster Germany
| |
Collapse
|
28
|
Chintakuntlawar A, Kidd M, Al-Kali A, Wilson W, Thompson CA. Toxoplasmosis in patients with hematologic malignancies. Leuk Lymphoma 2014; 56:536-8. [DOI: 10.3109/10428194.2014.926348] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
29
|
Hakko E, Ozkan HA, Karaman K, Gulbas Z. Analysis of cerebral toxoplasmosis in a series of 170 allogeneic hematopoietic stem cell transplant patients. Transpl Infect Dis 2013; 15:575-80. [PMID: 24103000 DOI: 10.1111/tid.12138] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Revised: 10/16/2012] [Accepted: 04/04/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Cerebral toxoplasmosis is a rare but fatal complication in hematopoietic stem cell transplant patients, which mostly is caused by reactivation of latent disease. METHODS In this study, we report an analysis of cerebral toxoplasmosis in a series of 170 allogeneic stem cell transplant patients during a 30-month period at our institution. RESULTS Among these allogeneic stem cell transplant patients, 5 were diagnosed with cerebral toxoplasmosis by brain magnetic resonance imaging and polymerase chain reaction of Toxoplasma gondii DNA. The incidence of cerebral toxoplasmosis was found to be 2.94%. CONCLUSION Mortality rate is known to be very high in cerebral toxoplasmosis; therefore, it is life saving to diagnose the disease in the early stages and start treatment promptly, especially in high-endemic countries like Turkey.
Collapse
Affiliation(s)
- E Hakko
- Infectious Diseases, Anadolu Medical Center, Kocaeli, Turkey
| | | | | | | |
Collapse
|
30
|
Cerebral toxoplasmosis after tandem high-dose chemotherapy and autologous hematopoietic cell transplant for neuroblastoma. J Pediatr Hematol Oncol 2013; 35:e50-2. [PMID: 22995924 DOI: 10.1097/mph.0b013e3182677e84] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Toxoplasmosis is a well-recognized life-threatening complication of hematopoietic cell transplantation (HCT). This report describes a pediatric patient with stage 4 neuroblastoma who developed cerebral toxoplasmosis after tandem high-dose chemotherapy with autologous HCT. Toxoplasmosis is rare in patients undergoing autologous HCT; however, tandem autologous HCT is more immunosuppressive than a single autologous HCT. Toxoplasmosis is a potential complication in autologous as well as allogeneic transplants, and should be considered in any post-HCT patient with neurological dysfunction. Rapid diagnosis and immediate antimicrobial treatment are crucial to avoid morbidity and mortality. Evaluation of toxoplasma serology should be standard in all patients undergoing tandem autologous HCT and seropositive patients should be started on appropriate prophylactic therapy.
Collapse
|
31
|
Madi D, Achappa B, Rao S, Ramapuram JT, Mahalingam S. Successful treatment of cerebral toxoplasmosis with clindamycin: a case report. Oman Med J 2012; 27:411-2. [PMID: 23074553 DOI: 10.5001/omj.2012.100] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Accepted: 07/02/2012] [Indexed: 11/03/2022] Open
Abstract
Toxoplasmosis is caused by infection with the obligate intracellular parasite Toxoplasma gondii. Toxoplasmosis is generally a late complication of HIV infection and usually occurs in patients with CD4 + T-cell counts below 200/μl. Co-trimoxazole (trimethoprim plus sulfamethoxazole) is the most common drug used in India for the treatment of AIDS-associated cerebral toxoplasmosis. Other alternative drugs used for the treatment of cerebral toxoplasmosis are clindamycin plus pyrimethamine and clarithromycin with pyrimethamine.A 30-year-old male known case of retroviral disease presented to Kasturba Medical College, India, with complaints of fever, headache and vomiting. Computed tomography scan of his brain showed irregular ring enhancing lesion in the right basal ganglia. Toxoplasma serology revealed raised IgG antibody levels. Based on the CT features and serology, diagnosis of cerebral toxoplasmosis was made. He was treated with clindamycin alone as he had history of sulfonamide allergy. The patient was symptomatically better after 48 hours. After 21 days, repeat CT of brain was done which was normal. The patient showed good clinical improvement within 48 hours and the lesion resolved completely within 3 weeks. The authors recommend using clindamycin without pyrimethamine in resource poor settings and in patients who do not tolerate sulfa drugs.
Collapse
Affiliation(s)
- Deepak Madi
- Department of Internal Medicine, Kasturba Medical College, Mangalore, India
| | | | | | | | | |
Collapse
|
32
|
Caner A, Dönmez A, Döşkaya M, Değirmenci A, Tombuloğlu M, Cağirgan S, Guy E, Francis J, Soyer NA, Gürüz Y. Determining Toxoplasma high-risk autologous and allogeneic hematopoietic stem cell transplantation patients by systematic pre-transplant PCR screening of stem cell originated buffy coat. Parasitol Int 2012; 61:565-71. [PMID: 22609887 DOI: 10.1016/j.parint.2012.05.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2012] [Revised: 05/08/2012] [Accepted: 05/09/2012] [Indexed: 11/19/2022]
Abstract
The diagnosis of Toxoplasma infection or disease in hematopoietic stem cell transplantation (HSCT) patients is achieved mainly by PCR screening; however screening did not find wide field of use in practice due to costly expenditures of PCR. This study aimed to determine patients at high risk of Toxoplasma infection or disease before transplantation by stem cell originated buffy coat PCR and subsequently to screen them. Buffy coats collected from 12 autologous and 18 allogeneic HSCT patients' donors were investigated by PCR before transplantation. After transplantation, blood and sera collected at fixed time intervals were screened by two PCR methods and serological assays. Screening results first time assessed a toxoplasmosis incidence level as 25% in autologous HSCT patients and increased incidence level in allogeneic HSCT patients to 22%. Importantly, buffy coat PCR was first time performed before transplantation, to determine the risk of toxoplasmosis. Buffy coat PCR results showed that four patients were at high risk of toxoplasmosis before transplantation. After transplantation, these patients experienced toxoplasmosis. In conclusion, for the determination of patients at risk of toxoplasmosis, clinicians should consider buffy coat PCR in combination with serology before transplantation. After transplantation, PCR screening can be initiated in high risk patients upon clinical suspicion.
Collapse
Affiliation(s)
- Ayşe Caner
- Department of Parasitology, Ege University Medical School, Bornova/Izmir, 35100, Turkey.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
33
|
Robert-Gangneux F, Dardé ML. Epidemiology of and diagnostic strategies for toxoplasmosis. Clin Microbiol Rev 2012; 25:264-96. [PMID: 22491772 PMCID: PMC3346298 DOI: 10.1128/cmr.05013-11] [Citation(s) in RCA: 997] [Impact Index Per Article: 83.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
The apicomplexan parasite Toxoplasma gondii was discovered a little over 100 years ago, but knowledge of its biological life cycle and its medical importance has grown in the last 40 years. This obligate intracellular parasite was identified early as a pathogen responsible for congenital infection, but its clinical expression and the importance of reactivations of infections in immunocompromised patients were recognized later, in the era of organ transplantation and HIV infection. Recent knowledge of host cell-parasite interactions and of parasite virulence has brought new insights into the comprehension of the pathophysiology of infection. In this review, we focus on epidemiological and diagnostic aspects, putting them in perspective with current knowledge of parasite genotypes. In particular, we provide critical information on diagnostic methods according to the patient's background and discuss the implementation of screening tools for congenital toxoplasmosis according to health policies.
Collapse
Affiliation(s)
- Florence Robert-Gangneux
- Service de Parasitologie, Faculté de Médecine et Centre Hospitalier Universitaire de Rennes, Rennes, France.
| | | |
Collapse
|
34
|
Infections in Leukemia and Hematopoietic Stem Cell Transplantation. LEUKEMIA AND RELATED DISORDERS 2012. [PMCID: PMC7178857 DOI: 10.1007/978-1-60761-565-1_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Infections are one of the most common complications in patients diagnosed with leukemia and serve as a major obstacle to treatment. Through the early 1970s, infections were the most common cause of death in patients diagnosed with acute leukemia, but improvement in treatment and supportive care over the past few decades, coupled with expanded prophylaxis and prevention regimens, have led to reduction in both the frequency and severity of infections. Regardless, due in part to an aging cancer population and the diversity of cancer treatments and procedures, infectious diseases remain a major cause of morbidity and mortality in patients with leukemia.
Collapse
|
35
|
Pustavoitau A, Bhardwaj A, Stevens R. Analytic Review: Neurological Complications of Transplantation. J Intensive Care Med 2011; 26:209-22. [DOI: 10.1177/0885066610389549] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Recipients of solid organ or hematopoietic cell transplants are at risk of life-threatening neurological disorders including encephalopathy, seizures, infections and tumors of the central nervous system, stroke, central pontine myelinolysis, and neuromuscular disorders—often requiring admission to, or occurring in, the intensive care unit (ICU). Many of these complications are linked directly or indirectly to immunosuppressive therapy. However, neurological disorders may also result from graft versus host disease, or be an expression of the underlying disease which prompted transplantation, as well as injury induced during radiation, chemotherapy, surgery, and ICU stay. In rare cases, neuroinfectious pathogens may be transmitted with the transplanted tissue or organ. Diagnosis may be a challenge because clinical symptoms and findings on neuroimaging lack specificity, and a biological specimen or tissue diagnosis is often needed for definitive diagnosis. Management is centered on preventing further neurological injury, etiology-targeted therapy, and balancing the benefits and toxicities of specific immunosuppressive agents.
Collapse
Affiliation(s)
- Aliaksei Pustavoitau
- Departments of Anesthesiology Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Anish Bhardwaj
- Departments of Neurology and Neurological Surgery, Tufts University School of Medicine, Boston, MA, USA,
| | - Robert Stevens
- Departments of Anesthesiology Critical Care Medicine, Neurology, Neurosurgery, and Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
36
|
Pneumonia in the Cancer Patient. PRINCIPLES AND PRACTICE OF CANCER INFECTIOUS DISEASES 2011. [PMCID: PMC7120955 DOI: 10.1007/978-1-60761-644-3_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
37
|
Cavattoni I, Ayuk F, Zander AR, Zabelina T, Bacher A, Cayroglu E, Knospe V, Illies T, Aepfelbacher M, Richard G, Kröger N, Bacher U. Diagnosis of Toxoplasma gondii infection after allogeneic stem cell transplant can be difficult and requires intensive scrutiny. Leuk Lymphoma 2010; 51:1530-5. [PMID: 20578813 DOI: 10.3109/10428194.2010.494260] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Infectious complications remain a major problem after allogeneic hematopoietic stem cell transplant (HSCT). Specifically Toxoplasma gondii infection is a life-threatening condition in immunocompromised patients. In order to highlight the difficulties in obtaining an early and definitive diagnosis, we report three cases of toxoplasmosis after HSCT for hematologic malignancies: two cases of T. gondii retinochoroiditis, and one case of encephalitis. All patients had unrelated donors and received antithymocyte globulin; none had received trimethoprim/sulfamethoxazole prophylaxis. Toxoplasmosis occurred early post-transplant and diagnosis was obtained by real-time PCR. In one case, the correct diagnosis could only be established by PCR analysis of a retinal biopsy specimen. Rapid diagnosis--by invasive approaches--and an immediate onset of antiparasite treatment are crucial to avoid disseminated and often lethal Toxoplasma infections in the post-transplant period. Post-transplant prevention strategies and treatment to control advanced infection in this setting are discussed.
Collapse
Affiliation(s)
- Irene Cavattoni
- Interdisciplinary Clinic for Stem Cell Transplantation, University of Hamburg, Germany.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
38
|
Schmidt-Hieber M, Schwender J, Heinz WJ, Zabelina T, Kühl JS, Mousset S, Schüttrumpf S, Junghanss C, Silling G, Basara N, Neuburger S, Thiel E, Blau IW. Viral encephalitis after allogeneic stem cell transplantation: a rare complication with distinct characteristics of different causative agents. Haematologica 2010; 96:142-9. [PMID: 20851868 DOI: 10.3324/haematol.2010.029876] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Limited data are available on characteristics of viral encephalitis in patients after allogeneic stem cell transplantation. DESIGN AND METHODS We analyzed 2,628 patients after allogeneic stem cell transplantation to identify risk factors and characteristics of viral encephalitis. RESULTS Viral encephalitis occurred in 32 patients (1.2%, 95% confidence interval 0.8%-1.6%) and was associated with the use of OKT-3 or alemtuzumab for T-cell depletion (P < 0.001) and an increased mortality (P = 0.011) in comparison to patients without viral encephalitis. Detected viruses included human herpesvirus-6 (28%), Epstein-Barr virus (19%), herpes simplex virus (13%), JC virus (9%), varicella zoster virus (6%), cytomegalovirus (6%) and adenovirus (3%). More than one virus was identified in 16% of the patients. The median onset time was 106 days after allogeneic stem cell transplantation for the total group of 32 patients, but onset times were shortest in those with human herpesvirus-6 encephalitis and longest in those with JC virus-associated progressive multifocal leukoencephalopathy. The probability of a sustained response to treatment was 63% (95% confidence interval 44%-82%) with a median survival of 94 (95% confidence interval 36-152) days after onset, but significant variation was found when considering different causative viruses. Patients with herpes simplex virus encephalitis had the most favorable outcome with no encephalitis-related deaths. CONCLUSIONS The use of OKT-3 or alemtuzumab for in vivo T-cell depletion is associated with an increased risk of viral encephalitis after allogeneic stem cell transplantation. Different viruses are frequently associated with distinct characteristics such as onset time, response to treatment and outcome.
Collapse
Affiliation(s)
- Martin Schmidt-Hieber
- Medizinische Klinik III (Hämatologie, Onkologie and Transfusionsmedizin), Charité Campus Benjamin Franklin, Berlin, Germany.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
39
|
Rossi CL, Nascimento FS, Barros-Mazon SD, Dias DF, Vigorito AC, Souza CAD. Serological monitoring of a Toxoplasma infection after hematopoietic stem cell transplantation. Rev Inst Med Trop Sao Paulo 2010; 52:225-7. [DOI: 10.1590/s0036-46652010000400012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2010] [Accepted: 06/24/2010] [Indexed: 11/22/2022] Open
Abstract
We report a primary response to Toxoplasma gondii following a hematopoietic stem cell transplantation in a patient with multiple myeloma. The primary response to T. gondii was supported by IgM, IgG and IgA seroconversion. The patient was promptly treated and there were no complications related to toxoplasmosis in the subsequent months.
Collapse
|
40
|
Toxoplasmosis in allo-SCT patients: risk factors and outcomes at a transplantation center with a low incidence. Bone Marrow Transplant 2010; 46:273-7. [PMID: 20436521 DOI: 10.1038/bmt.2010.102] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Toxoplasmosis in allo-SCT patients is rare in the United States but has a mortality of 60-90%. In this retrospective study, we identified patients with definite and probable toxoplasmosis after allo-SCT at our institution from 1994 to 2009 using ICD-9 codes and the pathology database. Of 3626 patients who underwent allogeneic SCT, we identified 8 with definite toxoplasmosis and 1 with probable toxoplasmosis, an incidence of 0.25%. International patients had a significantly higher incidence of toxoplasmosis than did US patients (1.6 versus 0.15% (P=0.002)). Three patients presented with toxoplasmosis <30 days after transplantation and six developed toxoplasmosis within 100 days of starting high-dose corticosteroids. Two patients were diagnosed postmortem. Six of the remaining seven patients died despite ≥2 weeks of therapy. Co-morbidities, particularly infections, were the primary cause of death in one case and a contributing factor in the remaining six cases. On the basis of these results, we conclude that all allo-SCT patients from countries with high Toxoplasma seropositivity and seropositive patients from the United States should undergo serial PCR screening during the first month after transplantation and during corticosteroid use. All patients who test positive should undergo preemptive therapy.
Collapse
|
41
|
Kim KH, Song KH, Jeon JH, Park WB, Park SW, Kim HB, Kim NJ, Kim I, Oh MD. A Case of Cerebral Toxoplasmosis Following Tandem Autologous Stem Cell Transplantation in a Multiple Myeloma Patient. Infect Chemother 2010. [DOI: 10.3947/ic.2010.42.3.181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Kye-Hyung Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Kyoung-Ho Song
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Hyun Jeon
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Wan Beom Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Sang-Won Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Hong Bin Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Nam Joong Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Inho Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Myoung-don Oh
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| |
Collapse
|
42
|
Tomblyn M, Chiller T, Einsele H, Gress R, Sepkowitz K, Storek J, Wingard JR, Young JAH, Boeckh MJ, Boeckh MA. Guidelines for preventing infectious complications among hematopoietic cell transplantation recipients: a global perspective. Biol Blood Marrow Transplant 2009; 15:1143-238. [PMID: 19747629 PMCID: PMC3103296 DOI: 10.1016/j.bbmt.2009.06.019] [Citation(s) in RCA: 1155] [Impact Index Per Article: 77.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2009] [Accepted: 06/23/2009] [Indexed: 02/07/2023]
|
43
|
|
44
|
Edvinsson B, Lappalainen M, Anttila VJ, Paetau A, Evengård B. Toxoplasmosis in immunocompromized patients. ACTA ACUST UNITED AC 2009; 41:368-71. [PMID: 19229764 DOI: 10.1080/00365540902783319] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Infection with the cosmopolitan parasite Toxoplasma gondii is often associated with severe consequences and a high mortality rate in immunocompromized patients. Non-specific symptoms make diagnosis challenging. Monitoring of patients at risk is of value. We here present 8 cases of toxoplasmosis in immunocompromized patients with suggestions for preventive monitoring.
Collapse
Affiliation(s)
- Benjamin Edvinsson
- Centre for Microbiological Preparedness, Swedish Institute for Infectious Disease Control, Solna, Sweden
| | | | | | | | | |
Collapse
|
45
|
Schmidt-Hieber M, Zweigner J, Uharek L, Blau IW, Thiel E. Central nervous system infections in immunocompromised patients: update on diagnostics and therapy. Leuk Lymphoma 2009; 50:24-36. [PMID: 19031169 DOI: 10.1080/10428190802517740] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Infections of the central nervous system (CNS) are increasingly reported in patients with malignancies. Heavily immunocompromised patients like those after allogeneic stem cell transplantation (SCT) or previous T cell depleting treatment regimens (e.g. with fludarabine or alemtuzumab) are at highest risk for cerebral infections. The spectrum of causative organisms may vary greatly, depending on the underlying malignancy, its treatment and various other factors. Toxoplasma gondii and fungi are the leading causative organisms in patients after allogeneic SCT, but also viruses such as herpes simplex virus or JC virus may be detected in these patients. Definitive diagnosis of cerebral infection still remains a high challenge, although diagnostics have improved by the wide availability of imaging techniques and polymerase chain reaction in recent years. Novel therapeutic options are arising, particularly for fungal CNS infections. Here, we summarise aspects on epidemiology, clinical symptoms and prognosis of CNS infections in patients with malignancies. Additionally, we give an overview on the diagnostics and management of cerebral infections in these patients including evidence evaluation of efficacy of treatment.
Collapse
Affiliation(s)
- Martin Schmidt-Hieber
- Medizinische Klinik III, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany.
| | | | | | | | | |
Collapse
|
46
|
Adurthi S, Sahoo T, Chakka K, Radhika B, Appaji L, Bapsy P, Ramesh C, Jayshree R. Acute toxoplasmosis in nonstem cell transplant patients with haematological malignancies: a study from a regional cancer institute in South India. Hematol Oncol 2009; 26:229-33. [PMID: 18504773 DOI: 10.1002/hon.864] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The frequency of Toxoplasma gondii (Tgondii) infections was investigated during febrile episodes in nonstem cell transplant patients with haematological malignancies (HM). One hundred and sixty-two febrile episodes in 125 HIV-negative patients with HM undergoing treatment at Kidwai Memorial Institute of Oncology, Bangalore, India comprised the study group. Plasma from anticoagulated whole blood was used for amplifying the B1 gene of T. gondii by nPCR. Specific antibodies to T. gondii (IgM and IgG) were tested using commercial kits. Corticosteroid and cotrimoxazole usage during these episodes was 50 and 41%, respectively. Twenty-two of the febrile episodes (14%) were positive for T. gondii; nine of which did not have any other concomitant infecting pathogen and were seen in symptomatic patients. While majority of these (13%) were 'Toxoplasma infection', there was a single case of 'probable Toxoplasma disease' (0.6%). In four of the fatal febrile episodes, T. gondii was the causative agent; two of which did not have any other concomitant infection. None of the patients had undergone stem cell transplantation.
Collapse
Affiliation(s)
- S Adurthi
- Department of Microbiology, Kidwai Memorial Institute of Oncology, Bangalore 560 029, India
| | | | | | | | | | | | | | | |
Collapse
|
47
|
Megged O, Shalit I, Yaniv I, Stein J, Fisher S, Levy I. Breakthrough cerebral toxoplasmosis in a patient receiving atovaquone prophylaxis after a hematopoietic stem cell transplantation. Pediatr Transplant 2008; 12:902-5. [PMID: 18194354 DOI: 10.1111/j.1399-3046.2007.00891.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
We describe a case of breakthrough cerebral toxoplasmosis during atovaquone therapy in a child who was intolerant of conventional prophylactic regimens after hematopoietic stem cell transplantation. The available data on the efficacy of atovaquone prophylaxis in Toxoplasma sero-positive stem cell transplant recipients remain limited, and other strategies, such as preemptive strategy using toxoplasma PCR or TMP-SMX desensitization should be considered in this setting.
Collapse
Affiliation(s)
- Orli Megged
- Infectious Diseases Unit, Schneider Children's Medical Center of Israel, Petah Tiqwa, Israel
| | | | | | | | | | | |
Collapse
|
48
|
Caner A, Döşkaya M, Karasu Z, Değirmenci A, Guy E, Kiliç M, Zeytunlu M, Francis J, Bozoklar A, Gürüz Y. Incidence and diagnosis of active toxoplasma infection among liver transplant recipients in Western Turkey. Liver Transpl 2008; 14:1526-32. [PMID: 18825713 DOI: 10.1002/lt.21558] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Toxoplasmosis is a serious and potentially life-threatening disease in liver transplant recipients while they are immunosuppressed. We report the clinical and laboratory findings related to active toxoplasma infection associated with 40 immunosuppressed liver transplant procedures that took place over a 12-month period at a major transplant unit in Izmir, Turkey. Twenty-seven (67.5%) of the 40 transplant recipients were found to be seropositive for toxoplasma infection and therefore at risk of reactivated infection. From the serological status of the donors, which was ascertained in 38 of 40 cases, we identified 3 (7.9%) of 38 transplants to be from a seropositive donor to a seronegative recipient. In 10 (26.3%) of 38 transplants, both the donor and recipient were seronegative, and this excluded toxoplasma as a risk. A comparison of real-time polymerase chain reaction (PCR) and nested PCR was undertaken in combination with a range of serological assays (the Sabin-Feldman dye test, enzyme immunoassay immunoglobulin M, and immunosorbent agglutination assay immunoglobulin M). Ethylene diamine tetraacetic acid blood samples from 3 of the 30 recipients at risk from toxoplasma were found positive by PCR, but only 1 of these was found positive in both assays. Among the 3 PCR-positive patients, immunoglobulin M and immunoglobulin G antibody levels increased in only 1 patient. Correlations between symptoms, laboratory findings, and clinical management (use of anti-toxoplasma therapy) are presented. Our findings suggest that toxoplasma presents a significant risk to our liver transplant population and that PCR is a helpful addition in identifying active infections and hence in informing clinical management decisions.
Collapse
Affiliation(s)
- Ayşe Caner
- Department of Parasitology, Ege University Medical School, Bornova/Izmir, Turkey
| | | | | | | | | | | | | | | | | | | |
Collapse
|
49
|
Edvinsson B, Lundquist J, Ljungman P, Ringdén O, Evengård B. A prospective study of diagnosis of Toxoplasma gondii infection after bone marrow transplantation. APMIS 2008; 116:345-51. [PMID: 18452424 DOI: 10.1111/j.1600-0463.2008.00871.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Active infection with Toxoplasma gondii in immunocompromised transplant recipients can lead to toxoplasmosis, which may have a rapid disease course and in some cases be fatal. It is of paramount importance to diagnose toxoplasmosis at an early stage, and to initiate specific treatment to improve the outcome. Polymerase chain reaction (PCR) is today the primary diagnostic tool to diagnose toxoplasmosis in immunocompromised patients. Timely diagnosis may, however, be difficult if toxoplasmosis is at first asymptomatic. To investigate the magnitude of toxoplasmosis after bone marrow transplantation (BMT), we conducted a screening study by PCR where 21 autologous and 12 allogeneic BMT recipients were included. Peripheral blood samples were taken one week prior to BMT; thereafter, blood samples were drawn weekly for the first 6 months, and monthly up to one year after BMT. The samples were analyzed by conventional PCR and real-time PCR. T. gondii DNA was detected in peripheral blood from one patient 5 days post allogeneic BMT. There were no clinical signs of toxoplasmosis. Medical records were reviewed and showed a previously undiagnosed eye infection in another allogeneic BMT recipient. These two patients were seropositive for T. gondii. We concluded that monitoring for T. gondii DNA in peripheral blood samples using PCR might be a valuable method for identifying toxoplasma-seropositive stem cell transplant recipients.
Collapse
Affiliation(s)
- Benjamin Edvinsson
- Swedish Institute for Infectious Disease Control, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | | | | | | | | |
Collapse
|
50
|
Diagnostic and therapeutic implications of neurological complications following paediatric haematopoietic stem cell transplantation. Bone Marrow Transplant 2007; 41:253-9. [PMID: 17982498 DOI: 10.1038/sj.bmt.1705905] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Neurological complications are a relevant cause of morbidity and mortality after haematopoietic stem cell transplantation (SCT). We retrospectively analysed neurological complications of 165 paediatric patients who underwent SCT between 1996 and 2003. In all, 111 (67%) transplantations were allogeneic and 54 (33%) transplantations were autologous. Post-SCT neurological complications were seen in 24% of patients. They were seen in six children after autologous SCT and in 11 and 23 cases after allogeneic-related and -unrelated SCT. Neurological symptoms occurred between day +22 and +912 after transplantation and were classified into two groups. The first group (n=21) offered non-repetitive symptoms lasting less than 24 h without any cerebral imaging and cerebrospinal fluid(CSF) abnormalities. The second group (n=19) was characterized by progressive neurological symptoms, pathological MRI findings and/or abnormal results in CSF. Those with a progressive clinical course resulted from infections (n=10), drug toxicity (n=5), cerebrovascular events (n=2) and the central nervous system (CNS) relapse of the underlying disease (n=2). In particular, cerebral aspergillosis and toxoplasmosis after allogeneic unrelated SCT are a major challenge and are associated with a high mortality. In conclusion, our data suggest that patients presenting with progressive neurological symptoms after SCT require prompt diagnostic procedures and initiation in antimicrobial therapy in case of any findings suggestive of CNS infection.
Collapse
|