Acute Toxoplasma Dissemination With Encephalitis in the Era of Biological Therapies

Toxoplasmosis in patients with an autoimmune disease and immunosuppressive agents: A multicenter study and literature review

Background

Cases of Toxoplasma reactivation or more severe primary infection have been reported in patients receiving immunosuppressive (IS) treatment for autoimmune diseases (AID). The purpose of this study was to describe features of toxoplasmosis occurring in patients with AID treated by IS therapy, excluded HIV-positive and transplant patients.

Methods

A multicenter descriptive study was conducted using data from the French National Reference Center for Toxoplasmosis (NRCT) that received DNA extracts or strains isolated from patients, associated with clinical data. Other cases were retrieved through a questionnaire sent to all French parasitology and internal medicine departments. Furthermore, a systematic literature review was conducted.

Results

61 cases were collected: 25 retrieved by the NRCT and by a call for observations and 36 from a literature review. Half of the cases were attributed to reactivation (50.9%), and most of cases (49.2%) were cerebral toxoplasmosis. The most common associated AID were rheumatoid arthritis (28%) and most frequent treatments were antimetabolites (44.3%). Corticosteroids were involved in 60.7% of cases. Patients had a favorable outcome (50.8%) but nine did not survive. For 12 cases, a successful Toxoplasma strain characterization suggested the possible role of this parasitic factor in ocular cases.

Conclusion

Although this remains a rare condition, clinicians should be aware for the management of patients and for the choice of IS treatment.

Comprehensive Overview of Toxoplasma gondii-Induced and Associated Diseases

Toxoplasma gondii (T. gondii) is a prevalent protozoan parasite of medical and veterinary significance. It is the etiologic agent of toxoplasmosis, a neglected disease in which incidence and symptoms differ between patients and regions. In immunocompetent patients, toxoplasmosis manifests as acute and chronic forms. Acute toxoplasmosis presents as mild or asymptomatic disease that evolves, under the host immune response, into a persistent chronic disease in healthy individuals. Chronic toxoplasmosis establishes as latent tissue cysts in the brain and skeletal muscles. In immunocompromised patients, chronic toxoplasmosis may reactivate, leading to a potentially life-threatening condition. Recently, the association between toxoplasmosis and various diseases has been shown. These span primary neuropathies, behavioral and psychiatric disorders, and different types of cancer. Currently, a direct pre-clinical or clinical molecular connotation between toxoplasmosis and most of its associated diseases remains poorly understood. In this review, we provide a comprehensive overview on Toxoplasma-induced and associated diseases with a focus on available knowledge of the molecular players dictating these associations. We will also abridge the existing therapeutic options of toxoplasmosis and highlight the current gaps to explore the implications of toxoplasmosis on its associated diseases to advance treatment modalities.

Serology for Toxoplasma in Immunocompromised Patients: Still Useful?

Toxoplasmosis represents one of the most common comorbidity factors in solid organ or hematopoietic stem cell transplant recipients as well as in other immunocompromised patients. In the past decades, availability and performance of molecular tools for the diagnosis or the exclusion of toxoplasmosis in these patients have greatly improved. However, if accurately used, serology remains a complementary and essential diagnostic tool for physicians and medical parasitologists for the prevention and management of toxoplasmosis in immunocompromised patients as well. It is required for determination of the immunological status of patients against Toxoplasma. It also helps diagnose and monitor complex cases of opportunistic Toxoplasma infection in immunocompromised patients. New perspectives are available to further enhance their yield and ease of use.

Targeted therapies for autoimmune/idiopathic nonmalignant diseases: risk and management of opportunistic infections

INTRODUCTION

The management of patients affected by autoimmune/idiopathic diseases has been revolutionized by the development of targeted therapies (TT). However, the use of TT is complicated by several adverse events, like opportunistic infections (OIs). The potential of TT to predispose to OIs mainly depends on the site of action; nevertheless, such associations are far from being deterministic, because many factors could increase the infection risk.

AREAS COVERED

The impact on the infective risk of different TT used for autoimmune/idiopathic diseases is far from being completely understood. Indeed, many post-marketing reports documented severe or unexpected infections in patients treated with TT that did not emerge during registrative trials. In this review, the authors attempt to provide an easy and practical update about the 'infectious' safety of TT and examine the management strategies of OIs and other infections more frequently observed in the course of treatment with TT.

EXPERT OPINION

The authors suggest to precisely schedule the clinical management of these subjects, both to prevent and eventually treat promptly the TT-related infectious complications. A coordinated approach should be implemented from different medical specialties to improve the overall understanding of safety of TT and, in general, the management of opportunistic infections in immune-compromised hosts.

Severe acute toxoplasmosis infection following ustekinumab treatment in a patient with psoriasis vulgaris

A 26-year-old man undergoing therapy with 45 mg ustekinumab (Stelara) for chronic psoriasis vulgaris was referred by his general practitioner to an infectious diseases department for fatigue, fever, night sweating, generalised lymphadenomegaly and unexplained weight loss. Physical examination revealed bilateral occipital, cervical, axillary and inguinal lymphadenomegalies in addition to splenomegaly. Preliminary investigation revealed elevated Plasmodium lactate dehydrogenase and an inversion of the CD4/CD8 ratio. Whole-body spiral CT scanning with and without contrast showed splenomegaly and highlighted supradiaphragmatic and subdiaphragmatic lymphadenopathies. A complete Infectious Disease Test Panel revealed high levels of anti-Toxoplasma gondii antibodies. Immunoglobulin G avidity was negative. Peripheral blood lymphocyte phenotyping was performed to exclude underlying lymphatic neoplasia. The diagnosis of severe acute toxoplasmosis infection in the setting of immune response modifiers was made. Ustekinumab was suspended indefinitely and the patient underwent monthly serological tests to monitor the immune response until all symptoms resolved and the serological testing was negative for Toxoplasma.