Do pregnancy, postpartum period and lactation predispose to recurrent toxoplasmic retinochoroiditis?

Ocular Toxoplasmosis: Advances in Toxoplasma gondii Biology, Clinical Manifestations, Diagnostics, and Therapy

Toxoplasma gondii, an obligate intracellular parasite, is a globally prevalent pathogen capable of infecting a wide range of warm-blooded animals, including humans. Ocular toxoplasmosis (OT), a severe manifestation of T. gondii infection, can lead to potentially blinding complications. This comprehensive review delves into the current understanding of T. gondii biology, exploring its complex life cycle, diverse transmission routes, and strain diversity. This article provides an in-depth analysis of the clinical manifestations of OT, which can result from both congenital and acquired infections, presenting a spectrum of signs and symptoms. The review examines various diagnostic strategies employed for OT, including clinical examination, multimodal imaging techniques such as fundus fluorescein angiography (FFA), indocyanine green angiography (ICGA), optical coherence tomography (OCT), and optical coherence tomography angiography (OCTA), as well as laboratory tests including serology and molecular methods. Despite extensive research, the specific mechanisms underlying ocular involvement in T. gondii infection remain elusive, and current diagnostic options have limitations. Moreover, the treatment of active and recurrent OT remains a challenge. While existing therapies, such as antimicrobial agents and immunosuppressants, can control active infections, they do not offer a definitive cure or completely prevent recurrence. The clinical endpoints for the management of active and recurrent OT are also not yet well-established, and the available treatment methods carry the potential for adverse effects. This article highlights the need for future research to elucidate the pathogenesis of OT, investigate genetic factors influencing susceptibility to infection, and develop more sensitive and specific diagnostic tools. Enhancing global surveillance, implementing robust prevention strategies, and fostering multidisciplinary collaborations will be crucial in reducing the burden of OT and improving patient outcomes. This comprehensive review aims to provide a valuable resource for clinicians, researchers, and policymakers, contributing to a better understanding of T. gondii infection and its impact on ocular health.

Impact of gender on clinical features and outcomes of ocular toxoplasmosis

AIM

To investigate the effect of gender on the clinical features and outcomes of ocular toxoplasmosis.

METHODS

262 patients (139 women and 123 men) presenting to a tertiary referral uveitis service in Ribeirão Preto, Brazil, with serological and clinical evidence of ocular toxoplasmosis were prospectively enrolled in an observational study. Predefined data items including demographics, descriptors of uveitis and ocular toxoplasmosis, best-corrected visual acuity and ocular complications were disaggregated by gender and compared statistically.

RESULTS

Approximately equal numbers of women and men had active versus inactive ocular toxoplasmosis. In both women and men, most infections were remotely acquired. Men were significantly more likely to present with primary active disease than women (24.4% vs 12.9%); conversely, women were significantly more likely to present with recurrent active disease than men (36.0% vs 28.5%). One toxoplasmic retinal lesion was observed in more eyes of men than eyes of women (50.4% vs 35.3%), while women's eyes were more likely to have multiple lesions than men's eyes (54.7% vs 39.8%). Lesions in women's eyes were significantly more likely to occur at the posterior pole compared with those in men's eyes (56.1% vs 39.8%). Measures of vision were similar for women and men. There were no significant differences in measures of visual acuity, ocular complications, and occurrence and timing of reactivations between the genders.

CONCLUSION

Ocular toxoplasmosis has equivalent outcomes in women and men, with clinical differences in the form and type of disease, as well as characteristics of the retinal lesion.

Considerations in the management of ocular toxoplasmosis in pregnancy: a review of literature

Ocular toxoplasmosis is the most common cause of infectious posterior uveitis. Available literature is still conflicting regarding the incidence of recurrence during pregnancy as various calculations were employed in the different published studies. Although earlier reports have suggested a difference in presentation and an increase in severity during pregnancy, newer studies appear to show otherwise. Further diagnostic testing, including serologic and intraocular fluid sampling, may be indicated to increase the diagnostic accuracy in this special population of patients. The management of ocular toxoplasmosis during pregnancy is challenging as the foetus is additionally considered in the choice of treatment. Traditionally preferred anti-toxoplasmosis regimens containing antifolate drugs, such as pyrimethamine and trimethoprim-sulfamethoxazole, cannot be used routinely in pregnant patients, especially during the first trimester. This review includes literature on alternative treatments for ocular toxoplasmosis during pregnancy, including spiramycin and intravitreal treatment options.

Gender differences in retinal diseases: A review

Gender medicine is a medical specialty that addresses gender differences in health and disease. Traditionally, medical research and clinical practice have often been focused on male subjects and patients. As a result, gender differences in medicine have been overlooked. Gender medicine considers the biological, psychological, and social differences between the genders and how these differences affect the development, diagnosis, treatment, and prevention of disease. For ophthalmological diseases epidemiological differences are known. However, there are not yet any gender-based ophthalmic treatment approaches for women and men. This review provides an overview of gender differences in retinal diseases. It is intended to make ophthalmologists, especially retinologists, more sensitive to the topic of gender medicine. The goal is to enhance comprehension of these aspects by highlighting fundamental gender differences. Integrating gender medicine into ophthalmological practice helps promote personalized and gender-responsive health care and makes medical research more accurate and relevant to the entire population.

Risk factors for recurrences and visual impairment in patients with ocular toxoplasmosis: A systematic review and meta-analysis

BACKGROUND

Ocular toxoplasmosis (OT) is caused by the parasite Toxoplasma gondii. OT is the leading cause of posterior uveitis globally; it is a recurrent disease that may result in visual impairment and blindness. This systematic review and meta-analysis aim to summarize and evaluate the risk factors for recurrences, visual impairment, and blindness described in the literature worldwide.

METHODS AND FINDINGS

We performed a systematic literature search in PubMed, Embase, VHL, Cochrane Library, Scopus, and DANS EASY Archive. All studies reporting patients with clinically and serologically confirmed OT presenting any clinical or paraclinical factor influencing recurrences, visual impairment, and blindness were included. Studies presenting secondary data, case reports, and case series were excluded. An initial selection was made by title and abstract, and then the studies were reviewed by full text where the eligible studies were selected. Then, the risk of bias was assessed through validated tools. Data were extracted using a validated extraction format. Qualitative synthesis and quantitative analysis were done. This study was registered on PROSPERO (CRD42022327836).

RESULTS

Seventy two studies met the inclusion criteria. Fifty-three were summarized in the qualitative synthesis in three sections: clinical and environmental factors, parasite and host factors, and treatment-related factors. Of the 72 articles, 39 were included in the meta-analysis, of which 14 were conducted in South America, 13 in Europe, four in Asia, three multinational, two in North America and Central America, respectively, and only one in Africa. A total of 4,200 patients with OT were analyzed, mean age ranged from 7.3 to 65.1 year of age, with similar distribution by sex. The frequency of recurrences in patients with OT was 49% (95% CI 40%-58%), being more frequent in the South American population than in Europeans. Additionally, visual impairment was presented in 35% (95% CI 25%-48%) and blindness in 20% (95% CI 13%-30%) of eyes, with a similar predominance in South Americans than in Europeans. On the other hand, having lesions near the macula or adjacent to the optic nerve had an OR of 4.83 (95% CI; 2.72-8.59) for blindness, similar to having more than one recurrence that had an OR of 3.18 (95% CI; 1.59-6.38). Finally, the prophylactic therapy with Trimethoprim/Sulfamethoxazole versus the placebo showed a protective factor of 83% during the first year and 87% in the second year after treatment.

CONCLUSION

Our Systematic Review showed that clinical factors such as being older than 40 years, patients with de novo OT lesions or with less than one year after the first episode, macular area involvement, lesions greater than 1 disc diameter, congenital toxoplasmosis, and bilateral compromise had more risk of recurrences. Also, environmental and parasite factors such as precipitations, geographical region where the infection is acquired, and more virulent strains confer greater risk of recurrences. Therefore, patients with the above mentioned clinical, environmental, and parasite factors could benefit from using prophylactic therapy.

Clinical, Socio-economic and Environmental Factors Related with Recurrences in Ocular Toxoplasmosis in Quindío, Colombia

PURPOSE

To identify the sociodemographic, clinical, and environmental factors associated with recurrences in ocular toxoplasmosis (OT).

METHODS

Retrospective analysis of clinical records of patients who consulted in the Health Centre at Universidad del Quindío between 2004 and 2017. Patients with retinochoroiditis due to Toxoplasma gondii infection and follow up >12 months were included. Comparisons were made with a recurrence index adjusted for months of follow up. For the statistical analysis, the Kruskal-Wallis test and analysis of variance (ANOVA) tests were performed in Epi Info 7.2 and SPSS 14.0. A statistical significance is shown if p ≤ 0.05.

RESULTS

A total of 58 patients were included, with median age of 28 years (range 1-61) and 55.1% were women. The median of recurrences was 1.4 (range 0.6-16.6). High recurrence index was present in 43.1% of the patients. A higher size of lesions was observed in low socioeconomic groups (p = .016) and patients with congenital infection had more bilateral compromise (p = .002). Intake of boiled water was related to a lower recurrence index (p = .04).

CONCLUSIONS

Low socioeconomic level was associated with bigger lesions and congenital infection was related with higher frequency of bilateral OT. Finally, intake of boiled water is related to a lower recurrence index of OT.