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Aerts R, Mehra V, Groll AH, Martino R, Lagrou K, Robin C, Perruccio K, Blijlevens N, Nucci M, Slavin M, Bretagne S, Cordonnier C. Guidelines for the management of Toxoplasma gondii infection and disease in patients with haematological malignancies and after haematopoietic stem-cell transplantation: guidelines from the 9th European Conference on Infections in Leukaemia, 2022. THE LANCET. INFECTIOUS DISEASES 2024; 24:e291-e306. [PMID: 38134949 DOI: 10.1016/s1473-3099(23)00495-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 07/19/2023] [Accepted: 07/25/2023] [Indexed: 12/24/2023]
Abstract
Patients with haematological malignancies might develop life-threatening toxoplasmosis, especially after allogeneic haematopoietic stem-cell transplantation (HSCT). Reactivation of latent cysts is the primary mechanism of toxoplasmosis following HSCT; hence, patients at high risk are those who were seropositive before transplantation. The lack of trimethoprim-sulfamethoxazole prophylaxis and various immune status parameters of the patient are other associated risk factors. The mortality of toxoplasma disease-eg, with organ involvement-can be particularly high in this setting. We have developed guidelines for managing toxoplasmosis in haematology patients, through a literature review and consultation with experts. In allogeneic HSCT recipients seropositive for Toxoplasma gondii before transplant, because T gondii infection mostly precedes toxoplasma disease, we propose weekly blood screening by use of quantitative PCR (qPCR) to identify infection early as a pre-emptive strategy. As trimethoprim-sulfamethoxazole prophylaxis might fail, prophylaxis and qPCR screening should be combined. However, PCR in blood can be negative even in toxoplasma disease. The duration of prophylaxis should be a least 6 months and extended during treatment-induced immunosuppression or severe CD4 lymphopenia. If a positive qPCR test occurs, treatment with trimethoprim-sulfamethoxazole, pyrimethamine-sulfadiazine, or pyrimethamine-clindamycin should be started, and a new sample taken. If the second qPCR test is negative, clinical judgement is recommended to either continue or stop therapy and restart prophylaxis. Therapy must be continued until a minimum of two negative PCRs for infection, or for at least 6 weeks for disease. The pre-emptive approach is not indicated in seronegative HSCT recipients, after autologous transplantation, or in non-transplant haematology patients, but PCR should be performed with a high level of clinical suspicion.
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Affiliation(s)
- Robina Aerts
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium; Department of Internal Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Varun Mehra
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Andreas H Groll
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Department of Pediatric Hematology and Oncology, University Children's Hospital Münster, Münster, Germany
| | - Rodrigo Martino
- Servei d'Hematologia, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Katrien Lagrou
- Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Christine Robin
- Department of Haematology, Assistance Publique des Hôpitaux de Paris, Henri Mondor Hospital, Créteil, France
| | - Katia Perruccio
- Pediatric Oncology Hematology, Mother and Child Health Department, Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Nicole Blijlevens
- Department of Haematology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Marcio Nucci
- Department of Internal Medicine, University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Monica Slavin
- Department of Infectious Diseases and Sir Peter MacCallum Department of Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Stéphane Bretagne
- Université Paris Cité, and Parasitology and Mycology laboratory, Assistance Publique des Hôpitaux de Paris, Saint Louis Hospital, Paris, France
| | - Catherine Cordonnier
- Department of Haematology, Assistance Publique des Hôpitaux de Paris, Henri Mondor Hospital, Créteil, France; University Paris-Est-Créteil, Créteil, France.
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Xu C, Chen X, Zhu G, Yi H, Chen S, Yu Y, Jiang E, Zheng Y, Zhang F, Wang J, Feng S. Utility of plasma cell-free DNA next-generation sequencing for diagnosis of infectious diseases in patients with hematological disorders. J Infect 2023; 86:14-23. [PMID: 36462587 DOI: 10.1016/j.jinf.2022.11.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 11/07/2022] [Accepted: 11/22/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Plasma cell-free DNA Next-Generation Sequencing has been used as a non-invasive and comprehensive method for the etiological diagnosis of infectious diseases. However, only a handful of studies have described the real-world utility of this technique in patients with hematological disorders, a cohort of patients that are distinctive due to neutropenia and weakened immune functions. METHODS We retrospectively analyzed the results of plasma cell-free DNA sequencing performed on 184 and 163 specimens collected from hematological patients suspected of infections with (Group I) or without (Group II) neutropenia, respectively. The diagnostic performance and the clinical impact of plasma sequencing were comparatively evaluated to conventional microbiological tests and a composite reference standard (conventional tests combined with the clinical assessment). RESULTS The overall positive detection rate of plasma cell-free DNA sequencing was significantly higher than that of conventional microbiological tests (72.6% vs.31.4%, P < 0.001). The positive rate of conventional microbiological tests in Group I was lower than that in Group II (25.5% vs. 38.0%, P = 0.012). Combining plasma sequencing with conventional tests yielded a positive detection rate of 75.0% and 74.8% for these two groups, respectively. Using the composite reference standard, the sensitivity and specificity of plasma sequencing were 89.1% and 65.1%, respectively. The proportions of the positive impact of cell-free DNA sequencing results in the Group I were higher than in the Group II in terms of both diagnosis and treatment (diagnosis: 54.3% vs. 40.5%, P = 0.013; treatment: 45.7% vs.30.7%, P = 0.004). A total of 73 patients (21.0%) benefited from plasma sequencing through adjustment of the antibiotic regimen. CONCLUSIONS The diagnostic yield of conventional microbiological tests was low in patients with neutropenia. Combining conventional tests with plasma cell-free DNA sequencing significantly improved the detection rate for pathogens and optimized antibiotic treatment. Our findings on the clinical impact warrant confirmation through larger, multicenter, randomized controlled trials. Moreover, the cost-effectiveness of this testing strategy remains unknown and requires further exploration.
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Affiliation(s)
- Chunhui Xu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China; Microbiology laboratory, Tianjin Union Precision Medical Diagnostic Co., Ltd, 301617, Tianjin, China
| | - Xin Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Guoqing Zhu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Huiming Yi
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Shulian Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Yuetian Yu
- Department of Critical Care Medicine, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Erlie Jiang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Yizhou Zheng
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Fengkui Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Jianxiang Wang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Sizhou Feng
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.
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Aerts R, Mercier T, Beckers M, Schoemans H, Lagrou K, Maertens J. Toxoplasmosis after allogeneic haematopoietic cell transplantation: experience using a PCR-guided pre-emptive approach. Clin Microbiol Infect 2021; 28:440-445. [PMID: 34634458 DOI: 10.1016/j.cmi.2021.09.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 09/23/2021] [Accepted: 09/25/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Prophylaxis with trimethoprim-sulphamethoxazole (TMP-SMZ) is recommended in Toxoplasma-seropositive allogeneic haematopoietic cell transplant (HCT) recipients to prevent reactivation, but it is associated with numerous side effects. We report our experience of a pre-emptive approach guided by a polymerase chain reaction (PCR) in patients not receiving prophylaxis. METHODS In this retrospective, single-centre experience, seropositive recipients and seronegative recipients receiving a graft from a seropositive donor were screened by PCR for the presence of Toxoplasma gondii DNA in peripheral blood until at least 6 months after transplantation. Confirmed PCR positivity triggered a pre-emptive anti-Toxoplasma therapy. Cases of Toxoplasma reactivation (using the European Society for Blood and Marrow Transplantation definitions) were compared with four controls (without reactivation), matched in time and recipient serostatus, to identify risk factors for reactivation by multivariate analysis. RESULTS From November 2001 to August 2020, 1455 consecutive adult patients (59 cases and 1396 controls) were screened. The overall 1-year cumulative incidence of toxoplasmosis was 4.1% and the 1-year cumulative incidence in the seropositive recipients was 8.5%. Reactivation was associated with second transplant (OR 2.51, 95%CI 1.28-4.94, p 0.011), myeloablative conditioning (OR 2.24, 95%CI 1.17-4.41, p 0.011), total body irradiation (OR 2.29, 95%CI 1.17-4.44, p 0.010), acute graft-versus-host disease (GvHD) (OR 2.27, 95%CI 1.26-4.08, p 0.008) and use of high-dose corticosteroids (OR 2.08, 95%CI 1.14-3.78, p 0.018). In multivariate analysis only acute GvHD remained significant (adjusted OR 2.54, 95%CI 1.16-5.71, p 0.021). CONCLUSIONS A PCR-based pre-emptive approach might serve as an acceptable alternative for patients unable to start with or to continue TMP-SMZ prophylaxis. Acute GvHD was identified as the single independent predictor for reactivation.
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Affiliation(s)
- Robina Aerts
- Department of Internal Medicine, University Hospitals Leuven, Leuven, Belgium; Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Toine Mercier
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium; Department of Haematology, University Hospitals Leuven, Leuven, Belgium
| | - Mariëlle Beckers
- Department of Haematology, University Hospitals Leuven, Leuven, Belgium; Department of Oncology, KU Leuven, Leuven, Belgium
| | - Hélène Schoemans
- Department of Haematology, University Hospitals Leuven, Leuven, Belgium; Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Katrien Lagrou
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium; Department of Laboratory Medicine, University Hospitals, Belgium
| | - Johan Maertens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium; Department of Haematology, University Hospitals Leuven, Leuven, Belgium.
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Hoellinger B, Ursenbach A, Villard O, Guffroy B, Simand C, Lioure B. Unusual presentation of toxoplasmosis with gastro-intestinal involvement in HLA non-identical stem cell transplantation. Transpl Infect Dis 2021; 23:e13616. [PMID: 33871919 DOI: 10.1111/tid.13616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 02/23/2021] [Accepted: 04/05/2021] [Indexed: 01/14/2023]
Abstract
Toxoplasmosis is a life-threatening infection in allogenic stem cell recipients usually involving the brain or retina and more rarely lungs or bone marrow. Digestive involvement has only been reported in AIDS patient. We report about a 38-year-old man who received a haploidentical allograft for acute myeloid leukemia and developed an unusual digestive presentation with severe protein-losing enteropathy following grade III acute digestive GvHD treated with steroids and ruxolitinib. Diagnosis was brought up because of concomitant brain involvement. Digestive symptoms fully recovered after treatment with sulfamethoxazole-trimethoprim. Digestive toxoplasmosis could be considered as a differential diagnosis or complication of severe digestive GvHD.
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Affiliation(s)
- Baptiste Hoellinger
- Department of Infectious Diseases, University Hospital of Strasbourg, Strasbourg, France
| | - Axel Ursenbach
- Department of Infectious Diseases, University Hospital of Strasbourg, Strasbourg, France
| | - Odile Villard
- Parasitology Department, University Hospital of Strasbourg, Strasbourg, France
| | - Blandine Guffroy
- Department of Hematology, ICANS (Institut for Cancer Strasbourg-Europe), Strasbourg, France
| | - Célestine Simand
- Department of Hematology, ICANS (Institut for Cancer Strasbourg-Europe), Strasbourg, France
| | - Bruno Lioure
- Department of Hematology, ICANS (Institut for Cancer Strasbourg-Europe), Strasbourg, France
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Arshadi M, Akhlaghi L, Meamar AR, Alizadeh Ghavidel L, Nasiri K, Mahami-Oskouei M, Mousavi F, Rampisheh Z, Khanmohammadi M, Razmjou E. Sero-molecular detection, multi-locus genotyping, and clinical manifestations of ocular toxoplasmosis in patients in northwest Iran. Trans R Soc Trop Med Hyg 2020; 113:195-202. [PMID: 30624725 DOI: 10.1093/trstmh/try137] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 11/23/2018] [Accepted: 12/05/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Our goal was to use molecular techniques to verify and characterise clinical diagnoses of ocular toxoplasmosis. Clinical cases were evaluated against IgM and IgG Toxoplasma antibodies, and IgG avidity was tested. B1 gene was assessed for molecular detection, and multi-locus genotyping were conducted to type Toxoplasma infections. METHODS A cross-sectional study was conducted in 33 patients with suspected active ocular toxoplasmosis. Patients were examined by an ophthalmologist and clinical manifestations were recorded. Toxoplasma gondii IgG and IgM from serum samples were analysed by chemiluminescence immunoassay and ELISA. Acute vs chronic infection was evaluated by IgG avidity testing. Molecular diagnosis of T. gondii infection targeted the B1 gene, and the T. gondii genotype was determined by amplification of the GRA6, SAG2, SAG3, BTUB and APICO loci. The correlation of age, gender, occupation, education, contact with cats or soil, and the consumption of undercooked meat with the incidence of ocular toxoplasmosis was evaluated. RESULTS Twenty-eight patients (84.8%) were seropositive, two (6%) were both IgG and IgM positive, while one (3%) showed IgG avidity <40%. Molecular testing confirmed toxoplasmosis in 27 patients (81.8%). Chorioretinal scarring (p=0.014) and posterior uveitis (p=0.004) was significantly associated with ocular toxoplasmosis patients. Multi-locus genotyping showed genotype I. Ocular toxoplasmosis showed no significant correlation with gender, age, behaviours, occupation or education. CONCLUSION Clinical manifestations, serological and molecular detection of Toxoplasma were highly correlated in the diagnosis of ocular toxoplasmosis. Genotype I was predominant in ocular toxoplasmosis in northwest Iran. A larger comparative study should be conducted to provide a broader view of the molecular epidemiology of T. gondii genotypes and its role in toxoplasmosis.
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Affiliation(s)
- Mehdi Arshadi
- Department of Parasitology and Mycology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Lame Akhlaghi
- Department of Parasitology and Mycology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Ahmad Reza Meamar
- Department of Parasitology and Mycology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Leila Alizadeh Ghavidel
- Department of Ophthalmology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Kamal Nasiri
- Department of Ophthalmology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mahmoud Mahami-Oskouei
- Department of Parasitology and Mycology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Farideh Mousavi
- Department of Ophthalmology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Zahra Rampisheh
- Preventive Medicine and Public Health Research Center, Iran University of Medical Sciences, Tehran, Iran.,Department of Community Medicine, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Majid Khanmohammadi
- Department of Parasitology and Mycology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Elham Razmjou
- Department of Parasitology and Mycology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
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Safdar A, Pouch SM, Scully B. Infections in Allogeneic Stem Cell Transplantation. PRINCIPLES AND PRACTICE OF TRANSPLANT INFECTIOUS DISEASES 2018. [PMCID: PMC7121717 DOI: 10.1007/978-1-4939-9034-4_11] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HSCT) has become a widely used modality of therapy for a variety of malignant and nonmalignant diseases. Despite advances in pharmacotherapy and transplantation techniques, infection remains one of the most severe and frequently encountered complications of allo-HSCT. This chapter will address the risk factors for development of infection following allo-HSCT, including those related to the host, the conditioning regimen, and the graft, as well as the timing of opportunistic infections after allo-HSCT. The most common bacterial, viral, fungal, and parasitic infections, as well as issues surrounding their diagnostics and treatment, will be discussed. Finally, this chapter will address vaccination and other preventative strategies to be utilized when caring for patients undergoing allo-HSCT.
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Affiliation(s)
- Amar Safdar
- grid.416992.10000 0001 2179 3554Clinical Associate Professor of Medicine, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX USA
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Senoo Y, Sekiya N, Sasaki S, Yoshioka K, Watakabe-Inamoto K, Hagino T, Muto H, Najima Y, Igarashi A, Doki N, Kobayashi T, Kakihana K, Sakamaki H, Ohashi K. Diagnostic open brain biopsy following initial negative results of cerebrospinal fluid assessment for Toxoplasma. Transpl Infect Dis 2017; 19. [PMID: 28100042 DOI: 10.1111/tid.12666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 10/21/2016] [Accepted: 11/13/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Yasushi Senoo
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Noritaka Sekiya
- Department of Laboratory Medicine, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Shugo Sasaki
- Department of Laboratory Medicine, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Kosuke Yoshioka
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Kyoko Watakabe-Inamoto
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Takeshi Hagino
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Hideharu Muto
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Yuho Najima
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Aiko Igarashi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Noriko Doki
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Takeshi Kobayashi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Kazuhiko Kakihana
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Hisashi Sakamaki
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Kazuteru Ohashi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
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Immunity to Infections after Haploidentical Hematopoietic Stem Cell Transplantation. Mediterr J Hematol Infect Dis 2016; 8:e2016057. [PMID: 27872737 PMCID: PMC5111540 DOI: 10.4084/mjhid.2016.057] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 09/21/2016] [Indexed: 02/06/2023] Open
Abstract
The advantage of using a Human Leukocyte Antigen (HLA)-mismatched related donor is that almost every patient who does not have an HLA-identical donor or who urgently needs hematopoietic stem cell transplantation (HSCT) has at least one family member with whom shares one haplotype (haploidentical) and who is promptly available as a donor. The major challenge of haplo-HSCT is intense bi-directional alloreactivity leading to high incidences of graft rejection and graft-versus-host disease (GVHD). Advances in graft processing and pharmacologic prophylaxis of GVHD have reduced these risks and have made haplo-HSCT a viable alternative for patients lacking a matched donor. Indeed, the haplo-HSCT has spread to centers worldwide even though some centers have preferred an approach based on T cell depletion of G-CSF-mobilized peripheral blood progenitor cells (PBPCs), others have focused on new strategies for GvHD prevention, such as G-CSF priming of bone marrow and robust post-transplant immune suppression or post-transplant cyclophosphamide (PTCY). Today, the graft can be a megadose of T-cell depleted PBPCs or a standard dose of unmanipulated bone marrow and/or PBPCs. Although haplo-HSCT modalities are based mainly on high intensity conditioning regimens, recently introduced reduced intensity regimens (RIC) showed promise in decreasing early transplant-related mortality (TRM), and extending the opportunity of HSCT to an elderly population with more comorbidities. Infections are still mostly responsible for toxicity and non-relapse mortality due to prolonged immunosuppression related, or not, to GVHD. Future challenges lie in determining the safest preparative conditioning regimen, minimizing GvHD and promoting rapid and more robust immune reconstitution.
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Villard O, Cimon B, L'Ollivier C, Fricker-Hidalgo H, Godineau N, Houze S, Paris L, Pelloux H, Villena I, Candolfi E. Serological diagnosis of Toxoplasma gondii infection: Recommendations from the French National Reference Center for Toxoplasmosis. Diagn Microbiol Infect Dis 2015; 84:22-33. [PMID: 26458281 DOI: 10.1016/j.diagmicrobio.2015.09.009] [Citation(s) in RCA: 124] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 09/03/2015] [Accepted: 09/09/2015] [Indexed: 11/17/2022]
Abstract
Toxoplasmosis manifests no clinical signs in 80% of cases in immunocompetent patient, causing immunization characterized by the persistence of cysts, particularly in brain, muscles, and retina. Assessing the serological status, based on testing for serum toxoplasma IgG and IgM antibodies, is essential in cases that are increasingly at risk for the more severe disease forms, such as congenital or ocular toxoplasmosis. This disease also exposes immunosuppressed patients to reactivation, which can lead to more widespread forms and increased mortality. By interpreting the serological results, we can estimate the risk of contamination or reactivation and define appropriate prophylactic and preventive measures, such as hygienic and dietetic, therapeutic, biological, and clinical follow-up, according to the clinical context. We hereby propose practical approaches based on serological data, resulting from a consensus of a group of experts from the French National Reference Center Network for Toxoplasmosis, according to both routine and specific clinical situations.
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Affiliation(s)
- O Villard
- Institut de Parasitologie et de Pathologie Tropicale de Strasbourg, Université de Strasbourg, Hôpitaux Universitaires de Strasbourg, 1-3 rue Koeberlé, F-67000 Strasbourg, France.
| | - B Cimon
- Laboratoire de Parasitologie-Mycologie, Centre Hospitalier Universitaire, 4 rue Larrey, F-49933 Angers Cedex 9, France
| | - C L'Ollivier
- Laboratoire de Parasitologie-Mycologie, Hôpital de la Timone, 264 rue Saint Pierre, F-13385 Marseille Cedex 05, France
| | - H Fricker-Hidalgo
- Laboratoire de Parasitologie-Mycologie, Centre Hospitalier Universitaire A. Michallon et Université de Grenoble BP 217, 38043 Grenoble Cedex, France
| | - N Godineau
- Laboratoire de Parasitologie-Mycologie, Centre Hospitalier de Saint-Denis, 2 rue du Docteur Pierre Delafontaine, BP 279, F-93205 Saint-Denis Cedex, France
| | - S Houze
- Laboratoire de Parasitologie Mycologie, AP-HP Hôpital BICHAT-Claude Bernard, 46 rue Henri Huchard, F-75877 Paris Cedex 18, France
| | - L Paris
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Laboratoire de Parasitologie-Mycologie, 47-83 Boulevard de l'Hôpital, F-75651 Paris Cedex 13, France
| | - H Pelloux
- Laboratoire de Parasitologie-Mycologie, Centre Hospitalier Universitaire A. Michallon et Université de Grenoble BP 217, 38043 Grenoble Cedex, France
| | - I Villena
- Laboratoire de Parasitologie-Mycologie, Hôpital Maison Blanche, Centre Hospitalier Universitaire et Université de Reims Champagne Ardennes, 45 rue Cognacq-Jay, F-51092 Reims Cedex, France
| | - E Candolfi
- Institut de Parasitologie et de Pathologie Tropicale de Strasbourg, Université de Strasbourg, Hôpitaux Universitaires de Strasbourg, 1-3 rue Koeberlé, F-67000 Strasbourg, France.
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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.
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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
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11
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Sumi M, Aosai F, Norose K, Takeda W, Kirihara T, Sato K, Fujikawa Y, Shimizu I, Ueki T, Hirosima Y, Ueno M, Ichikawa N, Watanabe M, Kobayashi H. Acute exacerbation of Toxoplasma gondii infection after hematopoietic stem cell transplantation: five case reports among 279 recipients. Int J Hematol 2013; 98:214-22. [PMID: 23749548 DOI: 10.1007/s12185-013-1379-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Revised: 05/22/2013] [Accepted: 05/28/2013] [Indexed: 11/30/2022]
Abstract
Toxoplasmosis is a rare and possibly underestimated complication following hematopoietic stem cell transplantation (HSCT) associated with a high mortality rate, although the incidence of toxoplasmosis after HSCT in Japan has not been established. We retrospectively studied patients with toxoplasmosis after HSCT, and identified five patients who had been diagnosed with an acute exacerbation of toxoplasmosis among 279 HSCT recipients at our institution between 1998 and 2011, representing an incidence of 1.8 %. Among 87 autologous HSCT recipients, one definite case was diagnosed. The serological test for Toxoplasma gondii before HSCT was positive in 18 of 192 allogeneic HSCT recipients. Of the 18 seropositive patients, three had definite infections, and one had possible infection. All four definite cases were diagnosed at autopsy. In the definite cases, three allogeneic HSCT recipients had disseminated or pulmonary toxoplasmosis and one autologous HSCT recipient had toxoplasmic encephalitis, although toxoplasmosis was not suspected at the premortem examination due to non-specific clinical and radiological manifestations. Thus, acute exacerbation of toxoplasmosis should be suspected in recipients after HSCT. Early diagnosis and treatment for toxoplasmosis would certainly contribute to a decrease in mortality after HSCT.
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Affiliation(s)
- Masahiko Sumi
- Department of Hematology, Nagano Red Cross Hospital, 5-22-1 Wakasato, Nagano City, Nagano 380-8582, Japan.
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12
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Pott S, Koethe M, Bangoura B, Zöller B, Daugschies A, Straubinger RK, Fehlhaber K, Ludewig M. Effects of pH, sodium chloride, and curing salt on the infectivity of Toxoplasma gondii tissue cysts. J Food Prot 2013; 76:1056-61. [PMID: 23726205 DOI: 10.4315/0362-028x.jfp-12-519] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Toxoplasma gondii is one of the most common zoonotic parasites in the world. The parasite causes no or mild symptoms in immunocompetent humans. However, a high potential hazard exists for seronegative pregnant women and immunocompromised patients. The consumption of meat containing tissue cysts or oocyst-contaminated vegetables and fruits or the handling of cat feces poses a high risk of infection with T. gondii. It is known that raw minced meat, raw fresh sausages, and locally produced raw meat products are possible causes of T. gondii infection. The infectivity of T. gondii tissue cysts in meat products depends, among other factors, on the pH and the salt concentration. Therefore, the impact of these two factors on the tissue cysts was examined. For this purpose, dissected musculature and brain from experimentally infected mice (donor mice) were placed in a cell culture medium (RPMI 1640). The medium was adjusted to different pH values (pH 5, 6, and 7) with lactic acid and to different salt concentrations (2.0, 2.5, and 3.0%) with sodium chloride (NaCl) or nitrite-enriched curing salt (NCS) for the various tests. After storage at 4°C for different time periods, the materials were fed to bioassay mice. Later, the brains were examined for presence of T. gondii to assess the infectivity. The data show that T. gondii tissue cysts have a high pH tolerance. Cysts were infectious in the muscle for up to 26 days (pH 5). In contrast to their tolerance to pH, cysts were very sensitive to salt. Muscle cysts survived at an NaCl concentration of up to 2.0% only, and for no longer than 8 days. At NaCl concentrations of 2.5 and 3.0%, the cysts lost their infectivity after 1 day. When NCS instead of NaCl was used under the same conditions, T. gondii muscle cysts retained infectivity for only 4 days at 2.0%. Consequently, NCS (NaCl plus 0.5% nitrite) has a stronger effect on T. gondii cysts than does common table salt. Sausages produced with low NaCl concentration and short contact times pose a potential risk for susceptible individuals.
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Affiliation(s)
- S Pott
- Institute of Food Hygiene, University of Leipzig, An den Tierkliniken 1, 04103 Leipzig, Germany
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13
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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: 983] [Impact Index Per Article: 81.9] [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.
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Affiliation(s)
- Florence Robert-Gangneux
- Service de Parasitologie, Faculté de Médecine et Centre Hospitalier Universitaire de Rennes, Rennes, France.
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14
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Sumi M, Hata S, Sato K, Fujikawa Y, Shimizu I, Ueki T, Akahane D, Ueno M, Ichikawa N, Kobayashi H. Severe pulmonary toxoplasmosis mimicking viral pneumonitis after a third allogeneic stem cell transplantation in a man with acute lymphoblastic leukemia. Intern Med 2012; 51:2943-7. [PMID: 23064573 DOI: 10.2169/internalmedicine.51.7837] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 22-year-old man with acute lymphoblastic leukemia underwent allogeneic stem cell transplantation (allo-SCT) twice, then underwent allo-SCT a third time due to relapse. On day 27, he developed acute respiratory distress, and bilateral interstitial infiltrates were noted on CT images. Despite receiving intensive treatment, the patient died on day 32 from progressive respiratory failure. An autopsy revealed evidence of diffuse alveolar damage caused by the genus Toxoplasma. At present, toxoplasmosis is considered to be a rare infectious complication in Japan. However, the actual incidence of toxoplasmosis may be higher than currently believed due to a lack of suspicion of the diagnosis in patients, difficulty in making a diagnosis and low autopsy rates.
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Affiliation(s)
- Masahiko Sumi
- Department of Hematology, Nagano Red Cross Hospital, Japan.
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15
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Identification of Toxoplasma gondii SUB1 antigen as a marker for acute infection by use of an innovative evaluation method. J Clin Microbiol 2011; 49:2419-25. [PMID: 21543561 DOI: 10.1128/jcm.00464-11] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
By the separation of Toxoplasma lysate using two-dimensional gel electrophoresis and its analysis with human serum samples and mass spectrometry, the subtilisin-like protein (SUB1) was identified to be a potential marker for acute toxoplasmosis. Following expression of the C-terminal domain of SUB1 in Escherichia coli, it was tested in a line blot assay using a total of 80 human serum samples. Two computer programs based on different evaluation strategies were used for judgment of the line blot results: (i) a time-dependent method with a predefined cutoff value and (ii) a fixed-time-point method with a calculated cutoff. Thereby, SUB1 was proven to be rather reactive with specific immunoglobulin A (IgA), IgM, and IgG of patients with an acute infection. This finding makes this antigen an attractive candidate for improving diagnosis of toxoplasmosis and demonstrates that not only the selection of respective antigens but also the evaluation method chosen are important for the evaluation of new diagnostic markers.
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16
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Bories P, Zink E, Mattern JF, Villard O, Berceanu A, Bilger K, Candolfi E, Herbrecht R, Abou-Bacar A, Lioure B. Febrile pancytopenia as uncommon presentation of disseminated toxoplasmosis after BMT. Bone Marrow Transplant 2011; 47:301-3. [PMID: 21423121 DOI: 10.1038/bmt.2011.62] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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