Genotyping of Toxoplasma gondii strain directly from human CSF samples of congenital toxoplasmosis clinical case

This report describes a case of congenital toxoplasmosis in a newborn in Southern Italy. A pregnant mother had been admitted at the 20th week of her pregnancy on account of pharyngodynia and laterocervical lymphadenopathy. Although serological testing of the mother's serum documented a seroconversion with positive IgG and IgM anti-Toxoplasma antibodies during II trimester, the woman refused to perform prenatal diagnosis for congenital toxoplasmosis. Fetal ultrasound scan already showed mild asymmetrical triventricular hydrocephaly and cerebral calcifications. After birth, real-time PCR on cerebrospinal fluid and blood samples of the newborn showed a positive result for 529bp-repeat element DNA of T. gondii, In addition brain magnetic resonance imaging and computed tomography showed a characteristic diffuse brain tissue loss associated with hydrocephalus. For the first time molecular characterization of T. gondii isolate was performed directly from the newborn's CSF samples by using nested-PCR-RFLP of sag-2 and pk1 genes. The PCR-RLFP analysis revealed that the isolate belongs to the clonal type II, the predominant lineage causing human toxoplasmosis, as confirmed by DNA sequencing.

Agreement between ultrasonography and computed tomography in detecting intracranial calcifications in congenital toxoplasmosis

AIM

To evaluate the agreement between ultrasound (US) and computed tomography (CT) in detecting intracranial calcification in infants with congenital toxoplasmosis.

MATERIALS AND METHODS

Forty-four infants referred for investigation of congenital toxoplasmosis were prospectively evaluated, and the diagnosis was confirmed or ruled out by serological testing and by follow-up in the first year of life. The investigation protocol included cranial US and cranial CT, and examinations were conducted and interpreted by two radiologists blinded to the results of the other imaging test and to the diagnostic confirmation.

RESULTS

The diagnosis of congenital toxoplasmosis was confirmed in 33 patients, and agreement between US and CT findings was found in 31 of these cases. Both methods detected calcifications in 18 patients, and neither detected calcifications in 13 patients. Overall agreement was 94% and the kappa coefficient was 0.88 (95% confidence interval: 0.71, 1; p<0.001), which revealed almost perfect agreement between the two diagnostic methods.

CONCLUSION

In this study, US and CT demonstrated equal sensitivity in the detection of intracranial calcification in infants with congenital toxoplasmosis.

[Contribution of the real time PCR in antenatal diagnosis of congenital toxoplasmosis]

BACKGROUND

The antenatal diagnosis of congenital toxoplasmosis rests in Tunisia on ultrasonography coupled with biological explorations. Among these explorations the search of Toxoplasma gondii by means of real time PCR in amniotic fluid is the examination of choice.

AIM

We report the results of 33 parturients for which the biological examinations allowed to retain the notion of perigravidic or pergravidic toxoplasmic infection.

METHODS

They were 13 patients having a seroconversion during the pregnancy, 19 having anti-toxoplasmic IgM with a low or intermediate index of avidity and a patient having presented a symptomatic anteconceptional primary infection. The ADN was extracted by means of the Kit (Qiagen). Genic amplification by PCR TaqMan targeted a portion of 71 pairs of bases of the B 1 gene.

RESULTS

The PCR was positive among 9 patients (27.3%). They were a patient having presented a symptomatic toxoplasmosis during the pregnancy, 4 patients having consulted only in the 2nd quarter and for which the index of avidity was intermediate and 4 patients having presented seoconversions of 1st (n=1) of 2nd (n=2) or 3rd trimester. Among these patients, 2 had a medical interruption of pregnancy. The 7 others were put under pyrimethamine sulfadiazine. The neonatal assessment practised at 5 new-born babies was negative in all the cases. The PCR was negative for 24 patients. 18 pregnancies were followed. The neonatal serology was negative. The follow-up of 13 newborn child showed the disappearance of the antitoxoplasmic IgG between the 6th and 12th month.

Outcome for children infected with congenital toxoplasmosis in the first trimester and with normal ultrasound findings: a study of 36 cases

OBJECTIVE

We wished to investigate the prognosis of children infected with Toxoplasma gondii during the first trimester of pregnancy and whose ultrasound findings were entirely normal, in order to find out whether congenital toxoplasmosis did or did not justify termination of pregnancy if there was no fetal abnormality on ultrasound.

STUDY DESIGN

A prospective and retrospective study was carried out by 12 French centers who enrolled 36 children infected with T. gondii during the first trimester of pregnancy and whose ultrasound examinations showed no anomaly. The outcome of these children after the age of 12 months (mean 50 months, range 12-144 months) was analyzed.

RESULTS

Of the 36 infected children, 28 (78%) presented subclinical toxoplasmosis. Only specific IgG antibodies persisted after 1 year. The principal manifestation in 7 children (19%) was chorioretinitis without major vision loss. Their intellectual development was entirely normal. One child (3%) developed severe congenital toxoplasmosis.

CONCLUSION

Since 97% of children infected with toxoplasmosis during the first trimester of pregnancy are asymptomatic or only slightly affected, we believe that in such circumstances termination of pregnancy is not indicated. However, appropriate treatment is essential and prenatal ultrasound examinations should be free of any anomaly.

Too Late Prenatal Diagnosis of Fetal Toxoplasmosis: A Case Report

OBJECTIVE

We describe a case of severe fetal hydrocephalus due to toxoplasmosis which could not be diagnosed until late gestational age due to the lack of a serologic surveillance program during pregnancy; moreover, this case points to the usefulness of molecular biology tools in the diagnostic process. Abnormal ultrasound in the 2nd trimester was noticed and Toxoplasma gondii was demonstrated in amniotic fluid at the 28th week of gestation both by PCR and by mice inoculation. Fansidar and folinic acid were administered. The newborn suffered from progressive hydrocephalus, seizures, and pathological muscular tonus; ultrasound examination showed massive cerebral calcifications. Ophthalmologic examination revealed bilateral choroidoretinitis. Congenital toxoplasmosis was confirmed by the detection of anti- T. gondii IgM and IgA in the neonatal serum.

CONCLUSION

The presented case is an example of severe fetal toxoplasmosis diagnosed and treated in utero.

Estudo pré-natal da hiper-refringência endocárdica fetal e sua relação com toxoplasmose materna

OBJECTIVE

To compare a group of fetuses whose mothers had acute or recent toxoplasmosis with a group of fetuses whose mothers had no systemic disease, analyzing the presence of changes in endocardial refringence.

METHODS

This study assessed 91 fetuses of mothers diagnosed with acute or recent toxoplasmosis, detected by seroconversion or the presence of elevated IgM and IgG titers, confirmed through the IgM-capture ELISA. They were compared with a control group comprising 182 fetuses selected from a low-risk population participating in a prenatal screening program for heart diseases.

RESULTS

No significant difference was observed between the mean gestational (29.2+/-4.6 weeks; 29.2+/-4.6 weeks) and maternal (25.7+/-6.7 years; 26+/-5.4 years) ages in the 2 groups. Areas of endocardial hyperechogenicity were observed in 69 fetuses whose mothers had toxoplasmosis (75.8%) and in only 6 fetuses of the control group (3.3%) (P<0.001). In 52 patients of the group studied (75.4%), endocardial hyperrefringence was diffuse, and, in 17 (24.3%), it was focal. In the control group, focal distribution was observed in 5 fetuses (83.3%).

CONCLUSION

The prenatal echocardiographic image of focal or diffuse endocardial hyperrefringence is more prevalent in pregnancies with maternal toxoplasmosis than in the healthy ones, and an association between fetal endocardial hyperechogenicity and maternal disease exists.

Fetal toxoplasmosis and negative amniocentesis: necessity of an ultrasound follow-up

Prenatal diagnosis of congenital toxoplasmosis relies on the PCR test on amniotic fluid and ultrasound follow-up of the fetus. We report two cases of toxoplasma infection during the first trimester of gestation with a discrepant diagnosis of fetal infection. PCR performed more than four weeks after the estimated date of contamination was negative. Ultrasound follow-up was normal up to the third trimester when major hydrocephalus was detected, leading to pregnancy termination. In both cases, post-mortem examination revealed a diffuse infection with severe brain lesions. These observations confirm the necessity to continue a monthly ultrasound follow-up, even if amniocentesis is negative, in case of fetal toxoplasma infection in pregnancy.

Imaging of an atypical case of congenital toxoplasmosis

In this article we describe the cranial computerized tomography findings of an infant with congenital toxoplasmosis, which was performed because she showed an atypical clinical course consisting of meningitis and multiple cerebral abscesses. In this case the cranial computerized tomography allowed the diagnosis of hydrocephalus and multiple cerebral abscesses, and guided the therapeutic approach.

Three-dimensional ultrasonography in obstetrics: the clinical value

To investigate the clinical value of three-dimensional ultrasonography (3DUS) in obstetrics, various 3DUS rendering methods including surface mode, transparent mode and multiplanar mode were employed to scan 30 fetuses in second and third trimester by using the transabdominal volume transducer. The results showed that surface mode could vividly demonstrate the surface morphologic features of the fetuses, as well as the stereo-shape and the spatial relationship among the surface structures. The face, limbs, umbilical cord and outer genitalia of the fetus could be well displayed by surface mode. Transparent mode could reveal the bony structures under the surface, such as ribs, vertebrae, crania, etc. The result was not affected by the sophisticated curvature of these bony structures and the success rate was up to 100%. When rendered by multiplanar mode, the region of interest (ROI) could be viewed from different directions. It should be concluded that 3DUS could serve as a supplement to two-dimensional ultrasonography (2DUS). 3DUS might play an important role in prenatal diagnosis and enhance the diagnostic confidence level of the physicians.

Incidence and clinical significance of echogenic vasculature in the basal ganglia of newborns

Cranial sonography has become the main modality of the investigation and diagnosis of a wide variety of neonatal intracranial abnormalities. Occasionally, cranial sonograms reveal basal ganglia and thalami bright echoes. It is believed that these lesions are indicative of vasculitis due to intrauterine infections, in particular with cytomegalovirus (CMV). We hypothesized that the incidence of proven neonatal intrauterine TORCH infection is low and that screening of all asymptomatic infants with bright lenticulostriate echodensities would not be cost-effective. We reviewed brain sonograms of 3700 infants, performed over a period of 3 1/2 years. Echogenic basal ganglia vasculature were observed in 75 patients (2%). Chart review performed for clinical presentation and TORCH studies showed that only one infant had confirmed intrauterine congenital infection, which was by CMV. This infant had no signs or symptoms of CMV. In addition, there were 4 patients with chromosomal anomalies among the 75 patients (5%), of these one had trisomy 13 and another-trisomy 21. Our results indicate that echogenic basal ganglia blood vessels are not an exceptional finding on cranial sonograms, and are seldom associated with intrauterine infection. We conclude that it is not cost-effective to screen infants with echogenic basal ganglia blood vessels for intrauterine infection, unless clinical suspicion exists.

Fetal cataract in congenital toxoplasmosis

We report a case of the prenatal diagnosis of fetal cataract due to congenital toxoplasmosis. To the best of our knowledge, this is the first report of such a case. We discuss the long-term ocular sequelae of the condition and how they should affect prenatal counselling.

Congenital toxoplasmosis: prenatal diagnosis, treatment and postnatal outcome

We report a female patient with congenital toxoplasmosis who presented with hydrops fetalis and cerebral abnormalities, detected on fetal ultrasound. Following prenatal treatment, the hydrops fetalis resolved and at four months of age she has normal growth and development. This case emphasizes the potential good prognosis in cases with congenital toxoplasmosis detected and treated prenatally.

Radiological signs in newborns exposed to primary Toxoplasma infection in utero

A total of 44 181 serum samples from 16 733 pregnant women were analyzed for findings suggesting primary Toxoplasma infection. Thirty-seven newborns exposed to maternal primary Toxoplasma infection in utero were studied prospectively with ultrasound, CT, and MRI for signs of intrauterine infection. Their mothers had been treated during pregnancy, and all infants were treated. The children were assigned to three groups according to their mothers' serological status, and the radiological results were compared with the clinical outcome. Although radiological signs were scarce, ultrasound findings combined with maternal serology were found to be significantly related to clinical outcome.

Ascending paralysis due to myelitis in a newborn with congenital toxoplasmosis

We present a female neonate in her second week of life with borderline microcephaly, microphthalmia and progressive ascending sensory and motor deficit leading to complete paralysis with respiratory failure and death at 27 days of age. Neurological imaging revealed, in addition to cerebral atrophy, marked hydrocephalus, ependymal basal ganglia calcification, leptomeningeal enhancement, and patchy myelitis throughout the entire spinal cord. CSF cytological examination revealed the presence of a mononuclear pleocytosis with Toxoplasma gondii trophozoites free in the CSF and within the cytoplasm of some macrophages, and a 100-fold raised protein content. To our knowledge, this is the first reported case of clinical acute spinal cord involvement in congenital toxoplasma infection, proven by the presence of toxoplasma trophozoite in the CSF.

Resolution of intracranial calcifications in infants with treated congenital toxoplasmosis

PURPOSE

To determine the natural history of intracranial calcifications in infants with treated congenital toxoplasmosis.

MATERIALS AND METHODS

Between January 1982 and March 1994, cranial computed tomography was performed in 56 infants with treated congenital toxoplasmosis when they were newborns and approximately 1 year old. Locations and sizes of intracranial calcifications were noted.

RESULTS

Forty newborns had intracranial calcifications. By 1 year of age, calcifications diminished or resolved in 30 (75%) and remained stable in 10 (25%) of these treated infants. Ten (33%) of the 30 infants whose calcifications diminished versus seven (70%) of the 10 infants with stable calcifications received less intensive antimicrobial treatment than the other treated infants. In contrast, a small number of infants who were untreated or treated 1 month or less had intracranial calcifications that increased or remained stable during their 1st year of life.

CONCLUSION

Diminution or resolution of intracranial calcifications was an unexpected and remarkable finding in infants with treated, congenital toxoplasmosis, consonant with their improved neurologic functioning.

Cranial disjunction and visual failure in a slit ventricle syndrome with patent shunt

A 6.5-year-old child who received a shunt at 3 weeks of age for triventricular hydrocephalus related to his congenital toxoplasmosis developed symptoms of intracranial hypertension and papilloedema. Computed tomographic scan demonstrated slit ventricles. The shunt device was shown to be patent on isotope transit study. Spontaneously the cranial sutures widened and headaches disappeared, but loss of vision occurred and did not reverse despite optic nerve sheath fenestration. We suspect that a rapid drop in intracranial pressure played a role in the pathogenesis of our patient's blindness. This possible complication should be taken into account when calvarial expansion is planned in a patient with an intracranial hypertension syndrome with papilloedema in the presence of slit ventricles and a patent shunt.

Congenital toxoplasmosis complicated by central diabetes insipidus in an infant with Down syndrome

We describe an infant with the unusual combination of Down syndrome, congenital toxoplasmosis, and central diabetes insipidus. Hydrocephalus was documented by fetal ultrasonography at 36 weeks' gestation. He developed central diabetes insipidus as a neonate, followed by interstitial pneumonia, anemia, and hepatosplenomegaly. The patient's serum titer for Toxoplasma-specific IgM (ELISA) at 37 days after delivery was negative, but the Toxoplasma SAG1 gene was detected from the cells of the cerebrospinal fluid on the same day using the polymerase chain reaction (PCR) method. Congenital toxoplasmosis can contribute to the development of central diabetes insipidus in infants. PCR was useful in diagnosing congenital toxoplasmosis rapidly and accurately.

Congenital toxoplasmosis in twins: a case report

We report a case of congenital toxoplasmosis in a twin pregnancy at 21 weeks of gestation. The complete antenatal investigation included ultrasound examination, cordocentesis and amniocentesis. The ultrasonographic evaluation showed a distinct morphological aspect confirmed by the fetal biological profile. The time lag between placental and fetal infection, or the immunological fetal responses could explain the varying stages of the fetal disease. This is another case which early demonstrates that there may exist a distinct clinical pattern in bichorial pregnancy with varying biological fetal responses. It underlines the importance of cordocentesis in the case of maternal toxoplasma seroconversion, enabling us to gather a maximum number of biological data for complete appreciation of the fetal status. The information obtained permits a precise adaptation of the medical decision.

[Congenital toxoplasmosis in a 6-week-old infant]

A case of congenital toxoplasmosis was observed in an infant aged 6 weeks with fatal outcome. Histological changes produced by Toxoplasma gondii in the brain are described.

Linear areas of echogenicity in the thalami and basal ganglia of neonates: an expanded association. Work in progress

A retrospective review of 2,320 neonatal cranial sonograms obtained in 1,324 patients identified 25 patients with areas of echogenicity in their thalami and basal ganglia that were of a linear or branching linear distribution. Four of these patients had cytomegalovirus infection. Other major diagnoses encountered included Down syndrome, trisomy 13 syndrome, neonatal asphyxia, non-immune hydrops, and fetal alcohol syndrome. Results of the study suggest a broader etiologic basis for linear areas of echogenicity in the basal ganglia and thalami of children than has previously been reported. These patients warrant complete screening for possible in utero infection and perhaps also chromosomal analysis.

Results of a preventive program for congenital toxoplasmosis

All pregnant women followed during the period 1982-87 were screened for toxoplasmosis, and 35 patients had documented seroconversion or doubtful toxoplasmosis titers. One patient opted for pregnancy termination. The remaining were followed with a protocol that included serial ultrasound examinations and prophylactic antibiotic treatment of the mother and neonate. No fetal abnormalities related to congenital toxoplasmosis were found. All the infants had negative toxoplasmosis test titers at birth; at follow-up only one was found to have developed a subclinical infection, at 2 months of age. Our data suggest that antiparasitic treatment during pregnancy for those at risk for Toxoplasma infection may reduce the transmission rate.

Pachygyriclike changes: topographic appearance at MR imaging and CT and correlation with neurologic status

Studies of 23 pediatric patients with pachygyriclike changes (PLCs) examined with computed tomography (CT) and magnetic resonance (MR) imaging were reviewed to determine topographic patterns and correlate them with various clinical syndromes and degrees of neurologic impairment. Three types of topographic distributions were identified: unilateral, diffuse, and bilateral nondiffuse (of which eight of 10 showed frontotemporal predominance). PLCs were an isolated finding in seven patients, were associated with various congenital syndromes in nine patients, and were associated with congenital infection in seven patients, six of whom showed marked white matter abnormalities. Although most patients had severe developmental delay, three with nondiffuse PLCs had less severe impairment, permitting less required care.

Congenital toxoplasmosis in a 15 day-old infant. A case report

A case congenital toxoplasmosis in a 15-day old infant was reported, citing the difficulties encountered in establishing the diagnosis due to the wide range of the disease's clinical spectrum. Congenital toxoplasmosis was suspected after finding hydrocephalus, cerebral calcification, and chorioretinitis. Serology tests with the ELISA technique were highly positive for antibodies against IgG, whereas anti-IgM was negative. The patient died before the second serological analysis was done. The final diagnosis of congenital toxoplasmosis was eventually established at autopsy, based on the detection of T. gondii in the brain, testicular, liver, spleen and striated muscle tissues.

Congenital toxoplasmosis. Clinical and neuroradiological evaluation of the cerebral lesions

A study of 31 observations of congenital toxoplasmosis shows that there is a clear relationship between the cerebral lesions as observed on CT scan, neurological symptoms, and the date of maternal infection. The appearance of the CT scan is characteristic of cases with early maternal seroconversion (before the 20th week of pregnancy), of cases with maternal infection between the 20 and 30th week of pregnancy, and of cases with late maternal seroconversion (after the 30th week of pregnancy). Preventive maternal treatment does not change the pattern of the cerebral lesions observed on CT scan and thus proves ineffective in conferring real protection.

Neurological toxoplasmosis presenting as a brain tumor. Case report

✓ A case of congenital toxoplasmic mass lesion is reported in an infant born to a mother who acquired Toxoplasma infection during her pregnancy. Radical surgery followed by chemotherapy appeared to be curative. Previously described cases of acquired and congenital mass lesions due to Toxoplasma infection are summarized. The possible delayed onset and the misleading features that congenital toxoplasmosis may display are stressed.

[Congenital toxoplasmosis with hydranencephaly. A case report (author's transl)]

Hydranencephaly is an uncommon finding in congenital toxoplasmosis. The authors report a new case and emphasize the toxoplasmic etiology of this malformation, the possibility of normal neurologic examination at birth, and the usefulness of cranial transillumination whenever congenital toxoplasmosis is suspected in a neonate.

Computed tomography in the evaluation of congenital cerebral toxoplasmosis

This report deals with the contribution of computed tomography (CT) to the diagnosis of congenital toxoplasmosis in two infants. Computed tomography revealed diffuse hydrocephalus and confirmed the periventricular nature of the brain calcifications. The clinical, radiographic, and CT findings are discussed.

[Intracerebral calcifications. Etiology and symptomatic (author's transl)]

The importance of x-ray-investigations of skull is demonstrated in ten remarkable examples. Mostly intracerebral calcification follows inflammatory, traumatic, neoplastic or metabolic disease. In spite of the simplification of contrast-investigations which have assumed great importance x-ray-films of skull often permit specific diagnostic assessment and therefore should be done first.