A zoonoziz, caused by T.gondii, an intracellular protozoan parasite Its more common in tropical &...
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Transcript of A zoonoziz, caused by T.gondii, an intracellular protozoan parasite Its more common in tropical &...
Introduction
A zoonoziz , caused by T.gondii , an intracellular protozoan parasite
Its more common in tropical & coastal regions
is less common in regions that are either cold ,warm or at high elevation
1 of every 900 pregnancies in the USA
Transmission Cats
host for T. gondii They acquire infection by
eating infected wild rodents and birds
A week after infection, the cat begins to shed oocysts in its feces
Shedding of the oocysts persists for about 2 weeks
within days to weeks these oocysts sporulate and become extremely infectious
Transmission
Food ingestion of
contaminated food is an important cause of toxoplasmosis
Meat is the most common infected food
unpasteurized milk and unfiltered water sources also are at risk
Organ transplantation
Pathophysiology Acute toxoplasmosis generally is well tolerated
in immunocompetent adults may result in vertical infection to the fetus and
lead to potentially serious consequences
In immunocompetent adult, symptoms usually are mild or inapparent
In about 10%: fever fatigue Malaise headache myalgias lymphadenopathy
These symptoms will resolve in weeks to months without specific therapy
Pathophysiology
In immunosuppressed : signs and symptoms often will be more pronounced can result in significant ocular and CNS abnormalities
Reactivation infection in immunosuppressed pregnant women also can cause fetal infection
T. gondii
three forms trophozoites or proliferative tissue cysts Oocytes
Trophozoite is seen in the acute phase of the infection in the human
Mulitiplies every 4-6 hours
cells ruptureReleasing
organisms to invade other cells
Utero Transmission
Newborns become infected in utero by transplacental passage of the parasite when the mother has acute infection
Chronic infections (onset precedes pregnancy) do not lead to congenital infection except in the rare circumstance of an
immunocompromised host with reactivation likelihood of fetal infection increases with each
trimester of pregnancy Fetal infection is :
15% in the first trimester, 25% second, 60% in third trimester
Utero Transmission
The severity of damage associated with timing of maternal infection the risks decrease toward term
Severe fetal disease or fetal death: occurs in about 10% of cases when infection
occurs during the first trimester extremely rare with infection during the third
trimester Mild damage is more frequent in the
second and third trimesters (about 5%)
Utero Transmission
Subclinical infections increase from about 2% with first-trimester infections to 50% with third-trimester infections
acute infection could be associated with preterm delivery and stillbirth but not with spontaneous abortion
TRANSPLACENTAL TRANSMISSION
Time of infection Likelihood of transmission in
untreated mothers
Disease in infant
>6 months before conception
No Risk ---
<6 months before conception
Very Low Risk
---
First trimester 10-25% Most severe
Second trimester 30-54% Less severe
Third trimester 60-65% Usually Asymptomatic
Diagnosis in Pregnancy
1. Maternal Infection usually is asymptomatic 10% to 20% of infected mothers have
lymphadenopathy (Posterior cervical is the most frequent )
The infection also can result in a mononucleosis like syndrome with:
fatigue assitude and rarely, can cause encephalitis The clinical picture can be much more severe in
immunocompromised adults.
1. Maternal Infection
clinicians are forced to rely on serologic tools for the diagnosis of toxoplasmosis in pregnancy
diagnosis of primary infection : demonstration of a seroconversion to this
organism significant rise in antibody titer obtained from
maternal sera taken at two different times detection of toxoplasma-specific IgM antibody
Maternal Infection
Adults with primary infection develop IgG and IgM antibody to toxoplasma rapidly
Toxoplasma-specific IgG antibody: develops within after infection peaks in 6 to 8 weeks2 weeks drops down over the subsequent several months then persists for life
Toxoplasma-specific IgM develops within 10 days after infection remains elevated for 6 months to more than 6 years
Maternal Infection
IgM titers may not provide useful information to document recent primary infection in pregnant women
The IFA test frequently is more useful than ELISA in differentiating remote from recent primary infection of a pregnant woman
In any case, the presence of IgG and the absence of IgM suggest an infection that is probably at least a year old
Maternal Infection
Up to 40% of positive toxoplasma-specific IgM are false positives
Avidity testing is a newer type of testing
Approximately 50% of placentas of congenitally infected infants will show T. gondii cysts on histologic slides
Additional cases can be detected by the presence of parasites in the cord blood
Maternal Infection
The organism also has been isolated from placental tissue of acutely infected mothers in 2% to 25% of cases
Isolation of organisms from tissue specimens, buffy coat heparinized blood body fluids
2. Prenatal Diagnosis
Antenatal diagnosis of fetal toxoplasmosis culture of amniotic fluid fetal blood
The main difficulties with culture techniques: some assays may take up to several weeks few laboratories are able to perform the assay
amniocentesis performed too early in gestation occasionally can be falsely negative
Prenatal Diagnosis
Toxoplasma-specific IgM, when present in fetal blood from cordocentesis, also has been used to diagnose fetal infection prenatally
fetal-specific IgM antibody frequently does not develop until after 21
to 24 weeks gestation is positive in only about 50% of infected
cases
Additionally, cordocentesis is a procedure that entails some risk.
Prenatal Diagnosis
the PCR has been used to detect T. gondii in amniotic fluid and has been shown to be useful in the detection of in utero infections
Prenatal ultrasound also may demonstrate abnormalities
Ventriculomegaly and hydrocephalus as well as microcephaly will be poor prognosticators
Intracranial calcifications, placentomegaly, hepatomegaly cataracts, and hydrops may be other signs
3. Neonatal Infection
Most congenitally infected newborns are asymptomatic at birth
Literature has shown that detection of toxoplasma-specific immunoglobulin A (IgA) may be a reliable method for the diagnosis of toxoplasmosis in the newborn
Demonstration of toxoplasma-specific IgM infection may be diagnostic, although in newborns approximately 20% of infections are not detectable by
toxoplasma-specific IgM at birth
A number of these asymptomatic, untreated infants will go on to have delayed and potentially serious manifestations
Neonatal Infection
20% with clinically obvious symptoms at birth will exhibit multiple findings
The most frequent clinical findings are : Chorioretinitis jaundice Fever Hepatosplenomegaly
in severe cases : Hydrocephaly microcephaly cerebral calcifications
Treatment
Treatment of acute toxoplasmosis in immunocompetent, nonpregnant adults is primarily supportive
the prognosis following acute infection is good, except in cases of profound immunosuppression
The treatment in pregnancy is a bit more complex
Treatment In Europe spiramycin is the first-line agent
used agent generally does not cross the
placenta, and if fetal infection is detected, women also are treated with a combination of pyrimethamine folinic acid sulfonamide
Treatment Although not definitive, treatment with these
regimens may prevent maternal-to-fetal transmission of the infection or improve the outcome among infected fetuses
The standard dosage is : 25 mg of pyrimethamine by mouth given daily 1 g of sulfadiazine by mouth four times daily for 1 year Folinic acid, 6 mg given intramuscularly or by mouth every
other day
***Pyrimethamine is a folic acid antagonist and therefore may have teratogenic effects when given in the first
trimester
Prevention
avoid eating raw or undercooked meat Fruits and vegetables should be peeled and
washed before eating proper hand hygiene Gloves should be used for gardening and
during any contact with soil or sand Pregnant women should avoid close contact
with cat feces need for obstetricians to educate pregnant
patients about these important preventive steps
Prevention
routine serologic screening programs screening of newborns and the institution
of treatment during the neonatal period to minimize the morbidity
Many infections in children that otherwise would be missed on routine clinical examination can be detected with IgM assays
Treatment of these infected infants has been associated with very low rates of subsequent neurologic or retinal disease