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Toxoplasmosis

Sherylee Sanchez Santiago

November 4th, 2019

Toxoplasmosis

  • Most common CNS infection with AIDS who are not receiving appropiate prophylaxis.
  • Caused by intracellular protozoan Toxoplamasma gondii
  • Occurs by consuming infected undercooked meat, ingestion of oocysts from cat feces or infected soil.
  • In the US some cases have been associated with:
  • Eating raw shellfish
  • Patient's at higher risk when CD4 <100 cells/ uL
  • No transmission by person-person

Clinical Manifestations

Clinical Manifestations

  • Focal encephalitis with
  • Headache
  • Confusion
  • Motor weakness
  • Fever
  • Seizures
  • Stupor
  • Coma

Extracerebral toxoplasmosis

Pneumonitis

Chorioretinitis

Extracerebral toxoplasmosis

Other Manifestations including:

  • Liver
  • Gastrointestinal Tract
  • Bone Marrow
  • Bladder

Diagnosis

  • Immune assays
  • Anti-toxoplasma immunoglobulin G (IgG) antibodies
  • CT
  • MRI
  • Brain biopsy (usually reserved for pts failing to respond specific treatment)

Diagnosis

CT scan of the brain showing contrast enhancing lessions of toxoplasmosis

CT Scan

Toxoplasma gondii (encephalitis)

Preventing Disease : Primary Prophylaxis

Primary Prophylaxis

  • Initiate when:
  • (+) anti-toxoplasma IgG AND CD4 <100 cells/uL
  • Discontinue when:
  • CD4 >200 cells/uL for >3 months (on ART)

Prophylaxis Treatment

Preferred regimen

  • TMP/SMX 1 DS daily

Prophylaxis Treatment

Alternative regimens

  • TMP/SMX 1DS 3x/ week*
  • TMP/SMX 1SS daily*
  • Dapsone 50mg/d + pyrimethamine 50mg/wk + leucovorin 25 mg/wk*
  • Atovaquone 1,500mg PO daily +/- pyrimethamine 75 mg PO daily + leucovorin 10mg PO daily

Preventing Exposure

(For those patients with seronegative antitoxo-igG)

Preventing Exposure

  • Avoid eating raw undercooked meat (including: lamb, beef, or pork)
  • Wash hands after contact with raw meat, gardening or contact with soil
  • Wash fruits and vegetables before eating them raw
  • For cat owners: little box should be changed daily by an HIV (-)/ non-pregnant person

Acute treatment of TE

Tx of Toxoplasmosis

  • Duration of treatment: at least 6 weeks
  • Preferred regimen:
  • Pyrimethamine 200mg PO x 1, then
  • <60kg: pyrimethamine 50mg PO daily + sulfadiazine 1000mg PO q 6h + leucovorin 10-25mg PO daily
  • >60kg: pyrimethamine 75mg PO daily + sulfadiazine 1500mg PO q6h + leucovorin 10-25mg PO daily

Acute Treatment of TE

Alternative:

  • Pyrimethamine 200mg PO x1, then 50mg (<60kg) or 75 mg (>60kg) PO daily + Clindamycin 600mg q6h PO/IV +leucovorin 10-25mg PO daily.
  • TMP/SMX 5mg/kg (based on TMP) IV or PO BID
  • Pyrimethamine 200mg PO x1, then 50mg (<60 kg) or 75 mg (>60kg) PO daily + Atovaquone 1,500mg PO BID+ leucovorin 10-25mg PO daily
  • Atovaquone 1500 mg PO BID + sulfadiazine (1000-1500mg) q6h
  • Atovaquone 1500 mg PO BID

Acute Tx for TE

Monitoring

  • Response to therapy
  • Clinical response within 14 days; It should improve'

  • Adverse drug reactions

Monitoring

Adverse Drug Reactions

Pyrimethamine- Bone Marrow Suppression, GI upset, headache, rash

Sulfadiazine- Crystalluria, rash, fever, leukopenia, N/V/D, hepatitis

Adverse Drug Reactions

Clindamycin- N/V, fever, rash, hepatotoxity, diarrhea (including C. difficile colitis

TMP/SMX- Rash (including SJS) fever, leukopenia, thrombocytopenia, azotemia, hepatitis, hyperkalemia, photosensitivity

Atovaquone- Headache, nausea, diarrhea, rash, fever, increase ALT/AST

Preventing Recurrence: Secondary Prophylaxis

Initiate:

  • After patient completes acute tx for TE

secondary Prophylaxis

Discontinue when:

  • CD4>200 cells/uL for 6 months & asymptomatic w/ sustained viral suppression (on ART)

Preventing Recurrence: Secondary Prophylaxis

(chronic Maintenance Therapy)

Preferred:

  • Pyrimethamine 25-50mg PO QD +sulfadiazine 2,000-4,000mg PO daily in 2-4 divided doses +leucovorin 10-25mg PO daily

Preventing Recurrence: Secondary Prophylaxis

Alternative:

  • Pyrimethamine 25-50mg PO QD + clindamycin 600mg PO q 8hrs + leucovorin 10-25mg PO daily
  • TMP/SMX DS 1 tab daily or BID
  • Atovaquone 750- 1500mg PO BID +/- pyrimethamine 25 mg PO QD + leucovorin 10mg PO daily or sulfadiazine 2,000-4,000 mg PO daily in 2-4 divided doses

References

References

1. Porter SB, Sande MA. Toxoplasmosis of the central nervous system in the acquired immunodeficiency syndrome. N Engl J Med 1992; 327:1643.

2. San-Andrés FJ, Rubio R, Castilla J, et al. Incidence of acquired immunodeficiency syndrome-associated opportunistic diseases and the effect of treatment on a cohort of 1115 patients infected with human immunodeficiency virus, 1989-1997. Clin Infect Dis 2003; 36:1177.

3. Renold C, Sugar A, Chave JP, et al. Toxoplasma encephalitis in patients with the acquired immunodeficiency syndrome. Medicine (Baltimore) 1992; 71:224.

4. Luft BJ, Remington JS. Toxoplasmic encephalitis in AIDS. Clin Infect Dis 1992; 15:211.

5. Grant IH, Gold JW, Rosenblum M, et al. Toxoplasma gondii serology in HIV-infected patients: the development of central nervous system toxoplasmosis in AIDS. AIDS 1990; 4:519.

6. Blaser MJ, Cohn DL. Opportunistic infections in patients with AIDS: clues to the epidemiology of AIDS and the relative virulence of pathogens. Rev Infect Dis 1986; 8:21.

7. Leport C, Chêne G, Morlat P, et al. Pyrimethamine for primary prophylaxis of toxoplasmic encephalitis in patients with human immunodeficiency virus infection: a double-blind, randomized trial. ANRS 005-ACTG 154 Group Members. Agence Nationale de Recherche sur le SIDA. AIDS Clinical Trial Group. J Infect Dis 1996; 173:91.

Toxoplasmosis

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