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Toxoplasmosis -ˌplaz-ˈmō-səs

By Richard D. Pearson, MD, Emeritus Professor of Medicine, University of Virginia School of Medicine

Toxoplasmosis is infection caused by the single-celled protozoan parasite Toxoplasma gondii. Usually, the infection does not cause symptoms, but some people have swollen lymph nodes, fever, a vague ill feeling, and sometimes a sore throat or blurred vision and eye pain. In people with a weakened immune system due to AIDS or another condition, toxoplasmosis can reactivate, usually affecting the brain. A reactivated infection can cause weakness, confusion, seizures, or coma or spread throughout the body. Babies infected before birth (called congenital infection) can have birth defects, loss of vision, seizures, intellectual disability, and other abnormalities.

  • People acquire the infection by transferring the parasite's eggs from a contaminated object to the mouth or by eating contaminated food.

  • Most infections cause few or no symptoms.

  • Women who become infected during pregnancy may transmit the parasite to the fetus, sometimes causing a miscarriage, stillbirth, or serious problems in the baby.

  • Typically, only people with a weakened immune system have severe symptoms, usually resulting from brain inflammation (encephalitis), which may cause weakness on one side of the body, confusion, or coma.

  • Less often, other organs are affected in people with a weakened immune system.

  • Doctors usually diagnose the infection by doing blood tests that detect antibodies against the parasite.

  • Cooking meat thoroughly or freezing it and washing the hands thoroughly after handling raw meat, soil, or cat litter help prevent spread of the infection.

  • Most healthy people do not require treatment, but adults with symptoms and newborns and infants with the infection are treated with pyrimethamine plus sulfadiazine and leucovorin.

Toxoplasma gondii is present worldwide wherever there are cats. The parasite infects a large number of animals as well as people. Many people in the United States have been infected, although few ever develop symptoms. Severe infection usually develops only in fetuses and people with an immune system weakened by conditions such as AIDS, cancer, or use of drugs that suppress the immune system (immunosuppressants), particularly those used to suppress rejection of an organ transplant.

Did You Know...

  • The toxoplasmosis parasite produces eggs only in the intestine of cats.

Although the parasite can grow in the tissues of many animals, it produces eggs (oocysts) only in cells lining the intestine of cats. Eggs are shed in a cat’s stool and, after 1 to 5 days, become able to cause infection. Eggs in the soil are able to cause infection for months. Wild birds, rodents, deer, and many domestic animals (particularly pigs and sheep) may ingest the eggs in food or soil contaminated by cat stool. The eggs release forms of the parasite called tachyzoites. Tachyzoites spread in the animal's tissues and eventually form cysts.

Life Cycle of Toxoplasma gondii

  • 1a. Toxoplasma eggs are passed in cat stool. Many eggs are passed but usually for only 1 to 2 weeks. After 1 to 5 days in the environment, eggs become able to cause infection.

  • 1b. Cats can become reinfected by consuming food or other materials contaminated with the eggs.

  • 2. Other animals (such as wild birds, rodents, deer, pigs, and sheep) may consume the eggs in contaminated soil, water, plant material, or cat litter and become infected.

  • 3. Shortly after the eggs are consumed, the eggs release forms of the parasite that can move (called tachyzoites).

  • 4. Tachyzoites spread throughout the animal's body and form cysts in nerve and muscle tissue.

  • 5. Cats become infected after eating animals that contain these cysts.

  • 6a. People can become infected by eating undercooked meat containing these cysts.

  • 6b. People can also become infected if they eat food, water, or other materials (such as soil) contaminated with cat stool or when they touch a pet cat's litter and then touch their mouth.

  • 7. Rarely, people are infected when they have a blood transfusion or organ transplant that contains the parasite.

  • 8. Rarely, the infection is spread from mother to fetus.

  • 9. In people, parasites form cysts in tissues, usually in muscle and the heart, brain, and eyes. The cysts may remain for the rest of the person's life without causing symptoms. They may become active and cause symptoms if the person's immune system is weakened by a disorder or drug.

Transmission of Toxoplasma

People may acquire the infection in several ways:

  • Eating food, water, or other materials (such as soil) that are contaminated with cat stool containing Toxoplasma eggs

  • Eating meat that contains Toxoplasma cysts

  • Spread from a newly infected mother to a fetus

  • Rarely, having a blood transfusion or organ transplant that contains the parasite

People may swallow Toxoplasma eggs after they touch contaminated cat litter, soil, or other objects and then touch their mouth or handle and eat food without washing their hands. People may swallow cysts when they eat raw or undercooked meat (usually pork or lamb) from infected animals.

Rarely, the parasite is transmitted through blood transfusions or by an organ transplanted from an infected person.

Toxoplasmosis during pregnancy

A woman who acquires the infection during pregnancy can transfer Toxoplasma gondii to her fetus through the placenta. Infection is more severe if the fetus is infected early in the pregnancy. The result may be a fetus that grows slowly, premature birth, a miscarriage, stillbirth, or a baby born with birth defects. Congenital toxoplasmosis can cause problems with vision, seizures and intellectual disabilities later in life.

A woman who was infected before the pregnancy does not pass the parasite on to her fetus unless her immune system has been weakened (for example by HIV infection), reactivating her infection.

Toxoplasmosis in people with a weakened immune system

People with a weakened immune system, primarily those who have AIDS or cancer or who take drugs to suppress rejection of an organ transplant, are especially at risk of toxoplasmosis. If they have been infected in the past, developing a disorder that weakens the immune system or taking a drug that suppresses the immune system (immunosuppressants) may cause the infection to be reactivated.

A reactivated infection usually causes symptoms. The initial infection often causes no symptoms. A reactivated infection usually affects the brain, but it may affect the eye or spread throughout the body (disseminate).

In people with a weakened immune system, toxoplasmosis is very serious and may be fatal if untreated.

Symptoms

Most people with a healthy immune system have few or no toxoplasmosis symptoms and recover fully. About 10 to 20% of these people have swollen but painless lymph nodes. A few of these people also have intermittent low fevers, a vague ill feeling, muscle aches, and sometimes a sore throat. The symptoms disappear on their own, usually after several weeks.

Congenital toxoplasmosis

Children born with congenital toxoplasmosis may be severely ill and die before or shortly after birth, or they may have birth defects or other symptoms. Some never become ill. Others appear healthy at first but develop symptoms (such as seizures, intellectual disability, and chorioretinitis) months or even years later.

Typical symptoms in newborns can include

  • Infection of the lining of the back part of the eyeball and the retina (chorioretinitis)

  • Enlargement of the liver and spleen

  • Jaundice

  • Rash

  • Easy bruising

  • Seizures

  • A large head caused by accumulation of fluid in the brain (hydrocephalus)

  • A small head (microcephaly)

  • Intellectual disability.

Chorioretinitis can cause blurred vision, eye pain, sensitivity to light, and blindness.

Symptoms in people with a weakened immune system

Toxoplasmosis symptoms in people with a weakened immune system depend on the site of infection, as in the following:

  • Toxoplasmosis of the brain (encephalitis): Symptoms such as weakness on one side of the body, trouble speaking, problems with vision, headache, confusion, seizures, and coma

  • Toxoplasmosis that has spread throughout the body (acute disseminated toxoplasmosis): A rash, fever, chills, trouble breathing, and fatigue

In some people (usually those with a greatly weakened immune system), toxoplasmosis causes inflammation of the lungs (pneumonitis), the heart (myocarditis), or, less commonly, the liver (hepatitis). The affected organ may stop functioning adequately (called organ failure). Without treatment, these types of toxoplasmosis are usually fatal.

Diagnosis

  • Blood tests to detect antibodies against the parasite

  • If the brain may be affected, computed tomography or magnetic resonance imaging, followed by a spinal tap

The diagnosis of toxoplasmosis is usually based on blood tests that detect antibodies against the parasite. (Antibodies are proteins produced by the immune system to help defend the body against attack, including that by parasites.) The blood tests can be used to diagnose a new infection.

Sometimes tests to check for the parasite's genetic material (DNA) are also done on the samples of blood or on cerebrospinal fluid (the fluid that surrounds the brain and spinal cord), which is obtained by a spinal tap (lumbar puncture).

Doctors may do these blood tests in people who have a weakened immune system but have no symptoms of toxoplasmosis. The tests are done to look for evidence of a previous infection, which could reactivate if their immune system weakens further. However, if the person’s immune system is impaired by AIDS, the blood tests may indicate no infection when one is present (false-negative results).

If people report eye problems, doctors check the eyes for the damage typically caused by toxoplasmosis and do blood tests to check for antibodies to the parasite.

To determine whether a fetus has been infected, a doctor can take a sample of the fluid around the fetus (amniotic fluid) to be analyzed (a procedure called amniocentesis). The fluid is tested for antibodies to the parasite and for the parasite's genetic material. Because diagnosing toxoplasmosis during pregnancy or in the fetus or newborn is difficult, doctors often consult with an expert.

If toxoplasmosis of the brain is suspected, computed tomography (CT) or magnetic resonance imaging (MRI) of the brain is done, usually followed by a spinal tap to obtain a sample of cerebrospinal fluid for testing. Less commonly, a piece of infected brain tissue is removed and examined under a microscope (biopsied) to identify parasites.

Prevention

Pregnant women should avoid contact with cats. If contact is unavoidable, pregnant women should at least avoid cleaning cat litter boxes or wear gloves when doing so.

Meat should be cooked thoroughly, to a temperature of 165 to 170° F (74 to 77° C), and hands should be washed thoroughly after handling raw meat, soil, or cat litter.

Potential organ donors should be tested to prevent the spread of the parasite through transplanted organs.

Trimethoprim-sulfamethoxazole (an antibiotic) may be used to prevent reactivation of toxoplasmosis in certain people with AIDS or other conditions that cause the immune system to be weakened. People who cannot take this drug may be given pyrimethamine (used to treat malaria) plus sulfadiazine or clindamycin (antibiotics). Other options are atovaquone (an antiprotozoan drug) with or without pyrimethamine and dapsone with pyrimethamine. Because pyrimethamine can decrease blood cell production in the bone marrow, leucovorin (also called folinic acid) is given with it to help protect against this side effect.

People with AIDS are also given antiretroviral drugs, which help strengthen the immune system and reduce the risk that toxoplasmosis will be reactivated.

Treatment

  • Pyrimethamine and either sulfadiazine, clindamycin, or atovaquone, plus leucovorin

  • For eye infections, drugs effective against toxoplasmosis and a corticosteroid

Most infected people without symptoms and with a healthy immune system do not require treatment.

People with symptoms can be treated with pyrimethamine, sulfadiazine, and leucovorin. Leucovorin is given to help protect against decreased blood cell production in the bone marrow, which is a side effect of pyrimethamine. When pyrimethamine is not available, trimethoprim-sulfamethoxazole can be used. If people cannot take sulfadiazine, clindamycin or atovaquone can be used instead.

If people have a healthy immune system, they are usually treated for a few weeks.

People with AIDS or other conditions that weaken the immune system are given the same drugs but are treated longer (usually for at least 6 weeks), and the drugs are continued until their immune system improves.

In people with AIDS, toxoplasmosis tends to recur, so drugs to control toxoplasmosis are continued indefinitely unless the immune system improves (indicated by an increase in the CD4 count) and symptoms resolve. Doctors make sure that the most effective antiretroviral drugs are being used.

People with an eye infection can be given pyrimethamine plus sulfadiazine (or clindamycin) plus leucovorin. Prednisone or another corticosteroid is usually given at the same time to reduce inflammation.

Women who acquire toxoplasmosis during pregnancy should see a doctor who specializes in toxoplasmosis during pregnancy. The choice of drugs is complicated and depends on when the pregnant woman acquired the infection (which trimester) and whether the fetus has already been infected. Pyrimethamine can cause birth defects and is not used during the 1st trimester of pregnancy. Spiramycin (an antibiotic) may be used during the 1st trimester to help prevent the spread of toxoplasmosis from the woman to the fetus. Spiramycin is not commercially available in the United States, but doctors may obtain it from the U.S. Food and Drug Administration (FDA).

Newborns who were infected before birth are usually given pyrimethamine, sulfadiazine, and leucovorin for a year after birth.

Did You Know...

  • Women who acquire toxoplasmosis during pregnancy should see a doctor who specializes in toxoplasmosis during pregnancy.

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