2. TOXOPLASMOSIS
Toxoplasmosis is a systemic disease caused by the organism
Toxoplasma gondii.
Both Humans and Animals can be infected
Most patients have no recognizable symptoms and develop
immunity to the organism
An infection could show non-constitutional signs and symptoms
may reach the posterior segment of the eye through the
bloodstream, leading to formation of cysts within the retinal
tissue, or they may cause localized, relentless destruction of
the retina
Congenital or Acquired
3. TOXOPLASMOSIS
Toxoplasmosis is the most
common cause of infectious
retinochoroiditis in both adults
and children.
It is caused by the parasite
Toxoplasma gondii, a single-
cell obligate intracellular
protozoan parasite.
Cats are the definitive hosts
Humans and a variety of other
animals serve as intermediate
hosts.
4. TOXOPLASMA
OOCYST, or soil form
TACHYZOITE, or infectious
form
BRADYZOID or TISSUE
CYST, or latent form
5. TRANSMISSION
Ingestion of undercooked, infected meat
containing Toxoplasma cysts; contaminated water,
fruit, or vegetables or unpasteurized goat milk
from a chronically infected animal
Inadvertent contact with cat feces, cat litter, or soil
containing oocysts
transplacental transmission with primary infection
during pregnancy
Introduction of tachyzoites through a break in the
skin
blood transfusion or organ transplantation
6. PENETRATION & INVASION
Toxoplasma organisms then invade intestinal
mucosal cells and initiate the infection.
Tachyzoits are found in the circulatory system
and in nearly all tissues of the body.
In Immunocompetent states, the replication of the
tachyzoits eventually ceases and most organisms
are removed, although some may remain as
dormant bradyzoits within intercellular tissue cyst.
7. EPIDEMIOLOGY
Geographic area, age, and socioeconomic factors influence the
prevalence of the disease. The prevalence is highest in tropical
regions and lowest in cold regions of the world.
The reported seropositivity rates among healthy adults vary
considerably throughout the world.
70% and 80% of women of childbearing age in the United States
lack antibodies to T gondii, however, the incidence of
toxoplasmosis acquired during pregnancy is only 0.2%- 1%.
In southern Brazil, where the prevalence of toxoplasmosis is
extremely high, 1/770 births; Higher prevalence of ocular
involvement.
8. EPIDEMIOLOGY
Disease acquired early in pregnancy often results in spontaneous
abor- tion, stillbirth, or severe congenital disease, whereas that
acquired later in gestation may produce an asymptomatic,
normal-appearing infant with latent infection.
Besides the ingestions of the raw, uncooked meat, several ways
of transmission were also reprted:
Transconjunctival
Puppies- Inhilation of the oocyts
Food Consumed by humans may be contaminated by Insects and
cockroaches.
9. EPIDEMIOLOGY
TOXOPLASMIC RETINOCHOROIDITIS
It had been believed that most cases of toxoplasmic
retinochoroiditis represented a recrudescence of a
congenital disease.
But it is also more recognized at present are cases of
Acute Toxoplasmic Retinochoroiditis = After Systemic
Acquired Toxoplasmosis
10. CLINICAL MANIFESTATIONS
Clinical Entities of Toxoplasmosis
1. Congenital Toxoplasmosis
2. Acquired Systemic Toxoplasmosis
3. Toxoplasmosis in the Immunocompromised Host
4. Acquired or Reactivation of Latent Infection
5. Ocular Toxoplasmosis *
1. Congenital
2. Acquired Systemic
11. The prevalence of congenital toxoplasmosis has been
estimated to vary between 1:1000 and 1:10,000
The Disease is Bilateral in 65-85% of cases and
involves the macula in 58%
Toxoplasmic infection in consecutive siblings is rare,
but congenital ocular toxoplasmosis has been
described in siblings.
The classic presentation of congenital toxoplasmosis
includes retinochoroiditis, hydrocephalus, and
intracranial calcification
CONGENITAL TOXOPLASMOSIS
12. CONGENITAL TOXOPLASMOSIS
Retinochoroiditis,
which occurs in up to 80% of cases, is the MOST COMMON
abnormality in patients with congenital infections and is
BILATERAl in approximately 85% of affected individuals, with
a predilection for the posterior pole and macula.
Varying degrees of retinitis
Hepatosplenomegaly
Intracranial calcifications
Microcephaly
Developmental delay
13. CONGENITAL TOXOPLASMOSIS
Retinitis, sometimes with
associated choroiditis, iritis,
and anterior uveitis
The active area of retinal
inflammation is usually
thick- ened and cream-
colored with an overlying
vitritis.
So called “Satellite Lesion”
14. CONGENITAL TOXOPLASMOSIS
Diagnosis
PRIMARILY CLINICAL in nature based on the
characteristic retinal lesion.
Supported by ELISA for Toxoplasma AB
Lack of antibody essentially rules out the diagnosis.
Maternal IgM does not cross the placenta
15. CONGENITAL TOXOPLASMOSIS
Vision can be compromised by the location of the
reactivation adjacent to the macula or optic nerve or by
significant vitritis.
Most practitioners recommend treatment if the macula or
optic nerve is involved or if massive vitritis threatens vision.
Systemic treatment involves the use of 1or more
antimicrobial drugs with or without oral corticosteroids.
Pyrimethamine and sulfadiazine
17. TREATMENT
Other antibiotic treatment:
Trimethoprim/sulfamethoxazole (Bactrim)
Clindamycin
+pyrimethamine is the regimen of choice for the PROPHYLAXIS
against and TREATMENT of Toxoplasmosis
Azithromycin
18. ACQUIRED TOXOPLASMOSIS
Adult acute acquired toxoplasmosis presents as an acute febrile
illness associated with cervical lymphadenopathy.
Hilar and submental lymph node enlargement also may occur.
Hepatosplenomegaly, lymphocytosis with the presence of
atypical forms of lymphocytes, and hilar lymphadenopathy may
occur.
Acquired toxoplasmosis may present as fever of unknown origin
with or without abdominal pain.
The clinical manifestations of toxoplasmosis may mimic many
diseases, including
Hodgkin's disease and infectious mononucleosis
19. APPEARANCE
A unifocal area of acute-onset inflammation adjacent to
an old chorioretinal scar is virtually pathognomonic for
toxoplasmic chorioretinitis.
20. APPEARANCE
Classically, Ocular toxoplasmosis appears as a focal, white
retinitis with overlying moderate vitreous inflammation
("headlightin the fog"), often adjacent to a pigmented
chorioretinalscar
21. APPEARANCE
Retinal vessels in the vicinity of an active lesion may show
perivasculitis with diffuse venous sheathing and segmental
Arterial sheathing
(Kyrieleis arteriolitis)
22. OCULAR FINDINGS
Toxoplasma gondii is the most common cause of infection of the
RETINA. Ocular findings include involvement of the retina,
choroid, retinal vessels, macula, optic nerve, vitreous, and
anterior uvea.
23. OCULAR FINDINGS
Typical Manifestations
Focus of retinitis surrounded by fuzzy retinal edema
Pigmented atrophic retinochoroiditic scar adjacent to
the lesion or elsewhere in the fundus
Vitreous cells and exudates
Focal retinal vasculitis
Hyperemia of the optic nerve head
Cells and flare in the anterior chamber (rarely,
mutton-fat keratic precipitates)
In patients with recurrent ocular
toxoplasmosis: anterior segment findings,
including posterior synechiae, secondary
cataract, and secondary glaucoma
27. OCULAR FINDINGS
Optic Nerve
The CNS is frequently involved in toxoplasmosis. The optic nerve may
present with optic neuritis or papillitis associated with edema.
The diagnosis may be hard to make when patients present with severe
papillitis and no evidence of active retinal lesion.
Vitreous
Toxoplasma gondii is an obligate intracellular parasite and, therefore, the
organism does not invade the acellular vitreous cavity.
PVD- Posterior Segment Inflammation
Anterior Uvea
Anterior uveitis (granulomatous or nongranulomatous) may be associated with
Toxoplasma retinochoroiditis
In immunocompetent patients- anterior uveal inflammation
29. OCULAR COMPLICATIONS
Severe inflammatory changes within the globe secondary to
toxoplasmosis may lead to several complications.
Fuchs' heterochromic iridocyclitis- Unclear
Periphreal Anterior Synechia
Subretinal neovascularization
RRD, SRD
Cataract
CME
30. TOXOPLASMOSIS AMONG AIDS
PATIENTS
One of the most common parasitic infections in patients with AIDS
is toxoplasmosis.
This may occur in the retina or elsewhere in the body.
Toxoplasmic encephalitis is a fatal disorder if not treated early or
promptly.
Neuroimaging is warranted in AIDS patients presenting with these
findings because intracranial toxoplasmic lesions have been
reported in up to 29% of these patients who have toxoplasmic
chorioretinitis.
31. CEREBRAL TOXOPLASMOSIS
CT scan will show Ring Enhancing Lesions with darker areas of
Surounding edema that are typical of your toxoplasmosis.
32. TOXOPLASMOSIS IN
IMMUNOSUPPRESSED
Toxoplasmosis is becoming an important cause of mortality and
morbidity in patients.
Patients with impaired immunity such as those with lymphoma,
leukemia, malignancies, and AIDS.
Patients may present with fever, encephalitis, myocarditis, and
pneumonitis, which are the most common and serious of the
clinical manifestations.
Retinal Tears (rhegmatogenous)
33. NOTE
Focal retinitis in the absence of chorioretinal scarring
should raise the suspicion of acquired disease or
another cause for the necrotizing retinitis
Retinochoroiditis developing in immunocompromised
and older patients may present with atypical findings
including large, multiple, and/or bilateral lesions, with
or without associated chorioretinal scars.
Other ATypical Presentations
Unilateral neuroretinitis
Punctate outer retinal toxoplasmosis (PORT)
Small , multifocal lesions at the level of the deep retina with scant
overlying vitreous inflammation
Unilateral Pigmentary retinopathy simulating retinitis pigmentosa
34. DIAGNOSIS
In most instances, the diagnosis of Toxoplasmic retinochoroiditis is
made clinically, on the basis of the appearance of the characteristic
Lesion.
Serologic Evaluation through Indirect Fluorescent Antibody testing.
(ELISA) to confirm the diagnosis (to detect specific Anti T. Gondii
antibodies is commonly used to confirm exposure to the parasite )
IgG
First 2 weeks after infection, Remain detectable for life, Does cross placenta
IgM
Rise early During Acute Disease, typically detectable in less than a year, Does not
cross Placenta
PCR
Notas do Editor
Infection with the organism in immunocompetent individuals leads to a mild or subclinical systemic disease.
In some patients, the primary infection may lead to fever, fatigue, lymphadenopathy, and malaise.
Tachyzoits are the proliferative form of the parasite.
The organism is motile with a unique cytoskeletal structure allowing it to twist, wiggle, rotate, and glide. The rostrum of the tachyzoite is known as the conoid, which can extend, retract, tilt, and rotate. These movements allow the tachyzoite to find its target host cell and to penetrate the cell, establishing an intracellular existence.
Bradyzoites are slowly metabolizing organisms found in cysts formed within the tissue of the infected host.
Considering that the tissue cyst incorporates elements derived from the host into its outer wall, it is easily tolerated by the host, and no inflammatory reaction is seen around it
FIGURE toxoplasma bradyzoites inside cysts of tissue sections in chronically infected rabbit's retina (arrows). There were no signs of inflammation seen in the figure.
it may remain for years in certain tissues, such as the eye or muscles, without provoking any inflammatory reactions.
The number of organisms increases within the cyst in the retina, and once the cyst wall breaks down by mechanical stretching, the bradyzoites escape, convert into tachyzoites, and invade contiguous cells.
The oocyst appears to be an important method for the transmission of toxoplasmosis. Once ingested, the oocyst wall is digested by the gastric enzymes, trypsin and pepsin, thereby liberating Toxoplasma sporozoites
the resistance of toxoplasmosis within chronically infected tissues of animals may lead to transmission of the disease by the ingestion of undercooked meat, including mutton, beef, pork, and chicken.
Toxoplasma organisms then invade intestinal mucosal cells and initiate the infection (enteroepithelial cycle). In the intestinal mucosa, the organisms undergo asexual reproduction (endodyogeny, endopolygeny, splitting, schizogony) and sexual reproduction (gametogony cycles), culminating in the formation of zygotes, which develop into oocysts. The oocysts are shed in the feces of the definitive host.
Simultaneous with the enteroepithelial oocyst formation in cats, bradyzoites or sporozoites may invade and disseminate widely to all host tissue through the bloodstream or lymphatics, where they undergo an asexual cycle (extraintestinal cycle), particularly in muscle, heart, brain, lung, lymphoid tissue, retina, and central nervous system (CNS).
ranging from 3% to 10.8% in the United States to between 50% and 80% in France.
70% and 80% of women of childbearing age in the United States lack antibodies to T gondii, which places them at risk for contracting the disease; however, the incidence of toxoplasmosis acqUired during pregnancy is only 0.2%- 1%.
overall, 40% of primary maternal infections result in congenital infection; transplacental transmission is greatest during the third trimester.
Previously, apparently acquired toxoplasma retinitis was thought to represent reactivation o f a Congenital infection; however recent evidence suggest thaht most patients are infected posnatally.
IN ONE STUDY, acquired postnatal infection was thought to represent up to two-thirds of cases of toxoplasmic ocular diseas
Toxoplasmosis can be acquired congenitally via transplacental transmission from an infected mother to the fetus.
The area may be at the edge of an old flat atrophic scar, frequently in the macular area, or adjacent to the scar (a so-called satellite lesion).
Most cases are now assumed to be acquired but can only be distinguished from congenital disease if there is no scar adjacent to a site of active inflammation or with documentation of a previously normal fundus appearance.
it can be supported by a positive enzyme-linked immunosorbent assay (ELISA) for Toxoplasma antibody.
Because maternal lgM does not cross the placenta, finding toxoplasma-specific IgM in the infant serum is diagnostic ofcongenital infection in the infant.
Although the benefit of treatment has not been proven, most practitioners recommend treatment if the macula or optic nerve is involved or if massive vitritis threatens vision.
The most commonly used antimicrobials are pyrimethamine and sulfadi- azine. Steroids should never be used alone without antimicrobial coverage.
Small extramacular lesions may be observed without treatment.
Sight-threatening lesions are treated for 5-6 weeks with triple therapy pyrimethamine, sulfadiazine, and folinic acid.
Prednisone in low doses of 0.5-1 mg/kg per day for 3-6 weeks may be used to reduce macular or optic nerve inflammation and can be started on day 3 of antibiotic therapy.
Corticosteroids should not be used without concurrent antibiotic treatment or in immunocompromised patients due to the risk of exacerbation of the disease.
Folinic acid protects against the decrease in platelets and white blood cells induced by pyrimethamine.
Bactrim has been shown to be equivalent to triple therapy in the treatment of ocular toxoplasmosis and may be better tolerated.
Clindamycin and azythromycin can also be considered as alternative therapies.
AIDS patients require chronic maintenance treatment.
NON CONSTITUTIONAL S/SX: Patients develop malaise, myalgia, weakness, fatigue, headache, sore throat, and maculopapular rash with sparing of the palms and soles.
The course of the disease in the immunocompetent host is self-limited and often is benign. The signs and symptoms may persist for extended periods, and the generalized fatigue and malaise may occur for several months.
Focal condensation of vitreous and inflammatory cells may be seen overlying the pale yellow or gray-white raised lesion in the posterior pole
Theselesionsoccur more commonly in the posterior pole but may occasionally be seen immediately adjacent to or directly involving the optic nerve; they are sometimes mistaken for optic papillitis.
Toxoplasma gondii is the most common cause of infection of the retina. Ocular findings include involvement of the retina, choroid, retinal vessels, macula, optic nerve, vitreous, and anterior uvea.
Ocular toxoplasmosis most commonly presents as a focus of necrotizing
retinitis (Fig. 7) involving the inner layers of the retina and associated with a
whitish fluffy lesion surrounded by retinal edema.
Cells are seen in the vitreous overlying the lesion.
The retina is the primary site for the multiplying parasites, whereas the choroid and sclera may be the sites of contiguous inflammation. When the choroid is involved by the inflammatory reaction, the lesion is referred to as retinochoroiditis.
Severe Toxoplasma retinochoroiditis with large granuloma and overlying vitreous cells. A healed retinochoroiditic scar is seen in close proximity to the granuloma.
A small focus of Toxoplasma retinochoroiditis adjacent to a healed retinochoroiditic scar near the equator in the right eye
Typical punched-out Toxoplasma retinochoroiditic scar surrounded by Pigmentation
The central whitish area is the sclera and results from extensive necrosis of the retina and choroid.
Vitreous : Posterior vitreous detachment commonly is seen in patients with posterior segment inflammation from toxoplasmosis, and patients may develop precipitates of inflammatory cells on the posterior vitreous face.
Anterior uveitis (granulomatous or nongranulomatous) may be associated with Toxoplasma retinochoroiditis. In immunocompetent patients, the anterior uveal inflammation is a hypersensitivity reaction to the Toxoplasma antigens.
Fuchs' heterochromic iridocyclitis has been described in patients who had focal necrotizing retinochoroiditis characteristic of ocular toxoplasmosis.
The reason for the association of Fuchs' heterochromic iridocyclitis and toxoplasmosis is not clear.
Severe anterior uveitis may lead to peripheral anterior synechiae and secondary glaucoma in patients with chronic ocular toxoplasmosis.
the reason for neovascularization of the optic nerve and the retina is not well understood.
Retinal ischemia associated with severe retinal vasculitis may predispose to neovascularization of the retina. On the other hand, inflammatory reactions alone may cause neovascularization of the retina.
The disease may be a recrudescence of a latent infection or a newly acquired toxoplasmic infection.
In cases of recrudescence of the disease, it may result from rupture of the cyst and conversion of the bradyzoites into the tachyzoites within the tissue.
Toxoplasmic encephalitis is a fatal disorder if not treated early or promptly.
Clinical diagnosis and therapy of toxoplasmosis in patients with AIDS pose a challenge to the managing clinician.
n the CNS, toxoplasmic encephalitis may present as a mass lesion in the brain, toxoplasmoma. The differential diagnosis of such a focal lesion in patients with HIV infections include toxoplasmosis in 60% of the cases, primary CNS lymphoma in 25%, and multifocal leukoencephalopathy in 15%.
CT scan will show Ring Enhancing Lesions with darker areas of
Surounding edema that are typical of your toxoplasmosis
The vasularity in the organizing wall of the abcess leads to the observed bright ring enhancement with CT and MRI
Congenital toxoplasma infections can produce cerebritis with multifocal cerebral necrotizing lesions that may calcify.
Toxoplasmosis is becoming an important cause of mortality and morbidity in patients undergoing immunosuppressive therapy for malignancies, organ transplantation, or autoimmune disorders.
Patients with impaired immunity such as those with lymphoma, leukemia, malignancies, and AIDS also are at increased risk of acquiring severe infection by T. gondii.
The clinical manifestations of toxoplasmosis in the immunodeficient host may mimic other opportunistic pathogens. Diagnostic Dilemma for the Physician.
Patients may present with fever, encephalitis, myocarditis, and pneumonitis, which are the most common and serious of the clinical manifestations. More than 50% of these patients have CNS involvement.