TOXOPLASMOSIS (Internal Medicine)

PREPARED BY MOSES KAZEVU JR
TOXOPLASMOSIS
• This is caused by the protozoa Toxoplasma gondii.
• It is a zoonotic infection and cats are the definite host and excrete the oocytes in
their feces and can be transmitted from animal to humans.
• T. gondii cysts are also found in under-cooked meat.
• Human infection results from ingestion of oocytes (e.g. soil or water
contaminated with cat feces), ingestion of tissue cysts in undercooked meat or
vertically.
• This is the second most common cause of secondary CNS infection in patients
with AIDS.
• It is generally a late complication of HIV infection and usually occurs when the
CD4 cell count is less than 100/mm3.
• It is thought to represent a reactivation syndrome of prior infection
• Clinical features: may be asymptomatic of present with the following
➢ Onset- subacute
➢ Acute mononucleosis/flu-like illness: non-tender cervical lymphadenopathy
(commonest sign), eve, myalgia, sore throat, rash, hepatosplenomegaly.
(occurs 5 to 20 days after exposure.
➢ Fever, headache, hemiparesis, seizures and altered mental status
➢ Focal neurological signs (90%)
➢ Encephalitis picture (10%)- confusion or common and become more toxic.
In immunosuppressed individuals.
➢ Commonly affected areas- basal ganglia, brain stem and cerebellum
➢ Extracranial manifestations:
o Chorioretinitis (posterior uveitis) causing floaters or visual loss
o Myocarditis
o Pneumonitis (lung)
➢ Congenital infection is usually asymptomatic by may cause
o Hydrocephalus
o Calcifications
o Mononucleosis-like symptoms
• Diagnosis:
➢ Clinical: history and physical examination

➢ Neuroimaging (CT/MRI):
o Multiple ring enhancing lesions are
seen in 90% of patients with mass
effect and edema. (A solitary lesion on
MRI makes the diagnosis unlikely)
o Preferential location: basal ganglia,
grey-white junction, white matter
➢ Therapeutic trial +/- histology (biopsy)
o Histology: brain biopsy- in patients
with treatment failure (not possible in
Zambia)
• CSF-PCR sensitivity is variable.
• Serologic assays are of limited value, a
negative toxoplasma antibody test makes the
diagnosis less likely. (Ig M positive in 1 week
IgG is positive in 2 weeks)
Figure 1: : CT showing a ring enhancing lesion with
• Ocular disease: ophthalmoscopy shows iritis, adjacent edema (Pyogenic cerebral abscess).
vitritis and chorioretinitis (white retinal
lesions)
• Treatment:
➢ Regimen one: Loading dose of pyrimethamine 200mg (loading dose 200mg,
then 50mg daily) combined with sulfadiazine (2-4g/day) and folinic acid (10-
20mg/day)
➢ Regimen two: Fansidar (Pyrimethamine 25mg + Sulfadoxine 500mg) +
Folinic acid 10-20mg/day
o Dose: 525mg (2 tabs) PO BD for 2 days and then 1 tab PO/day, if
patient is very critical add Doxycycline 100 PO BD.
➢ Regimen 3: Pyrimethamine (loading dose 200mg, then 50mg daily) and
Folinic acid 10-20mg/day plus Clindamycin 450mg 8 hourly
➢ Note: Clindamycin and pyrimethamine may be used in patients allergic to
sulphonamide
➢ Duration of treatment is 6 weeks or 3 weeks after complete resolution of
lesions on CT.
➢ Continue suppressive therapy for life: Pyrimethamine 25mg/day +
Sulfadiazine 2g/day + folinic acid 5-10mg/day.
➢ HAART should be initiated as soon as the patient is clinically stable,

approximately 2 weeks after acute treatment has begun to minimize the risk
of IRIS.
➢ Side effect:
o Leucopenia (main side effect of treatment). A higher dose of fansidar (2
tab/day) has been found to be associatd with frequent incidence of fatal
hemorrhage
o Check for bleeding tendency such as gum bleeding, epistaxis, hematuria
o Do FBC once per week
o To prevent effects give folinic acid 10mg PO
o If there is bleeding tendency stop fansider and start Doxycycline 100mg
PO BD
o Alternatives:
 Co-trimoxazole or Clindamycin + Pyrimethamine/Primaquine
 Azithromycin, Clarithromycin, Doxycycline
➢ Indications for steroid use:
o Evidence of marked increased intracranial pressure and altered mentation
o Dose: administer: dexamethasone 8mg IV stat and then 4mg IV DIQ till
the suppressive/maintenance therapy: Fansidar 1 tab per day should be
continued. Suppressive therapy (Secondary prophylaxis) can be stopped
when the CD4 count is more than 200 for 6 months.
• Prevention: for all with CD4 count <100cells/microliter
➢ Use TMP-SMX 2 tablets per day
➢ TMP-SMX 2 tablets three times per week
➢ Alternatively: Dapson plus pyrimethamine plus folinic acid.
➢ Primary prophylaxis can be stopped if CD count> 200cells/ml for more than
3 months following antiretroviral therapy

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PREPARED BY MOSES KAZEVU JR

➢ Clinical: history and physical examination

➢ HAART should be initiated as soon as the patient is clinically stable,

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