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PubMed1998

The ocular manifestations of congenital infection: a study of the early effect and long-term outcome of maternally transmitted rubella and toxoplasmosis.

PURPOSE: To study the spectrum of adverse ocular effects which result from maternally transmitted rubella and toxoplasma infection; further, to record the long-term visual and neurodevelopmental outcomes of these 2 major causes of fetal infection. STUDY DESIGN AND PATIENTS: A series of 55 patients with congenital infection have been studied prospectively on a long-term basis. The study group included a cohort of 34 cases with congenital rubella syndrome demonstrated by virus isolation, and 21 cases with a clinical diagnosis of congenital toxoplasmosis and serologic confirmation. All patients had specific disease-related ocular defects. Rubella patients were first identified during or following the last major rubella epidemic in 1963-1964, and some have been followed serially since that time. A separate study group of representative toxoplasmosis patients presented for examination and diagnosis at varying time periods between 1967 and 1991. OBSERVATIONS AND RESULTS: This study confirms that a broad spectrum of fetal injury may result from intrauterine infection and that both persistent and delayed-onset effects may continue or occur as late as 30 years after original infection. Many factors contribute to the varied outcome of prenatal infection, the 2 most important being the presence of maternal immunity during early gestation and the stage of gestation during which fetal exposure occurs in a nonimmune mother. RUBELLA: As a criteria of inclusion, all 34 rubella patients in this study exhibited one or more ocular defects at the time of birth or in the immediate neonatal period. Cataracts were present in 29 (85%) of the 34, of which 21 (63%) were bilateral. Microphthalmia, the next most frequent defect, was present in 28 (82%) of the 34 infants and was bilateral in 22 (65%). Glaucoma was recorded in 11 cases (29%) and presented either as a transient occurrence with early cloudy cornea in microphthalmic eyes (4 patients), as the infantile type with progressive buphthalmos (1 patient), or as a later-onset, aphakic glaucoma many months or years following cataract aspiration in 11 eyes of 6 patients. Rubella retinopathy was present in the majority of patients, although an accurate estimate of its incidence or laterality was not possible because of the frequency of cataracts and nystagmus and the difficulty in obtaining adequate fundus examination. TOXOPLASMOSIS: Twenty-one patients with congenital toxoplasmosis have been examined and followed for varying time periods, 7 for 20 years or more. The major reason for initial examination was parental awareness of an ocular deviation. Twelve children (57%) presented between the ages of 3 months and 4 years with an initial diagnosis of strabismus, 9 of whom had minor complaints or were diagnosed as part of routine examinations. All cases in this study have had evidence of retinochoroiditis, the primary ocular pathology of congenital toxoplasmosis. Two patients had chronic and recurrent inflammation with progressive vitreal traction bands, retinal detachments, and bilateral blindness. Macular lesions were always associated with central vision loss; however, over a period of years visual acuity gradually improved in several patients. Individuals with more severe ocular involvement were also afflicted with the most extensive central nervous system deficits, which occurred following exposure during the earliest weeks of gestation. CONCLUSIONS: Although congenital infection due to rubella virus has been almost completely eradicated in the United States, the long-term survivors from the prevaccination period continue to experience major complications from their early ocular and cerebral defects. They may be afflicted by the persistence of virus in their affected organs and the development of late manifestations of their congenital infection. Congenital toxoplasmosis continues to be the source of major defects for 3,000 to 4,100 infants in the United States each year; the spectrum of defects is wide and may vary from blindness and severe mental retardation to minor retinochoroidal lesions of little consequence. Effective solutions for either the prevention or treatment of congenital toxoplasmosis have not been developed in this country but are under intensive and continuing investigation.

Child↗
PubMed2001

[Some aspects of immune response in toxoplasmosis].

OBJECTIVE: The study was performed to determine cell-mediated and humoral responses related to the clinical course of disease in adults with different forms of toxoplasmosis. METHODS: The cellular response was estimated by blastogenic transformation of T-lymphocytes induced by OKT3 mitogenic stimulus, as well as by a specific soluble toxoplasmic antigen. The phenotype analysis of T-lymphocytes was performed using monoclonal antibody on FACS flow cytometer. The humoral response was examined by determining the levels of toxoplasma-specific IgA, IgM and IgG antibodies and total serum immunoglobulins. RESULTS: Significant disruption of the cell-mediated response was not observed (T-lymphocyte proliferation test). In the group of patients with lymphadenopathy, an increased proportion of CD8+ lymphocytes was only noted in the first month of the disease, although enlargement of the cervical lymph nodes was observed for up to a year. The individuals in question were found to have IgA antibodies against the p30 antigen of T. gondii, mainly in the period of disease up to 7 months. The proportion of CD4+ lymphocytes was sub-normal in all patients of this group who were studied in the first two months of the disease, and in most of those studied later. Three out of 14 patients with the ocular form of toxoplasmosis only had recent foci of inflammation in the retina, and were also found to have specific IgM. These patients had depressed CD4+ levels, and showed no reaction from CD8+ lymphocytes. CONCLUSIONS: Sub-normal CD4+ population could have been the cause of the weak stimulation of CD8+ cells and an expression of this is the long course of disease. Sub-normal CD4+ cells may be also results the suppressing effect of the parasite.

Adolescent↗
PubMed1993

Detection of Toxoplasma gondii antigen-containing immune complexes in the serum of cats.

Enzyme-linked immunosorbent assays for the detection of Toxoplasma gondii antigen-containing IgM immune complexes (T gondii-specific IgM-IC) and IgG immune complexes (T gondii-specific IgG-IC) in the serum of cats were developed. Serum from clinically ill, naturally infected cats; healthy, naturally infected cats; and healthy cats experimentally inoculated with T gondii was assayed. All combinations of T gondii-specific IgM, IgG, antigens, IgM-IC, and IgG-IC were detected in naturally infected and experimentally infected cats. Clinically ill cats and cats with ocular signs of toxoplasmosis were more likely than healthy cats to have T gondii-specific IC in serum. It was concluded that T gondii-specific IC form in the serum of cats, may play a role in clinical disease development, and affect the results of T gondii-specific IgM, IgG, and antigen serologic assays.

Animals↗
PubMed1978

Juxtapapillary retinochoroiditis with a psychiatric disorder possibly caused by toxoplasma.

A 32-year-old man suffered from juxtapapillary retinochoroiditis in the right eye and a psychiatric disorder. The diagnosis of toxoplasmosis was supported by the clinical ocular findings, serologic examinations, and isolation of the organism from the cerebrospinal fluid. As the retinochoroidal lesion absorbed, the psychiatric symptoms also disappeared during the course of six weeks.

Adult↗
PubMed1996

[Hypertensive anterior uveitis of toxoplasmic origin after vitrectomy].

Two cases of vitrectomized congenital chorioretinal toxoplasmosis are presented. During a recurrence, an anterior segment inflammation with hypertony complicated both cases. Hypertony was efficiently controled by a specific antitoxoplasmosis therapy. The role of the vitreous barrier is suggested.

Adolescent↗
PubMedDate not supplied

[Clinical course of congenital toxoplasmosis in children].

Hundred eleven children with the congenital toxoplasmosis were treated at the Department of Infectious and Parasitic Diseases in Childhood in 1979-1988. Multi-symptomatic toxoplasmosis has been diagnosed in 35 cases, ocular form in 65, oligosymptomatic in 6, and asymptomatic in 5 cases. Clinical symptoms suggesting congenital toxoplasmosis was seen in the majority of children (63 cases) in the first year of life and the disease was diagnosed in 50% of cases (33 children) at this age. Congenital toxoplasmosis in the group of 78 children has been diagnosed later. The majority of cases was ocular form. Diagnosis of the oligo- and asymptomatic congenital toxoplasmosis is possible in the first year of life, only. A titre of antibodies is exclusively an indicator of the immunologic response, not a severity of infection and does not contribute to the prognosis. Antitoxoplasma drugs were administered to 102 children including 33 under the first year of life. Pyrimethamine, sulphonamides, and spiramycin were used in the treatment. Dosage, duration of therapy, and way of administration have been established individually in dependence of patients age and clinical form of the congenital toxoplasmosis. Two out of 35 children with multi-symptomatic congenital toxoplasmosis died whereas 13 demonstrate psychomotor retardation of significant degree despite the fact that 11 of them were treated in the first year of life.

Adolescent↗
PubMed1991

Current status of food-borne parasitic zoonoses in Singapore.

Parasitic infections adopt a rather low profile in the highly urbanized setting in Singapore. Very few food-borne parasitic infections are encountered. Apart from a few reports of infections with Clonorchis/Opisthorchis, Taenia spp. and hydatid disease, there are no other citations of such helminthic infections. Seroprevalence surveys have shown the presence of toxoplasmosis in local meat animals (sheep, pigs and cattle) and Toxoplasma strains have been isolated from the pig, tree shrew (Tupaia glis), slow loris (Nycticebus coucang) and guinea pigs. Human toxoplasmosis is prevalent in Singapore. Anti-Toxoplasma antibodies are found in the normal population as well as in clinical cases (cervical lymphadenopathy, ocular disease and congenital toxoplasmosis). Carcasses/organs from meat animals (sheep, pigs, cattle) slaughtered at local abattoirs were examined for parasites. The main parasites found were Ascaris suum, Dictyocaulus, Metastrongylus, Cysticercus ovis, Fasciola hepatica and Sarcocystis spp. Pigs were also examined for trichinosis and, thus far, these have all been negative.

Animals↗
PubMed1991

A review of 58 patients in Singapore with significantly high anti-Toxoplasma serotitres.

Over a 42-month period, 58 patients presenting at the Singapore General Hospital were identified to have IgG anti-Toxoplasma serotitres of 1:1024 or higher by the indirect immunofluorescence test. This retrospective study examines the clinical presentation and management of these 58 patients. About 60% of these 58 patients had presented with lymphadenopathy, 20% with ocular symptoms and 14% with bad obstetric history. Almost all patients with IgG anti-Toxoplasma serotitres exceeding 1:1024 had presented with lymphadenopathy (with a modal titre of 1:4096). In contrast, most of the patients who presented with ocular symptoms or bad obstetric history had lower modal titres. The majority of patients who had presented with lymphadenopathy were Chinese, aged 21 to 35. Typically, they presented with a painless, mobile, solitary cervical node of three to four weeks duration as the only symptom, had biopsies where the histopathology was suggestive of toxoplasmosis, received no treatment and experienced no sequelae. The study concludes that: acute toxoplasmosis is common in Singapore and presents typically as asymptomatic cervical lymphadenopathy in a young Chinese; the incidence of congenital infection is also believed to be high, based on the number of cases presenting with fetal wastage and the prevalence of ocular toxoplasmosis; pigs in Singapore may constitute an important reservoir for the transmission of this disease to man.

Adult↗
PubMed1980

[Ophthalmologic pathology in the pregnant woman].

Literature review and report of personal cases concerning the ocular physiopathological problems of pregnant women. Are studied especially chorioretinal perturbations: surgical and medical retinal detachment, diabetic retinopathy, choroiditis with pseudohistoplasmosis and toxoplasmosis. Are also studied the variations of the visual acuity, ocular tumors and pituitary tumors.

Adult↗
PubMedDate not supplied

[Neurologic disturbances in human immunodeficiency virus carriers in Yaoundé].

Neurological manifestations are frequent with the acquired immunodeficiency syndrome (AIDS). They can be seen at the onset of the illness but more often they are found during its terminal phase. The aim of this study is to describe the neurological complications observed in AIDS as well as the evolution in the intensive care unit of the Yaounde General Hospital, Republic of Cameroon. This prospective study was carried out during a two-year period at the intensive care unit. All patients who were HIV-positive and who presented a neurological disorder diagnosed during the interrogation and clinical examination were included in this study. In these patients, the following paraclinical examinations were performed: ocular fundi, CD4 lymphocytes titre, toxoplasmosis serology, lumbar tap, and cerebral scan. A diagnosis was made and the patients were treated accordingly. The appreciation of the evolution was done in relation with the clinical state and the mortality observed in the service. We recruited 51 patients in all, aged 38 years on average (+/- 7 years). There were 31 women and 20 men. The neurological disorders observed were 26 states of coma, 14 agitations with mental confusion, 6 meningitis syndromes, 5 hallucinations. The titre of CD4 showed an average of 146/mm3 (+/- 12). Toxoplasmosis serology was positive for 6 patients. The cerebrospinal fluid revealed 2 cases of purulent meningitis. The ocular fundi showed 5 cases of papillary oedema. The cerebral scan showed 8 cases of cerebral abscess, 4 cases of cerebral tumour and 6 cases of cerebral toxoplasmosis. These paraclinical findings have enabled us to establish the following classification of the patients: cerebral tumors (n=4); bacterial meningitis (n=2); aseptic meningitis (n=10); cerebral toxoplasmosis (n=6); sub-acute encephalopathy (n=21); cerebral abscess (n=8). These patients were treated according to the diagnosis. The clinical evolution was marked by recovery in 14 patients with improved clinical state and by mortality in 34 patients. Many neurological disorders exist in HIV infections. These complications vary according to the stage of the illness. They are caused either by opportunistic infections, by tumours or by the virus itself. The most frequent complication in our service is sub-acute encephalitis, which induces coma. This is due to the fact that the intensive care unit receives terminal patients coming from other services. This late recruitment of patients also explains the high mortality rate.

Acquired Immunodeficiency Syndrome↗
PubMed1993

Prevalence of latent toxoplasmosis and serological diagnosis of active infection in HIV-positive patients.

The seroprevalence of latent Toxoplasma gondii infection was determined in a cohort of 715 HIV-positive patients followed up at an HIV outpatient clinic. Using indirect immunofluorescence and direct agglutination assays for detecting IgG, the prevalence of anti-Toxoplasma gondii antibodies was shown to be 50%. During a four-year period, clinically apparent acute toxoplasmosis occurred in 47 patients (43 with cerebral, 3 with ocular and 1 with bone marrow toxoplasmosis) among the 360 patients positive for anti-Toxoplasma gondii IgG and in one patient (with cerebral toxoplasmosis) among the 355 patients who were serologically negative. A significant rise in IgG levels could be shown during acute toxoplasmosis episodes in only 30% of patients, compared with 3% of patients without active toxoplasmosis. During acute toxoplasmosis, IgM antibodies were detected in only two patients (6%) by an immunosorbent agglutination assay and in one (3%) by an enzymatic immunocapture assay. Specific IgA was detected by a non-enzymatic immunocapture assay in six patients (18%) during acute episodes. The very high predictive value (99.7%) of a negative IgG test remains the best serological parameter for excluding an acute episode of toxoplasmosis in HIV-positive patients.

Acute Disease↗
PubMed1991

Anti-toxoplasma antibodies in healthy adults and in different patient categories.

This study analyzes the anti-toxoplasma sero-titres and prevalence rates in normal healthy adults and in patients presenting with different symptom-complexes. The study was based on sera from 80 normal healthy adults and 2,185 patient sera samples from 2,032 patients (from various clinics and hospitals in Singapore) being investigated for the diagnosis or exclusion of toxoplasmosis, over a 42-month study period. About 15% of the healthy adults were found to have low IgG antibody titres (1:64 to 1:256), while 3.8% had high IgG titres (1:1024 or higher). Interestingly, among the patients investigated for toxoplasmosis: i) more than 20% of those presenting with lymphadenopathy (usually cervical) had antibody titres more than or equal to 1:1024; ii) more than half of all patients with an antibody titre of 1:4096, and more than three-quarters of all patients with a titre exceeding 1:4096 had presented with lymphadenopathy; iii) about 20% of those presenting with ocular symptoms had low antibody titres of 1:64 or 1:256, whereas 7% had higher titres. Malay (p less than 0.01) and Indian (p less than 0.05) patients had significantly higher seropositive rates than the Chinese. In particular, the Malays (p less than 0.00001) and Indians (p less than 0.01) had significantly higher incidence of low-positive titres (1:64, 1:256); conversely the Chinese patients had a significantly higher (p less than 0.01) incidence of high-positive titres (1:4096 or higher). Finally, the epidemiology and clinical profiles of patients presenting with acute toxoplasmic lymphadenitis are contrasted with that of patients presenting with ocular manifestations of congenital toxoplasmosis.

Adult↗
PubMed2003

Clinical presentation and follow up of children with congenital toxoplasmosis in Brazil.

We evaluated the clinical presentation and determined the ocular and neurologic sequelae in children with congenital toxoplasmosis in Brazil, taking into consideration the shortage of national publications on this disease. Follow-up evaluations were made of 43 children with congenital toxoplasmosis referred to Santa Casa de São Paulo, during a period of at least five years. Selection of the cases was based in clinical and laboratory criteria. A clear predominance of children with subclinical presentation of the disease at birth (88%) was found. Of the 43 children, 22 (51%) developed neurological manifestations. Using skull radiography, we detected neuroradiologic alterations in seven children (16%) and with tomography in 33 children (77%). Neurological sequelae were identified in 15 children (54%) in the group with cerebral calcifications and in 7 (47%) in the group without cerebral calcifications. We observed chorioretinitis in 95% of the cases. Reactivation of cicatricial lesions and the emergence of new ocular lesions were observed in five cases. The most frequent neurological manifestation was a delay in neuropsychomotor development. Most remarkable was the finding that cerebral calcifications were not associated with a higher incidence of neurological sequelae among the children. Chorioretinitis was the main ocular sequel of the infection, found in nearly all children; it can manifest years from birth, even in children submitted to specific therapy druing the first year of life, highlighting the importance of a follow-up of these children.

Brain Diseases↗
PubMed1999

Punctate outer retinal toxoplasmosis in an HIV-positive child.

PURPOSE: To discover whether the outer layer of the retina can be the site for toxoplasmosis in AIDS patients. METHODS: An HIV-positive child, who previously had a normal ocular examination, was reexamined three months later. This examination showed outer retinal lesions compatible with toxoplasmosis and positive IgM and IgG titers specific for that organism, despite the small drop in the CD4 count. RESULTS: During the first examination, the antibodies for toxoplasmosis were negative. At the three-months follow-up, the anti-toxoplasmosis antibodies were positive and the rest of the workup was negative, suggesting a strong correlation with the patient's fundus pattern. CONCLUSION: We describe a case of punctate outer retinal toxoplasmosis uveitis, which has been previously associated with immunocompetent hosts. We, however, believe that it can be seen in immunocompromised patients as well.

Child↗
PubMed2005

[Vestibular tests in infants with TORCH and after CNS infections].

Thorough evaluation of hearing and balance in infants with congenital and perinatal TORCH (ang. Toxoplasmosis, Other, Rubella, Cytomegalovirus, Herpes) infections and after infections of the central nervous system (CNS) is essential due to serious danger of inner ear damage. Caloric stimulation is one of the most reliable diagnostic methods of vestibular testing in infants. Recording of vestibular-evoked myogenic potentials (VEMPs) makes evaluation of the otolith organ and its pathways possible. Potentials resulting from sacculo-collic reflexes are recorded on the surface of the neck muscles. 76 infants aged 3 months, 40 healthy controls and 36 with risk factors of the inner ear damage: 25 with CMV infections, 7 after CNS system infections, 3 after congenital rubella and 1 with congenital Toxoplasmosis were included in the study. Values of VEMP measures did not differ between the groups. Complete lack of response to the stimuli was observed in 6 examined ears. Correlation was found between results of VEMPs, hearing threshold and caloric test. The vestibular organ was frequently impaired in the discussed group of infants. The obtained results correlate with one another due to simultaneous impact of the risk factors on the maculae of the ampullar and otolith systems causing damage to both of them.

Central Nervous System Infections↗
PubMed2006

Impact of visual impairment on measures of cognitive function for children with congenital toxoplasmosis: implications for compensatory intervention strategies.

OBJECTIVES: The purpose of this work was to determine whether visual impairment caused by toxoplasmic chorioretinitis is associated with impaired performance of specific tasks on standardized tests of cognitive function. If so, then we worked to determine whether there are patterns in these difficulties that provide a logical basis for development of measures of cognitive function independent of visual impairment and compensatory intervention strategies to facilitate learning for such children. METHODS: Sixty-four children with congenital toxoplasmosis with intelligence quotient scores > or = 50 and visual acuity sufficient to cooperate with all of the intelligence quotient subscales had assessments of their vision, appearance of their retinas, and cognitive testing performed between 3.5 and 5 years of age. These evaluations took place between 1981 and 1998 as part of a longitudinal study to determine outcome of congenital toxoplasmosis. Children were evaluated at 3.5 or 5 (37 children) or both 3.5 and 5 (27 children) years of age. Cognitive function was measured using the Wechsler Preschool and Primary Scale of Intelligence-Revised. Wechsler Preschool and Primary Scale of Intelligence-Revised scale scores were compared for children grouped as those children who had normal visual acuity in their best eye (group 1), and those who had impaired vision in their best eye (acuity < 20/40) because of macular disease (group 2). Demographic characteristics were compared for children in the 2 groups. Test scores were compared between groups using all of the 3.5-year-old visits, all of the 5-year-old visits, and using each child's "last" visit (ie, using the 5-year-old test results when a child was tested at both 3.5 and 5 years of age or only at 5 years, otherwise using the 3.5-year-old test results). The results were similar and, therefore, only the results from the last analysis are reported here. RESULTS: There were 48 children with normal visual acuity in their best eye (group 1) and 16 children with impaired vision because of macular involvement in their best eye (group 2). Ethnicity and socioeconomic scores were similar. There was a significantly greater proportion of males in group 2 compared with group 1 (81% vs 46%). There was no significant diminution in Wechsler Preschool and Primary Scale of Intelligence-Revised test scores between 3.5 and 5 years of age for the 27 children tested at both of these ages. Verbal intelligence quotient, performance intelligence quotient, full-scale intelligence quotient scores, and all of the scaled scores except arithmetic and block design were significantly lower for children in group 2 compared with group 1. The majority of the differences remained statistically significant or borderline significant after adjusting for gender. However, the difference in overall verbal scores does not remain statistically significant. Mean +/- SD verbal (98 +/- 20) and performance (95 +/- 17) intelligence quotients were not significantly different for children in group 1. However, verbal (88 +/- 13) and performance intelligence quotients (78 +/- 17) were significantly different for children in group 2. For children in group 2, their lowest scale scores were in object assembly, geometric design, mazes, and picture completion, all timed tests that involved visual discrimination of linear forms with small intersecting lines. In the 2 scales scored that did not differ between groups 1 and 2, arithmetic and block design, timing and vision but not linear forms were components of the tasks. Children with monocular and binocular normal visual acuity did not differ in verbal, performance, or full-scale intelligence quotients or any of the subscale tests. Difficulty with sight or concomitant neurologic involvement also seemed to impact the ability to acquire information, comprehension skills, and vocabulary and performance in similarities testing. After controlling for gender, however, these differences were diminished, and there were no longer differences in overall verbal scores. As noted above, results were generally similar when all of the tests for 3.5-year-olds or 5-year-olds were analyzed separately. At the 3.5-year visit there were fewer significant differences between the 2 groups for the verbal components than at the 5-year visit. CONCLUSIONS: In children with congenital toxoplasmosis and bilateral macular disease (group 2) because of toxoplasmic chorioretinitis, scaled scores were lowest on timed tests that require discrimination of fine intersecting lines. Although the severity of ocular and neurologic involvement is often congruent in children with congenital toxoplasmosis, ophthalmologic involvement seems to account for certain specific limitations on tests of cognitive function. Children with such visual impairment compensate with higher verbal skills, but their verbal scores are still less than those of children with normal vision, and in some cases significantly so, indicating that vision impairment might affect other aspects of cognitive testing. Patterns of difficulties noted in the subscales indicate that certain compensatory intervention strategies to facilitate learning and performance may be particularly helpful for children with these impairments. These patterns also provide a basis for the development of measures of cognitive function independent of visual impairment.

Child, Preschool↗