Toxoplasmosis: Summary of evidences, a Research line

Toxoplasmosis: Summary of evidences, a Research line José G. Montoya, MD Associate Professor of Medicine Associate Chief for Clinical Affairs Division of Infectious Diseases Stanford University School of Medicine

Palo Alto Medical Foundation Toxoplasma Serology Laboratory (PAMF-TSL) Jack S. Remington Valerie Dargelas Jose G. Montoya Brian Blackburn Cindy Press Jeanne Talucod Raymund Ramirez Beverly Gaylord Helen Canevari Gina Cruz Roy Cruz Michiko Matsuura Judith Beatty Kathy Messing Executive Assistant: Peggy Wakeman Websitehttp://www.pamf.org/serology/ E-mail toxolab@pamf.org Phone (650) 853 4828

Tachyzoites Tissue cysts T. gondii strains Type I Type II Type III Oocysts

Bowie WR et al. Lancet 1997;350:173-177 Bahia-Oliveira L et al. Emerg Infect Dis 2003; 9:55-62. Miller MA et al. Int J Parasitol 2002; 32:997-1006. Lopez Castillo CA et al. Rev Salud Publica 2005; 7(2):180-90

Toxoplasma gondii infects over one billion people worldwide Toxoplasmosis immunocompetent patient lymphadenopathy ocular disease fever hepatitis schizophrenia?? during pregnancy congenital disease localized and disseminated disease in immunocompromised patients Montoya JG, Liesenfeld O. Lancet. 2004; 363 (9425): 1965-76

T. gondii is an obligate intracellular parasite that establishes a latent state of infection for the life of the parasite T. gondii triggers a vigorous humoral and cellular immune response IgG becomes detectable 1-2 weeks after acquisition of infection and peaks between 3 and 6 months. A gradual decline occurs over months to years and lower titers persist for life IgM appears within the first week or 2 of infection. In some patients IgM antibodies may persist for > 1 year after primary infection. Montoya JG, Rosso F. Clinics in Perinatology. 2005; 32(3): 705-726

Humoral Immune responses are used for serological diagnosis of acute vs. chronic infection IgA appears within the first week or 2 of infection. In some patients IgA antibodies may persist for or reappear months after primary infection IgE appears within the first week or 2 of infection. Duration of detectable IgE antibodies in adults with acute infection is briefer than that of IgM and IgA antibodies. Among patients with detectable titers, IgE antibodies usually dissapear 2 to 3 months after primary infection AC/HS compares the titers obtained with formalin-fixed tachyzoites (HS antigen) with those obtained with acetonefixed tachyzoites (AC antigen). The AC preparation contains stage-specific antigents that are recognized by IgG antibodies early in infection Montoya JG, Rosso F. Clinics in Perinatology. 2005; 32(3): 705-726

Painless lymphadenopathy (LN) can the be the sole presentation of patients with toxoplasmic lymphadenitis (TL) LN can be localized or generalized Non-suppurative Non-necrotizing Occipital common but can present anywhere including abdominal Recurrence is rare Treatment is not indicated in the United States Systemic symptoms may be present and require treatment McCabe RE, Brooks RG, Dorfman RF, Remington JS.. Rev Infect Dis 1987; 9: 754-74

TL cannot be distinguished from other causes of LN including infectious, immunological, neoplastic, iatrogenic, and other miscellaneous causes it can be a source of high anxiety to patients and their health care providers of particular concern are those patients whose LN has been present for more than 6 weeks and less than 12 months in those settings, malignancy and infection need to be ruled out first, since they are among the most common etiologies Montoya JG, Remington JS. Clin Infect Dis. 1995 Apr;20(4):781-9

Diagnostic approach to patients with LN radiological studies to distinguish localized from generalized LN serological assays in the attempt to identify infectious causes fine needle aspiration to attempt to diagnose malignancies or infection complete excisional lymph node biopsy to diagnose infection or malignancy by histological analysis, immunochemistry testing, stains for different organisms, and/or cultures Montoya JG, Remington JS. Clin Infect Dis. 1995 Apr;20(4):781-9

Lymph Node Biopsy may be Diagnostic of Toxoplasmic Lymphadenitis reactive follicular hyperplasia irregular clusters of epithelioid histiocytes encroaching on and blurring the margins of the germinal centers focal distention of sinuses with monocytoid cells Dorfman, R. F., and J. S. Remington. 1973. NEJM. 289:878 881

Diagnosis of Toxoplasmic Lymphadenitis Lymph node biopsy Serological diagnosis IgG, IgM, IgA, IgE IgG: Dye test, AC/HS Montoya JG, Remington, JS. Toxoplasma gondii. In: Mandell G, Dolin A, Bennett J, eds. Principles and Practice of Infectious Diseases. Pages 3170-3198. Sixth Edition. Elsevier Churchill Livingstone. Philadelphia, PA

Serological Tests may be Diagnostic of Toxoplasmic Lymphadenitis Montoya JG, Remington JS. Clinical Infectious Diseases 1995;20:781-9

Toxoplasma Serological Profile (TSP) TSP = IgG, IgM, IgA, IgE, AC/HS Used successfully by our group at PAMF to determine whether serologic test results are more likely consistent with infection acquired in the recent or more distant past

TSP can be used to confirm positive IgM test results Liesenfeld O, Press C, Montoya JG, Gill R, Isaac-Renton JL, Hedman K, Remington JS. Journal of Clinical Microbiology 1997; 35:174-178

Use of the TSP in the setting of chorioretinitis Montoya JG, Remington JS. Clinical Infectious Diseases 1996; 23:277-282

Use of the TSP in patients with myositis and/or myocarditis Montoya JG, Jordan R, Lingamneni S, Berry GJ, Remington JS. Clinical Infectious Diseases 1997; 24:676-683

Use of the TSP during Pregnancy Liesenfeld O, Montoya JG, Tathineni NJ, Davis M, Brown BW, Cobb KL, Parsonnet J, Remington JS. American Journal of Obstetrics and Gynecology 2001; 184: 140-145

Confirmatory Serological Testing for Toxoplasmosis and Abortion in the United States ~20% of pregnant women will choose abortion when told they have IgM antibody ~60% of positive IgM tests reported by outside laboratories are falsely positive; thus, 6 of every 10 aborted fetuses are not infected Liesenfeld O. et al. Am J Obstet Gynecol 2001 Jan;184(2):140-5

Toxoplasma Serological Profile (TSP) Pregnancy Liesenfeld O, Montoya JG, Tathineni NJ, Davis M, Brown BW, Jr., Cobb KL, Parsonnet J, Remington JS. Am J Obstet Gynecol 2001; 184: 140-145 Lymphadenopathy Montoya JG, Remington JS. Clin Infect Dis 1995; 20: 781-90 Myositis or myocarditis Montoya JG, Jordan R, Lingamneni S, Berry GB, Remington JS. Clin Infect Dis 1997; 24: 676-683 Chorioretinitis Montoya JG, Remington JS. Clin Infect Dis 1996; 23: 277-282

IgG Avidity Test Antibody binding avidity for an antigen is initially low and increases thereafter 6M urea is used to break weak bond

MEAN AND RANGE OF TOXOPLASMA IgG AVIDITY TITERS FOLLOWING ONSET OF TOXOPLASMIC LYMPHADENOPATHY 0.700 0.600 0.500 0.400 0.300 0.200 0.100 0.000 37-48 25-36 13-24 7 through 12 6 5 4 3 2 1 0 Time from onset of lymphadenopathy to sampling of sera (months) Montoya JG., Huffman HB, Remington JS. J Clin Microbiol. 2004 Oct;42(10):4627-31

IgG avidity interpretation during gestation High avidity in the first 16 weeks essentially rules out that acute infection occurred during the first 4 months of pregnancy Low or equivocal avidity does not mean the patient has a recently acquired infection; low avidity antibodies may persist for more than five months or even one year

Montoya JG, Berry A, Rosso F, Remington JS. J Clin Microbiol. 2007 May;45(5):1463-8

An 18 yo woman, 34 weeks pregnant on 9/13/07, is found to have an abnormal fetal ultrasound DT (IgG) = 8000 IgM = 6.5 ACHS = >1600/3200 acute pattern

PCR in peripheral blood, cerebrospinal fluid and urine may be helpful for the diagnosis of CT Threshold Pos Control Amniotic fluid PCR

Seroprevalence of T. gondii infection in the United States A decline in seropositivity from 14.1% to 9.0% among U.S.-born persons ages 12 49 years has been documented in sera collected from the National Health and Nutrition Examination Survey (NHANES) 1999 2004 when compared to data from NHANES III (1988 1994). Jones J. et al. Am J Trop Med Hyg. 2007 Sep;77(3):405-10

Table 3. Examples of decreasing prevalence of T. gondii antibodies in different geographical locales. Country, City or Region * Years Seropositivity (Ig G) Switzerland, Geneva 14 1973 1987 87 % 47% France, Paris 13 UK, South Yorkshire 15 Sweden, Stockholm 21 Greece, Northern region 22 Poland, Lodz 23 USA, Palo Alto 1 US recruits 3 Costa Rica, Central Valley region 9 1965 1995 1969 1990 1969 1987 1984 2004 1998 2003 1970 2003 1965 1989 1980 2003 86% 54% 22% 8% 34% 18% 37% 24 % 45.4% 39.4% 24% 9% 14.4% 9.5% 70% 58%

Prevalence of infection with Toxoplasma gondii among pregnant women in Cali, Colombia, South America Rosso F. et al. Am J Trop Med Hyg. In press

Prevalence of Toxoplasma gondii among pregnant women in Cali is higher than expected Results A total of 955 pregnant women were studied Average age: 25.1 +/- 5.7 years Average gestational age: 23.8 +/- 10 weeks The seroprevalence for T.gondii antibodies: Ig G : 45.8 % (95% CI 41.83% - 48.24%) Ig M : 2.4 % (95% CI 1.5 3.6%) *36% in 1980 Rosso F. et al. Am J Trop Med Hyg. In press

Sera studied from 955 pregnant women from July to November 2005 Seroprevalence of of T.gondii infection in in Cali Cali -- Colombia, by by Age Age and and Social Economical Strata % seroprevalence 70.00% 70.00% 60.00% 60.00% 50.00% 50.00% 40.00% 40.00% 30.00% 30.00% 20.00% 20.00% 10.00% 10.00% 0.00% 0.00% Lower Lower SES SES Middle Middle SES SES Higher Higher SES SES 14 14 -- 19 19 20-29 20-29 30-40 30-40 Group Group Age Age Chi square for linear trend=9.53 p=0.002 Chi square for linear trend=4.28 p=0.07 Chi square for linear trend=0.14 p=0.704 Rosso F. et al. Am J Trop Med Hyg. In press

(A) (B) Geographic distribution of pregnant women positive for IgG toxoplasma antibodies Individual women who had both IgG and IgM T. gondii antibodies (black dots) shown in relation to social and economically deprived areas Rosso F. et al. Am J Trop Med Hyg. In press

Table 4: Comparison of T. gondii seroprevalence by age group between the general population of the western region of Colombia during 1980 12, and the pregnant women in Cali, Colombia during 2005 National Survey (1980) 12 10-19 years : 33.0% 20 29 years : 37.4% 30 39 years : 37.6% Present study (2005) 14 19 years : 39.0 % 20-29 years : 43.1% 30-39 years : 55.3% Rosso F. et al. Am J Trop Med Hyg. In press

Risk factors for acute Infection among pregnant women in Cali, Colombia Dr. Marisol Badiel Dr. Fernando Rosso Jefe Yanet Álvarez Otero Jefe Gloria Anais Tunubala Medical Student Alexa Bisinger Medical Student Jessica Telleria 892 women have been enrolled FCVL Hospital San Juan De Dios Hospital Joaquin Paz Borrero Comfandi U. del Valle U. Santiago de Cali