Infección de transmisión vertical por Toxoplasma gondii: seguimiento de los hijos de mujeres con primoinfección en una institución de asistencia médica colectiva; 2010-2015 / Vertical transmission of Toxoplasma gondii infections: follow up of children born to mothers diagnosed with a primary infection in a healthcare center between 2010 and 2015

La toxoplasmosis congénita (TC) afecta 1 a 2 niños cada 1.000 nacimientos al año. La mayoría de los recién nacidos infectados son asintomáticos pero la ausencia de tratamiento puede determinar secuelas oftalmológicas y neurológicas. Objetivo: describir el seguimiento de los hijos de mujeres con primoinfección por Toxoplasma gondii durante el embarazo derivados a una Policlínica de Infectología de la Médica Uruguaya entre diciembre de 2010 y mayo de 2015. Material y método: se incluyeron los hijos de mujeres con primoinfección por T.gondii durante el embarazo entre el 1 de diciembre de 2010 y el 31 de mayo de 2015. Se confirmó primoinfección mediante determinación inmunoenzimática de IgG e IgM específicas, complementada por IgM por inmunofluorescencia indirecta o test de avidez de IgG según el caso. El diagnóstico de infección congénita se realizó por la presencia de IgM o títulos de IgG estables o en aumento en los primeros 9 meses de seguimiento del niño. Resultados: se diagnosticó primoinfección en 34 mujeres. La mayoría controló adecuadamente el embarazo y ninguna presentó infección por VIH, sífilis o Chagas. Se confirmó TC en 3 niños nacidos a término, con peso adecuado, hijos de mujeres con primoinfección adquirida en el tercer trimestre y tratadas con espiramicina. Uno presentó coriorretinitis, los otros fueron asintomáticos. En todos la IgM fue negativa, el diagnóstico se confirmó con curva de IgG. Todos recibieron piremetamina, sulfadiazina y ácido folínico sin efectos adversos. A la fecha continúan en tratamiento y seguimiento dos de los tres niños. Discusión y conclusión: la captación temprana de la mujer embarazada, la indicación oportuna de medidas de prevención constituyen pilares fundamentales para reducir la TC. El tratamiento oportuno y adecuado puede prevenir las secuelas.

Congenital toxoplasmosis (CT) affects one to two children out of 1000 births per year. Most infected newborns present no symptoms, although the absence of treatment may result in eye and neurologic sequelae. Objective: to describe follow-up of children born to mothers diagnosed with a primary Toxoplasma gondii infection during pregnancy referred to an Infectology Policlinic of Medica Uruguaya between December, 2010 and May, 2015. Method: the children of women with Toxoplasma gondii primary infection during pregnancy between December 1, 2010 and May 31, 2015 were included in the study. Primary infection was confirmed through specific IgG and IgM immunoenzymatic techniques, complemented by IgM by indirect immunofluorescence or IgG avidity test, depending on the case. Diagnosis of congenital infection was done according to the presence of IgM or IgG stable or increasing titers in the first 9 months of follow-up of the children. Results: thirty four women were diagnosed with primary infection. Most of them were properly controlled during pregnancy and none of them were HIV, syphilis or Chagas positive. Congenital toxoplasmosis was confirmed in 3 children delivered on the date they were due, with adequate weight, children to mothers with primary infection acquired in the third trimester and treated with spiramycin. One of them evidenced chorioretinitis and the others were asymptomatic. IgM was negative in all cases, diagnosis being confirmed with IgG curve. All of them received pyrimethamine sulfadiazine and folinic acid, there being no side effects. Today, two of the three children are still under treatment and under follow-up. Discussion and conclusion: follow-up of pregnant women since early stages of pregnancy and the timely indication of preventive measures constitute essential pillars to reduce congenital toxoplasmosis. Timely and adequate treatment may prevent sequelae.

Presentación de un caso con toxoplasmosis congénita / Case presentation: congenital Toxoplasmosis

La toxoplasmosis, enfermedad conocida como “Parasitosis del Siglo XX”, cobra importancia en los neonatos cuyas madres se infectaron por primera vez durante la gestación. El objetivo del trabajo es presentar el caso de un recién nacido de 40 semanas con toxoplasmosis congénita. El peso al nacer fue de 3 500 g, Apgar 2/3. Requirió intubación orotraqueal y resucitación cardiopulmonar inmediata. Hubo presencia de líquido amniótico meconial, tiempo de rotura de membranas de 14 h, antecedentes maternos de sepsis vaginal, y con un descenso detenido de la presentación lo que llevó a cesárea de urgencia. A las 4 h de vida desarrolla cuadro de coagulación intravascular diseminada, acompañado de hipotonía marcada, mirada fija sin respuesta pupilar ni esfuerzo respiratorio. A las 48 h aparece insuficiencia renal aguda con evolución rápida a fallo múltiple de órganos. Ultrasonido de cráneo con aumento de la ecogenicidad cerebral, borramiento de las circunvoluciones cerebrales y ventrículos laterales dilatados. Evolución tórpida, sin recuperación neurológica, alteraciones del medio interno y trastornos del equilibrio ácido-base e hidroelectrolítico, empeoramiento progresivo de la función cardiaca y respiratoria, fallece a los 21 días de vida.

Toxoplasmosis, known as the "Twentieth century parasites disease", becomes important in infants whose mothers were infected for the first time during pregnancy. The aim of this work is to present the case of a 40 weeks newborn with congenital toxoplasmosis. The birth weight was 3 500 g, Apgar 2/3. Immediate endotracheal intubation and cardiopulmonary resuscitation was required. There were meconium, 14-hour membrane rupture time, maternal history of vaginal sepsis, detained presentation prompting emergency caesarean section. At 4 hours of life, disseminated intravascular coagulation develops, accompanied by marked hypotonia, staring with no pupillary response or respiratory effort. At 48 hours, acute renal failure appears with rapid progression of multiple organ failure. Skull ultrasound showed increased brain echogenicity, effacement of the cerebral convolutions and dilated lateral ventricles. Torpid evolution, with no neurological recovery, internal disorders and disorders of acid-base and electrolyte balance, progressive deterioration of the cardiac and respiratory functions, dies at 21 days of life. Decease occurs at 21 days of life.

Incidence of congenital toxoplasmosis among infants born to HIV-coinfected mothers: case series and literature review

Introduction: There is a paucity of data on the occurrence of congenital toxoplasmosis in children born to mothers dually infected with HIV and Toxoplasma gondii. Objective: To evaluate aspects of the mother–infant pairs associated with vertical transmission of toxoplasmosis in women co-infected with HIV in a referral center for perinatally acquired infections in Belo Horizonte, Brazil. Methods: Descriptive study of HIV vertically exposed children, with congenital toxoplasmosis, followed at a referral center (cohort/Belo Horizonte). Prenatal and post-natal variables for the mother–infant pairs were evaluated. A literature review with no filtering for time and language was performed to identify reports of congenital toxoplasmosis in HIV vertically exposed children. Results: Among 2007 HIV vertically exposed children evaluated in the period from 1998 to 2011, 10 cases of congenital toxoplasmosis were identified (incidence: 0.5%, 95% confidence interval: 0.24–0.91). In searching the literature 22 additional cases in 17 reports were found. Combining the findings of our cohort with other reported cases, 50% (16/32) of congenital toxoplasmosis in HIV vertically exposed children were from Brazil. The cases of congenital toxoplasmosis in HIV vertically exposed children identified in Brazil occurred mainly in the post-Highly Active Antiretroviral Therapy era (p = 0.002) and presented a lower death rate (p = 0.003) than those from other countries. In the cohort/Belo Horizonte, HIV infection was identified mainly during gestation; T. gondii vertical transmission was observed in pregnant women with CD4+>500 cells/mm3 and latent toxoplasmosis. High rates of ocular lesions (87.5%) and central nervous system involvement (70%) were detected. Conclusions: The risk of vertical transmission of T. gondii in HIV-infected women is low and has been usually associated with maternal immunosuppression and elevated viral load. However, ...

Prevención de la toxoplasmosis congénita en un hospital de Buenos Aires / Prevention of congenital toxoplasmosis in a Buenos Aires hospital

La prevención de la toxoplasmosis congénita se basa en la información de la mujer con medidas de prevención primaria, el diagnóstico serológico y el tratamiento de la embarazada y del niño. Se presentan los resultados de 12 años de implementación de un programa de prevención de la toxoplasmosis congénita, la tasa de madres infectadas, de transmisión vertical, de niños infectados y la gravedad de la afección causada. Se realizó un estudio observacional prospectivo sobre 12 035 gestantes atendidas en la maternidad del Hospital Alemán de Buenos Aires entre enero de 2000 y diciembre de 2011. Se observó una prevalencia de anticuerpos anti Toxoplasma gondii de 18.33% (2 206/12 035). Treinta y siete mujeres de 9 792 susceptibles tuvieron infección aguda, la tasa de incidencia de infección materna fue de 3.78 por 1 000 nacimientos. La tasa de transmisión transplacentaria de la infección fue 5.4% (2/37). Dos recién nacidos tuvieron toxoplasmosis congénita, uno no tuvo signos clínicos y el otro presentó coriorretinitis y estrabismo. Recibieron tratamiento 35 madres y los 2 niños con toxoplasmosis congénita. En conclusión: Las cifras de transmisión obtenida permiten considerar a este programa de prevención como un recurso válido para minimizar el impacto de la toxoplasmosis congénita.

The prevention of congenital toxoplasmosis is based on providing information to women, serologic diagnosis and treatment of the infected mother and child. In this article we present the results of 12 years of implementation of a congenital toxoplasmosis prevention program in which we measured the mother´s infection incidence rate, the transmission rate and the number and severity of infection in newborns. The study was performed on 12 035 pregnant women in the period 2000-2011. The prevalence rate of antibodies against Toxoplasma gondii was 18.33% (2 206/12 035). Thirty-seven out of 9 792 susceptible women presented acute infection and the mother's infection incidence rate was 3.78 per 1000 births. The transplacental transmission rate was 5.4% (2/37). Two newborns presented congenital toxoplasmosis infection, one had no clinical signs while the other presented strabismus and chorioretinitis. Thirty-five infected mothers and the two children with congenital infection were treated. The transmission rates obtained allow consider this prevention program as a valid resource to minimize the impact of congenital toxoplasmosis.

Desempenho da reação em cadeia da polimerase no líquido amniótico para diagnóstico da toxoplasmose congênita. Revisão sistemática e metanálise / Polymerase chain reaction performance in the amniotic fluid for the diagnosis of congenital toxoplasmosis. Systematic review and meta-analysis

A toxoplasmose é uma zoonose endêmica em todo o mundo causada pelo Toxoplasma gondii. Embora a maioria das infecções sejam subclínicas e assintomáticas, tem uma grande importância em hospedeiros imunocomprometidos e em recém-nascidos com infecção congênita. A infecção causada pelo Toxoplasma gondii durante a gestação pode causar graves lesões ao feto. A realização de exames laboratoriais para investigação diagnóstica da toxoplasmose congênita durante o prenatal é imprescindível para o tratamento correto da gestante e melhor prognóstico das crianças infectadas.O grande avanço no diagnóstico prenatal da infecção fetal pelo Toxoplasma gondii foi o uso da reação em cadeia da polimerase (PCR) no líquido amniótico. O objetivo da investigação é avaliar o desempenho diagnóstico da PCR para identificação da toxoplasmose fetal em gestantes com diagnóstico sorológico de toxoplasmose recente, através de uma revisão sistemática da literatura. Nessa revisão a sensibilidade global do teste da PCR foi de 77 por cento e a especificidade de 98,3 por cento, alcançando sensibilidade de 87 por cento e especificidade de 99 por cento quando realizado até cinco semanas após o diagnóstico materno. No entanto o desempenho do teste pode variar de acordo com o trimestre da gravidez. Pode ser recomendado para uso nas primeiras cinco semanas após o diagnóstico materno quando há suspeita de toxoplasmose fetal...

Avaliação sorológica de Toxoplasma gondii, em ovinos criados em dois municípios do nordeste paraense. Considerações relativas ao consumo humano de produtos e subprodutos dessa espécie / Evaluation serological of Toxoplasma gondii in sheep reared in two municipalities of northeastern Pará. Considerations for human consumption of products

No intuito de realizar uma investigação sorológica da toxoplasmose natural em ovinos, amostras de 350 soros de ovinos foram submetidas à reação de hemaglutinação indireta (HAI) para detecção de anticorpos anti-Toxoplasma gondii. Desta forma, objetivou-se nesta pesquisa realizar uma investigação sorológica inicial sobre a ocorrência da infecção pelo T.gondii em ovinos de dois municípios do Estado do Pará e a correlação da enfermidade em humanos por consumo de produto e subprodutos dessa espécie.

Congenital toxoplasmosis transmitted by human immunodeficiency-virus infected women

We report the occurrence of congenital toxoplasmosis in three infants born to HIV infected women who had high anti-toxoplasma IgG and negative IgM during pregnancy. We briefly reviewed available literature and discussed the possible transmission mechanisms of congenital toxoplasmosis among HIV infected pregnant women. Serum samples were tested for Toxoplasma gondii IgM and IgG antibodies using commercial enzyme immunoassay and IgG-avidity tests. In the first case, fetal death occurred at 28th week of gestation. In the second case, congenital toxoplasmosis was diagnosis at 6th month of life; and in the third case, an HIV-infected newborn, congenital toxoplasmosis was asymptomatic. These cases point out to the possibility of enhanced maternal-fetal transmission of T. gondii infection by HIV-infected women chronically infected, which may have important public health consequences, considering that increasing frequency of HIV-infection has been observed among women of childbearing age around the world.

Modelo para la dinámica de transmisión de la toxoplasmosis congénita / A model of congenital toxoplasmosis transmission dynamics

La toxoplasmosis es una zoonosis parasitaria de amplia distribución mundial, que infecta una gran proporción de poblaciones humanas y animales, producida por el parásito Toxoplasma gondii, siendo de gran importancia el contagio de mujeres gestantes, puesto que ésta zoonosis causa enfermedades en los fetos a través de infección transplacentaria; tradicionalmente se ha utilizado una tasa de infección madre-feto constante; sin embargo, hay evidencias de una fuerte relación con la semana de gestación de la madre en el momento de contagiar al feto. Este trabajo describe la dinámica de transmisión de la toxoplasmosis congénita a través de un modelo estructurado en la edad que tiene en cuenta la semana de gestación de la madre; el modelo está acoplado con un modelo espacio-temporal que describe la dispersión de T. gondii a través de gatos, el cual proporciona la cantidad de parásitos en el ambiente, de la cual depende que una mujer gestante se infecte. Se hacen simulaciones variando la cantidad de parásitos y la distancia a la que se encuentra la gestante del lugar del inóculo; además, se varían algunos parámetros equivalentes a posibles medidas de control. Se encuentran cambios importantes al comparar el comportamiento de las poblaciones de gestantes infectadas, cuando se usa tasa de infección madrefeto constante y cuando se usa tasa dependiente de la semana de gestación, lo que permite concluir que la semana de gestación en la que se encuentra la población de gestantes infectadas es fundamental en la transmisión de la infección al feto.

Toxoplasmosis is a parasitic zoonosis having worldwide distribution; it infects many human and animal populations and is produced by the parasite Toxoplasma gondii, this being of great importance in contagion of pregnant women since this zoonosis causes illness in the fetus through transplacental infection. A constant mother-foetus infection rate has traditionally been used. Nevertheless, there is evidence of a strong relationship between a mother's gestation week and the moment when a foetus becomes infected. This work describes congenital toxoplasmosis transmission dynamics by using an age-structured model taking a mother's gestational week into account. The model was adapted to a space-time model describing T. gondii dispersion through cats; this provided the amount of parasites in the environment depending on which a pregnant woman would become infected. Simulations were done, varying the amount of parasites and the pregnant mother-inoculum distance. Some parameters related to possible control measures were also varied. Important changes were found when comparing infected pregnant female population patterns, when a constant mother-fetus infection rate was used and when a dependent pregnancy week rate was used. This led to concluding that the gestation week in which the mothers became infected is fundamental in infection being transmitted to their fetuses.

Alta prevalencia de infección por Toxoplasma gondii en las embarazadas / High prevalence of toxoplasma gondii infection in pregnant women

Más del 80% de las embarazadas cursarán en forma asintomática su primoinfección por Toxoplasma gondii y por ello el diagnóstico es serológico. Este control serológico debe ser realizado de rutina con el fin de ofrecerle tratamiento oportuno y así, reducir la tasa de transmisión vertical o, si la infección ya se produjo, para reducir el daño en el feto.

Prevalence of acute toxoplasmosis infection among 41112 pregnant women and the mother-to-child transmission rate in a public hospital in South Brazil

Untreated acute toxoplasmosis among pregnant women can lead to serious sequelae among newborns, including neurological impairment and blindness. In Brazil, the risk of congenital toxoplasmosis (CTox) has not been fully evaluated. Our aim was to evaluate trends in acute toxoplasmosis prevalence from 1998-2005, the incidence of CTox and the rate of mother-to-child transmission (MTCT). A cross-sectional study was undertaken to dentify patients who fit the criteria for acute toxoplasmosis during pregnancy. Exposed newborns were included in a historical cohort, with a median follow-up time of 11 months, to establish definite diagnosis of CTox. Diagnoses for acute infection in pregnancy and CTox were based on European Research Network on Congenital Toxoplasmosis criteria. In 41,112 pregnant women, the prevalence of acute toxoplasmosis was 4.8/1,000 women. The birth prevalence of CTox was 0.6/1,000 newborns [95 percent confidence interval (CI): 0.4-0.9]. During the follow-up study, 12 additional cases were detected, increasing the CTox rate to 0.9/1,000 newborns (95 percent CI: 0.6-1.3). Among the 200 newborns exposed to Toxoplasma gondii,there were 37 babies presenting diagnostic criteria of CTox, leading to an MTCT rate of 18.5 percent (95 percent CI: 13.4-24.6 percent). The additional cases identified during follow-up reinforce the need for serological monitoring during the first year of life, even in the absence of evidence of congenital infection at birth.

Consenso argentino de toxoplasmosis congénita / Argentine Consensus of Congenital Toxoplasmosis

La transmisión de la infección por Toxoplasma gondii de la madre al hijo ocurre cuando la madre se infecta por primera vez en el transcurso del embarazo. Tanto el diagnóstico prenatal, como el del primer año de vida se basa en pruebas serológicas; y la mayoría de las veces es necesario realizar más de una de estas pruebas ya que tienen distintos porcentajes de sensibilidad y/o especificidad así como distintos niveles de complejidad. El recién nacido requiere seguimiento serológico en el primer año de vida o hasta que se descarte el diagnóstico de toxoplasmosis congénita. El diagnóstico temprano de la infección, en la mujer embarazada, permite un tratamiento oportuno y se indica con el propósito de reducir la tasa de transmisión y el daño congénito. Es posible que con un programa activo, de prevención y tratamiento temprano, se pueda reducir la tasa de incidencia de la toxoplasmosis congénita de alrededor del 5 por mil nacimientos a 0.5 por mil. El objetivo de este consenso fue revisar la literatura científica para la prevención, el diagnóstico y el tratamiento de la toxoplasmosis congénita, para que se pueda implementar en nuestro país.

The mother-to-child transmission in Toxoplasma gondii infection occurs only when the infection is acquired for the first time during pregnancy. The prenatal and early postnatal diagnosis can only be achieved by serological testing. Serologic tests have different sensitivities, specificities and complexities, so that different tests in more than one blood sample are necessary for the diagnosis. Serological follow-up of the infants should be conducted during the first year of life or until the diagnosis of congenital toxoplasmosis can be ruled out. Treatment recommendations try to reduce the transmission rate and the risk of congenital damage. Congenital toxoplasmosis incidence rate is approximately 5 per 1000 births, but can be reduced to 0.5 per 1000 with an active screening program. The aim of this consensus group was to review the scientific literature on congenital toxoplasmosis and prepare a statement on prevention, diagnosis and treatment that should be implemented in our country.

Toxoplasmose aguda: estudo da freqüência, taxa de transmissão vertical e relação entre os testes diagnósticos materno - fetais em gestantes em estado da Região Centro - Oeste do Brasil / Acute toxoplasmosis: study of the frequency, vertical tansmission rate and the relationship between maternal - fetal diagnostic tests during pregnancy in a Central - Western state of Brazil

OBJETIVOS: estabelecer a freqüência da toxoplasmose aguda em gestantes, a taxa de transmissão vertical e o resultado perinatal dos fetos infectados. Objetivou-se, ainda, avaliar a relação entre os principais testes materno-fetais de diagnóstico da toxoplasmose durante a gestação, bem como a relação entre faixa etária e a infecção aguda pelo Toxoplasma gondii. MÉTODOS: estudo prospectivo longitudinal com 32.512 gestantes submetidas à triagem pré-natal pelo Programa de Proteção à Gestante de Mato Grosso do Sul, no período de novembro de 2002 a outubro de 2003. Utilizaram-se método ELISA (IgG e IgM) e teste de avidez de anticorpos IgG para diagnóstico da toxoplasmose materna, e PCR no líquido amniótico, para diagnóstico da infecção fetal. A avaliação das variáveis foi feita pelas médias, ao passo que a correlação entre algumas variáveis foi avaliada pelo teste do c² e teste de Fisher bicaudado em tabelas de contingência de dupla entrada. RESULTADOS: encontrou-se freqüência de 0,42 por cento para a infecção aguda pelo T. gondii na população de gestantes, sendo 92 por cento delas expostas previamente à infecção e 8 por cento suscetíveis. Nas gestantes com sorologia IgM reagente, a faixa etária variou de 14 a 39 anos, com média de 23±5,9 anos. Não houve relação significativa estatisticamente entre faixa etária e infecção materna aguda pelo T. gondii (p=0,73). Verificou-se taxa de transmissão vertical de 3,9 por cento. Houve relação estatisticamente significativa (p=0,001) entre o teste de avidez (IgG) baixo (<30 por cento) e presença de infecção fetal, e ausência de toxoplasmose fetal quando a avidez apresentava-se elevada (>60 por cento). Houve associação significativa estatisticamente (p=0,001) entre infecção fetal (PCR em líquido amniótico) e infecção neonatal. CONCLUSÕES: a freqüência da toxoplasmose aguda materna apresentou-se abaixo do observado em outras investigações no Brasil. Entretanto a taxa de transmissão vertical não foi discordante do encontrado em outros estudos. O teste de avidez dos anticorpos IgG, quando associado à idade gestacional e data de realização do exame, mostrou-se útil para orientar a terapêutica e avaliar o risco de transmissão vertical, permitindo afastá-lo quando havia avidez elevada previamente a 12 semanas. O PCR positivo foi associado à pior prognóstico neonatal, demonstrando-se método específico para diagnóstico intra-útero da infecção fetal

Vertical toxoplasmosis in a murine model. Protection after immunization with antigens of Toxoplasma gondii incorporated into liposomes

Distinct Toxoplasma gondii antigens were entrapped within liposomes and evaluated for their ability to protect Balb/c mice against congenital transmission: soluble tachyzoite antigen (L/STAg), soluble tissue cyst antigen (L/SCAg), soluble tachyzoite plus tissue cyst (L/STCAg) or purified 32kDa antigen of tachyzoite (L/pTAg). Soluble tachyzoite antigen alone in PBS (STAg) or emulsified in Freund's Complete Adjuvant (FCA/STAg) was also evaluated. Dams were inoculated subcutaneously with these antigens 6, 4 and 2 weeks prior to a challenge with four tissue cysts of the P strain of T. gondii orally between 10 and 14 days of pregnancy. Significant diminution differences were observed between the frequency of infected pups born of the dams immunized with the antigens incorporated into liposomes and that of pups born of the dams immunized with antigen emulsified in FCA or non immunized group (p<0.05). There was a significant decrease in the number of pups born dead in the groups L/STAg, L/SCAg and L/pTAg when compared with pups from all other groups (p <0.05). All dams immunized with or without adjuvant showed an antibody response and a proliferation of T-cells. However, no correlation was found between immune response and protection against the challenge

Prevenção primária da toxoplasmose congênita / Primary prevention of congenital toxoplasmosis

Neste artigo, as autoras revisam alguns aspectos epidemiológicos da toxoplasmose, o ciclo vital do parasita e as formas de contaminação do ser humano. Discutem as medidas de prevenção da toxoplasmose congênita, dando ênfase a programas de prevenção primária da doença

Toxoplasmose congênita / Congenital toxoplasmosis

O autores fazem uma breve revisão sobre os principais aspectos da doença, abordando os seguintes tópicos: formas clínicas, transmissão, profilaxia e diagnóstco