Oral sex: A new, and possibly the most dangerous, route of toxoplasmosis transmission.

Toxoplasmosis is a parasitic disease widespread in the temperate zone. The definitive hosts of Toxoplasma gondii, which causes the disease, are cats. All warm-blooded vertebrates, including humans, can be intermediate hosts. A person is usually infected by ingesting oocysts, e.g. by consuming along with vegetables some contaminated soil, by drinking contaminated water, or by ingesting tissue cysts contained, for instance, in poorly cooked meat. Less common is congenital transmission or transmission via organ transplant from an infected donor. Recently, it has been suggested that toxoplasmosis could also be transmitted sexually from infected men to uninfected women. In this article, we discuss and present evidence for an alternative hypothesis, which suggests that toxoplasmosis could be transmitted by oral sex (via fellatio) from an infected man to an uninfected person (male or female), especially if the uninfected individual swallows the infected ejaculate. This hypothesis finds support in the following facts and findings: (1) Toxoplasma has been found in male ejaculate. (2) In several animal species, presence of the parasite in the seminal fluid of infected males can lead to infection of uninfected females during mating. (3) A higher prevalence of toxoplasmosis has been reported in both homosexuals and promiscuous individuals, i.e. in populations which practice a broader spectrum of sexual activities, including oral sex. (4) In heterosexual couples, a partner's infection seems to be a risk factor for infection in women but not in men. (5) A higher prevalence of toxoplasmosis in females compared to males has been observed in adolescents aged 10 to 14, where oral sex, including fellatio, is highly prevalent among those who have not yet engaged in penetrative intercourse. (6) On a theoretical level, one could expect that when an uninfected person swallows ejaculate containing Toxoplasma tissue cysts, this results in a similar infection pattern to ingestion of Toxoplasma-contaminated undercooked meat. (7) Approximately two-thirds of Toxoplasma infections in pregnant women cannot be explained by any of the known risk factors. (8) In both women and men who report practicing fellatio with men, there is a higher prevalence of toxoplasmosis than in corresponding controls. If our hypothesis is correct, an effective public health campaign with emphasis on early sexual education about the risks of unprotected oral sex will be necessary, especially in pregnant women and HIV-positive people. This route of toxoplasmosis transmission could be experimentally verified by force-feeding laboratory mice with the ejaculate of infected men.

Toxoplasmosis can be a sexually transmitted infection with serious clinical consequences. Not all routes of infection are created equal.

Toxoplasma gondii infects about 30% of the human population. Common sources of infection are oocysts in cat faeces contaminating drinking water or unwashed vegetables, undercooked meat containing tissue cysts, and organ transplants from infected donors containing tissue cysts. However, very often, it is not possible to identify any potential source of infection in mothers of children with congenital toxoplasmosis. Here we present a hypothesis suggesting that toxoplasmosis is transmitted from infected men to noninfected women during unprotected sexual intercourse, which can result in the most serious form of disease, congenital toxoplasmosis. Arguments for the hypothesis: (1) Toxoplasma tachyzoites are present in the seminal fluid and tissue of the testes of various animals including humans. In some species infection of females by artificial insemination with semen from infected males has been observed. (2) Up to two thirds of Toxoplasma infections in pregnant women cannot be explained by the known risk factors. (3) Prevalence of toxoplasmosis in women in child-bearing age covaries with the incidence of sexually transmitted diseases in particular countries. (4) In some countries, an increased incidence of toxoplasmosis has been reported in women (but not men) aged 25-35 years. This second peak of infection could be associated with women having regular unprotected sex after marriage. (5) Toxoplasmosis triggers schizophrenia in predisposed subjects. Onset of schizophrenia is about 2-3 years earlier in men than in women. However, this difference in the onset can be found only between Toxoplasma-infected patients. The increased onset of schizophrenia in infected women could be associated with the already mentioned second peak of toxoplasmosis incidence. (6) The prevalence of toxoplasmosis decreases in developed countries in last 20 years. This trend could be a result of decrease in promiscuity and increase in safe sex practices, both associated with the AIDS pandemics. (7) In women, probability of being Toxoplasma-infected correlates positively with the amount of unprotected sex with the child's father before the conception. Evidence against the hypothesis: Questionnaire study showed negative association between Toxoplasma infection and the number of earlier partners with whom the woman had unprotected sex. If our hypothesis turns out to be true, then sexual route of transmission, even if rare, could be responsible for a large part of cases of congenital toxoplasmosis. Women should be warned that having unprotected sex with men of positive or unknown toxoplasmosis status should be avoided during pregnancy.

Increased pregnancy weight gain in women with latent toxoplasmosis and RhD-positivity protection against this effect.

OBJECTIVE: RhD-positive subjects are protected against toxoplasmosis-associated impairment of psychomotor performance. Here we searched for RhD-positivity-associated maternal protection against the effects of toxoplasmosis. METHODS: In the present retrospective cohort study, we analysed data from 785 (139 RhD-negative) Toxoplasma-free and 194 (27 RhD-negative) Toxoplasma-infected pregnant women. We searched for effects of toxoplasmosis and Rhd-phenotype on maternal weight before pregnancy, pregnancy weight gain, fetal ultrasound data (biparietal diameter, abdominal circumference, femur length) and on birth length and weight. RESULTS: At pregnancy week 16, the RhD-negative mothers with toxoplasmosis gained more weight than others (P < 0.001). The difference of about 1600 g remained approximately constant from pregnancy week 16 until the end of pregnancy. Neither toxoplasmosis nor RhD phenotype had any effect on fetal bioparameter data or birth length and weight. CONCLUSION: The most parsimonious explanation for the observed data is that the RhD-positive phenotype might protect infected subjects against a broad spectrum of detrimental effects of latent toxoplasmosis, including excessive gestational weight gain.

Influence of latent toxoplasmosis on the secondary sex ratio in mice.

The sex ratio may be influenced by many factors, such as stress and immunosuppression, age of parents, parity and sex of preceding siblings. In animal systems, parasitism often changes the sex ratio of infected hosts, which can increase the probability of their transmission. The most common human protozoan parasite in developed countries, Toxoplasma gondii (prevalence 20%-80%), is known to change the behaviour of its intermediate hosts, thereby increasing the probability of transmission to its definitive host (the cat) by predation. The intermediate hosts, which under natural conditions are rodents, serve as the vector for Toxoplasma. Therefore, we speculate that Toxoplasma can alter the secondary sex ratio (i.e. male to female ratio in the offspring) of infected females to increase the proportion of (congenitally infected) male offspring, which are the more migratory sex in most rodent species. Here we studied the sex ratio of experimentally infected laboratory mice, expressed here as the proportion of males in the litter. In accordance with our hypothesis and results of previous retrospective cohort studies on human subjects, mice with toxoplasmosis produced a higher sex ratio than controls, in the early phase of latent infection. In the later phase of infection, mice with congenital toxoplasmosis had a lower sex ratio than controls, which is in accord with the Trivers-Willard hypothesis of sex ratio manipulation, suggesting that females in poor physical condition give birth to more female offspring.

Women infected with parasite Toxoplasma have more sons.

The boy-to-girl ratio at birth (secondary sex ratio) is around 0.51 in most populations. The sex ratio varies between societies and may be influenced by many factors, such as stress and immunosuppression, age, primiparity, the sex of the preceding siblings and the socioeconomic status of the parents. As parasite infection affects many immunological and physiological parameters of the host, we analyzed the effect of latent toxoplasmosis on sex ratios in humans. Clinical records of 1,803 infants born from 1996 to 2004 contained information regarding the mother's age, concentration of anti-Toxoplasma antibodies, previous deliveries and abortions and the sex of the newborn. The results of our retrospective cohort study suggest that the presence of one of the most common parasites (with a worldwide prevalence from 20 to 80%), Toxoplasma gondii, can influence the secondary sex ratio in humans. Depending on the antibody concentration, the probability of the birth of a boy can increase up to a value of 0.72, C.I.95 = (0.636, 0.805), which means that for every 260 boys born, 100 girls are born to women with the highest concentration of anti-Toxoplasma antibodies. The toxoplasmosis associated with immunosuppression or immunomodulation might be responsible for the enhanced survival of male embryos. In light of the high prevalence of latent toxoplasmosis in most countries, the impact of toxoplasmosis on the human population might be considerable.