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Pediatric Toxoplasmosis Clinical Presentation

  • Author: Itzhak Brook, MD, MSc; Chief Editor: Russell W Steele, MD  more...
 
Updated: Sep 16, 2015
 

History

Congenital toxoplasmosis is the consequence of transplacental hematogenous fetal infection by T gondii during primary infection in pregnant women. Primary infection in an otherwise healthy pregnant woman is asymptomatic in 60% of cases. Symptoms during pregnancy are frequently mild. The most common manifestations are fatigue, malaise, a low-grade fever, lymphadenopathy, and myalgias. Latent Toxoplasma infection with reactivation during pregnancy may lead to congenital infection only in immunocompromised women (most commonly, those with AIDS).

The classic triad of chorioretinitis, hydrocephalus, and intracranial calcifications cannot be used as a strict diagnostic criterion for congenital toxoplasmosis because a large number of cases would be missed. Congenital toxoplasmosis may occur in the following forms:

  • Neonatal disease
  • Disease occurring in the first months of life
  • Sequelae or relapse of previously undiagnosed infection
  • Subclinical infection

When clinically recognized in the neonate, congenital toxoplasmosis is very severe. Spontaneous abortions, prematurity, or still birth may result. Signs of generalized infection, such as the following, are usually present:

  • Intrauterine growth restriction
  • Fever
  • Chorioamnionitis (usually bilateral)
  • Cerebral calcification
  • Abnormal cerebrospinal fluid (xanthochromia and pleocytosis)
  • Vomiting
  • Eosinophilia
  • Abnormal bleeding
  • Jaundice
  • Hepatomegaly
  • Splenomegaly
  • Lymphadenopathy
  • Rash

Neurologic signs are severe and always present. They include the following:

  • Microcephaly or macrocephaly
  • Bulging fontanelle
  • Nystagmus
  • Abnormal muscle tone
  • Seizures
  • Delay of developmental milestone acquisition

Most cases of chorioretinitis result from congenital infection, although patients are often asymptomatic until later in life.[6] Symptoms include blurred vision, scotoma, pain, photophobia, and epiphora. Impairment of central vision occurs when the macula is involved, but vision may improve as inflammation resolves. Relapses of chorioretinitis are frequent but are rarely accompanied by systemic signs or symptoms.

Latent toxoplasmosis may reactivate in women with human immunodeficiency virus (HIV) and result in congenital transmission. Congenital toxoplasmosis in the infant with HIV appears to run a more rapid course than in infants without HIV.

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Physical Examination

In subacute congenital toxoplasmosis, symptoms may not be observed in patients until some time after birth.

Lymphadenopathy is the most common form of symptomatic acute toxoplasmosis in immunocompetent individuals. Patients typically present with painless, firm lymphadenopathy that is confined to 1 chain of nodes (most commonly cervical nodes). The suboccipital, supraclavicular, axillary, and inguinal groups may also be involved.

Other physical manifestations include a low-grade fever, occasional hepatosplenomegaly, and a rash. Ophthalmologic examination reveals multiple yellow-white, cottonlike patches with indistinct margins located in small clusters in the posterior pole.

Characteristically, a focal necrotizing retinitis develops that may atrophy and generate black pigment or that may be associated with panuveitis. Papillitis is usually indicative of CNS disease. Flare-up of congenitally acquired chorioretinitis is often associated with scarred lesions in proximity to the fresh lesions.

Because of multifocal involvement of the CNS, clinical findings widely vary. They include alterations in mental status, seizures, motor weakness, cranial nerve disorders, sensory abnormalities, cerebellar signs, meningismus, movement disorders, and neuropsychiatric manifestations in patients with immunocompromise.

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Contributor Information and Disclosures
Author

Itzhak Brook, MD, MSc Professor, Department of Pediatrics, Georgetown University School of Medicine

Itzhak Brook, MD, MSc is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians-American Society of Internal Medicine, American Medical Association, American Society for Microbiology, Association of Military Surgeons of the US, Infectious Diseases Society of America, International Immunocompromised Host Society, International Society for Infectious Diseases, Medical Society of the District of Columbia, New York Academy of Sciences, Pediatric Infectious Diseases Society, Society for Experimental Biology and Medicine, Society for Pediatric Research, Southern Medical Association, Society for Ear, Nose and Throat Advances in Children, American Federation for Clinical Research, Surgical Infection Society, Armed Forces Infectious Diseases Society

Disclosure: Nothing to disclose.

Coauthor(s)

Murat Hökelek, MD, PhD Professor, Department of Clinical Microbiology, Istanbul University Cerrahpasa Medical Faculty, Turkey

Murat Hökelek, MD, PhD is a member of the following medical societies: American Society for Microbiology, Turkish Society for Parasitology

Disclosure: Nothing to disclose.

Hakan Leblebicioglu, MD Chairman, Professor, Department of Infectious Diseases and Clinical Microbiology, Ondokuz Mayis University School of Medicine, Turkey

Hakan Leblebicioglu, MD is a member of the following medical societies: American Society for Microbiology, European Society of Clinical Microbiology and Infectious Diseases

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Russell W Steele, MD Clinical Professor, Tulane University School of Medicine; Staff Physician, Ochsner Clinic Foundation

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, Southern Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

Leslie L Barton, MD Professor Emerita of Pediatrics, University of Arizona College of Medicine

Leslie L Barton, MD is a member of the following medical societies: American Academy of Pediatrics, Association of Pediatric Program Directors, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

References
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  9. Paquet C, Yudin MH. Toxoplasmosis in pregnancy: prevention, screening, and treatment. J Obstet Gynaecol Can. 2013 Jan. 35(1):78-9. [Medline].

  10. McLeod R, Boyer K, Karrison T, et al. Outcome of treatment for congenital toxoplasmosis, 1981-2004: the National Collaborative Chicago-Based, Congenital Toxoplasmosis Study. Clin Infect Dis. 2006 May 15. 42(10):1383-94. [Medline].

  11. Felix JP, Lira RP, Zacchia RS, Toribio JM, Nascimento MA, Arieta CE. Trimethoprim-sulfamethoxazole versus placebo to reduce the risk of recurrences of Toxoplasma gondii retinochoroiditis: randomized controlled clinical trial. Am J Ophthalmol. 2014 Apr. 157 (4):762-766.e1. [Medline].

  12. Harding A. Trimethoprim-Sulfamethoxazole Prevents Ocular Toxoplasmosis Recurrence. Reuters Health Information. Available at http://www.medscape.com/viewarticle/819812. January 27, 2014; Accessed: September 17, 2015.

 
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