eMedicine Specialties > Ophthalmology > Infectious Disease
Toxoplasmosis: Treatment & Medication
Updated: Jul 27, 2007
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
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Treatment
Medical Care
- Because it is a self-limited condition, treatment of systemic acquired toxoplasmosis is usually not recommended.
- In the case of ocular toxoplasmosis, several therapeutic regimens have been recommended. Triple drug therapy refers to pyrimethamine, sulfadiazine, and prednisone. Quadruple therapy refers to pyrimethamine, sulfadiazine, clindamycin, and prednisone. Pyrimethamine should be combined with folinic acid to avoid hematological complications. The duration of treatment varies depending on the patient's response but usually lasts for 4-6 weeks.
- During pregnancy, spiramycin and sulfadiazine can be used in the first trimester. Throughout the second trimester, spiramycin, sulfadiazine, pyrimethamine, and folinic acid are recommended. Spiramycin, pyrimethamine, and folinic acid may be used during the third trimester.
- Corticosteroids
- Topical corticosteroids are used depending on the anterior chamber reaction.
- Depot steroid therapy is absolutely contraindicated in the treatment of ocular toxoplasmosis. The high-dose medication in close proximity to ocular tissues apparently overwhelms the host's immune response, leading to rampant necrosis and the potential for a blind, phthisical globe.
- Systemic corticosteroids are used as an adjunct to minimize collateral damage from the inflammatory response.
- Topical cycloplegic agents are used depending on the anterior chamber reaction and the degree of pain. They are also used to prevent formation of posterior synechiae.
- Antitoxoplasmic agents include the following:
- Sulfadiazine
- Clindamycin
- Pyrimethamine
- Atovaquone
- Azithromycin
Surgical Care
- Photocoagulation or cryotherapy
- Caution must be exercised if photocoagulation or cryotherapy is being considered in the treatment of intraocular toxoplasmosis.
- Intraretinal hemorrhages, vitreous hemorrhage, and retinal detachment have been reported as complications of such treatment. Tissue cysts can exist in a normal-appearing retina.
- Pars plana vitrectomy may be indicated in cases of retinal detachment secondary to vitreous traction or in cases where vitreous opacities persist.
Consultations
Vitreoretinal consultation is desired if pars plana vitrectomy is being considered. Consultations with internal medicine or infectious disease specialists are always recommended.
Activity
No restrictions of activity are necessary.
Medication
The mere presence of a focus of retinitis is not always an indication for treatment. Generally, small peripheral lesions heal spontaneously and may be followed conservatively. On the other hand, lesions within the vascular arcade, lesions near the optic disc (Jensen papillitis), lesions in the papillomacular bundle, or large lesions irrespective of location are treated. Patients with severe debilitating vitreitis are also treated aggressively.
In a prospective trial, treatment with several regimens failed to shorten the duration of inflammatory activity or to prevent recurrences. However, treatment did reduce the size of the ultimate chorioretinal scar. In addition, experts differ on their preferred initial treatment. In a report, one third of respondents preferred triple therapy (ie, pyrimethamine, sulfadiazine, prednisone), and a little more than one quarter of respondents preferred quadruple therapy (ie, pyrimethamine, sulfadiazine, clindamycin, prednisone).
Antibiotics
Therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Pyrimethamine (Daraprim)
A diaminopyrimidine that acts as a potent inhibitor of dihydrofolate reductase and is synergistic with sulfonamides.
Adult
75 mg PO qd or 50 mg PO bid loading dose, followed by 25 mg PO bid
Pediatric
1 mg/kg/d divided bid; after 2-4 d, dose is decreased to half and continued 4 more wk
Concurrent use of antifolic acids, such as methotrexate, and pyrimethamine may increase risk of bone marrow suppression; discontinue pyrimethamine therapy if signs of folate deficiency develop; mild hepatotoxicity may occur with concomitant administration of lorazepam and pyrimethamine
Documented hypersensitivity; megaloblastic anemia resulting from a folate deficiency
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
If signs of folate deficiency develop, reduce dose or discontinue drug depending on patient response; caution in hepatic or renal impairment; monitor for toxoplasmosis by performing semiweekly blood counts, including platelet counts; may precipitate hemolytic anemia in patients with G-6-PD deficiency, generally in presence of other stressful events
Sulfadiazine (Microsulfon)
Exerts bacteriostatic action through competitive antagonism with para-aminobenzoic acid (PABA).
Adult
2-4 g PO single dose, loading dose, followed by 1 g PO qid
Pediatric
<2 months: Not established
>2 months: 75 mg/kg (or 2 g/m2) as loading dose, followed by maintenance dose of 120-150 mg/kg/d (4 g/m2/d) in 4-6 divided doses; not to exceed 6 g/d
Increases effect of oral anticoagulants and oral hypoglycemic agents; sulfadiazine effects are decreased when administered concurrently with PABA or PABA metabolites of drugs, such as proparacaine, tetracaine, sunscreens, and procaine
Documented hypersensitivity
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Adverse effects include a skin rash and renal crystallization, which can be avoided by large intake of fluids; treatment should be stopped if crystalluria, albuminuria, or hematuria develops; caution in impaired renal or hepatic function or G-6-PD deficiency; adjust dose in renal insufficiency
Trimethoprim and sulfamethoxazole (Bactrim, Bactrim DS, Septra, Septra DS)
Exerts bacteriostatic action through competitive antagonism with para-aminobenzoic acid (PABA). Double strength (DS) tab contains 800 mg of sulfamethoxazole and 160 mg of trimethoprim. Regular strength tab contains 400 mg of sulfamethoxazole and 80 mg of trimethoprim.
Adult
1 DS tab PO bid for first 2 wk; then, 1 regular tab PO bid for next 3-4 wk
Pediatric
<2 months: Not recommended
>2 months: 8 mg/kg/d of trimethoprim plus 40 mg/kg/d of sulfamethoxazole divided bid
May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly patients; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine
Documented hypersensitivity; megaloblastic anemia secondary to folate deficiency; breastfeeding
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Discontinue at first appearance of skin rash or sign of adverse reaction; obtain CBCs frequently; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; prolonged IV infusions or high doses may cause bone marrow depression (if signs occur, give 5-15 mg/d leucovorin); caution in folate deficiency (eg, chronic alcoholics, elderly patients, those receiving anticonvulsant therapy, those with malabsorption syndrome); hemolysis may occur in individuals with G-6-PD deficiency; patients with AIDS may not tolerate or respond to TMP-SMZ; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); give fluids to prevent crystalluria and stone formation
Clindamycin (Cleocin)
Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes causing RNA-dependent protein synthesis to arrest. Some animal evidence exists that clindamycin is effective in the eradication of the encysted form.
Adult
300 mg PO qid
Pediatric
8-16 mg/kg/d divided tid/qid
Increases duration of neuromuscular blockade, induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin
Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis by allowing overgrowth of Clostridium difficile
Azithromycin (Zithromax)
Binds to the 50S ribosomal subunit and interferes with protein synthesis. Treats mild-to-moderate microbial infections.
Adult
500 mg PO day 1, followed by 250 mg/d for the next 4 d
Pediatric
Not established
May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine
Documented hypersensitivity; hepatic impairment; do not administer with pimozide
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Site reactions can occur with IV route; bacterial or fungal overgrowth may result with prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function, prolonged QT intervals, or pneumonia; caution in hospitalized, geriatric, or debilitated patients
Ubiquinone analogs
Inhibit ATP synthesis, which, in turn, causes inhibition of metabolic enzymes, causing the suppression of parasite growth.
Atovaquone (Mepron)
A hydroxynaphthoquinone that inhibits the mitochondrial electron transport chain by competing with ubiquinone at the ubiquinone-cytochrome-c-reductase region (complex III). The inhibition of electron transport by atovaquone will result in the inhibition of nucleic acid and ATP synthesis in the parasites. Atovaquone has shown activity against bradyzoites in animal models of toxoplasmosis.
Adult
750 mg (5 mL) PO bid
Pediatric
Not established
May increase zidovudine serum levels; coadministration with rifampin and rifabutin may decrease atovaquone levels; atovaquone may decrease levels of TMP-SMZ
Documented hypersensitivity
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Caution in elderly patients and in hepatic and renal impairment; adverse effects include rash, pruritus, headache, and nausea
Corticosteroids
Have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli. In cases where anterior uveitis is present, topical corticosteroids are used to treat the inflammation.
Prednisone (Deltasone, Meticorten, Orasone)
Used to limit inflammatory damage. Use of oral corticosteroids without antibiotic coverage may produce an immunodeficiency state that results in rapid spread of tachyzoites and widespread retinitis. Antiparasitic agents should be stopped only after the steroids have been stopped. They should never be used without antiparasitic coverage in the treatment of ocular toxoplasmosis. Corticosteroids are probably not indicated in patients who are immunosuppressed. Some specialists wait 24-48 h after the initiation of antibiotic therapy before starting prednisone, while others begin antibiotics and prednisone simultaneously.
Adult
60-100 mg/d PO for 1-2 wk; then, taper over 2-3 wk
Pediatric
Not established
Drugs, such as phenobarbital, phenytoin, and rifampin, induce hepatic enzymes and, therefore, increase the clearance of corticosteroids; other drugs, such as ketoconazole, inhibit clearance of corticosteroids, adjust dose accordingly; corticosteroids have an unpredictable effect on anticoagulants, so coagulation indices should be monitored
Documented hypersensitivity; systemic fungal infections
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Secondary adrenocortical insufficiency may be induced; in periods of stress, may require increased dosage; immunizations should be withheld when the patient is taking corticosteroids; caution in diabetics, hypertensives, and patients with known hypersecretory gastric disease (internal medicine consultation imperative in these instances)
Prednisolone acetate 1% (Pred Forte)
Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability. Frequency of application depends on degree of ocular inflammation.
Adult
1 gtt qid up to q1h
Pediatric
Administer as in adults; nasolacrimal duct occlusion is recommended to minimize systemic absorption
None reported
Documented hypersensitivity; herpetic, bacterial, or fungal keratitis
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Caution in hypertension; known to cause cataract formation with long-term use; suspect fungal invasion in any persistent corneal ulceration where a corticosteroid has been used or is in use (obtain fungal cultures when appropriate)
Folic acid derivatives
Used to counteract toxic effects of folic acid antagonists that act by inhibiting dihydrofolate reductase.
Leucovorin (Wellcovorin)
Reduced form of folic acid that does not require enzymatic reduction reaction for activation. Allows for purine and pyrimidine synthesis, both of which are needed for normal erythropoiesis.
Adult
5-15 mg IV/IM 3 times/wk together with a combination of pyrimethamine and sulfonamide
Pediatric
Not established
May enhance toxicity of 5-fluorouracil; in large doses, may counteract antiepileptic effect of phenobarbital, phenytoin, and primidone
Documented hypersensitivity; pernicious anemia or vitamin deficient megaloblastic anemias
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Do not administer intrathecally or intraventricularly
Cycloplegics
As in any eye with uveitis, posterior synechiae often form if a pupil is not mobilized. Anticholinergic agents, such as cyclopentolate, atropine, and homatropine, block the sphincter muscle of the iris and the muscle in the ciliary body that is responsible for accommodation to produce mydriasis and paralysis of accommodation.
Cyclopentolate 0.5%, 1%, 2% (AK-Pentolate, Cyclogyl)
Prevents muscle of ciliary body and sphincter muscle of iris from responding to cholinergic stimulation. Induces mydriasis in 30-60 min and cycloplegia in 25-75 min. Infants should not be given concentrations >0.5%.
Adult
1% solution: 1 gtt qid
Pediatric
Administer as in adults
Decreases effects of carbachol and cholinesterase inhibitors
Documented hypersensitivity; narrow-angle glaucoma
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Exercise caution in patients (eg, elderly persons) where increased intraocular pressure may be present; can cause toxic anticholinergic systemic adverse effects (common in children, especially infants) but incidence rare when used sparingly; compressing lacrimal sac by digital pressure for 1-3 min following application may minimize systemic absorption
More on Toxoplasmosis |
| Overview: Toxoplasmosis |
| Differential Diagnoses & Workup: Toxoplasmosis |
 Treatment & Medication: Toxoplasmosis |
| Follow-up: Toxoplasmosis |
| Multimedia: Toxoplasmosis |
| References |
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Further Reading
Keywords
Toxoplasma, Toxoplasma gondii, T gondii, congenital toxoplasmosis, acquired toxoplasmosis, toxoplasmosis in immunocompromised host, ocular toxoplasmosis, retinochoroiditis, chorioretinitis, chorioretinal scar, intraocular inflammation, intraocular toxoplasmosis
