Toxoplasmosis in Emergency Medicine Clinical Presentation

  • Author: Joseph U Becker, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Mar 10, 2010
 

History

  • Immunocompetent individuals
    • Usually asymptomatic, self-limited illness lasting, at most, weeks
    • Nonspecific, flulike illness, with prominent, symmetric, and nontender lymphadenopathy
  • Ocular toxoplasmosis (chorioretinitis)
    • Usually painful
    • Impaired vision, either sudden or gradual, depending on the site of infection
    • May see floaters
  • Immunocompromised individuals
    • May have flulike symptoms, lymphadenopathy
    • CNS toxoplasmosis - Seizure, dysequilibrium, cranial nerve deficits, altered mental status, focal neurologic deficits, headache
    • Toxoplasmic pneumonitis - Typical symptoms of a pulmonary infection, mirroring in particular Pneumocystis jiroveci, including nonproductive cough, dyspnea, chest discomfort, and fever
    • Symptoms associated with reactivation toxoplasmosis are dependent on the tissue or organ affected.
  • Congenital toxoplasmosis
    • May have variable symptoms, including petechial rash, jaundice, developmental delay, and seizure
    • Ventriculomegaly and cerebral calcification may be evident in CNS imaging
    • Visual defects, blindness
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Physical

  • Immunocompetent individuals
    • Usually asymptomatic
    • Isolated cervical or occipital adenopathy, symmetric, nontender, lasting 4-6 weeks
    • Infrequently, may cause myocarditis, polymyositis, pneumonitis, hepatitis, encephalitis
  • Ocular toxoplasmosis (chorioretinitis), shown in the image below Ophthalmic toxoplasmosis. Used with permission of Ophthalmic toxoplasmosis. Used with permission of Anton Drew, ophthalmic photographer, Adelaide, South Australia.
    • Decreased visual acuity; other deficits depend on the location of the lesion
    • White focal lesions with inflammation of vitreous humor (the classic "headlight in the fog" appearance) seen on ophthalmoscopic examination
    • Recurrent lesions at the border of the chorioretinal scars
  • Congenital toxoplasmosis
    • Usually normal prenatal sonogram findings but may show intracranial calcifications, dilated ventricles, enlarged liver, ascites, and thickened placenta
    • Neonatal hydrocephalus, microcephaly, intracranial calcifications, chorioretinitis, strabismus, blindness, epilepsy, psychomotor or mental retardation, thrombocytopenia (petechia), anemia
    • Rare classic triad - Chorioretinitis, hydrocephalus, and cerebral calcifications
  • Immunocompromised individuals (AIDS CD4 < 100)
    • Symptoms may be gradual in onset over a few weeks
    • Symptoms depend largely on the organ system and tissue involved
    • CNS toxoplasmosis - Seizure, mental status change, focal motor deficits, cranial nerve disturbances, sensory disturbances, cerebellar abnormalities, movement disorders, neuropsychiatric findings
    • Chorioretinitis (similar to that seen in immunocompetent individuals)
    • Pneumonitis (more common in patients who have undergone bone marrow transplantation and in patients with AIDS) - Nonproductive cough, blood-tinged sputum, hypoxia (symptoms indistinguishable from P jiroveci)
    • Septic shock–like presentation
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Causes

  • Immunocompetent individuals - Oral-fecal acquisition of parasite from food or water contaminated with cat feces (oocytes) or eating undercooked meat (especially pork and lamb) with tissue cysts
  • Ocular toxoplasmosis (chorioretinitis)
    • Usually reactivation of congenital infection
    • Few cases recorded as part of acute infection
  • Immunocompromised individuals - Almost always reactivation of latent infection
  • Congenital toxoplasmosis
    • Parasite crosses the placenta from maternal circulation and then enters the fetus.
    • Infection is less frequent but more serious if the mother becomes infected from up to 3 months before pregnancy until end of the second trimester.[14]
    • Infection of the fetus is more frequent but less severe if maternal infection occurs in the third trimester.[14]
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Contributor Information and Disclosures
Author

Joseph U Becker, MD  Fellow, Global Health and International Emergency Medicine, Stanford University School of Medicine

Joseph U Becker, MD is a member of the following medical societies: American College of Emergency Physicians, Emergency Medicine Residents Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Deepika Singh, MD  Staff Physician, Department of Emergency Medicine, Lawrence and Memorial Hospital, New London, CT

Deepika Singh, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, American Nurses Association, Emergency Medicine Residents Association, and Sigma Theta Tau International

Disclosure: Nothing to disclose.

Richard H Sinert, DO  Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center

Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Theodore J Gaeta, DO, MPH, FACEP  Clinical Associate Professor, Department of Emergency Medicine, Weill Cornell Medical College; Vice Chairman and Program Director of Emergency Medicine Residency Program, Department of Emergency Medicine, New York Methodist Hospital; Academic Chair, Adjunct Professor, Department of Emergency Medicine, St George's University School of Medicine

Theodore J Gaeta, DO, MPH, FACEP is a member of the following medical societies: Alliance for Clinical Education, American College of Emergency Physicians, Clerkship Directors in Emergency Medicine, Council of Emergency Medicine Residency Directors, New York Academy of Medicine, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Mark L Plaster, MD, JD  Executive Editor, Emergency Physicians Monthly

Mark L Plaster, MD, JD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians

Disclosure: M L Plaster Publishing Co LLC Ownership interest Management position

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Joseph Sciammarella, MD, to the development and writing of this article.

References

  1. Montoya JG, Liesenfeld O. Toxoplasmosis. Lancet. Jun 12 2004;363(9425):1965-76. [Medline].

  2. [Guideline] Kaplan JE, Benson C, Holmes KH, Brooks JT, Pau A, Masur H. Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. MMWR Recomm Rep. Apr 10 2009;58:1-207; quiz CE1-4. [Medline].

  3. Jones JL, Kruszon-Moran D, Sanders-Lewis K, Wilson M. Toxoplasma gondii infection in the United States, 1999 2004, decline from the prior decade. Am J Trop Med Hyg. Sep 2007;77(3):405-10. [Medline].

  4. Torok E, Moran E, Cooke F. Toxoplasmosis. In: Oxford Handbook of Infectious Diseases and Microbiology. Vol 1. New York: Oxford University Press; 2009:567.

  5. Remington JS. Toxoplasmosis in the adult. Bull N Y Acad Med. Feb 1974;50(2):211-27. [Medline].

  6. McCabe RE, Brooks RG, Dorfman RF, Remington JS. Clinical spectrum in 107 cases of toxoplasmic lymphadenopathy. Rev Infect Dis. Jul-Aug 1987;9(4):754-74. [Medline].

  7. Holland GN, Crespi CM, ten Dam-van Loon N, et al. Analysis of recurrence patterns associated with toxoplasmic retinochoroiditis. Am J Ophthalmol. Jun 2008;145(6):1007-1013. [Medline].

  8. Montoya JG, Remington JS. Toxoplasmic chorioretinitis in the setting of acute acquired toxoplasmosis. Clin Infect Dis. Aug 1996;23(2):277-82. [Medline].

  9. Gras L, Wallon M, Pollak A, et al. Association between prenatal treatment and clinical manifestations of congenital toxoplasmosis in infancy: a cohort study in 13 European centres. Acta Paediatr. Dec 2005;94(12):1721-31. [Medline].

  10. Luft BJ, Remington JS. Toxoplasmic encephalitis in AIDS. Clin Infect Dis. Aug 1992;15(2):211-22. [Medline].

  11. Porter SB, Sande MA. Toxoplasmosis of the central nervous system in the acquired immunodeficiency syndrome. N Engl J Med. Dec 3 1992;327(23):1643-8. [Medline].

  12. Hofman P, Bernard E, Michiels JF, Thyss A, Le Fichoux Y, Loubiere R. Extracerebral toxoplasmosis in the acquired immunodeficiency syndrome (AIDS). Pathol Res Pract. Sep 1993;189(8):894-901. [Medline].

  13. Thiebaut R, Leproust S, Chene G, Gilbert R. Effectiveness of prenatal treatment for congenital toxoplasmosis: a meta-analysis of individual patients' data. Lancet. Jan 13 2007;369(9556):115-22. [Medline].

  14. Desmonts G, Couvreur J. Congenital toxoplasmosis. A prospective study of 378 pregnancies. N Engl J Med. May 16 1974;290(20):1110-6. [Medline].

  15. Sacktor N, Lyles RH, Skolasky R, et al. HIV-associated neurologic disease incidence changes:: Multicenter AIDS Cohort Study, 1990-1998. Neurology. Jan 23 2001;56(2):257-60. [Medline].

  16. Levy RM, Mills CM, Posin JP, Moore SG, Rosenblum ML, Bredesen DE. The efficacy and clinical impact of brain imaging in neurologically symptomatic AIDS patients: a prospective CT/MRI study. J Acquir Immune Defic Syndr. 1990;3(5):461-71. [Medline].

 
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Ophthalmic toxoplasmosis. Used with permission of Anton Drew, ophthalmic photographer, Adelaide, South Australia.
 
 
 
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