Congenital toxoplasmosis in a reference center of Paraná, Southern Brazil

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The

Brazilian

Journal

of

INFECTIOUS

DISEASES

w w w . e l s e v i e r . c o m / l o c a t e / b j i d

Original

article

Congenital

toxoplasmosis

in

a

reference

center

of

Paraná,

Southern

Brazil

Jaqueline

Dario

Capobiango

a,∗

_,

_Regina

_Mitsuka

_Breganó

b

_,

_Italmar

_Teodorico

_Navarro

c

_,

Claudio

Pereira

Rezende

Neto

d

_,

_Antônio

_Marcelo

_Barbante

_Casella

e

_,

Fabiana

Maria

Ruiz

Lopes

Mori

f

_,

_Sthefany

_Pagliari

g

_,

_Inácio

_Teruo

_Inoue

h

_,

Edna

Maria

Vissoci

Reiche

i

a_Department_of_Clinical_Medicine,_Health_Sciences_Center,_Universidade_Estadual_de_Londrina_(UEL),_Londrina,_PR,_Brazil b_Department_of_Pathological_Sciences,_Biological_Sciences_Center,_Universidade_Estadual_de_Londrina_(UEL),_Londrina,_PR,_Brazil c_Department_of_Veterinary,_Agricultural_Sciences_Center,_Universidade_Estadual_de_Londrina_(UEL),_Londrina,_PR,_Brazil d_Medicine_Course,_Health_Sciences_Center,_Universidade_Estadual_de_Londrina_(UEL),_Londrina,_PR,_Brazil

e_Department_of_Surgery,_Health_Sciences_Center,_Universidade_Estadual_de_Londrina_(UEL),_Londrina,_PR,_Brazil f_Centro_{Universitário}_Filadélﬁa_(UNIFIL),_Londrina,_PR,_Brazil

g_Graduate_Program_in_Veterinary_Medicine,_Agricultural_Sciences_Center,_Universidade_Estadual_de_Londrina_(UEL),_Londrina,_PR,_Brazil h_Department_of_Gynecology_and_Obstetrics,_Health_Sciences_Center,_Universidade_Estadual_de_Londrina_(UEL),_Londrina,_PR,_Brazil i_Department_of_Pathology,_Clinical_Analysis,_and_Toxicology,_Health_Sciences_Center,_Universidade_Estadual_de_Londrina_(UEL),_Londrina,

PR,Brazil

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received17July2013

Accepted7November2013

Availableonline22March2014

Keywords: Toxoplasmagondii Congenitaltoxoplasmosis Chorioretinitis Diagnosis

a

b

s

t

r

a

c

t

Thisstudydescribesthecharacteristicsof31childrenwithcongenitaltoxoplasmosis

chil-drenadmittedtotheUniversityHospitalofLondrina,SouthernBrazil,from2000to2010.In

total,23(85.2%)ofthemothersreceivedprenatalcarebutonlyfour(13.0%)weretreatedfor

toxoplasmosis.Birthweightwas<2500gin37.9%oftheinfants.Duringtheﬁrstmonthoflife,

physicalexaminationwasnormalin34.5%,andforthosewithclinicalsignsandsymptoms,

themainmanifestationswerehepatomegalyand/orsplenomegaly(62.1%),jaundice(13.8%),

andmicrocephaly(6.9%).Duringophthalmicexamination,74.2%ofthechildrenexhibited

injuries,58.1%chorioretinitis,32.3%strabismus,19.4%microphthalmia,and16.2%

vitre-itis.Anti-ToxoplasmagondiiIgMantibodiesweredetectedin48.3%ofthechildren.Imaging

brainevaluationwasnormalin44.8%;braincalciﬁcations,hydrocephaly,orbothconditions

wereobservedin27.6%,10.3%,and17.2%,respectively,ofthepatients.Patientswith

cere-brospinalﬂuidprotein≥200mg/dLpresentedmorebraincalciﬁcations(p=0.0325).Other

sequelaewerevisualimpairment(55.2%ofthecases),developmentaldelay(31.0%),motor

deﬁcit(13.8%),convulsion(27.5%),andattentiondeﬁcit(10.3%).Allpatientsweretreated

withsulfadiazine,pyrimethamine,andfolinicacid,and55.2%ofthemexhibitedadverse

effects.Theresultsdemonstratethesigniﬁcanceoftheearlydiagnosisandtreatmentof

toxoplasmosisduringpregnancytoreducecongenitaltoxoplasmosisanditsconsequences.

∗ _{Corresponding}_author_at:_Department_of_Clinical_Medicine,_State_University_of_Londrina,_University_Hospital,_Street_Robert_Koch,_60,

86038-440,Londrina,PR,Brazil.

E-mailaddress:jaquedc@uel.br(J.D.Capobiango).

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Introduction

Toxoplasmosisisaworldwideinfectioncausedbythe

proto-zoanToxoplasmagondii(T.gondii),anobligatoryintracellular

parasite.1_In_Central_and_South_America,_50–80%_of_individuals

areseropositiveforIgGantibodiesagainstT.gondii,indicating

theirpreviousexposuretothisparasite.2 _The_prevalence_of

thisinfectionacquiredduringpregnancyrangesfrom10.3%

to75.2%indifferentcountries.3–7_In_Brazil,_the_{seroprevalence}

ofanti-T.gondiiIgGantibodiesrangesfrom49.2%to91.6%,8–10

andtheincidenceofcongenitaltoxoplasmosisvariesfrom0.3

to5.0per1000births.11–13

Therisk offetal transmissiondepends onfactors, such

as the maternal immune response, the gestational age at

infection,and theparasitevirulence.Theriskofcongenital

transmissionvaries from up to2% atthe periconceptional

period,10–25%intheﬁrsttrimesterofpregnancy,30–45%in

thesecondtrimester,60–65%inthethirdtrimester,andup

to80%beforechildbirth.1_However,_the_severity_of_congenital

diseaseishighwhentransmissionoccursinthebeginningof

thepregnancyanddecreaseswithgestationalage.1,2,4,7,8

Thediagnosisoftoxoplasmosisacquiredduringpregnancy

isbasedonlaboratorytestsbecausemorethan90%ofinfected

pregnantwomenareasymptomatic.Whenclinical

manifesta-tionsarepresent,ingeneral,theyarenonspeciﬁcandinclude

fever,headaches,myalgia,lymphadenopathy,andrash.14

The majority of children with congenital

toxoplasmo-sis do not exhibit signs or symptoms atbirth, presenting

insteadassubclinicalinfections;nevertheless,infected

chil-drenare atrisk ofdevelopinglate sequelae,mainly ocular

andneurological.Forthesymptomaticchildren,theseverity

ofclinicalmanifestationsisrelatedtothetrimesterof

preg-nancywhentransmissionoccurred,asfollows:fetaldeathin

theﬁrsttrimester;retinochoroiditis,microcephaly,and

men-talretardationinthesecondtrimester;andlymphadenopathy,

hepatosplenomegaly,eyeinjuries,andbraincalciﬁcationsin

thethirdtrimester.15_All_of_the_children_whose_mothers

pre-sentedacutetoxoplasmosisduringpregnancy,symptomatic

or not, may have congenital toxoplasmosis. Children born

withsignalsorsymptomsofcongenitaldiseasearealsoatrisk

andshouldundergoserologicalinvestigationtodetectspeciﬁc

anti-T.gondiiantibodies.15

Thepurposeofthisstudywastodescribethedemographic,

clinical,andlaboratorycharacteristics ofchildrenwith

con-genitaltoxoplasmosisthatreceivedtreatmentforcongenital

toxoplasmosisatonemedicalcenterinsouthernBrazil.

Materials

and

methods

Populationandstudydesign

The study included a retrospective cohort of 236 medical

recordsofsuspectedcongenitaltoxoplasmosisfromthe

Out-patient Reference Centre for Pediatric Infectious Diseases,

whichisthereferenceservice forcongenitaltoxoplasmosis

atthe OutpatientClinical Hospital, University ofLondrina,

Paraná State, Brazil. Thestudy identiﬁed 31 cases of

con-genital toxoplasmosis that occurred from January 2000 to

December2010.ThisstudywasapprovedbytheEthical

Com-mittee Involving Humansfrom the University of Londrina,

Londrina,Paraná,Brazil.

Diagnosticcriteria

Cases were deﬁned as congenitaltoxoplasmosis when the

infantexhibitedoneofthefollowingfeatures:anti-T.gondii

IgM and/or IgA antibodies after 10 days of life,

persis-tently elevated or increasing titers of IgG anti-T. gondii

(after three-weekintervals betweenthesamples),

seroposi-tiveforIgG after12 monthsoflife,retinochoroiditisand/or

hydrocephaly/cerebral calciﬁcations, and anti-T. gondii IgG

seropositivityandresponsetospeciﬁctreatment.16

Duringtheperiodofthestudy,anti-T.gondiiIgG

antibod-iesweredetectedbyindirectimmunoﬂuorescence(IFI)with

T.gondiiﬁxedonaglassslide.17 _For_the_detection_of_anti-T.

gondiiIgMantibodies,themethodsvariedintheperiod

eval-uated,but included indirect enzymeimmunoassay(ELISA),

chemiluminescence,andIgMcaptureELISA.

Statisticalanalysis

Datawererecordedinadatabase,andthestatistical

analy-siswasperformedusingtheEpiInfo3.4.3andGraphPadPrism

5.00software.Continuousvariableswereexpressedin

mini-mumandmaximumvalues,mean,standarddeviation,and

median.Categoricalvariableswerereportedinabsolute

fre-quency(n)andpercentage(%).Comparisonsbetweengroups

ofcategoricalvariableswereperformedbyChi-squareanalysis

orFisher’sexacttest,whenappropriate.Anoddsratio(OR)and

95%conﬁdenceinterval(CI)werealsocalculated.Theresults

wereconsideredsigniﬁcantwhenthep-valuewaslessthan

0.05(5%).

Results

Descriptionofthepopulation

Ofthe 31 childrenevaluated, 20 (64.5%) were male and 11

(35.5%) were female. Their birthweightsrangedfrom 1150

to3800g(median 2585g),and11 children(37.9%)hadbirth

weights<2500g.Gestationalageatdeliveryrangedfrom26.2

to41weeks(median36weeks).Maternalagerangedfrom14to

42years(median26years),and23/31(85.2%)pregnantwomen

receivedprenatalcare.

Clinicalanalysisofpregnantwomen

Among the 31 pregnant women evaluated, 16 (51.6%) did

not have a record of any clinical symptom, eight (25.8%)

were asymptomatic,and seven (22.5%) showed symptoms,

suchasfever(6.5%),adenomegaly(6.5%),ﬂu-likesymptoms

(6.5%),andmyalgia(3.2%).Thetoxoplasmosisinfectionwas

notdiagnosedin20/31(64.5%)duringpregnancy.Fourwomen

(12.9%)hadnotreceivedprenatalcare,and16(51.6%)hada

serologyrequested.Eleven(35.5%)pregnantwomenwere

sus-pectedcasesofrecentT.gondiiinfection,indicatedbypositive

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Table1–ClinicalmanifestationspresentedbychildrenwithcongenitaltoxoplasmosisattendedattheOutpatientClinic HospitaloftheStateUniversityofLondrina,Londrina,Paraná,fromJanuary2000toDecember2010.

Clinicalmanifestations Atbirth(n=20) Duringtheﬁrstmonthof life(n=29) n(%) n(%) Asymptomatic 10(50.0) 10(34.5) Symptomatic 10(50.0) 19(65.5) Hepatosplenomegaly 8(40.0) 13(44.8) Jaundice 0(0.0) 4(13.8) Esplenomegaly 1(5.0) 3(10.3) Hepatomegaly 0(0.0) 2(6.9) Microcephaly 1(5.0.) 2(6.9) Fever 0(0.0) 1(3.4) Macrocephaly 1(5.0) 1(3.4) Adenomegaly 0(0.0) 0(0.0)

conﬁrmedbyothertestsorserialsamples,andtheywerenot treatedfortoxoplasmosis.Onlyfour(12.9%)pregnantwomen infectedwithT.gondiireceivedspeciﬁctreatment(twowith sulfadiazine,pyrimethamine,andfolinicacid,andtwowith spiramycin).Theother27(87.0%)pregnantwomenreceived notoxoplasmosistreatment.

Clinicalanalysisofchildren

Twentychildren (64.5%) were examined at birth, and nine (29.0%)wereevaluatedinthefirstmonthoflife.Twochildren (6.5%)werereferredwithoutanyrecordofsignsorsymptoms. Onechild(3.2%)wasevaluated forthe firsttimeafternine months oflife with chorioretinitis, cataract, and microph-thalmia. One child (3.2%) was first evaluated at five years ofageandpresentedwithsequelaeofcongenitalinfection, suchasscarsofchorioretinitis,hyperactivity,attentiondeficit, andprecociouspuberty.Thefrequencyofclinical manifesta-tionsofcongenitaltoxoplasmosisatbirthandduringthefirst monthoflifeisshowninTable1.

The clinical classiﬁcation of the disease presented by

these31childrenwereasfollows:29(93.5%)wereclassiﬁed

inﬁrstmonthoflife;four (13.8%)were subclinicalwithout

signs or symptoms during infancy; 24 (82.8%) exhibited

neonataldisease withclinicalmanifestations,suchas

ocu-lar lesion (chorioretinitis) and/or neurological impairment

(hydrocephaly and/orcalciﬁcation);and one(3.2%)was

ini-tially asymptomatic but presentedfever and splenomegaly

at four monthsof age without neurologicalor ophthalmic

impairment.Amongthechildrenwithsubclinicalinfections,

one(3.2%)hadstrabismusandconvulsionsatfouryearsof

age.

Theophthalmicmanifestationsobservedinthechildren

duringtheﬁrstmonthoflifeandafterthisperiodaredescribed

inTable2.

Of all the patients, one (3.2%) child was exposed but

uninfectedwithHIV-1,andone(3.2%)wasco-infectedwith

HIV-1. One child (3.2%) was co-infected with HIV-1 and

cytomegalovirus (CMV),and three children (9.7%) were

co-infected withCMV.In oneinfantwith persistenthepatitis,

a CMVinfection was diagnosed bypolymerasechain

reac-tion; outofthree infantswithanti-CMVIgMantibody,one

presentedwithgiantcellhepatitis.

Thefrequencyofsequelaewaselevatedamongthe

chil-drenwithcongenitaltoxoplasmosis,asdescribedinTable3.

Two (6.2%)childrenpresentedwithendocrinedysfunctions,

Table2–Ophthalmologicmanifestationsobservedduringtheﬁrstmonthandaftertheﬁrstmonthoflifeinchildren withcongenitaltoxoplasmosistreatedattheOutpatientClinicHospitaloftheStateUniversityofLondrina,Londrina, Paraná,fromJanuary2000toDecember2010.

Ophthalmologicmanifestations Duringtheﬁrstmonthof life(n=29)

Aftertheﬁrstmonth oflife(n=31) n(%) n(%) Nomanifestationsa ₉_(31.0) ₈_(25.8) Chorioretinitis 16(55.2) 18(58.1) Strabismusb,c ₁_(3.5) ₁₀_(32.3) Microphthalmia 2(6.9) 6(19.4) Vitreitis 5(17.2) 5(16.2) Uveitis 3(10.3) 3(9.7) Cataractd ₁_(3.5) ₃_(9.7) Nystagmuse ₀_(0.0) ₃_(9.7)

a _In_one_patient_the_lesion_of_{chorioretinitis}_improved_without_leaving_a_scar;

b _One_(3.5%)_patient_exhibited_association_of_strabismus,_cataract,_and_{microphthalmia}_in_the_ﬁrst_month_of_life;

c _Seven_(22.6%)_patients_with_strabismus_associated_with_{chorioretinitis}_and_three_(9.7%)_patients_presented_strabismus_associated_with_cataract and/ormicrophthalmiaaftertheﬁrstmonthoflife;

d_One_(3.5%)_patient_presented_cataract_associated_with_{chorioretinitis}_in_the_ﬁrst_month_of_life. e _Three_(9.7%)_patients_presented_nystagmus_associated_with_{chorioretinitis}

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Table3–Sequelaesdetectedinchildrenwithcongenital toxoplasmosisattendedatOutpatientClinicHospitalof theStateUniversityofLondrina,Londrina,Paraná,from January2000toDecember2010. Sequelae Children(n=29) n % Notdetectablea ₉ _31.1 Detectable 20 68.9 Visual 16 55.2

Delayofpsychomotordevelopment 9 31.0

Convulsionb ₈ _27.5

Motordysfunction 4 13.8

Hyperactivityand/ordeﬁcitofattention 3 10.3

Precociouspuberty 2 6.9

Hypothyroidism 1 3.4

Ventricularperitonealshunt 1 3.4

Hearingdamagec ₃ _50.0

a _Two_children_lost_the_follow-up.

b _Four_children_presented_convulsion_during_the_ﬁrst_month_of_life. c _Detected_in_six_children,_all_of_them_with_hearing_damage_also presentedconcomitantneurologicalsequelae;1/31(3.4%)child co-infectedwithHIV-1whodiedwith12monthsoflifedueto herpeticencephalitisandseveresepsis.

onewithcentralprecociouspubertyandtheotherwith

sec-ondaryhypothyroidism.

Laboratoryanddiagnosticdata

Lumbarpunctureforcerebrospinalﬂuid(CSF)collectionwas

performed on 21 (67.7%) children. In the CSF, leukocytes

rangedfrom2to149cells/mm3_(median₁₉_cells/mm3_),

eryth-rocytesrangedfrom3to26,400cells/mm3_(median_56/mm3_),

andtheproteinconcentrationrangedfrom34to1594mg/dL

(median 104mg/dL). Althoughsix(28.6%)CSFsamples

pre-sented elevated erythrocyte count (>1000/mm3_), _high _CSF

proteinobserved could notbeexplained onlybythe

pres-enceofthesecells.Sixpatients(28.6%)presentedCSFprotein

>180mg/dL, but erythrocyte counts were>2500cells/mm3

in only one patient (erythrocyte=26,400cells/mm3 _and

protein=879mg/dL). Of the two patients (9.5%) with CSF

protein >1g/dL, the erythrocyte count was lower than

35cells/mm3_. _In _total, ₁₉ _patients _(90.4%) _who _underwent

lumbarpunctureforCSFcollectionalsoperformedimaging

exams.Ofthesepatients,10(52.6%)hadbraincalciﬁcations,

and two (10.5%) presentedwithbrain calciﬁcations

associ-atedwithhydrocephaly.Therewasanassociationbetweenthe

presenceof≥200mg/dLproteininCSFandbraincalciﬁcations

(p=0.0352)(Table4).

Brain computed tomography (CT) and ultrasonography

(USG)resultsarepresentedinTable5.

Fifteen ofthe 23 (65.2%) patients presentedophthalmic

injuries and concomitant brain lesions, while2/17 (11.8%)

patientsdidnotpresentophthalmicinjuriesbutshowedCNS

lesions(p=0.1897,OR:4.68,95%CI:0.73–29.85).Therewasno

associationbetweenthepresenceofeyeinjuriesandchanges

inbrainimaging(hydrocephalyandcalciﬁcations).In20male

patients,15(75%)showedeyeinjuries,whileamong11female

patients,nine(81.8%)showedeyeinjuries(p=1.00,OR:0.66,

95%CI:0.10–4.18).

Overall, 15 (48.3%) children showed detectable serum

levels of anti-T. gondii IgM antibodies. Two patients were

seronegative for anti-T. gondii IgM in the ﬁrst sample and

seropositive in the second sample. The serum levels of

anti-T. gondiiIgG were obtained during the ﬁrst week and

the ﬁrst,3rd, 6th, 9thand 12th monthsoflife. During the

ﬁrst week oflife,the values rangedfrom 1:16 to 1:128,000

[mode=1:64 (20%) and 1:4000 (20%)]; in the 2nd sample,

the levels ranged from 1:1024 to 1:128,000 [mode=1:8000

(33.3%)]. In the 3rd serial blood sample, the valuesranged

from 1:16 to 1:64,000 [mode=1:64,000 (27.3%)], and in the

4th serialbloodsample,theyrangedfrom 1:16to1:128,000

[mode=1:32,000 (20%)].In the 5th serial blood sample, the

valuesrangedfrom 1:256to1: 16,000[mode=1:4000(40%)],

and in the 6th serial sample, they ranged from 1:16 to

1:32,000 [mode=1:16 (33.3%)]. During serological evolution

of the patients, the rebound effect was detected in nine

patientsafterdiscontinuingtreatmentandwasdetectedby

anincreasedlevelofserumanti-T.gondiiIgGbetween15and

18monthsoflife,rangingfrom1:16to1:128,000[mode=1:1024

(28.6%)].

Table4–Resultsofimagingbrainexamsfromchildrenwithcongenitaltoxoplasmosis,accordingtothecerebrospinal ﬂuidproteinlevels,attendedatOutpatientClinicHospitaloftheStateUniversityofLondrina,Londrina,Paraná,from January2000toDecember2010.

CSFprotein(mg/dL)a _Imaging_brain_exams _Odds_ratio_(95%_CI) _p_valueb Withcalciﬁcationn/total

ofcases(%) Withoutcalciﬁcation n/totalofcases(%) ≥200 <200 5/5(1000) 5/14(35.7) 0/5(0.0) 9/14(64.3) 19.00 0.8729–413.6 0.0325 ≥180 <180 5/6(83.3) 5/13(38.5) 1/6(16.7) 8/13(61.5) 8.00 0.7107–90.05 0.1409 ≥150 <150 6/8(75.0) 4/11(36.4) 2/8(25.0) 7/11(63.6) 5.25 0.6979–39.50 0.1698 CSF,cerebrospinalﬂuid.

a _The_frequencies_of_imaging_brain_exams_were_distributed_according_the_different_cut-off_values_of_CSF_protein_levels;_CI:_conﬁdence_interval. b _Fisher’s_exact_test.

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Table5–Resultsobtainedinbraincomputedtomographyandultrasonographyperformedduringtheﬁrstmonthoflife ofchildrenwithcongenitaltoxoplasmosis,attendedatOutpatientClinicHospitaloftheStateUniversityofLondrina, Londrina,Paraná,fromJanuary2000toDecember2010.

Results BrainCT(n=24) BrainUSG(n=13) Oddsratio(95%CI) pvalue

n(%) n(%)

Nochanges 11(45.8) 6(46.1) 1.182(0.2950–4.735) 0.8134*

Hydrocephalus 0(0.0) 6(46.1) 0.02355(0.00118–0.4688) 0.0007†

Calciﬁcation 8(33.3) 0(0.0) 13.91(0.7337–263.7) 0.0324†

Hydrocephalusandcalciﬁcation 5(20.8) 0(0.0) 7.615(0.3877–149.6) 0.1398†

CT,computedtomography;USG,ultrasonography;CI,conﬁdenceinterval. ∗ _Chi-square_test,_p_<_0.05.

† _Fisher’s_exact_test,_p_<_0.05.

Treatmentdata

Children’s age for initiation of toxoplasmosis treatment

rangedfromonedaytoninemonths(medianage,onemonth).

Amongthe29infantswhoreceivedspeciﬁctherapy,28(90.3%)

receivedsulfadiazine,pyrimethamine, andfolinicacid,and

one (3.2%) received spiramycin. Ten infants (34.5%) were

treatedwithcorticosteroids(prednisone)associatedwith

spe-ciﬁctherapywhentheirCSFproteinwas≥1g/dLand/orwhen

theypresentedchorioretinitiswithmacularinjury.Two

chil-dren (6.5%) were not treated. One ﬁve-year-old child was

referredtothereferenceservicebutthemotheroftheother

childrefusedtreatment,andtheinfanthadnoclinical

follow-up. Theinfant who was treatedwith spiramycinfor three

monthsat another health service was switched toput on

sulfadiazine,pyrimethamine,andfolinicacid.Amongthe29

(93.5%)treatedinfants,thetreatmentwastemporarily

mod-iﬁed innine (31.0%):two children(6.9%)were treated with

clindamycin,one(3.5%)withpyrimethamineandfolinicacid,

andsix(20.7%)weretreatedwithspiramycin.

Regardingtheuseofassociatedtherapies,threechildren

weretreatedwithganciclovir,twowithzidovudine(AZT),and

onewithganciclovirassociatedwithAZT.

During the treatment for toxoplasmosis, 16 of the 29

patients (55.2%) presented adverse effects (Table 6). Six

patients (37.5%) received a combination of therapies. Four

patients received AZT, and three patients received

ganci-clovir.Oneinfanttreatedwithspiramycinwaspresentedwith

frequentvomitingthatimprovedwiththereintroductionof

sulfadiazine, pyrimethamine, and folinic acid.

Hematologi-calchanges,includingmildneutropeniaand/ormildanemia,

were reversedwith anincreaseddailydose offolinic acid.

When revertedto sulfadiazine,pyrimethamine, and folinic

acid therapy, patients who temporarily received modiﬁed

treatment because of adverse effects were treated with a

higherdailydoseoffolinicacid.

Discussion

As clinical signs and symptoms in pregnancy are limiting

factorsfordiagnosis,systematicserologicalscreening tests

duringpregnancyareimportantyetcontroversialtools,

par-ticularlyinregionswhereimmunoreactivitybeforepregnancy

islowandtheriskforseroconversionduringthepregnancyis

high.However,earlydiagnosisofT.gondiiinfectionand

appro-priateanti-parasitictreatmentaremeasuresthatcanreduce

transmissionandthe severityoffetalconsequences,which

justiﬁesthescreeningofallpregnantwomenwith

serologi-calteststhatdetectanti-T.gondiiIgGandIgMantibodies.15,18

Table6–Majoradverseeffectsobservedamongchildren withcongenitaltoxoplasmosisduringthetreatment withsulfadiazine,pyrimethamine,andfolinicacid, attendedatOutpatientClinicHospitaloftheState UniversityofLondrina,Londrina,Paraná,fromJanuary 2000toDecember2010.

Adverseeffects Children(n=29)

n %

Mildneutropeniaa_(1001–1499_cells/mm3₎ ₄ _13.8 Moderateneutropeniab_(501–1000_cells/mm3₎ ₇ _24.1 Severeneutropeniac_(≤500_cells/mm3₎ ₂ _6.9 Mildmegaloblasticanemia(Hemoglobin:

10.1–11.9g/dL)

1 3.5

Moderatemegaloblasticanemia(Hemoglobin: 8.1–10.0g/dL)

0 0.0

Severemegaloblasticanemiac_(Hemoglobin: ≤8.0g/dL)

1 3.5

Mildthrombocytopeniac_(platelets 101,000–140,000/mm3₎

1 3.5

Moderatethrombocytopeniad_(platelets 51,000–100,000/mm3₎

1 3.5

Severethrombocytopenia (platelets≤50,000/mm3₎

0 0.0

Mildhepatitis(ASTand/orALT≤twotimesthe referencevalue)

3 10.3

Moderatehepatitis(ASTand/orALT>twotimes thereferencevalue,andnormalprotrombine timetest)

1 3.5

Severehepatitis(protrombinetimetest<50.0% orINR>1.3)

0 0.0

AST,aspartateaminotransferase;ALT,alanineaminotransferase; INR,internationalnormalizedratio.

a ₁_patient_received_zidovudine_(AZT)_and_ganciclovir concomi-tantly,1patientreceivedganciclovirconcomitantly.

b ₁_patient_received_zidovudine_{concomitantly.}

c ₁ _patient _that _received _zidovudine _{concomitantly} _presented severe neutropenia, severe megaloblastic anemia, and mild thrombocytopenia.

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AstudyfromsouthernBrazilshowedthat47.8%ofpregnant

women were seropositive for T. gondii, indicating previous

exposuretotheparasite,and27.2%werenotcorrectly

diag-nosedforT.gondiiduringpregnancyduetosomefactors,such

aslackofprenatalcareorbecausetheserologicaltestswere

notperformed.13_Despite_the_good_prenatal_care_for_pregnant

womenevaluatedinthepresentstudy,serological

investiga-tionfortoxoplasmosiswasnotperformedinthemajorityof

pregnantwomen.

Thehighfrequencyofprematurityandthelowbirthweight

ofinfantsobservedinthepresentstudyareconsistentwith

previousBrazilianstudiesthatshowedbirthweightofinfected

childrenvaryingfrom1290to3790g.13,19–24

Congenitaltoxoplasmosis may present different clinical

forms, including subclinical infection, disease during the

neonatal period, severe disease, mild disease in the ﬁrst

monthoflife,sequelaeorreactivationofpreviously

undiag-nosedinfection.15

Innewbornsandsymptomaticinfants,clinical

presenta-tionisdividedintoneurologicalandgeneralizedforms.One

neurologicalform,Sabin’stetrad,resultsfromfetalinfection

atthebeginningofthepregnancyandproducesdiffuse

cere-bralcalciﬁcations,chorioretinitis,convulsions,hydrocephaly

ormicrocephaly.Thegeneralizedformresultsfrominfection

duringlatepregnancyandischaracterizedbychorioretinitis,

changes in CSF, hepatosplenomegaly, jaundice,

lymphade-nomegaly,thrombocytopenia,andanemia.15,18

Brazilian studies carried out between 1990 and 2010

showed that early clinical manifestations were present in

56–100%ofthechildrenevaluated.Chorioretinitiswaspresent

in67–80%,andbraincalciﬁcationswereobservedin11–100%

ofthecases,manyofthemwithoutprenataltreatment.13,19–25

Other studies reported the presence of hydrocephaly in

6.3–21%ofchildrenandmicrocephalyin5.3%oftheevaluated

children.24,26

Ocularinjuriesarenottotallydependentonthegestational

ageofmaternalinfection;theymayresultinseverecasesof

chorioretinitis,eveniftheinfectionisacquiredinthesecond

halfofthepregnancy.Furthermore,theriskofchorioretinitis

–themostfrequentsequela–persistsformanyyears.27_Of_the

ocularmanifestationsamongBrazilianchildrenwith

congen-italtoxoplasmosis,29–100%presentedchorioretinitisduring

theevolutionofthedisease,with12–84%presentingbilateral

injuries.Frequentsymptomsincludemicrophthalmia(9–25%

ofcases),strabismus(12–60%), nystagmus(3–47%),cataract

(1–14%),vitreitis(3–50%),andvisualdamage(50–100%).13,19–28

Therefore,the resultsofthepresent study areinline with

otherBrazilianstudies;however,itshowedhigherfrequency

ofsymptomaticchildrenatbirthandwithocular

manifesta-tionsthanotherstudiescarriedoutwithchildrenfromEurope

andNorthAmerica.27_One_possible_explanation_for_this_result

maybethepresenceofmorevirulent strainsofT.gondiiin

Brazil.29

Theriskfactorsassociatedwiththedevelopmentof

chori-oretinitis include female gender, brain calciﬁcations, and

delayofmaternaltreatmentafterseroconversion.18,30_In_the

present study, ocular injuries was neither associated with

childgendernorwiththepresenceofbraincalciﬁcations.

In agreement with other studies conducted in the

pre-treatmentperiodamongBrazilianandAmericanchildren,18

thepresentstudyshowedthat55.2%ofinfantsexhibited

neu-rologicalinjuriesinimagingexams,withcalciﬁcationin44.8%

ofcases.

Asymptomaticinfantsatbirthmayprogresswithno

infec-tionsequelae,butmayalsodevelopvisualdamage,delayed

neuropsicomotordevelopment,hydrocephaly,convulsionsor

deafness months or years afterbirth.15,18,20 _Sequelae_were

identiﬁedin68.9%ofpatientsevaluatedinthisstudy,andthe

mostfrequentsequelaewerevisualimpairmentand

neuro-logicaldamage.

Oneofthebeneﬁtsoftreatmentisthedecreaseinocular

and neurologicalsequelaeinT.gondii-infected children.18,31

Earlytreatmentpreventsoculardamageinchildren,asshown

in twolongitudinalstudies whereanew lesionduring the

follow-upwasdetectedin72%ofuntreatedchildrencompared

to31%oftreatedchildren.32,33

Studies suggest that CT is moresensitive than USGfor

detectingbraincalciﬁcations.34 _However,_a_study_comparing

brainCTandUSGin33childrenwithcongenital

toxoplasmo-sisfound94%agreementbetweentheseimagingexams.35

Inthepresentstudy,CTwasmoresensitivefordetecting

braincalciﬁcations,andUSGwasmoresensitivefordetecting

hydrocephaly.However,speciﬁctreatmentfortoxoplasmosis

providedduringtheperiodbetweenUSGandCTevaluations

may havebeen responsibleformissinghydrocephalyinCT

thatwasshownwithUSG.ThemajorityofUSGevaluations

wereperformedduringtheﬁrstmonthoflife.Thehigher

num-berofcaseswithbraincalciﬁcationsobservedbyCTcompared

tothose observedbyUSGmaybeexplainedbythenatural

evolutionoftheCNSlesions.

Congenitaltoxoplasmosiscanbetransmittedbypregnant

womeninfectedwithHIV-1whoarethosechronicallyinfected

withT.gondii;29,36_there_are_also_reported_cases_of_CMV_and_T.

gondiico-infection.15,37_In_the_present_study,_the_four_infants

co-infected with CMV showed clinical improvement when

ganciclovir wasadded tothe speciﬁctherapy for

toxoplas-mosis.Thisresultdemonstratestheimportanceofexcluding

otherassociatedinfectionsinpatientswithcongenital

toxo-plasmosis.

Among the adverse effects of toxoplasmosis treatment,

themostharmfulisneutropeniacausedbythe

myelotoxic-ityofsulfadiazineandpyrimethamine.15_In_the_present_study,

severe and moderate neutropenia were observed in a few

cases,andthemajorityofthemhadbeentreatedwithother

myelotoxicdrugsassociatedwithtoxoplasmosistreatment,

although alladverse effects were reversiblewithincreased

folinic acid doses and temporary interruptionofthe

treat-ment.Reversibleneutropeniawasalsoobservedinacohortof

patients,evaluatedfrom1981to2004inNorthAmerica,with

dailydosesofpyrimethaminefortwoorsixmonths.31

Inthepresentstudy,anti-T.gondiiIgMseroprevalencewas

lower than observed in previous studies that conﬁrmed T.

gondiiinfectionbythedetectionofIgMantibodiesin50–75%

ofnewborns.15,22,38_The_presence_of_anti-T._gondii_IgG

antibod-iesinanewbornserumsampleisnotevidenceofinfection

because maternalIgGantibodies are passivelytransmitted.

Thehalf-lifeofthisimmunoglobulinis23daysandmaternal

antibodiesmaypersistinthenewborncirculationforoneyear,

and about threemonthsarenecessary fora10-fold

(7)

assayedinserialsamplesfromthechildtoconﬁrma

congen-italinfection.15,26_However,_in_the_present_study_due_to_wide

variation(rangingfrom1:16to1:128,000)serumanti-T.gondii

IgGwasoflittlehelptodiagnose congenitaldisease.Other

serologicalmethodsarenecessarytoidentifycaseswithfalse

negativeresultsforanti-T.gondiiIgM.

Althoughthequalityofprenatalcareforsuspectedcases

oftoxoplasmosisin Londrinaand northernParaná in2006

wasnotascertained,arobustmulti-professionalteam,with

thesupportofgovernmentalinstitutions,starteddiscussions

aboutthisimportantpublichealthproblem,whichresultedin

theimplementationoftheSurveillanceProgramof

Congeni-talToxoplasmosis,ﬁrstintheBasicHealthUnitsofLondrina,

northofParaná,andafterwardsinotherlocationsinParaná

state.39,40_Its_objective_is_to_inform,_standardize,_and_guide_the

managementofmedicalprofessionalsincaringforpregnant

womenwithsuspectedorconﬁrmedtoxoplasmosisand

chil-drenwithcongenitaltoxoplasmosis.Todate,therehasbeen

excellentadherencetotheproposedprogramintheprimary

healthcareunits,decreasingthenumberofpregnantwomen

andchildrenunnecessarilyreferredtoreferencecentersfor

diagnosisandtreatmentoftoxoplasmosisby63.9%and42.6%,

respectively,attheUniversityofLondrinaHospital.

Further-more,theincorrectuseofsulfadiazinewasdecreasedby67.4%

aftertheprogramwasimplemented.39,40

Altogether,theresultsofthepresentstudydemonstrated

that from 2000 to 2010, the majority of pregnant women

whosechildrenpresentedcongenitaltoxoplasmosisandhad

receivedcareatthereferencecenterforPediatricInfectious

DiseasesoftheOutpatientClinicalHospitalofState

Univer-sityofLondrina,weregivennotreatmentfortoxoplasmosis

duringthepregnancy becausenodiagnostic testsfor

toxo-plasmosishadbeenrequested.Themajorityofchildrenwere

symptomaticin the ﬁrst month oflife, and chorioretinitis

wasthemostfrequentoculardamage.Ahighfrequencyof

sequelaewasalsoobservedinthiscohortofpatients.These

datareinforcetheimportanceofdiagnosisandtreatmentof

toxoplasmosisacquiredduringpregnancytoreducethe

occur-renceofcongenitaltoxoplasmosisanditscomplicationsinthe

child.Continuousassessment,consolidation,andexpansion

oftheSurveillanceProgramofCongenitalToxoplasmosis39,40

cancontributetotheimprovementofhealthcareforpregnant

womenwithsuspectedtoxoplasmosisandforthereduction

ofcongenitaltoxoplasmosisintheBrazilianpopulation.

Conﬂicts

of

interest

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1. MontoyaJG,BoothroydJC,KovacsJA.Toxoplasmagondii.In: Mandell,Douglas,Bennet,editors.Principlesandpracticeof infectiousdiseases.7th.ed.ChurchillLivingston:

Philadelphia;2010.

2. HillD,DubeyJP.Toxoplasmagondii:transmission,diagnosis andprevention.ClinMicrobiolInfect.2002;8:634–40.

3. AspockH.PreventionofcongenitaltoxoplasmosisinAustria. ArchPediatr.2003;10:16–7.

4.AntoniouM,TzouvaliH,SifakisS,etal.Incidenceof toxoplasmosisin5532pregnantwomeninCrete,Greece: managementof185casesatrisk.EurJObstetGynecolReprod Biol.2004;117:138–43.

5.NashJQ,ChisselS,JonesJ,WarburtonF,VerlanderNQ.Risk factorsfortoxoplasmosisinpregnantwomeninKent,United Kingdom.EpidemiolInfect.2005;133:475–83.

6.HungCC,FanCK,SuKE,etal.Serologicalscreeningand toxoplasmosisexposurefactorsamongpregnantwomenin theDemocraticRepublicofSãoTomeandPrincipe.TransR SocTropMedHyg.2007;101:134–9.

7.LiuQ,WeiF,GaoS,etal.Toxoplasmagondiiinfectionin

pregnantwomeninChina.TransRSocTropMedHyg. 2009;103:162–6.

8.Lopes-MoriFMR,Mitsuka-BreganóR,Gonc¸alvesDD,etal. Factorsassociatedwiththeseropositivityforanti-Toxoplasma

gondiiantibodiesinpregnantwomenofLondrina,Paraná,

Brazil.MemInstOswaldoCruz.2009;104:378–82.

9.ReicheEMV,MorimotoHK,FariasGN,etal.Prevalênciada tripanossomíaseamericana,síﬁlis,toxoplasmose,rubéola, hepatiteB,hepatiteCedainfecc¸ãopelovírusda

imunodeﬁciênciahumana,avaliadaporintermédiodetestes sorológicos,emgestantesatendidasnoperíodode1996a 1998noHospitalUniversitárioRegionaldoNortedoParaná (UniversidadeEstadualdeLondrina,Paraná,Brasil).RevSoc BrasMedTrop.2000;33:519–27.

10.Figueiró-FilhoEA,LopesAHA,SenefonteFRA,etal. Toxoplasmoseaguda:estudodafrequência,taxade transmissãoerelac¸ãoentreostestesdiagnósticos materno-fetaisemgestantesemEstadodaRegião Centro-OestedoBrasil.RevBrasGinecolObstet. 2005;27:442–9.

11.NetoEC,AneleE,RubimR,etal.Highprevalenceofcongenital toxoplasmosisinBrazilestimatedin3-yearoldprospective neonatalscreeningstudy.IntJEpidemiol.2000;29:941–7.

12.SegundoGRS,SilvaDAO,MineoJR,FerreiraMS.Congenital toxoplasmosisinUberlândia,MG,Brazil.JTropPediatr. 2004;50:50–3.

13.LagoEG,CarvalhoRL,JungblutR,SilvaVB,FioriRM.Screening

forToxoplasmagondiiantibodiesin2,513consecutive

parturientwomenandevaluationofnewborninfantsatrisk forcongenitaltoxoplasmosis.SciMed.2009;19:27–34.

14.KravetzJD,FedermanDG.Toxoplasmosisinpregnancy.AmJ Med.2005;118:212–6.

15.RemingtonJS,McleodR,ThulliezP,DesmontsG.

Toxoplasmosis.In:RemingtonJS,etal.,editors.Infectious diseasesofthefetusandnewborninfant.6thed. Philadelphia:Elsevier-Saunders;2006.

16.LebechM,JoynsonDHM,SeitzHM,etal.Classiﬁcationsystem andcasedeﬁnitionsofToxoplasmainfectionin

immunocompetentpregnantwomenandtheircongenitally infectedoffspring.EurJClinMicrobiolInfectDis.

1996;15:799–805.

17.CamargoME.Improvedtechniqueofindirect immunoﬂuorescenceforserologicaldiagnosisof toxoplasmosis.RevInstMedTrop.1964;6:117–8.

18.McleodR,KiefferF,SautterM,HostenT,PellouxH.Why prevent,diagnoseandtreatcongenitaltoxoplasmosis.Mem InstOswaldoCruz.2009;104:320–44.

19.MelamedJ,DornellesF,EckertGU.Alteraçõestomográficas cerebraisemcriançascomlesõesocularesportoxoplasmose congênita.JPediatr.2001;77:475–80.

20.SáfadiMAP,BerezinEN,FarhatCK,CarvalhoES.Clinical presentationandfollowupofchildrenwithcongenital toxoplasmosisinBrazil.BrazJInfectDis.2003;7:325–33.

21.CarvalheiroCG,Mussi-PinhataMM,YamamotoAY,Souza CBS,MacielLMZ.Incidenceofcongenitaltoxoplasmosis estimatedbyneonatalscreening:relevanceofdiagnostic

(8)

conﬁrmationinasymptomaticnewborninfants.Epidemiol Infect.2005;133:485–549.

22.LagoEG,NetoEC,MelamedJ,etal.Congenitaltoxoplasmosis: latepregnancyinfectionsdetectedbyneonatalscreeningand maternalserologicaltestingatdelivery.PaediatrPerinat Epidemiol.2007;21:525–31.

23.MelamedJ.Contributionstothehistoryofocular

toxoplasmosisinSouthernBrazil.MemInstOswaldoCruz. 2009;104:358–63.

24.Vasconcelos-SantosDV,AzevedoDOM,CamposWR,etal. CongenitaltoxoplasmosisinsoutheasternBrazil:resultsof earlyophtalmologicexaminationofalargecohortof neonates.Ophthalmology.2009;116:2199–205.

25.Bahia-OliveiraLMG,Wilken-AbreuAM,Azevedo-SilvaJ, OréﬁceF.ToxoplasmosisinsoutheasternBrazil:analarming situationofhighlyendemicacquiredandcongenital infection.IntJParasitol.2001;31:133–6.

26.RodriguesLMX,CastroAM,GomesMBF,AmaralWN,Avelino MM.Congenitaltoxoplasmosis:evaluationofserological methodsfordetectionofanti-ToxoplasmagondiiIgMand IgAantibodies.MemInstOswaldoCruz.2009;104: 434–40.

27.GilbertR,FreemanK,LagoEG,etal.OcularSequelaeof congenitaltoxoplasmosisinBrazilcomparedwithEurope. PLoSNeglTropDis.2008;2:1–7.

28.ResendeLM,AndradeGMQ,AzevedoMF,PerissimotoJ,Vieira ABC.Congenitaltoxoplasmosis:auditoryandlanguage outcomesinearlydiagnosedandtreatedchildren.SciMed. 2010;20:13–9.

29.DubeyJP,LagoEG,GennariSM,SuC,JonesJL.Toxoplasmosis inhumanandanimalsinBrazil:prevalence,highburdenof disease,andepidemiology.Parasitology.2012;139:

1375–424.

30.KiefferF,WallonM,GarciaP,ThulliezP,PeyronF,FranckJ. Riskfactorsforretinochoroiditisduringtheﬁrst2yearsoflife ininfantswithtreatedcongenitaltoxoplasmosis.Pediatr InfectDisJ.2008;27:27–32.

31.McleodR,BoyerK,KarrisonT,etal.ToxoplasmosisStudy Group.Outcomeoftreatmentforcongenitaltoxoplasmosis, 1981–2004:theNationalCollaborativeChicago-Based, CongenitalToxoplasmosisStudy.ClinInfectDis. 2006;42:1383–94.

32.PhanL,KaszaK,JalbrzikowskiJ,etal.Longitudinalstudyof neweyelesionsintreatedcongenitaltoxoplasmosis. Ophthalmology.2008;115:553–9.

33.PhanL,KaszaK,JalbrzikowskiJ,etal.Longitudinalstudyof neweyelesionsinchildrenwithToxoplasmosiswhowerenot treatedduringtheﬁrstyearoflife.AmJOphthalmol. 2008;146:375–84.

34.GrantEG,WilliamsAL,ShellingerD,SlovisTL.Intracranial calciﬁcationintheinfantandneonate:evaluationby sonographyandCT.Radiology.1985;157:63–8.

35.LagoEG,BaldisserottoM,Hoefel-FilhoJR,SantiagoD,Jungblut R.Agreementbetweenultrasonographyandcomputed tomographyindetectingintracranialcalciﬁcationsin congenitaltoxoplasmosis.ClinRadiol.2007;62:1004–11.

36.DelicioAM,MilanezH,AmaralE,etal.Mother-to-child transmissionofhumanimmunodeﬁciencyvirusinaten yearsperiod.ReprodHealth.2011;8:1–10.

37.ZegherF,SluitersJF,StuurmanPM,Van-Der-VoortE,BosAP, NeijensHJ.Concomitantcytomegalovirusinfectionand congenitaltoxoplasmosisinanewborn.EurJPediatr. 1988;147:424–5.

38.LebechM,AndersenO,ChristensenNC,etal.Feasibilityof neonatalscreeningfortoxoplasmainfectionintheabsenceof prenataltreatment.Lancet.1999;353:1834–7.

39.Mitsuka-BreganóR(dissertation)ProgramadeVigilânciaem SaúdedaToxoplasmoseGestacionaleCongênita:elaboração, implantaçãoeavaliaçãonomunicípiodeLondrina,Paraná. Londrina,Paraná,Brazil:UniversidadeEstadualdeLondrina; 2009.

40.Lopes-MoriFMR,Mitsuka-BreganóR,CapobiangoJD,etal. Programsforcontrolofcongenitaltoxoplasmosis.RevAssoc MedBras.2011;57:581–6.