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Case Report
DerDergigisisi
PARAZITO LOJI
223
Olgu Sunumu
Turkiye Parazitol Derg 2021;45(3):223-226
Received/Geliş Tarihi: 02.03.2021 Accepted/Kabul Tarihi: 21.06.2021
Address for Correspondence/Yazar Adresi: Tonay İnceboz, Dokuz Eylül University Faculty of Medicine, Department of Medical Parasitology,
İzmir, Turkey
Phone/Tel: +90 505 748 43 43 E-mail/E-Posta: tonay.inceboz@deu.edu.tr ORCID ID: orcid.org/0000-0002-5856-7865
Toxoplasma gondii is an obligate intracellular parasite that infects all animals, including humans, and causes toxoplasmosis. If
toxoplasmosis occurs during pregnancy, it may affect the foetus owing to transplacental transmission. Such transmission may
lead to foetal complications, some of which can be very serious, e.g. hydrocephaly and chorioretinitis; however, not all cases
of acute toxoplasmosis during pregnancy result in foetal complications. The decision whether to continue or terminate the
pregnancy is a difficult problem for families as well as healthcare professionals, thus making it important. Here we present a
case of acute toxoplasmosis at 6 weeks of pregnancy. The patient was directly advised to terminate the pregnancy. However, with
detailed laboratory analyses, close follow-up and treatment to prevent transplacental transmission, she successfully completed
the pregnancy and eventually delivered a healthy baby. By presenting this case, we aimed to review acute toxoplasmosis during
pregna ncy.
Keywords: Toxoplasma gondii, pregnancy, risk factors, congenital toxoplasmosis, seroprevalence
Toxoplasma gondii, insanlar dahil tüm hayvanları enfekte edebilen bir zorunlu hücre içi parazittir. Toxoplasma gondii’nin yaptığı
hastalığa Toksoplazmoz denir. Eğer toksoplazmoz gebelikte söz konusu olursa fetus transplasental geçile etkilenebilir. Her ne
kadar bu geçi, hidrosefali, koryoretinit gibi çok ciddi fetal problemlere yol açabilse de, tüm gebelik akut toksoplazmozlarında bu
durum mutlaka önemlidir. Çünkü gebeliğe devam etme veya sonlandırma kararı hem aileler için hem de sağlıkçılar için zordur.
Burada, akut toksoplasmoz tanısı ile gebeliğin 6. haftasında doğrudan gebelik sonlandırması ile bavuran, gebeliği arzu edilen
bir olgu sunuyoruz. Olgu, detaylı laboratuvar testleri, yakın takip ve transplasental geçii engelleyen tedavi ile gebeliği baarılı
bir ekilde sonlandırıp sağlıklı bir bebek sahibi olmutur. Bu olgu ile, gebelikte akut toxoplasmosis konusunu yeniden gözden
geçirmeyi hedefledik.
Anahtar Kelimeler: Toxoplasma gondii, gebelik, risk faktörleri, konjenital toksoplasmoz, seroprevalens
ABSTRACT
ÖZ
Cite this article as: İnceboz T, Korkmaz M, Dirim Erdoğan D, İnceboz Ü. Acute Toxoplasmosis During Pregnancy: A Hard
Call. Turkiye Parazitol Derg 2021;45(3):223-226.
INTRODUCTION
Toxoplasmosis is a disease in human and most
animals caused by Toxoplasma gondii (T. gondii),
which is an intracellularly protozoa (1,2). It affects
reticuloendothelial system and neural system. In
most infected-individuals, course of toxoplasmosis is
asymptomatic. Nevertheless, in some individuals, it
may cause fever, lymphadenopathy, fatigue, headache,
anemia. It may also be a life-threatening problem in
immune-suppressed peoples. If the acute infection
occurs during pregnancy, transplacental (vertical)
transmission may occur and may lead fetal problems
such as intracranial calcifications, hydrocephaly and
even intrauterine fetal demise. Due to these kind
of risks during the pregnancy, serologic testing for
toxoplasmosis is being advised or is even mandatory
in some countries (3-5).
The acute toxoplasmosis is uncommon during the
pregnancy and it is somewhat ‘‘tricky’’; on one hand
1Dokuz Eylül University Faculty of Medicine, Department of Medical Parasitology, İzmir, Turkey
2Ege University Faculty of Medicine, Department of Medical Parasitology, İzmir, Turkey
3Irenbe Obstetrics, Gynecology and IVF Center, İzmir, Turkey
Tonay İnceboz1, Metin Korkmaz2, Derya Dirim Erdoğan2, Ümit İnceboz3
Gebelikte Akut Toksoplazmoz: Zor Karar
Acute Toxoplasmosis During Pregnancy: A Hard
Call
DOI: 10.4274/tpd.galenos.2021.43043
İnceboz et al. Acute Toxoplasmosis During Pregnancy Turkiye Parazitol Derg 2021;45(3):223-226
224
the treatment of the pregnant is important, on the other hand
the investigation should be directed to fetus as to whether the
fetal transmission is present and if so, the degree of the fetal
damage should be searched. However, sometimes it is not as easy
as its theory. The role of the healthcare providers is to explain
the whole picture in detail and ask the couple decide the fate (4).
Serologic testing, ultrasonographic follow-up -especially for the
signs of any fetal involvement- are utmost important.
Here we aimed to present the course of a case with acute
toxoplasmosis that was diagnosed in very early pregnancy, and
ended up with a healthy baby girl. By doing so, we would like to
review the knowledge on toxoplasmosis and pregnancy.
CASE REPORT
Twenty-four year-old woman, G1P0 was admitted to our clinic
with a six-week pregnancy and the diagnosis of toxoplasmosis.
She was advised to have a pregnancy termination with the
information of high risk of having an “abnormal baby”. She
was anxious because she had a strong desire of continuation
of pregnancy, contradicting with the fear of -mentioned risk
of having- “abnormal baby”. She had a history of raw-meat
consumption. She had no fever but malaise that may be a
common feeling during the first months of pregnancy. She had no
lymphadenopathy nor hepatosplenomegaly during the physical
examination however she had fatigue. Transient increase in the
liver function tests namely aspartate aminotransferase (AST)
and alanine aminotransferase (ALT) were present. Transvaginal
ultrasonographic examination confirmed viable pregnancy of 6
weeks. Table 1 shows serum anti-toxoplasma antibodies (IgM,
IgG, IgG-avidity) analyses of the patient performed in three
different laboratories (Table 1). It seems an advantage to have the
results from three different laboratories in terms of diagnosis and
follow-up. When we consider all serological data and elevated liver
function test in the present case, it is most likely for her to have
the acute toxoplasmosis 1-2 months just before the pregnancy.
The diagnosis, risk of fetal transmission, importance of follow-
ups, repeat laboratory analyses, and adherence to prophylactic
medication were explained in detail to the couple but she
refused to have amniocentesis. They have decided to continue
the pregnancy. To decrease the risk of transplacental fetal
transmission spiramycine 3 g/day, orally was started. Follow-up
information and was shown in Table 1. Maternal seroconversion
was confirmed. Ultrasonographic examinations were all negative
for any sign of toxoplasmosis infection. At 39 weeks of pregnancy,
she was admitted to the hospital due to rupture of the membranes.
Due to cervical dystocia, cesarean section was performed and
Table 1. The patent’s serologcal results for toxoplasmoss durng the pregnancy (performed n 3 dfferent labs)
Weeks of pregnancy Results Performed lab
6th week IgM: 11
IgG: 104 Private lab
7th week IgG avidity: 27.77% Private lab
10th week IgG avidity: 29.72% Private lab
12th week
IgM: 1.26
IgG: 1/1.024 positive
IgG avidity: 55%
University hospital lab
18th week IgG Avidity: 35.86% Private lab
23th week IgM: 9.35
IgG: 59 Private hospital lab
27th week IgM: 7.81
IgG: 53.6 Private hospital lab
32th week IgM: 8.66
IgG: 58.2
Private hospital lab
39th week BIRTH
Postpartum 1st week
IgM: 1.11
IgG: 1/512
IgG avidity: 57% University hospital lab
The reference values of different laboratories
Private lab
IgG: Negative 0-7.2 U/mL, intermediate values: 7.2-8.8 U/mL, Positive: >8.8
U/mL
IgM: negative: 0-10
Avidity. low: < 20%, borderline: 20-30%, high: >30%
University hospital lab
IgG (Dilution series, in house ELISA)
IgM (ELFA, bioMérieux diagnostics) negative: <0.55; Intermediate : 0.55-
0.65, positive >0,65
Avidity. (In house ELISA) low: <20%; Borderline: 20-30%, high: >30%
Private hospital lab
IgM negative: 0-10
IgG negative: 0-7.2
İnceboz et al. Acute Toxoplasmosis During Pregnancy
Turkiye Parazitol Derg 2021;45(3):223-226
225
healthy baby girl (3.190 grams, 50 cm) was delivered. The cord
blood analysis for toxoplasmosis was negative for IgM but positive
for IgG antibodies. Two weeks later IgG was become negative,
pointing out the maternal transmission of IgG antibodies. Baby
girl is still very healthy and doing well now.
DISCUSSION
T. gondii is one of the most common parasite that infect around
1/3 of all human in the world (6). The disease caused by T. gondii
is called toxoplasmosis and may occur in anyone at any age (7-
9). The incidence of the acute infection during pregnancy is
difficult to investigate since the disease is very widespread.
However according to one detailed meta-analysis revealed that
prevalence of acute toxoplasmosis during pregnancy was around
1.1% (confidence interval: 0.9-1.2%) (10). Such an acute infection
during pregnancy may affect the baby; it has been estimated
that 1 in 1.000-1 in 10,000 babies born with intrauterinely
acquired toxoplasmosis (11). In another study, it was estimated
that around 190,000 new congenital toxoplasmosis cases occur
worldwide annually (12).
Most of the pregnant women with acute toxoplasmosis are
asymptomatic (13). In symptomatic cases lymphadenopathy,
fatigue, fever, flue-like symptoms may be present. In our case
there was no symptom or sign of the acute toxoplasmosis.
Although fatigue was present it is not certain whether it was one
of a common symptom of pregnancy or due to acute infection
with toxoplasma. Transient increase in the liver function tests
-namely AST and ALT- were the only abnormal finding in our case.
There are some clinical as well as experimental studies pointing
out the elevated amino-transferases somewhat a sign of hepatic
involvement (14-16). During the follow-up of the present case,
hepatic function tests decreased to their normal range. Thus,
if some hepatic involvement occurred this was just a transient
increase.
Diagnosis of acute toxoplasmosis infection during pregnancy
is a difficult task, since such a task put too much stress on
both physician, doctors in the lab and as well as the couple
involved. In our case we have followed her up with ultrasound
examinations and serum analyses. Typically, we have seen the
seroconversion. Maternal serology may sometimes be confusing.
When rheumatoid factor or antinuclear antibody is positive in the
blood, serological tests may be falsely positive (17,18). However
serological investigation is mandatory (19). When toxoplasma
IgM and IgG are tested, if both are negative, this means no
present or past infection. In this situation risk factors such as
raw-meat consumption must be avoided. If IgM is negative but
IgG is positive, this implies past infection with immunity, thus
no risk during pregnancy. If IgM is positive and IgG is positive
(or negative), this connotes acute infection. IgM antibodies can
be detected with in the first 2 weeks of infection, however, IgM
titers can remain elevated for a year or more; thus, the presence
of IgM antibody is not diagnostic of an acute toxoplasmosis
infection. To confirm the diagnosis IgG avidity may help, if this
value is high. High-avidity IgG antibodies develop at least 12-16
weeks after the infection. Thus, in a pregnant woman in her first
months of gestation, regardless of the IgM antibody test result,
a high-avidity IgG test result refers that basically there is no risk
for the fetal infection. In our case, at first, both toxoplasma IgM
and IgG were both positive. Even if IgG avidity seemed in gray-
zone, increased IgG avidity results by time also supports early
acute infection with toxoplasmosis. In the present case, there are
different lab results from different labs. Although just serum IgG
and IgM results from the different labs may be confusing for the
clinicians, as in our case, serum IgG avidity is “a good guide” to
make a decision for such cases. The follow-up serological tests
were confirmed this diagnosis as an acute toxoplasmosis during
the early stages of pregnancy.
It has been reported that up to two-thirds of cases of congenital
toxoplasmosis may not show any abnormality on ultrasound scans
(such as calcifications, microcephaly, hydrocephalus, ventricular
dilations, hepatosplenomegaly, ascites, and severe intrauterine
growth retardation) (20). We have shared this information with
the couple. She refused to have invasive diagnostic method
(amniocentesis).
Congenital toxoplasmosis may lead to a wide variety of problems
from chorioretinitis to fetal death. Classical triad of the
congenital infection is chorioretinitis, cranial calcifications and
hydrocephalus, however, 90% of the infants with congenital
toxoplasmosis are asymptomatic at birth (21). Transplacental
transmission of toxoplasma infection is tend to be ironically
“fetus friendly”. Transmission rate of infection is negligible if
the acute toxoplasmosis occurs at or during conception (0-0.6%)
and still low (3.5%) before 15 weeks of pregnancy, rising steadily,
reaching around 80-100% in the 3rd trimester (22). However
fetal damage risk is as the opposite; the damage risk higher if
the transmission occurs in early pregnancy, whereas it is very
small in late pregnancy. In our case, there were no signs of the
fetal involvement and again at birth no signs or symptoms, nor
serological clue of a congenital toxoplasmosis infection. The baby
girl is still healthy at her 2 years of age now.
In conclusion, toxoplasmosis is very common “neglected”
parasitary disease with a risk of fetal transmission if acute
infection occurred in pregnancy. However when fetal transmission
is not certain, the option of pregnancy termination should not
be offered before assessment of the situation in all aspects. The
importance of both serological as well as the ultrasonographic
follow-up should not be overlooked. There is one other important
lesson to remember; serological testing for toxoplasmosis should
ideally be checked before the “planned” conception.
* Ethics
Informed Consent: Informed consent was obtained.
Peer-revew: Externally and internally peer-reviewed.
* * Authorship Contributions
Concept: T.İ., M.K., Ü.İ., Design: T.İ., M.K., D.D.E., Ü.İ.,
Data Collection or Processing: T.İ., M.K., D.D.E., Analysis or
Interpretation: T.İ., M.K., D.D.E., Ü.İ., Literature Search: T.İ.,
M.K., Ü.İ., Writing: T.İ., M.K., Ü.İ.
Conflct of Interest: No conflict of interest was declared by the
authors.
Fnancal Dsclosure: The authors declared that this study
received no financial support.
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