Beruflich Dokumente
Kultur Dokumente
Toxoplasmosis: Diagnosis,
Treatment, and Prevention
in Congenitally Exposed
Infants
Alyson Kaye, CPNP, MS, BS
ABSTRACT
Toxoplasmosis is a rare disease caused by the obligate intracellular protozoan parasite, Toxoplasma gondii. Most
persons with toxoplasmosis in the United States are asymptomatic, but if a woman is infected during pregnancy, the parasite can cross the placenta and cause congenital
toxoplasmosis in the fetus. The severity of congenital toxoplasmosis depends on when in the pregnancy the mother is
exposed, but it can cause ocular and central nervous system
disease as well as lead to growth failure and hearing and vision abnormalities. Congenital toxoplasmosis is treated with
a combination of pyrimethamine, sulfadiazine, and leucovorin. It is important for pediatric nurse practitioners to be
aware of the clinical presentation and treatment of congenital
toxoplasmosis. J Pediatr Health Care. (2011) 25, 355-364.
KEY WORDS
Congenital toxoplasmosis, toxoplasmosis, ocular toxoplasmosis, retinochoroiditis, hydrocephalus, pPediatrics, nurse
practitioner, congenital infections, TORCH
www.jpedhc.org
355
Volume 25 Number 6
FIGURE 1. The cycle of exposure that leads to congenital toxoplasmosis. This figure is available in
color online at www.jpedhc.org.
d
d
d
November/December 2011
357
Volume 25 Number 6
359
360
Volume 25 Number 6
*Standard of care.
Trimethoprim
sulfamethoxazole
Clindamycin
First 6 months
Second 6 months
Consult infectious disease specialist
5-10 mg every 3 days
10 mg three times per week
Consult infectious disease specialist
A reduced form of folic acid
Folinic acid (leucovorin)*
1 mg/kg/day
1 mg/kg/day three times per week
First 6 months
Second 6 months
1 year
Length of therapy
Dose
Mechanism of action
Medication
TREATMENT
Standard of Care
The goal of initiating treatment is to arrest the replication
of the parasite and prevent further damage to the organs
involved. It is especially important to stop replication in
the eye to prevent irreversible damage to the retina and
optic nerve that can lead to permanent blindness
(Soheilian et al., 2005).
Currently, The World
The goal of initiating
Health Organization
treatment is to
and the Centers for Disease Control and Prearrest the
vention recommend
replication of the
pyrimethamine, sulfaparasite and
diazine, and leucovorin
as the standard of
prevent further
care for persons with
damage to the
congenital toxoplasorgans involved.
mosis (Rorman et al.,
2006). These medications were proven to be effective in a randomized prospective study called the National Collaborative
Chicago Based Congenital Toxoplasmosis Study
(NCCBTS). This study found that treatment with the
three aforementioned medications significantly decreased adverse signs and symptoms associated with
congenital toxoplasmosis, including ocular and central
nervous system symptoms and sensorineural hearing
loss (McLeod et al., 2006). This combination of medications also is recommended by the American Academy
of Pediatrics (AAP). For patients with sensitivity to sulfadiazine, clindamycin can be used in combination with
pyrimethamine as an alternative (AAP, 2009). Information regarding these medications and other alternative
medications that could be used to treat toxoplasmosis
can be found in the Table (Soheilian et al, 2005;
Taketomo, Hodding, & Kraus, 2008). A provider also
may add a corticosteroid to decrease the inflammation
caused by the replication of the parasite and to
manage the associated ocular complications (AAP,
2009; Soheilian et al., 2005).
Both pyrimethamine and sulfadiazine act by inhibiting folic acid synthesis in T. gondii. By using different
mechanisms of action, they complement one another
to create a combined effect (Schmidt et al., 2006).
Although they have been proven effective, they do not
come without serious adverse effects and should never
be prescribed without diagnostic confirmation of toxoplasmosis (Schmidt et al., 2006). As previously stated,
Adverse effects
This test should be performed at or after 18 weeks gestation and only in women with preliminary positive
serologic results indicative of acute exposure
(Montoya & Remington, 2008). Polymerase chain reaction testing of cerebrospinal fluid also can be used to
confirm the presence of infection in the central nervous
system after birth (Tamma & Serwint, 2007).
361
d
d
d
d
Volume 25 Number 6
toxoplasmosis. Most of these women knew toxoplasmosis was associated with cat litter but were unsure
as to why and did not know about exposure in the
environment through food, water, dirt, sand, or soil
(Jones, Ogunmodede et al., 2003).
Sporulated oocysts can be found in dirt, sand, or soil
and on the skins of raw fruits and vegetables grown in
these substrates (Lopez et al., 2000). Limiting contact
with dirt, sand, or soil can help prevent the ingestion
of oocysts from the environment, and if contact occurs,
an expectant mother should be taught to thoroughly
wash her hands to avoid ingesting the parasite
(Dimario et al., 2009; Lopez et al., 2000). Wearing
gloves while gardening, for example, also can limit the
contact a pregnant woman may have with these
environmental hazards (Pinard et al., 2003). The skins
of all raw fruit and vegetables should be washed and
then peeled away because oocysts may be attached to
these parts of the food and could be ingested. Again,
hand washing should be strongly emphasized after handling any raw food including fruits, vegetables, and
meat products (Lopez et al., 2000). T. gondii cysts can reside in the meat of many different types of mammals or
birds. In the United States, it is estimated that 8% of beef
and 20% of lamb and pork meat contains T. gondii tissue
cysts (Kravetz & Federman, 2005). All pregnant women
should be taught to never ingest raw meat and to cook
all meat to an internal temperature of at least 152F to
destroy the tissue cysts (Kravetz & Federman, 2005).
Because cats are the primary host for T. gondii, it is important that pregnant women be aware of the risks they
may pose. Contact with cat litter should be avoided if
possible, and if contact
is unavoidable, gloves
Because cats are
should be worn while
the primary host for
changing the litter box
and hands should be
T. gondii, it is
washed thoroughly afimportant that
terward (Lopez et al.,
pregnant women
2000; Pinard et al.,
2003). Frequent litter
be aware of the
changes should be
risks they may
done because it takes
pose.
several
days
for
oocysts to become
infectious, and the box should be thoroughly cleaned with disinfecting agents (Lopez et al.,
2000; Pinard et al., 2003). Preventing a cat from
hunting outdoors or eating raw meat also can prevent
the feline from being infected with T. gondii.
Practitioners should encourage pregnant women to
keep indoor-only cats and to feed them only canned
or dry food that has been bought in a store (Lopez
et al., 2000).
Providing education to expectant mothers is an important part of the provision of primary care for PNPs.
A practitioner should provide materials and information
Journal of Pediatric Health Care
FIGURE 3. An example of a handout that could be given to expectant mothers. This figure is available
in color online at www.jpedhc.org.
in a variety of languages and use common language instead of medical jargon to teach important points to patients. Handouts that are culturally sensitive and
appropriate for mothers with low literacy skills or who
cannot read should be used (Montoya & Remington,
2008). Using pictures and color demonstrations of
hand washing, cooking, and wearing gloves may be
helpful when teaching about toxoplasmosis if translation into another language is difficult (Montoya &
Remington, 2008). In addition, creating handouts that
a patient can simply hang in the home as a quick reminder may be useful. Figure 3 is an example of a handout for expectant mothers. Although research that looks
at the role of prenatal education in preventing congenital toxoplasmosis is limited, current recommendations
suggest that all pregnant women be given information
through written materials and discussions with medical
providers (Dimario et al., 2009). PNPs play an important
role in providing this information to their patients and to
expectant mothers.
www.jpedhc.org
CONCLUSION
PNPs play an active role in the primary care of infants. A
PNP may be the first medical provider who sees a newborn after he or she is released from the hospital and
can provide primary care throughout infancy and childhood. It is important that PNPs be able to recognize and
diagnose congenital toxoplasmosis as well as provide
and coordinate treatment and long-term follow-up
care for these patients.
The author wishes to thank Dr. Rita Marie John,
CPNP, DNP, EdD, Columbia University School of
Nursing, for her guidance and review of this article.
REFERENCES
American Academy of Pediatrics. (2009). Summaries of infectious
diseases. In L. K. Pickering, C. J. Baker, D. W. Kimberlin &
S. S. Long (Eds.), Red Book: 2009 report of the Committee
on Infectious Diseases (28th ed.). Elk Grove Village, IL: Author.
Bonfioli, A. A., & Orefice, F. (2005). Toxoplasmosis. Seminars in
Ophthalmology, 20(3), 129-141.
November/December 2011
363
364
Volume 25 Number 6