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Severe pulmonary toxoplasmosis after allo-SCT in two patients: from Toxoplasma genotyping to clinical management

Bone Marrow Transplantation volume 45, pages 580–583 (2010)Cite this article

Toxoplasma gondii infection can be a devastating disease in immunodeficient individuals. In these patients (AIDS, organ transplantation), severe toxoplasmosis can result mainly from reactivation of a latent infection. It can induce symptoms restricted to the central nervous system, lung, heart and eyes or cause disseminated infection.1 Although severe toxoplasmosis is a rare but often fatal event, disease severity and outcome might be influenced by parasite genotype.2 We report two cases of toxoplasmosis in haematopoietic SCT (HSCT; allo-SCT) patients, associated with non-type II strains of T. gondii. Susceptibility to toxoplasmosis of such non-HIV-immunocompromised patients is discussed in terms of underlying disease, toxoplasmosis prevention, clinical features, undergoing treatment and the potential role of the T. gondii genotype.

A 15-year-old girl with the myelodysplastic syndrome RAEB underwent unrelated cord blood graft with HLA-DRB1 mismatch. At transplant, she was in remission after induction-type chemotherapy. Myeloablative conditioning consisted of BU, CY and anti-thymoglobulin. GVHD prophylaxis was provided with CYA and i.v. corticotherapy. During the neutropenic phase, she received broad-spectrum antibiotics (ceftazidime, vancomycin and metronidazole). Her pretransplantation serological test was positive for T. gondii (Table 1). On day 35 after transplantation, she developed fever and interstitial lung disease, which improved with cotrimoxazole and roxithromycin treatment until day 53, when the treatment was discontinued for liver toxicity. Engraftment was documented on day 45. On day 40, CMV infection was diagnosed and treated with ganciclovir followed by foscarnet. The patient developed acute respiratory failure, deteriorated rapidly in spite of intensive supportive therapies, and she became confused on day 54. The brain computed tomography scan showed two hypodense lesions in the right frontal region; Toxoplasma DNA was detected in a blood sample on day 67, and intracellular parasites were identified in MRC5 fibroblast blood culture. The patient died on the same day. Bacterial, fungal and viral cultures were negative. Postmortem analysis of bronchoalveolar lavage, cerebrospinal fluids and pleural sample revealed positive detection of Toxoplasma DNA in lung specimens and blood samples (Table 1), in agreement with pulmonary toxoplasmosis disseminated secondarily. Direct genotyping at six T. gondii microsatellite loci (TUB2, TgM-A, W35, B17, B18 and M33) was done using multiplex PCR assay from bronchoalveolar lavage and blood samples. An atypical (recombinant) genotype was found (isolate referenced as LIL-2000-BRI).2

Table 1 Two cases of disseminated toxoplasmosis in HCST patients: laboratory data
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Authors and Affiliations

  1. Parasitology–Mycology Department—EA3609—Laboratoire associé du Centre National de Référence Toxoplasmose, Lille Hospital—Faculty of Medicine, Lille 2 University, Lille, France

    L Delhaes, J-C Mraz, E Fréalle, I Durand-Joly & E Dei-Cas

  2. Service des Maladies du Sang, Lille Hospital—Faculty of Medicine, Lille 2 University, Lille, France

    L Magro & I Yakoub-Agha

  3. Centre National de Référence Toxoplasmose/Toxoplasma Biological Resource Center, Centre Hospitalier-Universitaire Dupuytren, Limoges, France

    D Ajzenberg & M-L Dardé

  4. Laboratoire de Parasitologie-Mycologie, EA 3174-NETEC, Faculté de Médecine, Université de Limoges, Limoges, France

    D Ajzenberg & M-L Dardé

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  1. L Delhaes
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Correspondence to L Delhaes.

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Delhaes, L., Mraz, JC., Fréalle, E. et al. Severe pulmonary toxoplasmosis after allo-SCT in two patients: from Toxoplasma genotyping to clinical management. Bone Marrow Transplant 45, 580–583 (2010). https://doi.org/10.1038/bmt.2009.167

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