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Retinal and cerebral toxoplasmosis following nonmyeloablative stem cell transplant for chronic lymphocytic leukaemia

Bone Marrow Transplantation volume 36, pages 1019–1020 (2005)Cite this article

Toxoplasma gondii is a species of the phylum Apicomplexa. Infection caused by this obligate intracellular parasite is usually transient with mild clinical symptoms. Following mild primary infection, latent Toxoplasma cysts persist in multiple organs, where they may cause local (eg chorioretinitis), or disseminated infection on reactivation. The incidence of toxoplasmosis in an immunocompromised population reflects the prevalence of seropositivity. There is wide geographical variation in the prevalence of seropositivity to T gondii. Symptomatic T gondii infection following stem cell transplantation (SCT) is associated with a mortality rate of 66%.1 In the US, the rate of toxoplasmosis diagnosis (ante- or post mortem) post-SCT is 0.3%, while in France, an infection rate of 5% has been reported. Serological studies are of little value in making the diagnosis of T. gondii infection following SCT,2 thus the diagnosis of toxoplasmosis in this patient group poses a significant challenge. The relatively low level of infection in haemopoietic stem cell recipients may be due to the widespread use of co-trimoxazole prophylaxis for Pneumocystis carinii in these patients.3 Ocular toxoplasmosis in allo- or autograft transplant recipients is usually seen in the presence of widespread infection.4 In a post-mortem study, a combination of polymerase chain reaction (PCR) and immunohistochemistry performed on biopsies of involved organ samples yielded a sensitivity of 90%. We describe a case of retinal and cerebral toxoplasmosis in the absence of widespread disease, following SCT, in which retinal biopsy and PCR provided a definitive diagnosis.

A 33-year-old male, with heavily pre-treated chronic lymphocytic leukaemia (fludarabine and R-CHOP), underwent a sibling allogeneic reduced-intensity SCT in December 2003. The conditioning regimen used was Campath 1H 20 mg intravenously (i.v.) day −8, −7, fludarabine 30 mg/m2 day −7 to day −3, melphalan 140 mg/m2 day −2 and G-CSF 10 μg/kg daily from day −4.5 He received cyclosporine initially and subsequently tacrolimus as prophylaxis against graft-versus-host disease (GvHD). The post transplant course was complicated by life-threatening gastrointestinal haemorrhage on days 7–11 inclusive. He developed acute GvHD of the skin. Methylprednisolone 2 mg/kg was commenced on day 16. Oesophago-gastro-duodenoscopy and colonoscopy performed on day 47 revealed upper gastrointestinal candidiasis and cryptosporidium was identified on colonic biopsies. Histological changes consistent with GvHD were noted. The patient continued to receive high-dose steroid treatment, and was given paromomycin 1.0 g b.d. p.o. for cryptosporidium.

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Authors and Affiliations

  1. Department of Haematology, St James Hospital and Trinity College, Dublin, Ireland

    M Power, E Vandenberghe, E Conneally, P V Browne & S McCann

  2. Department of Ophthalmology, Eye and Ear Hospital, Dublin, Ireland

    D Kilmartin

  3. Mater Misericordiae Hospital, Dublin, Ireland

    D Kilmartin

  4. Department of Ophthalmology, Eye and Ear Hospital and St James's Hospital, Dublin, Ireland

    M O'Connor

  5. Diagnostic Imaging Department, St James's Hospital, Dublin, Ireland

    N Sheehy

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  1. M Power
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  2. E Vandenberghe
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Power, M., Vandenberghe, E., Conneally, E. et al. Retinal and cerebral toxoplasmosis following nonmyeloablative stem cell transplant for chronic lymphocytic leukaemia. Bone Marrow Transplant 36, 1019–1020 (2005). https://doi.org/10.1038/sj.bmt.1705177

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