A Case Study on Congenital Toxoplasmosis
In Partial Fulfillment of the Course Requirement in
Medical Technology Enhancement Program (MEP 401)
Submitted to:
[Name of CEP Instructor]
Submitted by:
SHIENETTE GRACE CAMINADE
KOBI CARL MANGOPOT
KRIZA MAE NANTIN
OCTOBER, 2021
CHAPTER 1
INTRODUCTION
Toxoplasmosis is a disease resulting from infection with the parasite Toxoplasma gondii (T.
gondii) a protozoan parasite that infects warm blooded animals, including humans. There are
three major clinical manifestations of the disease, Ocular toxoplasmosis in immunocompetent
individuals is one of the most frequently identified etiologies of uveitis, Toxoplasmic encephalitis
in immunocompromised patients as observed in patients with hematologic malignancies, organ
transplant recipients and lastly Congenital toxoplasmosis which is the main focus of this case
study, due to the fact that the patient is pregnant and infected with toxoplasmosis, the
congenital manifestation such as stated, results from the acquisition of infection during
pregnancy and vertical transmission that may lead to a variety of complications, T. gondii
infection during pregnancy can have devastating consequences in the fetus ranging from
stillbirth which is the worst scenario that could occur if a pregnant woman is infected with
toxoplasmosis, hydrocephalus, and ocular damage that could lead to blindness of the child
when born. Some of the infected newborns present with minor symptoms of the infection only,
but are still at risk of developing ocular lesion at any time due to the infection vertically
transmitted from their mother.
Congenital toxoplasmosis is a neglected infection, due to the fact that the mother is often
asymptomatic with the infection of toxoplasmosis, the infection being asymptomatic for the
pregnant mother is very alarming, countless amounts of vertical transmissions from mother to
fetus has occurred, due to the unnoticed infection of toxoplasmosis, this issue must be studied
well in order to come up with a better way in early detection of the infection to be able to avoid
complications during pregnancy, although the symptoms may not be that severe for a pregnant
mother that acquired the infection. As infected pregnant women are usually asymptomatic, the
diagnosis relies only on serological tests. Maternal infection by Toxoplasma gondii during
pregnancy may have serious consequences for the fetus, ranging from miscarriage, central
nervous system involvement, retinochoroiditis.
CHAPTER 2
PATIENT DATA
A 28 year old woman named Krizza Batumbakal is 6 months pregnant with her 2nd baby,
and she states that she is generally feeling unwell, has a headache, fever and swollen lymph
nodes, she also states that she has been experiencing unusual muscle aches in her legs and
arms.
MEDICAL HISTORY
Mrs. Batumbakal did not feel those symptoms way back her 1st pregnancy aside from
the muscle aches that she experiences in her legs caused by the abrupt increase in weight due
to pregnancy, she also stated that she has not been diagnosed with any disease before that
could lead to the acquisition of the symptoms she stated, due to this unusual phenomenon she
underwent a checkup to be able to assess the situation especially due to the fact that she is
pregnant, this is a good measure in order to keep both her and the baby safe from
complications during pregnancy.
LABORATORY TESTS/RESULTS
The following tests were done to the patient in order to assess the situation, a CBC was
first done to check for the overall condition of the patient, and assess the cause of the
symptoms that arose during her pregnancy. An ultrasound and fetal monitoring test was done to
assess the condition of the baby inside the womb of the patient, a serologic test was done in
order to assess the presence of a parasitic infection that correlates to the symptoms, the patient
has a result of IgG antibody greater than 8.79 IU/mL which is considered positive for infection.
Due to the detection of an existing infection which is suspected to be toxoplasmosis and also
based on the symptoms of the patient, the physician requested the collection of CSF from the
patient to confirm the type of infection. After the collection, it is then stained using
immunofluorescence staining technique and viewed under the microscope, which confirmed the
presence of Toxoplasma gondii infection.
A Toxoplasma-positive reaction, stained by
immunofluorescence
CHAPTER 3
DEFINITION OF THE CASE
ANATOMY & PHYSIOLOGY
Muscle is one of the organ affected in this case study. Muscles of the human body that
operate with the skeletal system, are controlled by the mind, and are involved with movement,
posture, and balance. Striated muscle (or skeletal muscle), smooth muscle, and cardiac muscle
are the three types of muscle. Smooth muscle is present in the walls of blood arteries, as well
as organs like the urine bladder, intestines, and stomach, and is controlled in an involuntary
manner. Cardiac muscle makes up the heart's bulk and is responsible for the essential pumping
organ's regular contractions; it too is under involuntary control. Lymph nodes are located at the
intersection of major blood vessels in the neck, axilla, thorax, abdomen, and groin. An adult has
about 800 lymph nodes. In the body, lymph nodes are tiny structures that act as filters for
foreign substances such as cancer cells and infection. The lymph nodes contain immune cells
that may aid in the battle against infection by fighting and eliminating bacteria that have been
brought in via the lymphatic system.
PATHOPHYSIOLOGY
Congenital toxoplasmosis is generally asymptomatic. Toxoplasmosis is more common in
immunocompromised people with abnormalities in T-cell–mediated immunity, such as those
with hematologic malignancies, bone marrow and solid organ transplants, or acquired
immunodeficiency syndrome (AIDS). T gondii infection, whether primary or chronic (latent), is
usually asymptomatic in immunocompetent people. A tiny proportion of these individuals
develop retinochoroiditis, lymphadenitis, or, in rare cases, myocarditis and polymyositis. At
birth, infected newborns exhibit anemia, thrombocytopenia, and jaundice. Mental retardation,
convulsions, visual abnormalities, spasticity, hearing loss, and other serious neurologic
sequelae may occur in affected survivors.
CHAPTER 4
LABORATORY RESULTS
TEST
RESULT
NORMAL
INTERPRETATION
RATIONALE
VALUE
CBC
1. WBC count
1.
2. Hemoglobin
3. Hematocrit
4. Platelet
Count
2.
13 × 10^9
1. 5.8-13.2x
/L
10^9/L
5 g/L
3.
30.5
4.
95 × 10^9
/L
2. 11.3-
1. NORMAL
2. DECREASED
often
indicates
that
the
patient's body is fighting itself
3. DECREASED
14.8g/dL
4. DECREASED
3. 34.7-44.5
- A high white blood cell count
against
an
infection
disease
and
is
or
stressed.
However, it is typical to have
4. 150-450
a high white blood cell count
10^9/μL
during pregnancy. After all,
the patient's body is already
going
through
significant
stress
as
result
a
of
pregnancy. A high white blood
cell count on its own is no
cause
for
alarm.
Headache,
Fever,
swollen
lymphnodes are due to the
high level of white blood cells.
-
It
is
typical
for
the
hematocrit and hemoglobin
concentrations to decrease
during the first trimester of
pregnancy, since the plasma
volume grows faster than the
red cell mass. The patient's
iron intake should be twice
that of nonpregnant women.
Her body need this iron to
produce more blood in order
to provide oxygen to her
baby.
- At the beginning of the first
trimester, the platelet count of
all
women
decreases
throughout pregnancy. Also,
protozoal infections like T.
gondii
thrombocytopenia,
cause
or
low
platelet count.
Ultrasound and
A thorough ultrasound
Fetal
examination should be done
Monitoring Test
to rule out conditions
including hydrocephaly,
microcephaly, and intracranial
calcifications.When instances
of acute infection in
pregnancy are discovered, it
is important to act quickly.
Treatments may be carried
out to decrease the chance of
fetal complications. When
there are changes in the
ultrasound examination, the
procedure is followed by an
assessment of the patient.
Treatment with amniotic fluid
is indicated.
Serologic Test
ELISA
IgG antibody
0-3 IU/ml
INCREASED
A positive IgG test indicates
greater than
that the mother has been
8.79 IU/mL
infected in the past or is
currently infected. As shown
in the table, it has an
increased IgG antibody which
is higher than the normal
value. IgG testing must be
repeated every 4 to 6 weeks
until the antibody completely
disappears. Indirect
serological techniques, such
as IgG and IgM antibody
detection, are often employed
in immunocompromised
patients and pregnant
women. The body produces
IgG antibodies many weeks
after infection and provides
long-term protection.
Immunoglobulin G levels
increase during active
infection and subsequently
stabilize when the
Toxoplasma infection ends
and the parasite goes
dormant. After being exposed
to T. gondii, a person will
have some measurable
amount of IgG antibody in
their blood for the rest of their
life and will be immune
(protected) from re-infection.
CSF
POSITIVE
a cerebrospinal fluid (CSF)
FOR
sample is collected from the
TOXOPLASM
lower back from a pregnant
OSIS
woman using amniocentesis.
INFECTION
CSF will be stained using an
immunofluorescence staining
technique to confirm what
type of infection it is.
CHAPTER 5
SUMMARY
A 28-year-old pregnant patient was found to have been infected with Toxoplasma gondii in
her 6th month of pregnancy after the many laboratory tests that were done on her. The patient
has presented symptoms such as muscle aches, headache, swelling of lymph nodes, and
fever. The said parasite can be transmitted through fecal-oral route and any close-contact with
cats and consumption of improperly prepared food can be two of the most possible reasons
why a person can get infected with it. Moreover, the patient's health status was then assessed
through the laboratory tests that were requested to perform on her. The diagnosis was
confirmed through CSF testing in which a CSF sample was collected from the patient to
determine the presence of the suspected parasite through immunofluorescence staining, , that
eventually resulted to be positive for toxoplasmosis after the microscopic examination was
done.
CONCLUSION
According to the information and results that were tackled above, the pregnant female
patient had an ultrasound and fetal monitoring test and also underwent into many other tests
including CBC, wherein her hemoglobin, hematocrit, and platelet count were decreased but her
WBC count remained normal. The patient’s results in her serological test was found to have an
increase in IgG antibody which gave a hint onto what type of infection is affecting the patient,
and it was further confirmed that the infection was toxoplasmosis by staining a CSF sample
collected from the patient, wherein Toxoplasma gondii was found under the microscope. In
addition to that, the patient have also shown the same signs and symptoms of people with
toxoplasmosis. In conclusion, Mrs. Krizza Batumbakal has a toxoplasmosis and it can be
transmitted vertically which will eventually affect the health condition of the fetus.
RECOMMENDATIONS
The patient in this study is confirmed to be infected with Toxoplasma gondii and to prevent
it from spreading in the patient’s placenta, it is recommended that she must take spiramycin, an
antiparasitic drug used to treat toxoplasmosis. It is also advisable that she must undergo into an
amniocentesis to determine if her fetus is infected with the said parasite or not. If the vertical
infection is confirmed, both the patient and her baby’s health should be monitored and must be
treated with pyrimethamine, sulfadiazine, and folinic acid. Additionally, if the patient gets treated
with toxoplasmosis, in order to prevent reinfection from happening again, the patient must not
drink any untreated water and must always wear gloves whenever she is gardening and if she
ever gets pregnant again, it is advisable to avoid changing cat litter or adopt any stray cats.
With these being said, the chances of being infected by Toxoplasma gondii again, or any other
parasites that can be transmitted through eating will be reduced.
CHAPTER 6
BIBLIOGRAPHY
REFERENCES
McAuley J. B. 2014. Congenital Toxoplasmosis. Journal of the Pediatric Infectious Diseases
Society, 3 Suppl 1 (Suppl 1), S30–S35. https://doi.org/10.1093/jpids/piu077
Dubey, J. P., Miller, N. L., and Frenkel, J. K. 1970. The Toxoplasma gondii oocyst from cat
feces. The Journal of experimental medicine , 132 (4), 636–662.
https://doi.org/10.1084/jem.132.4.636
Montoya J. G. 2018. Systematic screening and treatment of toxoplasmosis during pregnancy: is
the glass half full or half empty?. American journal of obstetrics and gynecology, 219 (4),
315–319.https://doi.org/10.1016/j.ajog.2018.08.001
Dunn, D., Wallon, M., Peyron, F., Petersen, E., Peckham, C., and Gilbert, R. 1999. Mother-tochild transmission of toxoplasmosis: risk estimates for clinical counselling. Lancet (London,
England), 353 (9167), 1829–1833.https://doi.org/10.1016/S0140-6736(98)08220-8
Daffos, F., Forestier, F., Capella-Pavlovsky, M., Thulliez, P., Aufrant, C., Valenti, D., and Cox,
W.L. 1988. Prenatal management of 746 pregnancies at risk for congenital toxoplasmosis.
The New England Journal of Medicine, 318(5), 271–275.
https://doi.org/10.1056/NEJM198802043180502
Gay-Andrieu, F., Marty, P., Pialat, J., Sournies, G., Drier de Laforte, T. and Peyron, F. 2003.
Fetal toxoplasmosis and negative amniocentesis: necessity of an ultrasound follow-up.
Prenatal diagnosis, 23 (7), 558–560. https://doi.org/10.1002/pd.632
Olariu, T. R., Blackburn, B. G., Press, C., Talucod, J., Remington, J. S. and Montoya, J. G.
2019. Role of Toxoplasma IgA as Part of a Reference Panel for the Diagnosis of Acute
Toxoplasmosis during Pregnancy. Journal of clinical microbiology, 57(2), e01357-18.
https://doi.org/10.1128/JCM.01357-18
Rahbari, A. H., Keshavarz, H., Shojaee, S., Mohebali, M. and Rezaeian, M. 2012. IgG avidity
ELISA test for diagnosis of acute toxoplasmosis in humans. The Korean journal of
parasitology, 50(2), 99–102. https://doi.org/10.3347/kjp.2012.50.2.99
Kodym, P., Machala, L., Roh´acov´a, H., Sirock´a, B. and Mal´y, M. 2007. Evaluation of a
commercial IgE ELISA in comparison with IgA and IgM ELISAs, IgG avidity assay and
complement fixation for the diagnosis of acute toxoplasmosis. Clinical microbiology and
infection : the official publication of the European Society of Clinical Microbiology and
Infectious Diseases , 13 (1), 40–47. https://doi.org/10.1111/j.1469- 0691.2006.01564.x
Olariu, T. R., Blackburn, B. G., Press, C., Talucod, J., Remington, J. S. and Montoya, J. G.
2019. Role of Toxoplasma IgA as Part of a Reference Panel for the Diagnosis of Acute
Toxoplasmosis during Pregnancy. Journal of clinical microbiology, 57(2), e01357-18.
https://doi.org/10.1128/JCM.01357-18