Toxoplasmosis and

Leishmaniasis
 Protozoal infections

• amebiasis and infection with free-living amebas

• diseases caused by red blood cell parasites
– malaria
– babesiosis
• leishmaniasis
• tripanosomiasis
– Chaga’s disease
– sleeping sickness
• toxoplasmosis
• protozoal intestinal infections
• trichomoniasis
Leishmaniasis
 Leishmaniasis
• Protozoal, endemic, and vector-borne zoonosis
• Leishmania donovani, L. mexicana, L. tropica.....
• immunology (pathogenesis)
– progresion of disease – Th1 (IFN-g) Th2 (IL-4)
– healing and resistence to infection – expanding numbers of
leishmania-specific Th1 cells
• three forms of illness
– visceral
– cutaneus
– mucosal
Vector – sandflies
 Visceral leishmaniasis
• more than 90 % of the world’s cases occur in
Bangladesh, northeastern India, Nepal, Sudan, and
northeastern Brazil
• L. donovani complex
• transmission
– vector (phlebotomine sandflies)
– vertical (congenitally)
– parenterally (through blood transfusion, ivud)
• pathogenesis
– infection begins in macrophages at the inoculation site
– disemination throughout the mononuclear-phagocyte
system
– specific and nonspecific anergy
 Visceral leishmaniasis

• clinical manifestations
– subclinical or symptomatic
– life-threatening disease
– acute, subacute, or chronic course
– the incubation period ranges from weeks to months, but
can be as long as years
– kala-azar (Hindi) – black fever, the skin of some patients
turns gray
– fever, profound cachexia, impressive splenomegaly,
hepatomegaly (reticuloendothelial cell hyperplasia),
peripheral lymphadenopathy
 Visceral leishmaniasis
• abnormal laboratory findings
– pancytopenia
• bone-marrow infiltration
• hypersplenism
• autoimmune
• bleeding
– hypergammaglobulinemia (polyclonal B cell activation)
– hypoalbuminemia
• big papula on skin at the inoculation site
• post-kala-azar dermal leishmaniasis
• relapse of visceral infection can occur
 Visceral leishmaniasis
• diagnosis
– demonstration of the parasite on stained slides or in cultures of a
tissue aspirate or a biopsy specimen (bone marrow, liver, spleen)
– detection of antibody to leishmania
• differential diagnosis
– other tropical infections that cause fever or organomegaly (typhoid
fever, brucellosis, miliary TB, malaria, schistosomiasis)
– leukemia and lymphoma
• treatment
– pentavalent antimonial compound
– lipid formulations of AmB
– miltefosine, the oral agent
Toxoplasmosis
 Etyology
• Oocyst
– formed exclusively in the intestines of cats
– is expelled into the environment through the cat's feces
– in the environment to form a sporulated oocyst with sporozoites

• Tachyzoite
– feature of acute infection
– it is detected during acute infection, or during reactivation of chronic infection
– can infect any type of cell
– this form is located and reproduce in the host cell vacuoles

• Cyst
– develops inside the host cell cytoplasm
– is situated in the tissues of animals and humans
– contains bradyzoites
Forms of T. gondii in the tissues of
the host
 Epidemiology

transmission and life cycle of T. gondii

cysts
other animals human
insufficient thermal proccesing of meat

cysts oocysts oocysts transfusion

transplantation
laboratory

cats
 Pathogenesis
• the initial site of infection is a gastrointestinal tract
• penetration of bradyzoites (released from tissue
cysts) or sporozoites (released from oocysts) in
intestinal epithelial cells, where it continues the life
cycle of T. gondii and development tachyzoites
• dissemination of tachyzoites via the mesenteric
lymph nodes to distant organs through lymphatic
system and bloodstream
• during acute infection, in the form of tachyzoite, T.
gondii can infect any type of cell
 Toxoplasmosis

• in immunocompetent person

• in immunocompromised person

• ocular infection

• in pregnant women

• congenital toxoplasmosis
 Toxoplasmosis in immunocompetent
person
• acute infection
– usually asymptomatic (80 – 90 %)
– the most common manifestation is cervical
lymphadenopathy (70 – 80 %), or generalized
lymphadenopathy (20 – 30 %)
• headache, malaise, fatigue, and fever (20 – 40 %)
• self-limited
• symptoms resolve within several weeks
• chronic infection (latent infection)
– can persist throughout life, with little
consequence
 Toxoplasmosis in
immunocompromised person
• patients with AIDS and those receiving
immunosuppressive therapy for lymphoproliferative
disorders are at greatest risk
• reactivation of latent infection (95% cases) or
acquisition of parasites from exogenous sources
• principal opportunistic infection of the CNS
• encephalitis develops when the CD4 cell count falls
below 100/ml
• encephalopathy, meningoencephalitis, and mass
lesions (abscesses)
• the differential diagnosis includes herpes
encephalitis, cryptococcal meningitis, PML, and
primary CNS lymphoma.
Cerebral toxoplasmosis in patients
with AIDS
Multiple brain abscesses
 Congenital toxoplasmosis
• there is no risk if the mother becomes infected ≥ 6 months
before conception
• if the mother becomes infected during the first trimester, the
incidence is lowest (15 %), but the disease in the neonate is
very severe
• if maternal infection occurs during the third trimester, the
incidence of transplacental infection is greatest (65 %), but
the infant is ussually asymptomatic at birth
• severe congenital toxoplasmosis – wide rang of clinical
manifestations: hydrocephalus, microcephaly, mental
retardation, chorioretinitis, multiorgan failure and intrauterine
fetal death
• persistence of the parasite in newborns can ultimately result
in reactivation and further damage decades later.
• if treated appropriately, more than 70 % of children have
normal developmental, neurologic, and ophtalmologic
findings
 Congenital toxoplasmosis
Clinical features Differential diagnosis
• chorioretinitis, strabismus, blindness • chorioretinitis – CMV, HSV,
• retardation, epilepsy, encephalitis, rubella, syphilis
microcephaly, calcification of the • encephalitis – CMV, rubella
brain, hydrocephalus • typical for congenital
• anemia, thrombocytopenia toxoplasmosis – intensive
• jaundice, rash, pneumonitis, diarrhea hyperproteinorachia
• spontaneous abortion, premature
birth, stillbirth newborn

T. gondii do not cause genetic malformations

Scar of retinitis during congenital
toxoplasmosis
 Ocular toxoplasmosis
• due to congenital infection (reactivation of
infection acquired during fetal period)
• very low incidence of OT following acute infection
• a variety of manifestations including blurred
vision, scotoma, photophobia, and eye pain
• macular involvement occurs with loss of central
vision, and nystagmus is secondary to poor
fixation
• involvement of the extraocular muscles may lead
to disorders of convergence and to strabismus
Retinitis as a result of reactivation
of chronic T. gondii infection

macula is not affected

Retinitis as a result of reactivation
of chronic T. gondii infection

macula is affected
Retinitis during acute T. gondii
infection

macula is not affected

 Diagnostic procedures
• isolation serological tests
– from blood or other body fluids
confirms diagnosis of acute
toxoplasmosis • the primary method for diagnosis
– inoculation in mice – more sensitive • detection of antibodies to T. gondii
– Isolation on tissue culture - faster • high incidence of false-positive and
• histological diagnosis false-negative results
– detection of tachyzoites confirms • antibodies persist for years and are
acute toxoplasmosis present in large numbers of healthy
– CSF, amniotic fluid, BAL, tissue people, and is therefore difficult to
– fluorescent staining, interpret the results
immunoperoxidase, Wright-Giemsa • there is no test that could confirm
staining independently acute / chronic
• PCR – detection of T. gondii DNA infection
• lymphocyte proliferation test – an • therefore, uses a panel of tests - T.
indicator of chronic infection gondii serologic profile (TSP)
• serological tests
Detection of tachyzoites in CSF
T. gondii tachyzoites in the lung –
immunoperoxidase staining
T. gondii cyst in the myocardium
T. gondii cysts in microglia
 Diagnostic procedures
• isolation serological tests
– from blood or other body fluids
confirms diagnosis of acute
toxoplasmosis • the primary method for diagnosis
– inoculation in mice – more sensitive • detection of antibodies to T. gondii
– Isolation on tissue culture - faster • high incidence of false-positive and
• histological diagnosis false-negative results
– detection of tachyzoites confirms • antibodies persist for years and are
acute toxoplasmosis present in large numbers of healthy
– CSF, amniotic fluid, BAL, tissue people, and is therefore difficult to
– fluorescent staining, interpret the results
immunoperoxidase, Wright-Giemsa • there is no test that can confirm
staining independently acute / chronic
• PCR – detection of T. gondii DNA infection
• lymphocyte proliferation test – an • therefore, uses a panel of tests - T.
indicator of chronic infection gondii serologic profile (TSP)
• serological tests
 Diagnostic procedures (II)

• TSP:
– Sabin-Feldman »dye« test (IgG)
– ELISA IgM, IgA, IgE
– ISAGA-IgE
– AC/HS test (differential agglutination test and
detects IgG antibodies)

• interpretation whether the infection is acute

or chronic is performed based on the results
of TSP
 Diagnostic procedures (III)
• Two crucial moments in diagnosis:
1. determine the existence of T. gondii infection -
detection of IgG antibodies: negative results
exclude the diagnosis of toxoplasmosis

2. determine whether it is acute or reactivation of

chronic infection
• IgM negative - excludes acute infection
• IgM positive – we should perform confirmatory tests for
acute infection (TSP)
 Interpretation of serological tests in
pregnancy (I)
no possible indeterm. chronical chronical (false likely
infect. acute inf. positive acute) acute

IgG - - - ± ± ± + + +
IgM - ± + + - ± - ± +

prevention need nothing

repeat the tests in three weeks

no acute TSP
Interpretation of serological tests in
pregnancy (II)
positive TSP

acute toxoplasmosis
•treat pregnant women with spiramycin
•PCR T. gondii DNA in amniotic fluid in 18. weeks of gestation
negative – testing of newborn
positive – abortion or treatment
•postnatal diagnosis
detection IgA in blood of the newborn
PCR T. gondii DNA from CSF, blood, urine of newborn
ophtalmological examination and CT endocranium of the newborn
 Treatment (I)
• currently available anti- In immunocompetent
toxoplasmosis drugs are person
effective against tachyzoite;
do not remove cystic forms
(bradizoites) – no treatment unless they
are visible signs of visceral
• dual therapy; monotherapy form of the disease
is not effective
– the treatment lasts 2 - 4
• dose in weeks
immunocompromised
patients are usually higher – lymphadenopathy should
than those in not be treated
immunocompetent
patients, and treatment last
longer
 Treatment (II)
In immunocompromised Ocular toxoplasmosis
person
• treatment of toxoplasmosis in AIDS • indications for treatment:
patients helped in the creation of – impaired vision
the doctrine of treatment other – macular or peripapilar lesions
immunodeficient patients
• chronic, asymptomatic infection – inflammation of the vitreous
should not be treated – the presence of multiple active
• there are the most experience in lesions
the treatment of TE – acute infection
• treatment consists of: • the disease can be “self-limited”
– induction treatment* • sometimes vitrectomy is necessary
– primary and secondary**
prophylaxis
*pyrimethamine 100 mg/1.day, then 25 – 50 mg/day + sulfadiazine 1 g/6 h + folinic acid
15mg per day, 4 – 6 weeks
**TMP-SMX 1 tablet per day or 1DS tablet 3 times per week
 Treatment (III)
Acute infection of Congenital
pregnant women toxoplasmosis
• reduces the risk of fetal infection • Sulfadiazine + Pyrimethamine –
• spiramycin 3g/day (does not pass 12 months
the placental barrier) • spiramycin
• if there is evidence of fetal • examinations
infection:
– sulfadiazine 4 g/day, – CSF
pyrimethamine 25 mg/day, – neuroimaging (CT, MRI)
folinic acid 15 mg/day – fundus examination
– abortion
• pyrimethamine is teratogenic
(not recommended its use in the
first trimester of pregnancy)
• chronic (latent) infection should
not be treated
 Students!!!!
• That's all
• Thank you for your attention

•You were great, and I

was not so bad.