Clinical Vignette 43
A young woman who was 33 weeks pregnant presented with 2 weeks of low-grade fever associated with an enlarged right cervical lymph node. Fine needle aspiration of the lymph node had been performed by an ENT surgeon, showing an epithelioid granuloma and reactive follicular hyperplasia. TB PCR was negative. Serological testing results are shown below:
- EBV VCA IgA – negative
- CMV IgM – negative
- CMV IgG – positive
- Toxoplasma IgM – positive
- Toxoplasma IgG – negative
Question: How should this young woman be managed?
[Updated 22 August 2015]
A model answer was provided by Dr. Mahbubur Rahman in the comments to this vignette. In essence, the young mother-to-be has acute toxoplasmosis, and the key is to determine whether there has been foetal transmission. This is usually done via amniocentesis (only at 18 weeks or more of gestation) and PCR of the amniotic fluid for Toxoplasma gondii. An ultrasound examination of the foetus should also be carried out. Spiramycin should be offered if the amniotic fluid PCR is negative (i.e. foetus has not been infected), but a combination of pyrimethamine and sulfadizine with folinic acid rescue should be offered if foetal infection is confirmed. Spiramycin does not cross the maternal-foetal blood barrier. The Canadian guidelines can be found here.
A case of Toxoplasmosis. When the diagnosis of acute infection is made during pregnancy, it is important to determine whether fetal infection has occurred by chorionic villus sampling, amniocentesis and by PCR. Ultrasound findings of hydrocephaly, intracranial calcifications, or hydrops may provide indirect evidence of congenital Toxoplasma infection. When the diagnosis of acute Toxoplasma infection is established during 33 week of pregnancy and ideally confirmed in the fetus, the management option is to treat the mother in an effort to reduce the fetal effects. There is evidence from European trials that the severity of congenital infection can be reduced by such an approach. The regimen available in the United States includes sulfadiazine, 1 g orally four times a day, and pyrimethamine, 25 mg orally four times a day, both for 28 days. Sever et al.; suggested that folinic acid, 6 mg intramuscularly (IM) or orally three times a week, be given to lessen the hematologic effects of the pyrimethamine, a folic acid antagonist. Spiramycin has been used effectively in Europe.
A model answer :-).
This is Mahbubur Rahman from icddr,b Dhaka, Bangladesh. I met you in Cox’s Bazar in Antibiotic Resistance Workshop in 2010. I hope you are doing well.
Regards and best wishes,
Mahbubur Rahman M.D, PhD, FRCP (Edin) Post-Docs (Commonwealth, London University College Hospital and Humboldt Fellowship, Germany)
ID Physician and Clinical Microbiologist and Molecular Biologist