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.