Monitoring congenital toxoplasmosis - ESCMID
Transcript of Monitoring congenital toxoplasmosis - ESCMID
Monitoring congenital toxoplasmosis
F. PeyronHôpital de la Croix Rousse
Lyon. FranceBertinoro 4/10/10 1
Infant from mother who seroconverted during pregnancy
2 situations
• -Ante and /or perinatal work up negative
• -Ante and /or perinatal work up positive
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Situation I
Ante and /or perinatal work up negative
>70 % of the cases
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Congenital toxoplasmosis
Severe malformations
Sub clinical forms ;Late onset of ocular
lesions
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At BirthA healthy looking baby born from
mother who seroconverted
Ante natal negative work-up
and
Perinital negative work-up
Do not rule out a congenital infection
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Healthy baby with negative work-up
• We can not rule out a congenital infection on the basis of a negative work-up.– sensitivity of perinatal test : 75%– Late maternal infection
How to know?
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How to know?
• One year of serological follow up
• Without treatment
Mandatory !Bertinoro 4/10/10 7
How to rule out a congenital infection?
1 year follow- up
Maternal IgGIn utero
IgG at birth Decreasing titers NegativationAt 1 year
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One year of serological follow-up
• Rhythm of sampling:
– Every month, 2 or 3 months ?
– Don’t harass the baby (and the mother)
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Do not stop folow-up before a negative serology
• Post natal serological troughNon infected infant
Maternal antibodies
Infected infant
1 year
Infected infant
BirthBertinoro 4/10/10 10
If serology is still positive at 1 year
• Congenital toxoplasmosis
• Benefit of starting treatment ?
• Funduscopy CT scan if no ultrasound at birth
• Follow up
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Situation II
Ante and /or perinatal work up positive
<30 % of the cases
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Congenital Toxoplasmosis
Clinical presentation at birth
Asymptomatic in majority of cases
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The classic triad
• Hydrocephalus
• Intracerebral calcifications
• Retinochoroiditis
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Clinical presentation
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Fœtal infectionIgM /IgAAt birth
Persisting IgG
Is he infected?Yes
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II. Congenital toxoplasmosis
-Treatment
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Treatment : 12 months
• Pyrimethamine1 mg / kg once daily months Sulfadiazine50 mg / kg / day twice dailyFolinic acid 50 mg every 7 days
• After 2 months :• Pyrimethamine1.25 mg / kg every 10 days
Sulphadoxine 25 mg / kg every 10 days Folinic acid 50 mg every 7 days
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Post natal treatment :Reduction of sequellae
•Pyrimethamine+ sulfonamidesGiven 1 year to infected newborns
•Rational : unclear (long lasting parasitemia ?)
•No activity against cysts
1 year
? ?
Non consensus
Treatment efficacy
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• On the outcome– No RCT– Available studies biased :
• Recruitment• Ante natal treatment effect• Age of pregnancy at maternal contamination• Length of follow-up
– Toscane study (year treatment versus 3 months)
II. Congenital toxoplasmosis
-Follow upAnd outcome
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Evolution of serologyMind the traps!
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treatment
Chorioretinitis
negativation
rebound
An
tibo
dies
Congenital Toxoplasmosis
A healthy looking baby
-If brain ultrasonography is normal:
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Congenital Toxoplasmosis
A healthy looking baby
will he develop ocular lesions?
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Risk factors for retinochorioditisduring the first 2 years
• Delay of >8 weeks between maternal seroconversion and treatment onset
• Female gender
• Cerebral calcifications
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Lyon cohort
• Early diagnosis and treatment
• Ophtalmogical follow-up:• every 3 months for the first 2 years• yearly thereafter
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Lyon cohort2060 live born children
72 %not infected(negative serology)
22%
Infected7%
symptomatic
6 % lost to follow-
up
Mother to child transmission
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Outcome of congenital toxoplasmosis
• Ocular lesion (s) in 79 children (24 %)
• (Majority of them inactive when diagnosed)
• No bilateral visual impairment
Among 327 infected childrenMedian follow up 6 years (6 months-14 years)
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Age at diagnosis of first retinal lesion
long term followlong term follow--up of 327 congenitally infected up of 327 congenitally infected childrenchildren
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5 10210 age in year
50 %
58 % 76 %76 %95%95%
Importance of long term follow upImportance of long term follow up
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Same cohort 6 years later
Findings at last ophthalmic examination
• 27 new ocular lesions19 peripheral
(maximum age of occurrence = 17 years)
• 4 new ocular events
• No bilateral visual impairment
median follow up = 11 years ( + 6 years)
• 71 % (232/327) of children: no lesions
• 18 % (60/327): retinochoroiditis only
• 11 %: neurological sign ± retinochoroiditis
• cranial calcifications: 31 children
• hydrocephalus: 6
• microcephalus: 1
Other manifestations of congenital toxoplasmosis
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Reactivation of ocular toxoplasmosisduring pregnancy
• 18 women with ocular lesions (35 pregnancies)
• 7 recurences during pregnancy
• No congenital infections
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102 patients (different cohort)
• Enrolled at the beginning of the French program
• 42 ocular lesions (41.2%, biased)– 10 diagnosed between 10- 19
years– 12.7% reduced visual acuity – 11.8% at least one recurrence
• 11 intracranial calcifications
• Majority cope well
Follow-up >18 years
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102 adults with congenital toxoplasmosis
• Age range : 18- 33 years
• Psychological General Well-Being Index (PGWBI)
• Visual functioning (VF14) questionnaire
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Study cohort(n = 102)
General population (age-matched)
Mean Standard deviation Mean Standard deviation
Anxiety 71.2 19.3 72.2 19.6
Positive well-being
64.7 17.0 64.0 18.7
Vitality 64.7 15.2 68.0 18.5
Depressed mood
85.9 17.9 83.5 17.1
Self-control 80.7 16.0 82.5 17.2
General health
84.7 16.1 78.4 18.4
Global score 74.7 14.2 73.7 15.3
Quality of life
74.7 73.7
Quality of life in 102 adults with congenital toxoplasmosis
• VF14 (visual functional impairment)
• Score range 0-100
• Results : 97.3
• Localization of ocular lesion does not predict visual performance
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Conclusion
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In our settingParents and adolescents are told
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that Congenital toxoplasmosis
• Is a chronic ophthalmologic disease
• which has an overall good prognosis
• But lasts all the life
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• Well designed clinical trials (ante and post natal treatments)– 2 French studies
• Ante natal treatment • Post natal 3 months/12 months
What we urgently need
?
The biggest danger for the fetus is not T.gondii but mother’s anxiety
What ever you decide
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-Educational programme
- Reference laboratory
- Well trained clinicians
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