Monitoring congenital toxoplasmosis - ESCMID
Transcript of Monitoring congenital toxoplasmosis - ESCMID
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Monitoring congenital toxoplasmosis
F. PeyronHôpital de la Croix Rousse
Lyon. FranceBertinoro 4/10/10 1
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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
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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
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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
Very rareBertinoro 4/10/10 14
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Clinical presentation
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16Bertinoro 4/10/10
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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
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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)
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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
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Congenital Toxoplasmosis
A healthy looking baby
-If brain ultrasonography is normal:
No neurologic sequelaeBertinoro 4/10/10 25
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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)
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• 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
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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
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?
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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