Ericka Viana Machado Carellos

Congenital Toxoplasmosis in Southeastern Brazil: Results of Early Ophthalmologic Examination of a Large Cohort of Neonates

OBJECTIVE To report results of early ophthalmologic examinations in a large cohort of newborns with congenital toxoplasmosis (CT) after neonatal screening. DESIGN Cross-sectional analysis of a cohort. PARTICIPANTS A total of 178 newborns with confirmed CT from 146,307 screened babies (95% of live births) from Minas Gerais state, southeastern Brazil. METHODS From November 2006 to May 2007, newborns underwent neonatal screening by immunoglobulin (Ig)M capture of dried blood samples. On all positive or suspected cases, confirmative serology was performed on babies and their mothers. Congenital toxoplasmosis was confirmed in newborns who had IgM and/or IgA and IgG, or IgG associated with suggestive ocular lesions (with IgM and IgG in the mother). Ophthalmologic evaluation consisted of indirect ophthalmoscopy with a lid speculum. Pediatric examination and radiologic studies of the central nervous system were also performed. In selected cases, biomicroscopy of the anterior segment, fundus photographs, or ultrasonography (B-scan) was performed. MAIN OUTCOME MEASURES Prevalence of retinochoroidal lesions, either cicatricial or active, and their location and associated findings, such as vascular sheathing, hemorrhage, vitreous opacities, and retinal detachment, were evaluated. The occurrence of cataract, microphthalmia, microcephaly, intracranial calcification, and hydrocephalus was also recorded. RESULTS Of 146,307 neonates screened, 190 had CT, yielding a prevalence of 1 in 770 live births, of whom 178 (93.7%) underwent standardized ophthalmologic examination at an average age of 55.6+/-16.6 days. Of these 178 infants, 142 (79.8%) had retinochoroidal lesions consistent with CT in at least 1 eye. Bilateral involvement was noted in 113 patients (63.5%). Macular involvement was seen in 165 eyes (46.3%) of 111 patients (62.4%). Active lesions were observed in 142 eyes (39.9%) of 85 patients (47.8%). These lesions were located in the macula of 75 eyes (21.1%) and were associated with retinal vascular sheathing in 44 eyes (12.4%). CONCLUSIONS A high prevalence of CT was encountered (1/770) with high rates of early retinochoroidal involvement ( approximately 80%) and many active lesions (in approximately 50%), indicating a possibly more severe ocular involvement by CT in Brazil than in other parts of the world. The hypotheses of higher parasite virulence and increased individual susceptibility are being currently investigated.

Avaliação da aplicação do protocolo de triagem pré-natal para toxoplasmose em Belo Horizonte, Minas Gerais, Brasil: estudo transversal em puérperas de duas maternidades

This cross-sectional study of 420 women in two public maternity hospitals from August 2004 to May 2005 evaluated the application of a prenatal toxoplasmosis serological screening protocol in Belo Horizonte, Minas Gerais State, Brazil, and the information provided to susceptible pregnant women. Ninety-eight percent of women received prenatal care and 97% underwent the initial serological screening test, at an average of 16 weeks gestational age. The initial testing identified 163 women as susceptible to toxoplasmosis: 44% of these did not undergo repeat serological testing, and 42% of them did not remember having received information on the prevention of toxoplasmosis infection. Early prenatal care and a high number of prenatal visits were associated with repeat serological testing and orientation regarding its implications. Orientation on risk factors included: avoiding contact with cats (95%), not handling or eating raw meat (70%), and washing vegetables carefully before consumption (53%). Inadequate adherence to the prenatal screening protocol for toxoplasmosis, as detected in this study, may be generating health system costs without a corresponding improvement in the quality of perinatal care.

Congenital toxoplasmosis from a chronically infected woman with reactivation of retinochoroiditis during pregnancy.

OBJECTIVE To report a rare case of congenital toxoplasmosis from an immunocompetent mother with chronic infection who had reactivation of ocular disease during pregnancy. DESCRIPTION The newborn was asymptomatic at birth and identified by neonatal screening (IgM anti-Toxoplasma gondii in dried blood) among other 190 infants with congenital toxoplasmosis during a 7-month period. His mother had had a non-treated episode of reactivation of toxoplasmic retinochoroiditis during pregnancy, with stable IgG titers and negative IgM results. Results of IgM and IgG in the newborns serum, as well as IgG immunoblotting were positive and active retinochoroidal lesions were detected in his peripheral retina. The neonate was treated with sulfadiazine, pyrimethamine and folinic acid. At 14 months of life, the child remained asymptomatic, with regression of retinochoroidal lesions and persistence of IgG. COMMENTS It is possible that systematic neonatal screening in areas with high prevalence of infection may identify these cases.

Adverse socioeconomic conditions and oocyst-related factors are associated with congenital toxoplasmosis in a population-based study in Minas Gerais, Brazil.

Objective Congenital toxoplasmosis is a public health problem in Brazil. This study aimed to determine risk factors associated with congenital toxoplasmosis in Minas Gerais which is the second largest Brazilian State based on number of inhabitants, and its territorial extension is larger than that of France. Methods: Population-based case-control study to assess the association between congenital toxoplasmosis and maternal exposure to infection risk factors. The study included mothers/children participating in the Minas Gerais Newborn Screening Program. The cases consisted of 175 mothers of infected children, and the controls consisted of 278 mothers of children without suspected infection. The associations were assessed through binomial logistic regression with p≤0.05. Results The variables associated with lower probability of toxoplasmosis were: older mother age (OR = 0.89; CI95% = 0.85–0.93), higher level of education (OR = 0.85; CI95% = 0.78–0.92), access to potable water (OR = 0.21; CI95% = 0.08–0.51), and home with flush toilet (OR = 0.18; CI95% = 0.04–078). The variables associated with higher probability of infection were: cats in the neighborhood (OR = 2.27; CI95% = 1.27–4.06), owning or visiting homes with domestic cats (OR = 1.90; CI95% = 1.09–3.31), handling the soil (OR = 2.29; CI95% = 1.32–3.96), and eating fresh meat not previously frozen (OR = 3.97; CI95% = 2.17–7.25). After stratification according region of residence (rural or urban/peri-urban), home with flush toilet and consumption of treated water were protective against the disease only in the rural stratum. Conclusions In Minas Gerais, congenital toxoplasmosis has been associated with poor socioeconomic conditions. Considering maternal exposure to sources of Toxoplasma gondii, the predominating risk factors were those related to the ingestion of oocysts. It is expected that these results will contribute to development of a program for prevention of congenital toxoplasmosis adapted to the reality of the population of Minas Gerais. The differences between populations living in rural and urban areas regarding the main risk factors for toxoplasmosis point to the need of considering regional specificities in planning strategies to control congenital toxoplasmosis.

Association Between IgG Subclasses Against Toxoplasma gondii and Clinical Signs in Newborns With Congenital Toxoplasmosis

Background: The aim of this study was to evaluate the association between clinical signs of congenital toxoplasmosis and IgG subclasses found in newborns participating in the Minas Gerais State Neonatal Screening Program. Methods: Neonates with confirmed congenital toxoplasmosis underwent standardized ophthalmologic evaluation, neuroimaging studies and hearing assessment, as well as enzyme-linked immunosorbent assay testing for total IgG and its subclasses (IgG1, IgG2, IgG3 and IgG4) against soluble (STAg) and recombinant (rSAG1 and rMIC3) antigens of Toxoplasma gondii. Results: Newborns with congenital toxoplasmosis but without ocular lesions were more likely to present anti-rMIC3 total IgG when compared with those newborns with active or cicatricial retinochoroidal lesions. Detection of anti-rMIC3 IgG2 and IgG4 was associated with presence of retinochoroidal lesions and intracranial calcifications, with higher mean reactivity index values than unaffected newborns with congenital toxoplasmosis. Anti-STAg IgG3 was associated with newborns without neurologic damage. Conclusions: Specific subclasses of IgG antibodies reacting with recombinant antigens of T. gondii may serve as biomarkers of neurologic and ocular changes in newborns with congenital toxoplasmosis.

Congenital toxoplasmosis in the state of Minas Gerais, Brazil: a neglected infectious disease?

This study aimed to investigate the distribution of congenital toxoplasmosis in the state of Minas Gerais, Southeastern Brazil and describe the demographic and socioeconomic profile of the municipalities associated with the disease. An ecological study was conducted using socioeconomic indicators of a database (MGSSRI) created by Fundação João Pinheiro (a government technical support agency of Minas Gerais), in order to show the development of the municipalities in the state. The prevalence of toxoplasmosis was the outcome and the items of the MGSSRI were the explanatory variables. Of 146,307 newborns screened (November 2006 to May 2007), 190 had congenital toxoplasmosis, yielding a prevalence of 1·3/1000, ranging from 0 to 76·9/1000 in the municipalities. The multivariate model indicated a higher occurrence of toxoplasmosis in municipalities with smaller populations and worse indexes of tax performance. Congenital toxoplasmosis appears to be a neglected disease in the state of Minas Gerais, given the high prevalence found and its concentration in municipalities with worse socioeconomic indexes.

High Frequency of Bone Marrow Depression During Congenital Toxoplasmosis Therapy in a Cohort of Children Identified by Neonatal Screening in Minas Gerais, Brazil

Background: There are few studies reporting frequency and control of adverse events associated with congenital toxoplasmosis treatment. The objective of this study is to describe treatment adherence and adverse hematologic events in a cohort of children identified with congenital toxoplasmosis in Minas Gerais, Brazil. Methods: Children were treated with sulfadiazine, pyrimethamine and folinic acid and were evaluated clinically and by laboratory tests at regular intervals. Results: Of 146,307 live newborns who participated in the Neonatal Screening Program in Minas Gerais in 2006–2007, 190 had congenital toxoplasmosis. Among the 171 children whose treatment data were available, 73.1% completely adhered to antiparasitic therapy. Hematologic adverse events (macrocytic anemia and/or neutropenia and/or thrombocytopenia) were diagnosed in 44% of them. The most common adverse event was neutropenia (31%). In most cases, it was not severe and reversed after increase in folinic acid dosage (25.7%) or temporary treatment suspension (1.8%). No infections were observed in association with neutropenic events. Significant associations were detected between macrocytic anemia and lower weight Z score at first medical appointment (P = 0.03), and between severe neutropenia (<500/mm3) and lower weight Z score toward the end of treatment (P = 0.04). Conclusions: The high frequency of hematologic adverse events found, especially in malnourished children, highlight the importance of careful monitoring of these children throughout treatment, as well as considering nutritional aspects and the need for higher doses of folinic acid. With adequate monitoring, antiparasitic treatment was feasible and relatively safe in the setting of this large screening program for congenital toxoplasmosis.

The approach to neonatal congenital infections - toxoplasmosis and syphilis

The infections that affect the binomial mother-son during pregnancy are of great concern to obstetricians and pediatricians because of its frequency and difficulty in reaching an etiological diagnosis that is important for early treatment. Most newborns with congenital infection are asymptomatic; this shows the importance of laboratory screening for diseases that are transmitted during the pregnancy-puerperal cycle of women. This review aims to provide recommendations with regard to congenital infection by Treponema pallidum and Toxoplasma gondii. Syphilis is one of the diseases with the highest rates of mother-to-child transmission and is a public health problem still with insufficient control in the country. The diagnosis of maternal infection, performed with VDRL and confirmed with a treponemic test, indicates immediate treatment in pregnant women and their partners. The congenital infecThe approach to neonatal congenital infections – toxoplasmosis and syphilis Roberta Maia de Castro Romanelli1, Ericka Viana Machado Carellos1, Flavia Alves Campos2, Aline Silva de Paula Pinto3, Barbara Araujo Marques4, Leni Marcia Anchieta1, Glaucia Manzan Queiroz de Andrade1 1 Medica Pediatra. Doutora. Professora Adjunta do Departamento de Pediatria da Faculdade de Medicina da Universidade Federal de Minas Gerais – UFMG. Belo Horizonte, MG – Brasil. 2 Medica Pediatra. Mestre em Ciencias da Saude-Saude da Crianca e do Adolescente. Hospital Infantil Joao Paulo II da Fundacao Hospitalar do Estado de Minas Gerais _ FHEMIG, Hospital Mater Dei. Belo Horizonte, MG – Brasil. 3 Medica. Pediatra Infectologista. Ambulatorio do Programa DST/AIDS da SMS da Prefeitura Municipal de Contagem. Contagem, MG – Brasil. 4 Medica. Pediatra Infectologista. Mestranda em Ciencias da Saude-Saude da Crianca e do Adolescente da Faculdade de Medicina da UFMG. Belo Horizonte, MG – Brasil. Abordagem neonatal nas infeccoes congenitas – toxoplasmose e sifilis DOI: 10.5935/2238-3182.20140053

Study of brainstem auditory evoked potentials in early diagnosis of congenital toxoplasmosis

INTRODUCTION Congenital toxoplasmosis is an infectious disease with high prevalence in tropical countries. It is characterized by neurological, ophthalmological and auditory sequelae. OBJECTIVE The aim of this study was to evaluate and describe the brainstem auditory evoked potential in infants aged 1-3 months diagnosed with congenital toxoplasmosis and to compare them with infants of the same age group without the infection. METHODS This is an observational, analytical and cross-sectional study in which brainstem auditory evoked potential was investigated in infants with congenital toxoplasmosis. The following audiological exams were performed: transient-evoked otoacoustic emissions, clinical and automatic brainstem auditory evoked potential. RESULTS 100 children participated in the study, but the final sample consisted of 76 children. Of the 37 children with toxoplasmosis included in the study, 28 completed the neurological imaging evaluation, and of these, 3 (10.7%) showed an altered neurological examination. At the brainstem auditory evoked potential assessment, two children without toxoplasmosis and 10 children with congenital toxoplasmosis had results suggestive of alterations in the brainstem auditory pathway maturation. CONCLUSION 10 (27%) children were identified with a possible unilateral alteration in the electrophysiological assessment. There was a 5-fold higher risk for a child between 1 and 3 months of age with toxoplasmosis to have an altered brainstem auditory evoked potential compared to a child of the same age range without the infection.

Treat or not to treat infant with possible congenital toxoplasmosis? Diagnostic classification system could aid decision

Introduction: Despite of a diagnostic classification system based on serological, parasitological and clinical criteria, there are few studies evaluating if it could aid on treatment decision of infants suspected of congenital toxoplasmosis. Objective: Evaluate a modified diagnostic classification system (Lebech et al) on treatment decision of children suspected of infection, and describe characteristics of the mother/child pair. Methods: Cross-sectional study of 222 children suspected of congenital toxoplasmosis seen between 2008-2011. In current practice, some professionals use the diagnostic classification system to aid decision treatment of children suspected of infection, and others not. The association between the diagnostic classification applied at birth and at three months of age and the confirmation of congenital toxoplasmosis was evaluated. The two groups of professionals were compared regarding the decision of treating toxoplasmosis. The project was approved by the Ethics Committee of UFMG. Results: Congenital toxoplasmosis was confirmed in 44 of 222 children; 84.1% of Treat or not to treat infant with possible congenital toxoplasmosis? Diagnostic classification system could aid decision Flávia Alves Campos1, Gláucia Manzan Queiroz Andrade2, Jacqueline Domingues Tibúrcio3, Talita Pouzas Soares Martins4, Roberta Maia de Castro Romanelli5, Fernanda de Souza Vanni Rocha1, Ericka Viana Machado Carellos6 Tratar ou não crianças com toxoplasmose congênita suspeita? Contribuição de um sistema de classificação diagnóstica para decisão DOI: 10.5935/2238-3182.20170025