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Heurkens, A.H.M.

Koelma, I.A.

Meer, J.W.M. van der

Planque, M.M. de

Polderman, A.M.

NARCIS 

Failure to diagnose fatal disseminated toxoplasmosis in a bone marrow transplant recipient : the possible significance of declining antibody titres.

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Journal o f Infection ( 1989) 18, 283-288
CASE REPORT
Failure to diagnose fatal disseminated toxoplasmosis in a 
bone marrow transplant recipient: the possible significance
of declining antibody titres
A. H. M. Heurkens,* I. A. Koelma,f M. M. de Planque,:j:
A. M. Polderman§ and J. W. M. van der Meer||
* Departments of Rheumatology, f  Pathology, £ Immunohaematology and
Bloodbank, §Parasitology and || Infectious Diseases, University Hospital
Leiden, The Netherlands
Accepted for publication II  October 1988
S u m m ary
A 46-year-old patient with acute myelogenous leukaemia developed lethal dis­
seminated toxoplasmosis 8 weeks after allogeneic bone marrow transplantation. 
Clinical features included pulmonary infiltrates, respiratory insufficiency and 
neurological signs.
Post-transplantation toxoplasma serological tests were characterised by declining 
IgG titres and failure to detect IgM, whereas titres of IgG against the various herpes 
viruses remained constant and even increased over the same period. Circulating 
toxoplasma antigen could not be detected. Post mortem, specific immune complexes 
were identified in serum. Autopsy revealed widely disseminated toxoplasmosis with 
several foci in the brain, lungs and various other organs as well as concomitant 
infection with cytomegalovirus.
Introduction
Patients who undergo allogeneic bone marrow transplantation for acute 
myelogenous leukaemia1 become severely immunocompromised for prolonged 
periods of time and are at risk of opportunistic infections.2
T o  date, up to 20 cases of toxoplasmosis in bone marrow allotransplant 
recipients have been reported.3-11 Because of non-specific symptomatology 
and the equivocal results o f serological tests, the diagnosis was often not 
established until autopsy.
Case report
A  46-year-old man with acute myelogenous leukaemia (M 5A) achieved 
complete remission after treatment with daunorubicin, vincristine and 
cytarabine. After consolidation therapy with the same drugs as well as an 
intensive course of cyclophosphamide and total body irradiation, allogeneic 
bone marrow transplantation (B M T ) was performed. T o  prevent graft-versus- 
host disease (G V H D ) cyclosporin A  was given.
Haemopoiesis recovered within 4 weeks and the patient was discharged 
from hospital on the 27th day after B M T . A t that time, prednisone (120 mg)
0163-4453 / 89/030283  +  06 $0 2 .0 0 /0 © 1989 T h e  British Society for the Study of Infection
284 A. H . M. H E U R K E N S  E T  A L
was prescribed because of grade I G V H D  of the skin and probably the 
intestine. Doses of prednisone and cyclosporin A  were tapered off during the 
next few days. On day 37 after B M T , the patient was readmitted because of 
severe G V H D  of the skin (Grade III, proven by biopsy) and probably of the 
gut (diarrhoea) and liver (rise in the serum concentration of bilirubin). 
Treatment consisted of intravenous methylprednisolone, immunoglobulins, 
plasma, human albumin and total parenteral nutrition.
T h e selective anti-microbial modulation regimen (oral polymyxin B, 
neomycin, nalidixic acid and amphotericin B) was replaced by intravenous co- 
trimoxazole.2 Surveillance cultures did not reveal growth of micro-organisms. 
A  temporary improvement was seen within a few days.
T w o  weeks later, the patient suddenly became dyspnoeic and expectorated 
foamy sputum. On physical examination of the lungs, râles were heard. An 
X-ray of the chest revealed areas of alveolar consolidation in the lower fields 
of both lungs. Within several hours respiratory insufficiency developed and 
the patient became unconscious.
Intubation and artificial respiration with extra oxygen and positive end- 
expiratory pressure resulted in good arterial oxygenation. Nevertheless, coma 
persisted and a right-sided hemiparesis developed with deviation of the eyes 
to the right. T h e  patient suffered generalised seizures, starting in the right 
hand, which could not be controlled. Four successive blood cultures remained 
sterile. Because of the severely prolonged bleeding time, a lumbar puncture 
was not performed. Computed tomographic scanning of the brain (without 
contrast) did not show any abnormalities. T h e  final clinical course was 
characterised by high fever, shock and renal insufficiency. On day 57 after 
B M T , within 3 days of the sudden onset of the above-mentioned signs, the 
patient died.
Pathological findings
A t autopsy, performed within 5 h of death, a mild degree of jaundice was 
observed; the brain (1350 g) contained a small lesion in the parietal region of 
the left cerebral hemisphere. Microscopical studies revealed necrotic foci that 
contained several pseudocysts of Toxoplasma gondii surrounded by single 
tachyzoites (Plate 1). Pseudocysts and single tachyzoites of T. gondii were also 
found in the heart, lungs, adrenals, liver and bone marrow. In the oedematous 
lungs (2500 g) necrotic foci of pneumonia also contained the parasite. In 
addition, cytomegalic cells were identified in the lungs (Plate 2) and the adrenal 
glands. T h e  liver (1850 g) exhibited steatosis, cholestasis and some pericentral 
necrosis but was without evidence of G V H D . G V H D  was demonstrated in the 
skin and the colon. T h e  bone marrow was cellular without evidence of 
leukaemia. Epithelial cells of the renal tubules were vacuolated but histological 
features o f cyclosporin intoxication were absent.
Post-mortem cultures of the lungs, liver and spleen grew enterococci; 
Staphylococcus epidermidis was isolated from the lungs. Probably neither of 
these bacterial species is of clinical significance in view of the sterile blood 
cultures ante-mortem. Viral culture of the lungs yielded cytomegalovirus
(C M V ).
Journal of Infection Plate I
™ ite I. Pseudocysts and single tachyzoites of Toxoplasma gondii in a section of brain. Haematoxylin and
eosin. x 400 .
0
A. H .  M  H e u r k e n s  at al. {Facing p. 284)
Journal of Infection Plate 2
Plate 2 . An alveolar cell, found in the lung, was filled with Toxoplasma gondii. Elsewhere, cytomegalic cells
were seen. Haematoxylin and eosin. x 400 .
Toxoplasmosis in an immunocompromised patient 285
Table I Results of toxoplasma serological tests
r p  • •
1 iming IgG titre* Ig M f
Circulating
antigen:):
4 weeks before 160 Negative Negative
B M T
i week before 160 Negative Negative
B M T
4 weeks after 80 Negative Negative
B M T
7 weeks after 20 Negative Negative
B M T
* An IgG titre ^  80 is considered to be specific in the test-system used, 
f  Tests performed by three methods: E L IS A , antibody capture E L IS A  and Western blot 
technique.
t  Sought by dot-immunobinding technique.
B M T  =  Bone marrow transplant; E L IS A  =  enzyme-linked immunosorbent assay.
Serological findings
An indirect enzyme-linked immunosorbent assay (E L IS A ) for detecting 
toxoplasma-specific Ig G  and I g M 12 as well as an antibody-capture E L I S A  
that included the use of peroxidase-labelled antigen in anti-human-IgM- 
coated trays (also for detecting specific IgM ) were performed.13
In addition, the IgM-specific response to separate T. gondii antigens was 
analysed by the Western blot technique. T h e  presence of IgM  antibodies 
reactive with the 6 kDa antigen was used as the criterion for positivity.14 An 
attempt was made to detect circulating T. gondii antigens by use of a dot- 
immunobinding technique.10
Results of the tests, done on four different serum samples, are summarised 
in Table I. T h e  Ig G  titre o f 160 is compatible with past infection with 
T. gondii. Serological evidence could not be found for reactivation of the old 
infection (declining Ig G  titres, lack of detectable IgM  and detectable 
circulating antigen). Post mortem studies o f two samples of serum (one 
obtained before and one after B M T )  revealed the presence of circulating Ig G  
complexes containing T. gondii antigen (tests kindly performed by D r van 
Knapen, National Institute of Public Health and Environmental Hygiene, 
Bilthoven, the Netherlands).16 Extensive quantitative serological analysis of 
these same samples yielded titres for Ig G  antibodies against C M V  (E L IS A  for 
early antigens) ranging between 1600 and 800. Similarly, immunofluorescence 
tests for Ig G  against varicella-zoster virus and Epstein-Barr virus showed 
constant titres (ranging between 128 and 256 and 256 and 512, respectively). 
Anti-herpes simplex virus (H SV) Ig G  titres had increased significantly (64 to 
256) (Table II).
286 A. H.  M.  H E U R K E N S  E T  A L .
Table II Serum litres of IgG antibodies against Toxoplasma gondii and
herpes-type viruses
Toxoplasma CM V HSV vsv EBV
r p  • •I iming IgG
E L IS A
IgG
IFA
IgM IF A -Ig G IF A -IgG IF A -Ig G
4 weeks before 
B M T
160 1600 Negative 64 128 256
I week before
B M T
160 1600 Negative 64 128 512
4 weeks after
B M T
80 1600 Negative 256 256 512
7 weeks after
B M T
20 800 Negative 256 128 256
E L IS A  =  Enzyme-linked immunosorbent assay; IFA  =  indirect immunofluorescence assay; 
CM V  =  cytomegalovirus ; H SV  =  herpes simplex virus; VZV =  varicella-zoster virus; 
EBV =  Epstein-Barr virus; B M T  =  bone marrow transplant
D iscussion
Bone marrow transplant patients are extremely susceptible to opportunistic 
infections because of their immunocompromised state,2 which is induced by 
chemotherapy, irradiation, immunosuppressive drugs and G V H D .2 l< M ore­
over, cytomegalovirus infection, as in our patient, has been shown to produce 
further immune suppression.18 Our patient developed rapidly fatal dis­
seminated toxoplasmosis with C M V  infection. T h e fatal toxoplasma infection 
arose in spite o f treatment with co-trimoxazole (400 mg sulfamethoxazole and
80 mg trimethoprim, twice daily, intravenously). T h e  efficacy of co- 
trimoxazole in toxoplasmosis has not been established in human beings 
although there is some evidence for activity in animal models.19 T h e  association 
of viral, bacterial or protozoal infections with disseminated toxoplasmosis has 
been described before.6,20-23 As a rule the concomitant infection is a D N A -  
virus (C M V , H S V ).22,23 T h e  diagnosis of toxoplasmosis in severely immuno­
compromised hosts is notoriously difficult because the clinical and radiological 
features are non-specific 4*21-22-20 and serological tests are of little help.4,0 
Because of the relatively high incidence of cerebral toxoplasmosis among 
patients with A I D S ,26 (in a recent study from the University Medical Centre 
in Amsterdam cerebral toxoplasmosis was diagnosed in 12 %  of these patients; 
personal communication P. Portegies) many clinicians nowadays start treat­
ment for toxoplasmosis whenever clinical evidence and the cerebral computed 
tomographic images are compatible with this diagnosis. Such an approach is 
not warranted in B M T  patients because of the rarity of toxoplasmosis among 
these patients.
In our patient, reactivation of an old T. gondii infection, which led to 
extensive proliferation of the parasite in various organs, was accompanied not 
by a rise in antibody titre but by a decreasing titre. In retrospect, this decrease
Toxoplasmosis in an immunocompromised patient 287
in Ig G  titre was selective, since none of the viral titres sought decreased at the 
same time. T h e decreasing titre can probably be explained by the short half- 
life of the specific antibodies during active infection and the fact that the rate 
of production of these antibodies was presumably not yet optimal. Also, the 
antibodies may not have been detectable because they were contained in 
immune complexes, which were in fact detected post mortem. Decreasing 
specific antibody titres have been reported in fatal C M V  infections in B M T  
patients.27
Failure to detect T. gondii antigen, despite massive proliferation of the 
parasite, has also been reported by others. Brooks et a l} h could detect 
circulating antigens in only two of six congenitally infected infants. T h e 
negative results of this test are consistent with several explanations: poor 
sensitivity of the test, containment of antigen within immune complexes or 
intermittent antigenaemia, as have been suggested by Araujo and Remington.28 
In conclusion, there is a great need for reliable diagnostic tests for suspected 
disseminated toxoplasmosis in severely immunocompromised patients. T h e  
antigen detection test includes the use of a polyvalent toxoplasma antiserum. 
Monoclonal antibodies directed specifically against circulating antigen might 
possibly improve both specificity and sensitivity of the test. More experience 
is needed to validate the detection of these antibodies in immune complexes. 
For the time being, our experience suggests that toxoplasmosis should be 
suspected when the specific antibody titres falls while others remain constant.
(The authors would like to thank Dr F. Knapen for critically reading the manuscript 
and Ms J. Ravensbergen and A. A. J. P. Postma for their secretarial assistance.)
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Failure to diagnose fatal disseminated toxoplasmosis in a bone marrow transplant recipient : the possible significance of declining antibody titres.

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