This is the first report of congenital toxoplasmosis in dizygotic twins in Brazil. We emphasize the need for early diagnosis of the mother and follow-up of children with suspected or confirmed infection from birth to adolescence, in order to avoid the hazard and damage from congenital toxoplasmosis.Este é o primeiro relato de caso de toxoplasmose congênita em gêmeos dizigóticos no Brasil. Os autores enfatizam a necessidade de diagnóstico precoce das gestantes e do acompanhamento de crianças do nascimento à adolescência, a fim de evitar riscos e danos decorrentes da infecção congênita

Araújo, Silvana Marques de

Falavigna, Dina Lúcia Morais

Falavigna, Luis Felipe Morais

Falavigna-Guilherme, Ana Lúcia

Nakazora, Deise

Pelloso, Marcela Castilho

Roncada, Eduardo Vinicius

Revista do Instituto de Medicina Tropical de São Paulo

English

Este é o primeiro relato de caso de toxoplasmose congênita em gêmeos dizigóticos no Brasil. Os autores enfatizam a necessidade de diagnóstico precoce das gestantes e do acompanhamento de crianças do nascimento à adolescência, a fim de evitar riscos e danos decorrentes da infecção congênita.This is the first report of congenital toxoplasmosis in dizygotic twins in Brazil. We emphasize the need for early diagnosis of the mother and follow-up of children with suspected or confirmed infection from birth to adolescence, in order to avoid the hazard and damage from congenital toxoplasmosis

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Rev. Inst. Med. trop. S. Paulo49(2):117-118, March-April, 2007(1) Programa de Pós-graduação em Análises Clínicas, Universidade Estadual de Maringá, PR, Brasil.(2) Departamento de Medicina, Universidade Estadual de Maringá, PR, Brasil.(3) 15ª Regional de Saúde do Estado do Paraná, PR, Brasil.(4) Hospital de Clínicas, Universidade Federal do Paraná, PR, Brasil.(5) Programa de Pós-graduação em Ciências da Saúde, Universidade Estadual de Maringá, PR, Brasil.Correspondence to: Dra. Dina Lúcia Morais Falavigna, Laboratório de Parasitologia, Departamento de Análises Clínicas, Av. Colombo 5790, Bloco I-90, sala 11, 87020-900 Maringá, PR,Brasil. Tel: +55-44-3261-4877; fax: +55-44-3261-4860. E-mail: dlmfalavigna@uem.brCASE REPORTCONGENITAL TOXOPLASMOSIS IN DIZYGOTIC TWINS, PARANÁ, BRAZILDina Lúcia Morais FALAVIGNA(1), Eduardo Vinicius RONCADA(2), Deise NAKAZORA(2), Marcela Castilho PELLOSO(3), Luis Felipe Morais FALAVIGNA(4),Silvana Marques de ARAÚJO(1) & Ana Lúcia FALAVIGNA-GUILHERME(5)SUMMARY This is the first report of congenital toxoplasmosis in dizygotic twins in Brazil. We emphasize the need for early diagnosis ofthe mother and follow-up of children with suspected or confirmed infection from birth to adolescence, in order to avoid the hazardand damage from congenital toxoplasmosis.KEYWORDS: Congenital toxoplasmosis; Twins; Paraná; Brazil.INTRODUCTIONIn twin pregnancy, the clinical course of congenital toxoplasmosisis concordant for monozygotic twins and is generally discordantbetween dizygotic ones, where one twin is symptomatic and the otherhas a subclinical infection5. The severe clinical pattern, with delayedneuropsychomotor development, microcephaly, retinochoroiditis andcerebral calcifications, can occur in less than 10% of patients withcongenital toxoplasmosis6. The electronic databanks PubMed, Scieloand Lilacs revealed only 23 references from 1950 to the present dateabout congenital toxoplasmosis in twins, mainly in Europe. This casereport describes, for the first time in Brazil, a case of congenitaltoxoplasmosis in dizygotic twins, emphasizing the necessity forsystematic assessment of congenital toxoplasmosis in newborns.CASE REPORTA 20-year-old woman, pregnant for the first time, initiated prenatalcare at the Health Public Service in Flórida, a municipality located inthe northeastern part of the State of Paraná, at six weeks’ gestation. At12 weeks of pregnancy the following routine prenatal diagnostic testswere performed: VDRL (nonreactive), HIV (nonreactive),toxoplasmosis (nonreactive: IgM index 0.109 and IgG 0.1 IU/mL),partial urine and hemogram with normal results. At 23 weeks ofpregnancy, an ultrasonograph revealed a topic, dichorionic anddiamniotic twin pregnancy. In all, seven prenatal consultations weredone, without incident. At 31 weeks of pregnancy the patient developedsymptoms of premature amniorrhexis, and was sent to the MaringáRegional University Hospital (MRUH), in full labor.At birth, the first twin, JV, had an Apgar score of 9/10/10, weight1935 g, height 44 cm, head circumference 31 cm, thoracic perimeter28 cm, good general state, good suction and normal reflexes. The secondtwin, JH, was born normally, with an Apgar score of 9/10/10, weight2200 g, height 42.5 cm, head circumference 31 cm and thoracicperimeter 30 cm. However, during follow up he was wailing, in a poorgeneral state, hypoactive, icteric, with poor suction, a depressed fontaneland lack of the Moro reflex. Both newborns remained in an incubatorin the neonatal ICU of the MRUH until the 7th day of life, when theywere discharged.During the neonatal period, the mother observed that JH alwaysappeared more lethargic than JV, and that at 20 days his eyelid did notopen correctly. When consulted, the ophthalmologist requestedserologic tests for toxoplasmosis (anti-Toxoplasma gondii ELISA-MEIA), after examining the retina. The results, available two monthsafter the request, presented IgM index of 4.590 and IgG > 300 IU/mLand confirmed the diagnosis of congenital toxoplasmosis. On beingreferred to the MRUH Infectious Diseases Service, JH showed lethargy,sudoresis while nursing, palpebral ptosis and delayedneuropsychomotor development. Subsequently serologic tests (anti-T.gondii ELISA-MEIA) were requested for the mother and her twins;the mother was reactive for IgG (> 300 IU/mL) and the children reactivefor IgM (indices above 0.720). Both children received antimicrobialtreatment with sulfadiazine, pyrimethamine and leucovorin from fiveto 15 months. A fundoscopy of JH’s right eye revealed a whitish macularlesion typical of retinochoroiditis; the left eye showed no changes.The retinochoroiditis lesions had not enlarged by the end of thetreatment. JH also had microcephaly and, in the computerized118FALAVIGNA, D.L.M.; RONCADA, E.V.; NAKAZORA, D.; PELLOSO, M.C.; FALAVIGNA, L.F.M.; ARAÚJO, S.M. & FALAVIGNA-GUILHERME, A.L. - Congenital toxoplasmosis indizygotic twins, Paraná, Brazil. Rev. Inst. Med. trop. S. Paulo, 49(2): 117-118, 2007.tomography of the cranium, the presence of cerebral calcificationsconfirmed the diagnosis of Sabin’s Tetrad.JV showed appropriate neuropsychomotor development for his age,and was attentive to verbal stimuli, active, with good muscle tone andreflexes. Although he showed no symptoms of toxoplasmosis, heunderwent the same treatment for 15 months. However, at the age ofseven years, JV was subjected to an ophthalmic test at school, whichrevealed impaired vision in his left eye and visual cloudiness. Anophthalmologic examination revealed a macular lesion of retino-choroiditis in the left eye and normal vision in the right one.DISCUSSIONThe occurrence of congenital toxoplasmosis in dizygotic twins withdiscordant clinical signs has been reported by other investigators4,5,7.PEYRON et al.5 observed 15 pairs of dizygotic twins, where one ofeach pair presented subclinical toxoplasmosis, and the other had thedisease (13 cases) or a lethal infection (two cases). This variabilitysuggests that the placenta has an important role in the control ofinfection by T. gondii, one fetus being more affected than the other1.This case report indicates the difficulty of the Brazilian PublicHealth Services in identifying primo-infection by T. gondii duringpregnancy, and the management of infants suspected of beingcongenitally infected. The public-health service was slow in followingup the pregnant woman, in collecting biological material for thechildren’s diagnosis, in providing the results and in beginning theirtreatment.Retinochoroiditis is the most frequent long-term sequel incongenital toxoplasmosis2 and the risk of new lesions persists for manyyears3. The reported case reinforces the necessity for early diagnosis,and effective follow-up of pregnant women and their children frombirth to adolescence, in order to reduce the hazard and damage ofcongenital toxoplasmosis. We highlight the need for physicians to putinto practice the state protocols for follow-up and treatment of pregnantwomen with toxoplasmosis and their exposed children. The diagnosticmethods prescribed in the state protocols must be available in the public-health laboratories.RESUMOToxoplasmose congênita em gêmeos dizigóticos, Paraná, BrasilEste é o primeiro relato de caso de toxoplasmose congênita emgêmeos dizigóticos no Brasil. Os autores enfatizam a necessidade dediagnóstico precoce das gestantes e do acompanhamento de criançasdo nascimento à adolescência, a fim de evitar riscos e danos decorrentesda infecção congênita.REFERENCES1. COUVREUR, J.; DESMONTS, G. & GIRRE, J.Y. - Congenital toxoplasmosis in twins:a series of 14 pairs of twins: absence of infection in one twin in two pairs. J. Pediat.,89: 235-240, 1976.2. COUVREUR, J.; DESMONTS, G.; TOURNIER, G. & SZUTERKAC, M. - Étude d’unesérie homogéne de 210 cas de toxoplasmose congénitale chez dês nourissons agesde 0 a 11 mois et dépistés de façon prospective. Ann. Pediat., 31: 815-819, 1984.3. KOPPE, J.G. ; LOEWER-SIEGER, D.H. & ROEVER-BONNET, H. - Results of 20-year follow-up of congenital toxoplasmosis. Lancet, 1(8475): 254-256, 1986.4. KRAVETZ, J.D. & FEDERMAN, D.G. - Toxoplasmosis in pregnancy. Amer. J. Med.,118: 212-216, 2005.5. PEYRON, F.; ATEBA, A.B.; WALLON, M. et al. - Congenital toxoplasmosis in twins: areport of fourteen consecutive cases and comparison with published data. Pediat.infect. Dis. J., 22: 695-701, 2003.6. SAFADI, M.A.P. & FARHAT, C.K. - Toxoplasmose. In: FARHAT, C.K.; CARVALHO,E.S.; CARVALHO, L.H.F.R. & SUCCI, R.C.M., ed. Infectologia pediátrica. Rio deJaneiro, Guanabara Koogan, 2002. p. 612-619.7. SIBALIC, D.; DJURKOVIC-DJAKOVIC, O. & NIKOLIC, R. - Congenital toxoplasmosisin premature twins. Folia Parasit., 33: 1-6, 1986.Received: 10 February 2006Accepted: 11 September 2006

Congenital toxoplasmosis in dizygotic twins, Paraná, Brazil

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Toxoplasmose congênita em gêmeos dizigóticos, Paraná, Brasil

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