Pulmonary Toxoplasmosis in Bone Marrow Transplant Recipients: Report of Two Cases and Review

Clinical Infectious Diseases, Jul 1999

Toxoplasma gondii may cause disseminated disease in bone marrow transplant (BMT) recipients. Pulmonary toxoplasmosis in BMT patients is rarely described. Mortality rates of >90% have been previously reported. Since pulmonary toxoplasmosis is extremely difficult to diagnose, it is very often detected only at autopsy. Two cases of pulmonary toxoplasmosis in BMT recipients that were diagnosed by visualization of T. gondii tachyzoites in bronchoalveolar lavage fluid and by a new semi-nested PCR method amplifying 18S rRNA from bronchoalveolar lavage fluid are presented, and the literature on pulmonary toxoplasmosis in BMT patients is reviewed.

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Pulmonary Toxoplasmosis in Bone Marrow Transplant Recipients: Report of Two Cases and Review

Pulmonary Toxoplasmosis in Bone Marrow Transplant Recipients: Report of Two Cases and Review Andreas Sing 0 Lorenz Leitritz 0 Andreas Roggenkamp 0 Hans-Jochem Kolb 0 Andreas Szabados 0 Volker Fingerle 0 Ingo B. Autenrieth 0 J u¨rgen Heesemann 0 0 From the Max-von-Pettenkofer-Institut fu ̈r Hygiene und Medizinische Mikrobiologie and Medizinische Klinik III, Klinikum Großhadern, Ludwig-Maximilians-Universita ̈t , Munich , Germany Toxoplasma gondii may cause disseminated disease in bone marrow transplant (BMT) recipients. Pulmonary toxoplasmosis in BMT patients is rarely described. Mortality rates of >90% have been previously reported. Since pulmonary toxoplasmosis is extremely difficult to diagnose, it is very often detected only at autopsy. Two cases of pulmonary toxoplasmosis in BMT recipients that were diagnosed by visualization of T. gondii tachyzoites in bronchoalveolar lavage fluid and by a new semi-nested PCR method amplifying 18S rRNA from bronchoalveolar lavage fluid are presented, and the literature on pulmonary toxoplasmosis in BMT patients is reviewed. - Case 1. A 37-year-old woman with Hodgkin’s disease received a BMT from her HLA-identical brother; both recipient and donor had IgG, but no IgM or IgA, antibodies to T. gondii. Twenty-one days after transplantation, she developed severe dermal graft-versus-host disease (GVHD) that prompted OKT3 and methotrexate therapy. On day 49, fever developed. Blood cultures remained negative for fungi and bacteria. A thoracic roentgenogram revealed interstitial infiltrates in the basal areas of both lungs and in the left upper field. Her temperature rose to 39°C. The lactate dehydrogenase level was 930 U/mL; the C-reactive protein concentration increased from 0.7 mg/dL on day 50 to 17.5 mg/dL on day 54. Because of rapid deterioration of her pulmonary condition, she was intubated on day 53. BAL was performed. Examination of the fluid did not demonstrate Pneumocystis carinii organisms. On the Giemsa-stained slides, abundant T. gondii tachyzoites were identified. Antitoxoplasmic therapy with pyrimethamine, clindamycin, and folinic acid was immediately started; nevertheless, she died 2 days later. Permission for autopsy was not granted. PCR analysis of the BAL fluid and a endotracheal aspirate obtained on day 55 that was negative by Giemsa staining yielded T. gondii DNA. Case 2. A 49-year-old woman with Philadelphia (Ph) positive chronic myelogenous leukemia received an allogeneic BMT from an unrelated HLA-identical donor. Donor and recipient had low titers of IgG, but no IgM, antibodies to T. gondii. Despite cyclosporine and methotrexate prophylaxis, she developed dermal and intestinal GVHD 12 days after transplantation. She became dyspneic on day 31 with no corresponding radiographic or CT finding. Five days later, patchy infiltrations were seen on chest roentgenograms. On day 40, dyspnea worsened dramatically and she was intubated. BAL fluid specimens from three different locations were negative for P. carinii and bacteria. Despite intensive care, the patient died on day 43. PCR analysis of the three BAL fluid specimens and a postmortem lung biopsy sample were positive for T. gondii DNA. Reexamination of the three BAL fluid smears that was performed with knowledge of the positive results of PCR analysis revealed the following number of tachyzoites: 2, 1, and 0. Autopsy showed disseminated toxoplasmosis involving the heart, kidneys, spleen, liver, pancreas, and lungs. Other diagnostic procedure(s), result EA MS, negative; EA PCR analysis, positive; blood PCR analysis, positive Autopsy Autopsy Autopsy Autopsy Blood PCR analysis, positive; BM IF, positive; BM MS, negative; radiology, negative Autopsy Lung biopsy (method ND), positive Autopsy Blood culture, positive; CSF analysis (method ND), positive Autopsy Blood culture, positive; blood IF, negative; BM IF, positive; BM culture, negative; ascitic fluid IF, positive; ascitic fluid culture, negative Autopsy Autopsy Autopsy Autopsy Autopsy Autopsy Autopsy Blood PCR analysis, positive; autopsy Autopsy BM MS, negative Blood culture, negative Blood MS, positive; autopsy Blood culture, negative; autopsy Postmortem Time of diagnosis Intra vitam Postmortem Postmortem Postmortem Postmortem Intra vitam Postmortem Intra vitam Postmortem ND Postmortem Intra vitam Postmortem Postmortem Intra vitam Postmortem Postmortem Intra vitam Intra vitam Postmortem Postmortem Postmortem Postmortem Intra vitam Therapy, duration Pyr/Sdz, Cm No ND ND ND Pyr/Sdz, 3 mo No No ND TMP-SMZ, Cm ND Pyr/Sdz, 21 d No No No No No No No No TMP-SMZ, 2 mo TMP-SMZ No Pyr/Sdz, Srm Pyr/Sdz Day of onset 149 140 NOTE. AA 5 aplastic anemia; ALL 5 acute lymphocytic leukemia; AML 5 acute myelogenous leukemia; BAL 5 bronchoalveolar lavage; BM 5 bone marrow; CGL 5 chronic granulocytic leukemia; Cm 5 clindamycin; CML 5 chronic myelogenous leukemia; EA 5 endotracheal aspirate; GVHD 5 graft-versus-host disease; HD 5 Hodgkin’s disease; IF 5 immunofluorescence; IgA-l 5 IgA-l myeloma; MDS 5 myelodysplastic syndrome; MS 5 microscopy; ND 5 not described; NHL 5 non-Hodgkin’s lymphoma; PR 5 present report; Pyr/Sdz 5 pyrimethamine/sulfadiazine; Srm 5 spiramycin; TMP-SMZ 5 trimethoprim-sulfamethoxazole; 1 5 after transplantation; 2 5 before transplantation; . . . 5 survived. Methods DNA extraction and PCR analysis were performed as described previously [ 7 ]. Specific primers amplifying T. gondii DNA (To18sF, 59-TTGACTTCGGTCTGCGACG-39; To18sR2, 59-GGCACGAACGCGCCACAA-39; and To18sR1, 59-AACACGAAGTTCCTGATCCT-39) were chosen by comparing 11 sequences of T. gondii 18S rRNA with 1,400 small subunit (SSU) rRNA sequences contained in a database by means of ARB software [ 8 ]. The primers To18sF, To18sR1, and To18sR2 did not find any SSU rRNA from organisms pathogenic for humans within a distance of up to four mismatches. In a previous evaluation, semi-nested PCR analysis detected specific DNA from as few as 50 T. gondii organisms (authors’ unpublished data). In comparison with microscopy and PCR analysis with use of primers targeting the B1 gene [ 9, 10 ], semi-nested PCR analysis had 100% sensitivity and 100% specificity. In direct immunofluorescence, fluorescein-labeled goat antibody to human IgG (Fluoline; bioMe´rieux, Marcy l’Etoile, France) served as detecting antibody. IgG and IgM for direct immunofluorescence (bioMe´rieux), IgG and IgM for Enzygnost ELISA (Behring Diagnostics, Marburg, Germany), and IgA for Platelia (Sanofi, Marnes-La Coquette, France) were used according to the manufacturers’ instructions. A search of the English-, French-, German-, and Spanishlanguage literature from 1966 to 1998 was performed by using MEDLINE. Reference lists in the retrieved articles were also reviewed for cases. Results and Discussion Toxoplasmosis is a rare opportunistic infection in BMT recipients. In two large series of 4,312 and 662 BMT patients, incidences of 0.28% and 0.45%, respectively, were found [ 9, 11 ]. Review of the literature for toxoplasmosis after bone marrow transplantation identified 57 cases. In 25 of these cases, T. gondii had spread to the lungs, mostly as part of toxoplasmosis dissemination to multiple organs. Rarely, isolated cases of toxoplasmic pneumonia have been reported. The clinical and diagnostic features of the 25 previously described BMT patients with pulmonary toxoplasmosis and our two patients are summarized in table 1. Because of the limitations of any literature review, however, the reported cases may not be representative of all cases of toxoplasmic pneumonia in BMT patients. Pretransplantation seropositivity of the recipient, an allogeneic transplant, and the presence of GVHD are considered to be the main risk factors for toxoplasmosis after bone marrow transplantation [ 11, 25 ]. The same holds true for toxoplasmic pneumonia: 85% of patients were seropositive before transplantation, 75% developed GVHD, and all patients except one (case 12) had received an allogeneic transplant. The onset of pulmonary symptoms ranged between day 7 and 1 year after transplantation. In most cases, the symptoms started within the first 6 weeks after transplantation. Omitting two patients with unusually late onsets of disease (cases 5 and 6), the median time of onset was day 46 after transplantation. It is noteworthy that seven patients developed pulmonary toxoplasmosis despite prophylaxis with either trimethoprimsulfamethoxazole (six patients) or pyrimethamine/sulfadiazine (one patient), which was given mainly before transplantation. None of the patients, however, was receiving pyrimethaminesulfadoxine prophylaxis, which was found to be highly protective against toxoplasmosis in BMT recipients [ 27 ]. Ninety-two percent of the BMT patients with pulmonary toxoplasmosis died. Only two patients (cases 6 and 20) survived. Patient 6, however, had an unusually late onset of disease that occurred 1 year after bone marrow transplantation, and patient 20 presented with an isolated case of pulmonary toxoplasmosis. About one-half of the patients died within 3 days after the onset of pulmonary symptoms, while only one-sixth survived for .1 week. If the patient with late onset toxoplasmosis (case 5) and the patient with a very prolonged survival time of 235 days (case 10) are disregarded, the median time of death was 49 days and the median survival time was ;5 days. Although antitoxoplasmic therapy was started for eight patients, all of them died except two (cases 6 and 20) who received pyrimethamine/sulfadiazine (which may be the most appropriate treatment of severe toxoplasmosis). Pulmonary toxoplasmosis after bone marrow transplantation was mainly found in patients who were seropositive before transplantation, suggesting reactivation of latent infection. Only three cases in previously seronegative BMT recipients were documented. In one of these cases (case 20), the donor was seropositive, which suggests transplant-related transmission. Diagnosis of pulmonary toxoplasmosis was established intravitally for only one-third of the patients. BAL fluid is the material of choice for diagnosing pulmonary toxoplasmosis by means of microscopic examination of respiratory specimens [ 1– 6 ]; however, in not even one-half of the cases was BAL performed. The method most often yielding a positive diagnostic result was microscopic examination: in seven of eight cases (including ours) in which the diagnostic outcome from BAL was reported, tachyzoites could be visualized. However, this method depends on the amount of T. gondii organisms in BAL fluid (these organisms were very scanty in our second case and were detected only after knowledge of the positive result of PCR analysis). Direct immunofluorescence was less sensitive than microscopy and was documented only once as positive (case 12, in which culture and direct microscopy were also positive). For our two patients, direct immunofluorescence was nondiagnostic. Culture was only rarely undertaken, but this test was positive for two patients. The most sensitive method, albeit in a very small sample of three cases, was PCR analysis: T. gondii DNA was detected in BAL fluid specimens with use of primers targeting the B1 gene [ 9 ], while our two cases were diagnosed by semi-nested PCR analysis amplifying 18S rRNA from BAL fluid and a Giemsa stain–negative endotracheal aspirate. Serology might have contributed to diagnosis in only about one-fourth of the cases, if any increases in titers of IgG that were reported by different investigators are considered diagnostic. However, IgM was not detectable in any of these patients. Besides BAL fluid specimens, blood seems to be the most promising material for detecting T. gondii, especially for PCR analysis (which revealed specific DNA in three cases). In conclusion, pulmonary toxoplasmosis is often a lethal complication in BMT patients that develops mainly in the first 2 months after transplantation and is hard to diagnose. Unexplained fever not responding to antibiotic treatment, nonspecific aspects of thoracic roentgenography, an elevated lactate dehydrogenase level, and rapid deterioration of the pulmonary condition should prompt an immediate search for T. gondii by using a broad armamentarium of methods including microscopy and PCR analysis of BAL fluid and blood specimens. Because of the high mortality rate, antitoxoplasmic therapy should be started immediately. Acknowledgments The authors thank Karin Tybus, Friederike Pfaff, Birgit Groß, and Ulrike Wilhelm for their expert technical assistance. 1. Pomeroy C , Filice GA . Pulmonary toxoplasmosis: a review . Clin Infect Dis 1991 ; 14 : 863 - 70 . 2. Bonilla CA , Rosa UW . Toxoplasma gondii pneumonia in patients with the acquired immunodeficiency syndrome: diagnosis by bronchoalveolar lavage . South Med J 1994 ; 87 : 659 - 63 . 3. Bottone EJ . 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Andreas Sing, Lorenz Leitritz, Andreas Roggenkamp, Hans-Jochem Kolb, Andreas Szabados, Volker Fingerle, Ingo B. Autenrieth, Jürgen Heesemann. Pulmonary Toxoplasmosis in Bone Marrow Transplant Recipients: Report of Two Cases and Review, Clinical Infectious Diseases, 1999, 429-433, DOI: 10.1086/520228