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),
EA MS, negative; EA PCR
analysis, positive; blood PCR
Blood PCR analysis, positive;
BM IF, positive; BM MS,
negative; radiology, negative
Lung biopsy (method ND),
Blood culture, positive; CSF
analysis (method ND),
Blood culture, positive; blood IF,
negative; BM IF, positive;
BM culture, negative; ascitic
fluid IF, positive; ascitic fluid
Blood PCR analysis, positive;
BM MS, negative
Blood culture, negative
Blood MS, positive; autopsy
Blood culture, negative; autopsy
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.
DNA extraction and PCR analysis were performed as
described previously [
]. 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
]. 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 [
semi-nested PCR analysis had 100% sensitivity and 100%
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 [
]. 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
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
]. 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 [
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
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
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
]; 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
], 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.
The authors thank Karin Tybus, Friederike Pfaff, Birgit Groß,
and Ulrike Wilhelm for their expert technical assistance.
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