Toxoplasma gondii Efrat Rorman , Chen Stein Zamir , Irena Rilkis
Transcription
Toxoplasma gondii Efrat Rorman , Chen Stein Zamir , Irena Rilkis
Reproductive Toxicology 21 (2006) 458–472 Review Congenital toxoplasmosis—prenatal aspects of Toxoplasma gondii infection Efrat Rorman a,∗ , Chen Stein Zamir b , Irena Rilkis a,c , Hilla Ben-David a a National Public Health Laboratory, Ministry of Health, P.O. Box 8255, Tel Aviv 61082, Israel b District Health Office, Ministry of Health, Jerusalem, Israel c National Toxoplasmosis Reference Center, Ministry of Health, Israel Received 26 August 2004; received in revised form 11 October 2005; accepted 24 October 2005 Available online 28 November 2005 Abstract Toxoplasma gondii (T. gondii) is the cause of toxoplasmosis. Primary infection in an immunocompetent person is usually asymptomatic. Serological surveys demonstrate that world-wide exposure to T. gondii is high (30% in US and 50–80% in Europe). Vertical transmission from a recently infected pregnant woman to her fetus may lead to congenital toxoplasmosis. The risk of such transmission increases as primary maternal infection occurs later in pregnancy. However, consequences for the fetus are more severe with transmission closer to conception. The timing of maternal primary infection is, therefore, critically linked to the clinical manifestations of the infection. Fetal infection may result in natural abortion. Often, no apparent symptoms are observed at birth and complications develop only later in life. The laboratory methods of assessing fetal risk of T. gondii infection are serology and direct tests. Screening programs for women at childbearing age or of the newborn, as well as education of the public regarding infection prevention, proved to be cost-effective and reduce the rate of infection. The impact of antiparasytic therapy on vertical transmission from mother to fetus is still controversial. However, specific therapy is recommended to be initiated as soon as infection is diagnosed. © 2005 Elsevier Inc. All rights reserved. Keywords: Toxoplasmosis; Toxoplasma gondii; Congenital infection; Diagnosis; Treatment; Epidemiology Contents 1. 2. 3. 4. ∗ Case report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The parasite . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1. Life cycle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2. Mechanism of infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.3. Virulence of T. gondii strains . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Congenital toxoplasmosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1. Incidence and prevalence in pregnant women and infants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.2. Diagnostic evaluation, manifestation and consequences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.3. Prenatal laboratory diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.3.1. Sabin Feldman dye test (SFDT) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.3.2. Enzyme immunoassays (EIA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.3.3. Immunosorbent agglutination assay test (IAAT) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.3.4. Indirect fluorescent assay (IFA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.3.5. Avidity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.3.6. Animal and cell culture inoculation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Corresponding author. Tel.: +972 50 6242904; fax: +972 3 6826996. E-mail address: [email protected] (E. Rorman). 0890-6238/$ – see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.reprotox.2005.10.006 459 459 459 460 460 460 461 461 461 463 463 465 465 465 465 466 E. Rorman et al. / Reproductive Toxicology 21 (2006) 458–472 459 4.3.7. Molecular diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Laboratory diagnosis of infants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.4.1. Western blots . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Treatment of congenital toxoplasmosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.1. Primary prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.1.1. Vaccine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.2. Secondary prevention – screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 466 467 467 467 468 468 468 468 468 469 4.4. 5. 6. 1. Case report A 26-year-old woman from a rural village in northern Israel presented with cervical lymphadenopathy during the 13th week of her first pregnancy. The woman was otherwise healthy and without any symptoms. She was followed up by her primary care physician and as the lymphadenopathy did not resolve, was sent for surgical consultation during the 26th week of pregnancy. The surgeon referred her to laboratory tests for Toxoplasma gondii-specific antibodies and for various other infections. The results obtained from testing a serum sample from the 26th week of gestation, performed at the Israel National Toxoplasmosis Reference Center were: positive for total T. gondii-specific immunoglobulins (Ig) (250 IU/ml by Sabin Feldman Dye Test) and for T. gondii-specific IgM antibodies (by ELFA, Enzyme-Linked Fluorescent immuno-Assay) with low IgG avidity (0.027). These results were reported and an additional serum sample, as well as an earlier sample (whether available) were requested. Blood samples were subsequently delivered to our laboratory; from the 12th (sample drawn as part of the routine pregnancy follow-up) and from the 34th weeks of pregnancy. The results of the earlier sample were negative for both total Ig and IgM antibodies. The results from the 34th week were positive for total T. gondii-specific immunoglobulins (250 IU/ml by Sabin Feldman Dye Test) and negative for T. gondii-specific IgM antibodies (by ELFA, Enzyme-Linked Fluorescent immuno-Assay) with low IgG avidity (0.055). The sum interpretation of the three above tests results of the 12th, 26th and 34th week of pregnancy was consistent with definite recent T. gondii infection (seroconversion, constant high T. gondii-specific immunoglobulins, emergence and disappearance of IgM, low avidity and cervical lymphadenopathy). Amniocentesis was performed during the 35th week of pregnancy and PCR result for T. gondii DNA in the amniotic fluid was positive. The woman was referred for follow-up at a high risk pregnancy clinic in a tertiary medical center. Anti-T. gondii therapy including Pyrimethamine, Sulfadiazine and folinic acid was started and continued until birth. The pregnancy course was otherwise uneventful and fetal growth assessment through ultrasound follow-up did not reveal any abnormality. During the 38th week of pregnancy a female infant was born by spontaneous delivery. Birth weight was 2830 g and head circumference was 33 cm. Physical examination was normal. Laboratory tests including complete blood count, glucose, electrolytes, liver function tests and cerebro-spinal fluid (CSF) tests were all normal. Cranial ultrasonography, brain stem evoked response (BERA), audiometry and eye examination were all normal. Tests for T. gondii in the infant included: PCR of CSF—negative, immuno-sorbent agglutination assays (IgM-ISAGA)—negative and Sabin Feldman Dye Test (SFDT)—positive (250 IU/ml), probably reflecting maternal antibodies transfer. Despite the serological indicators of maternal infection (most probably towards the end of the first trimester) and positive PCR of the amniotic fluid, there was no evidence of congenital toxoplasmosis in the neonate. The infant was treated with the same therapeutic protocol as the mother planned to be continued until the age of 1 year. Medical evaluation, auditory and ophthalmic tests at the age of 4 and 8 months revealed normal physical growth and development and intensive follow-up continues (at the age of 6 months laboratory analysis was reported to be normal). This case demonstrates the complexity of establishing clinical diagnosis and interpretation of laboratory results in regard to T. gondii infection in pregnancy. The favourable outcome despite the timing of infection may be attributed to providing anti parasitic therapy, although the specific role of therapy or other unknown variables is unclear. Since many T. gondii infections are sub-clinical or present with non-specific signs, physicians should be able to integrate clinical and laboratory data in order to make diagnostic and therapeutic decisions. 2. The parasite T. gondii is a member of the phylum Apicomplexa, order Coccidia, which are all obligate intracellular protozoan parasites. Other members of this phylum include known human pathogens such as Plasmodium (malaria) and Cryptosporidium. 2.1. Life cycle The life cycle of T. gondii consists of two stages—asexual and sexual: the asexual stage takes place in the intermediate hosts, which are mammals or birds. During this phase rapid intracellular growth of the parasite as tachyzoite takes place (generation time in vitro is 6–8 h). The oval or crescent-shaped tachyzoites can infect and multiply in almost any nucleated mammalian or avian cell [1]. Following accumulation (64–128), tachyzoites are secreted into the blood stream [2] and spread in the body, leading to development of an acute disease (parasitemia). The normal immune response and transformation of the tachyzoite into cystforming bradyzoites limit the acute stage and establish a chronic infection. Bradyzoites differ from tachyzoites mainly in their 460 E. Rorman et al. / Reproductive Toxicology 21 (2006) 458–472 extremely slow multiplication rate (their name reflects this slow process) and in the distinct set of proteins they express [1,3–5]. The cysts are formed mainly in neural and muscular tissues, especially brain, skeletal and cardiac muscles, and can persist, inactivated, in the body for a very long time. In the immunocompromised patient the release of bradyzoites from the cyst may cause acute encephalitis. The sexual stage takes place in the intestine of the definitive host. Known definitive hosts are members of the feline family, predominantly domestic cats. When bradyzoites or oocytes are ingested by a feline, formation of oocytes proceeds in the epithelium of the small intestine. Several million unsporulated oocytes may be released in the feces of a single cat over a period 3–18 days, depending on the stage of T. gondii ingested [1]. Under mild environmental conditions oocytes may sporulate within a 3-week period [6], then infecting humans and other intermediate hosts. Oocysts can spread in the environment and contaminate water, soil, fruits, vegetables and herbivores following consumption of infected plant material. Investigation of outbreaks of toxoplasmosis has led to recovery of oocytes from soil [7] but not from water [8–10]. Oocytes have been found to be very stable, especially in warm and humid environments, and resistant to many disinfecting agents [11], but survive poorly in arid, cold climates [12]. 2.2. Mechanism of infection T. gondii has been shown to migrate over long distances in the host’s body; crossing biological barriers, actively enter the blood stream, invade cells and cross substrates and non-permissive biological sites such as the blood-brain-barrier, the placenta and the intestinal wall. At the same time, the parasite minimizes exposure to the host’s immune response, by rapidly entering and exiting cells. These two functions share common mechanisms which depend on Ca2+ regulation [13]. Unlike many bacteria and viruses, T. gondii actively enters the cell, in a mechanism which is mediated by the parasites’ cytoskeleton and regulated by a parasite-specific calciumdepended secretion pathway [2,14]. The first step of cell invasion by T. gondii is recognition of an attachment point. The two special organelles involved in this invasion process, rhoptries and micronemes, each discharging proteins during the process [5,15]. Following the rapid cellular invasion the parasite resides within a vacuole, derived primarily from the host cell’s plasma membrane [2,16]. The active motion of T. gondii, called “gliding”, occurs with no major changes in cell shape. It is fast (about 10 times faster than the “crawling” rate of amoeboid cells), and consists of both circular gliding in a counter-clockwise direction and clockwise helical gliding [17–21]. As an obligatory parasite, it’s invasive capabilities play an important role in virulence and pathogenicity, since it can only survive intracellularly where it gets nutrients and escapes from the host’s immune response [22]. The most virulent T. gondii strain has been shown to exhibit superior migratory capacity [23] and a subpopulation of this strain displays a special, long distance migration phenotype [14]. The ability to cross biological barriers is associated with acute virulence and is linked to genes on chromosome VII [24,25]. The genome of T. gondii, consisting of 14 chromosomes, is currently being investigated and sequenced [26] (http://ToxoDB.org). 2.3. Virulence of T. gondii strains Clinical manifestations and severity of illness following infection are affected by features of the interaction between the parasite and the host and include strain virulence, inoculum size, route of infection, competence of the host’s immune response (both cellular and humoral), integrity of the host’s mucosal and epithelial barriers, host’s age and genetic background [27]. Various strains of T. gondii have long been known to differ in virulence and pathogenicity [28,29]. These strains can be classified by immunologic assays, isoenzyme analysis and molecular analysis [30–33]. There are three T. gondii clonal lineages, of them one carries conserved genetic loci, suspected of coding for the virulence trait [24]. Grigg et al. [34] demonstrated that a sexual recombination, performed in vitro, between the two relatively avirulent strains can give rise to the virulent strain. This is in accordance with polymorphism analysis of the three T. gondii strains, which indicated that they emerged within the last 10,000 years, following a single genetic cross [34,35]. Acquisition of an efficient mechanism to spread by direct oral transmission, bypassing a sexual phase, leads to successful clonal expansion of this virulent lineage [35,36]. Genetic background plays a significant role in increased susceptibility to T. gondi in humans; HLA-DQ3 appears to be a genetic marker associated with susceptibility to developing toxoplasma-dependent encephalitis [37,38]. 3. Epidemiology T. gondii infection is most frequently caused by ingestion of row or undercooked meat, which carries tissue cysts, by consuming infected water or food or by accidental intake of contaminated soil. Toxoplasmosis is also an occupational hazard for laboratory workers. A total of 47 laboratory-acquired cases have been reported, 81% of them were symptomatic cases [39]. Tender et al. [40] collected data of nation-wide T. gondii seroprevalence in women at child-bearing age (1990–2000). The rates of positive sero-prevalence, were 58% in Central European countries, 51–72% in several Latin-American countries and 54–77% in West African countries. Low seroprevalence, 4–39%, was reported in southwest Asia, China and Korea as well as in cold climate areas such as Scandinavian countries (11–28%). In the US 15% of females at childbearing age were found to be seropositive [41]. It should be noted that seropositive prevalence in the same country may differ among populations or geographical regions and world-wide prevalence is higher in older populations. In a limited case–control study that included six large European centers it was shown that the consumption of undercooked meat was the major risk factor for toxoplasmosis infection [42]. Another study aimed to determine the prevalence of T. gondii in edible meat tested 71 meat samples from commercial sources in the UK for the parasite—positive results were found in 27 E. Rorman et al. / Reproductive Toxicology 21 (2006) 458–472 samples. Twenty-one of these contaminated meat samples carried the virulent T. gondii type I [43]. Although cats play a definite role in the epidemiology of toxoplasmosis, no significant correlation between human toxoplasmosis infection and cat ownership could be proven [44]. Furthermore, the oocytes are not found on cat fur but rather are buried in the soil as they are shed with cat faeces [45–47]. Data regarding seroprevalence of specific T. gondii antibodies in the Israeli population are based on several regional surveys performed in collaboration with the Israeli National Toxoplasmosis Reference Center. The prevalence in certain subpopulations of pregnant women in northern Israel had been reported to be 21% on average and the incidence rate of infection acquired during pregnancy estimated as 1.4% [48]. Human contact with infected oocyst from contaminated soil [7,49,50] and water [8–10] were associated with several reported epidemics caused by T. gondii. Only in one case were T. gondii oocysts recovered from the soil—the suspected source of infection [7]. There are ongoing efforts to develop sensitive detection techniques for environmental samples [11,51,52]. Unfortunately, isolation of oocytes from such samples is difficult, since infectious doses are small while large volume of sample is required for isolation of the organism. In addition, there is a lag period between the time of infection and the time that the contaminated source is tested, further reducing the likelihood of recovery of oocytes from the suspected environment during epidemiological investigation. T. gondii was reported to cause 0.8% of the total food-borne illnesses attributed to a known pathogen, and 20.7% of the total food-borne mortality caused by a known pathogen, in the United States in 1996–1997. Many of these cases involved HIV-infected patients [53]. The largest reported toxoplasmosis outbreak resulting from contaminated water occurred in British Columbia and caused acute infection in 100 people; 19 with retinitis and 51 with lymphadenopathy. The likely source was a municipal water system that used unfiltered, chloraminated surface water [10]. There was also a seasonal correlation to rainfall and turbidity in this water reservoir. In another small outbreak North of Rio de Janeiro, Brazil, the source of the parasite was traced to an unfiltered water source. It was also linked to high prevalence of seropositivity in this region of low socio-economic background [8]. 4. Congenital toxoplasmosis Most cases of acquired toxoplasma infection are asymptomatic and self-limited; hence many cases remain undiagnosed. The incubation period of acquired infection is estimated to be within a range of 4–21days (7 days on average) [10]. When symptomatic infection does occur the only clinical findings may be focal lymphadenopathy, most often involving a single site around the head and neck. Less commonly, acute infection is accompanied by a mononucleosis-like syndrome characterized by fever, malaise, sore throat, headache and an atypical lymphocytosis on peripheral blood smear [54]. In immunocompromised patients, most commonly HIV infected and organ transplant recipients, T. gondii may cause a severe central nervous system 461 disease, resulting in brain lesions or diffuse encephalitis. Other organs, such as the heart, lung, liver, and retina may also be involved. Most of these cases result from reactivation of latent infection [54] although re-infection with a different T. gondii strain in the transplanted organs may also occur. 4.1. Incidence and prevalence in pregnant women and infants The disease is caused by vertical transmission of T. gondii from a seronegative pregnant woman, who is acutely infected with T. gondii to her fetus. The prevalence of T. gondii and its incidence of human infection vary widely amongst various countries. Worldwide, 3–8 infants per 1000 live births are infected in utero [55]. Multiple factors are associated with the occurrence of congenital toxoplasmosis infection, including route of transmission, climate, cultural behaviour, eating habits and hygienic standards. This combination leads to marked differences even among developed nations. For example, the incidence of congenital infection in Belgium and France is 2–3 cases per 1000 live births—markedly higher than the US incidence, which is between 1 in 10,000 to 1 in 1000 live births [47,56]. In a research conducted in Goiania, Brazil, a region with a relatively high seroconversion rate, pregnant women were found to have a 2.2 times higher risk for seroconversion than non-pregnant women of equivalent characteristics. In addition, amongst pregnant women, adolescents were shown to have the highest risk for seroconversion [57]. The authors hypothesized that higher vulnerability to T. gondii infection during pregnancy may be due to a combination of pregnancy associated immunosuppression as well as hormonal changes. Only a few cases of congenital toxoplasmosis transmitted by mothers who were infected prior to conception have actually been reported [58–60]. One such case published recently involved a woman who had ocular toxoplasmosis 20 years prior to giving birth to a newborn, who suffered from congenital toxoplasmosis. The mother had a “toxoplasmic scar” in the retina and was tested positive for specific toxoplasma IgG antibodies. The newborn was found to be positive for both IgG and IgM antibodies and had a macular scar on the retina, typical to toxoplasmosis, as well as a calcified brain granuloma. [59]. Such a case could be attributed to re-infection with a different, more virulent strain or by reactivation of a chronic disease[58]. Chronically infected women, who are immunodeficienct, may also transmit the infection to their fetus; the risk of this occurrence is difficult to quantify, but it is probably low. Latent T. gondii infection may be reactivated in immunodeficient individuals (such as HIV-infected women) and result in congenital transmission of the parasite [61]. 4.2. Diagnostic evaluation, manifestation and consequences The diagnostic evaluation of T. gondii is part of routine pregnancy follow-up and differential diagnosis of intrauterine infection. Intrauterine ultrasonographic findings of T. gondii infection 462 E. Rorman et al. / Reproductive Toxicology 21 (2006) 458–472 are usually non-specific and in most cases no pathological evidences are revealed. In certain cases the ultrasonographic findings may include: intracranial calcifications, echogenic streaks, microcephalus, ventricular dilatation and hydrocephalus [62]. Gay-Andrieu et al. [63] described two cases of intrauterine infection in which the diagnosis was based upon hydrocephalus in fetal ultrasound, even though PCR of amniotic fluid was negative in both cases. The authors emphasized that hydrocephalus is the most frequent lesion detected by fetal ultrasound, reflecting the pathological process taking place within several months post-infection in cases of intrauterine infection of T. gondii. Additional ultrasonographic findings may include hepatomegaly, splenomegaly, ascitic fluid, cardiomegaly and placental abnormalities [55,64]. Safadi et al. [65] followed 43 children with congenital toxoplasmosis for a period of at least 5 years. Most of them (88%) had sub-clinical presentation at birth. The most common neurological manifestation was a delay in neuro-psychomotor development. Half of the children developed neurological manifestations, 7 children had neuroradiologic alterations in skull radiography, and 33 children in tomography. Notably, cerebral calcifications were not associated with an increased incidence of neurological sequelae. Chorioretinitis was the main ocular sequelae, found in almost all children and noted years after birth, despite specific therapy in the first year of life. An important step in the diagnosis of congenital toxoplasmosis and evaluation of time of infection is achieved by laboratory techniques, monitoring the immune response: titer and affinity of specific antibodies (Fig. 1). Other laboratory tools focus on direct detection of the parasite by animal or tissue inoculation or more commonly, by molecular techniques. Carvalheiro et al. studied the incidence of congenital toxoplasmosis in Brazil, based on persistence of anti-Toxoplasma IgG antibodies beyond the age of 1year. Disease incidence was estimated to be 3.3 per 10,000. A definitive diagnosis was confirmed in five infants with both serum IgM and/or IgA antibodies, and clinical abnormali- Fig. 1. Laboratory diagnosis of congenital toxoplasmosis. ties. They concluded that positive screening results must be carefully confirmed [66]. Laboratory methods and their implications in supporting evidence-based diagnoses are discussed below. The risk of fetal infection is multifactorial, depending on the time of maternal infection, immunological competence of the mother during parasitemia, parasite load and strain’s virulence [40]. The probability of fetal infection is only 1% when primary maternal infection occurs during the preconception period but increases as pregnancy progresses; infection acquired during the first trimester by women not treated with anti-T. gondii drugs results in congenital infection in 10 to 25% of cases. For infections occurring during the second and third trimesters, the incidence of fetal infection ranges between 30–54% and 60–65%, respectively [54]. The consequences are more severe when fetal infection occurs in early stages of pregnancy, when it can cause miscarriage (natural abortion or death occurs in 10% of pregnancies infected with T. gondii [67]), severe disease, intra-uterine growth retardation or premature birth. A multi-centre prospective cohort study evaluated the association between congenital toxoplasmosis and preterm birth, low birth weight, and small size for gestational age [68]. Freeman et al. reported that infected babies were born earlier than uninfected babies and that congenital infection was associated with an increased risk of preterm delivery when seroconversion occurred before 20 weeks of gestation. Congenital infection was not associated with low birth weight or small size for gestational age. The cause for shorter gestation is not yet known. The highest frequency of severe abnormalities at birth is seen in children whose mothers acquired a primary infection between the 10th and 24th week of gestation [67]. The likelihood of clinical symptoms in the newborn is reduced when infection occurs later. Clinical manifestations in newborns with congenital toxoplasmosis vary and can develop at different times before and after birth. Most newborns infected with T. gondii are asymptomatic at birth (70–90%) [61]. When clinical manifestations are present they are mainly non-specific and may include: a maculopapular rash, generalized lymphadenopathy, hepatomegaly, splenomegaly, hyperbilirubinemia, anemia and thrombocytopenia [69]. The classic triad of chorioretinitis, intracranial calcifications and hydrocephalus is found in fewer than 10% of infected infants [47]. Hydrocephalus and/or microcephaly may develop when intra-uterine infection results in meningo-encepahlitis [69]. All these signs and symptoms are included in the general work-up of suspected congenital TORCH infections: toxoplasmosis, other (syphilis, varicella-zoster, parvovirus B19), rubella, cytomegalovirus (CMV) and herpes infections. Cerebral calcifications can be demonstrated by cranial radiography, ultrasonography or computerized tomography. Neurologic impairment may initially present as seizures, necessitating specific evaluation and treatment. The most prevalent consequence of congenital toxoplasmosis is chorioretinitis. Chorioretinitis is diagnosed based on characteristic retinal infiltrates. Vutova et al. [70] investigated eye manifestations of congenital toxoplasmosis in 38 infants and children. The most frequent finding was chorioretinitis (92%), together with other E. Rorman et al. / Reproductive Toxicology 21 (2006) 458–472 ocular lesions in 71% of cases, and the second most common finding was microphthalmia with strabismus. Lesions of the anterior segment of the eye included iridocyclitis, cataracts and glaucoma. Other uncommon findings were diminished visual acuity and neurological sequelae such as hydrocephalus, calcification in the brain, paresis, and epilepsy. Wallon et al. [71] reported the clinical evolution of ocular lesions and final visual function, in a prospective cohort of 327 congenitally infected children in France. The children were identified by maternal prenatal screening and monitored for up to 14 years. After 6 years, 79 (24%) children had at least one retinochoroidal lesion. In 23 of them a new lesion was diagnosed within10 years, mainly in a previously healthy location. Normal vision was found in about two thirds of children with lesions in one eye, half the children with lesions in both eyes and none had bilateral visual impairment. Most of the mothers (84%) had been treated. A combination of pyrimethamine and sulfadiazine had been prescribed in all the children (38% before and 72% after birth). Late-onset retinal lesions and relapse can occur many years after birth, but the overall ocular prognosis of congenital toxoplasmosis seems satisfactory, when infection is identified early and appropriately treated. Early diagnosis and treatment are believed to reduce the risk of visual impairment. Relevant laboratory tests include complete blood count (CBC), liver function tests and specific T. gondii diagnostic tests as described in details below. If T. gondii infection is suspected at the time of birth, diagnostic work-up includes ophthalmic, auditory and neurological examinations, lumbar puncture and cranial imaging [69]. In a large percentage of children the disease sequelae may become apparent and present with visual impairment, mental and cognitive abnormalities of variable severity, seizures or learning disabilities only after several months or years [55]. Infants born to women infected simultaneously with HIV and T. gondii should be evaluated for congenital toxoplasmosis, considering the increased risk of reactivation of parasitemia and disease in these mothers. In a case–control study in Israel, Potasman et al. tested 95 children with variable neurological disorders: cerebral palsy, epilepsy and nerve deafness compared with a control group of 109 healthy children, for the presence of T. gondii-specific antibodies in the serum. They found that children with any of the neurological disorders were significantly more likely to have T. gondii specific IgG antibodies, especially those with nerve deafness (relative risk 2.5 and 7.1, respectively) [72]. A definite diagnosis cannot be made in the following situations: (1) the infant is older than one year of age and was not tested for toxoplasmosis previously, (2) either the child or the mother is seronegative, or (3) the mother was known to be seropositive prior to conception. 4.3. Prenatal laboratory diagnosis The principle method used to diagnose and evaluate timing of congenital infection relies on indirect evidence, and is based on detection of specific antibodies, by monitoring the immune response. Direct evidence is obtained by animal or tis- 463 sue inoculation or more commonly, by molecular techniques. It is important to combine all available clinical and laboratory data during the evaluation of toxoplasmosis diagnosis and providing treatment recommendations. Infection during gestation may cause serious damage to the fetus and hence, a major objective of the diagnosis is to estimate the time of maternal infection. IgG antibodies usually appear within two weeks of infection, peak within 6–8 weeks and persist in the body indefinitely [67]. IgM antibodies are considered the indicators of recent infection and can be detected by enzyme immunoassay (EIA) or immunosorbent agglutination assay test (IAAT) relatively early—within 2 weeks of infection. Uncertainty may arise as IgM may persist for years following primary infection [73]. IgA antibodies may also persist for more than a year [67] and their detection is informative mainly for the diagnosis of congenital toxoplasmosis. The level of specific IgE antibodies increases rapidly and remains detectable for less than 4 months after infection, which leaves a very short time to be used for diagnostic purposes [74]. However, IgE serology is not useful in samples from newborns. When serology alone is insufficient direct evidence for toxoplasma infection should be sought. Both the laboratory performing the tests and the referring physician should be aware of the limitations and select the best combination of tests available to timely evaluate the stage of toxoplasma infection [75]. Laboratory tests available are summarized in Table 1. 4.3.1. Sabin Feldman dye test (SFDT) This is the first test developed for the laboratory diagnosis of T. gondii infection [76], it is still considered the “gold standard”. SFDT detects the presence of anti-T. gondii specific antibodies (total Ig) and is performed only in reference centers. The change in antibody titer as determined in SFDT in consecutive serum samples taken at least 3 weeks apart is important for the evaluation of infection during pregnancy. A “significant” change is considered to be at least a four-fold difference. The absolute antibody titer is also important—values over 250 IU/ml are considered “high” suggestive of recent infection. The tested sera are serially diluted and incubated with live tachyzoites (carrying toxoplasma-specific antigens) in the presence of separated human plasma from “sero-negative” donors (providing complement components). The antigen–antibody–complement complexes formed are subsequently lysed in the presence of the dye methylene blue. End-point titer is established by counting the numbers of dead (unstained) and live (stained) parasites. The reported titer is that producing lysis of 50% of the organisms. End-point titer can be converted to international units (IU): additional standardization is achieved by preparation of a standardised control serum (consisting of a pool of sera), tested by numerous reference centers, and adjusted so that the SFDT value of this control serum is set at 1000 IU/ml [77]. Recently, the WHO recognized the first international standard for human anti-toxoplasma IgG, with an assigned potency of 20 IU per ampoule of total anti-toxoplasma antibodies [78]. 464 E. Rorman et al. / Reproductive Toxicology 21 (2006) 458–472 Table 1 Laboratory diagnostic tests for congenital toxoplasmosis Test Matrix Results Interpretation Time Degree of expertise equired Other remarks Suggested use Sabin Feldman Dye Test (SFDT) Serum Titer in international units (IU) of total specific Ig Quantitative data: detection of high (≥250 IU) antibodies titers and significant changes (≥×4) in titer in consecutive samples – important for evaluation of recent infection Routine = ∼2–4 × week High, reference center only Gold standard Confirmation of infection “hands on” = several hours Live parasites and animal injection → risk to lab employee Standardized assay (international effort) Possible false negative very early infection Very subjective and difficult to standardize Partial results (combine with IgM detection) Requires further testing, IgE – not in newborn Follow-up change in titer EIAa /total Igb Serum Positive/negative for total specific Ig Exposure to T. gondii Several hours Low = simple automated test IFAc -total Ig Serum Titer (in IU) of total specific Ig Exposure to T. gondii Several hours High, reference center only IgG by EIA Serum Positive/negative for specific IgG Abs Exposure to T. gondii Several hours Low = simple automated test IgM/IgA or IgE by EIA Serum Positive/negative for specific IgM, IgA or IgE Abs Possible recent infection with T. gondii Several hours Low = simple automated test IgM/IgA or IgE by IAAT Serum Positive/negative for specific IgM, IgA or IgE Abs Possible recent Infection with T. gondii Several hours Relatively high IgM/IgA or IgE by IFA Serum Positive/negative for specific IgM, IgA or IgE Abs Possible recent Infection with T. gondii Several hours High, reference center only IgG avidity Serum Avidity = functional affinity High avidity supports “past infection” (≥4 months) Several hours Relatively simple Mice Body fluids/tissue Positive/negative Presence of parasite 3–6 weeks High, reference center only Live parasites and animal injection → risk to lab employee Most sensitive and specific test Very subjective and difficult to standardize Supportive evidence Low sensitivity Screening test When SFDT is unavailable Screening test IgM – Screening IgM/IgA – Newborn IgE – Earlier IgM/IgA – Newborn Western blot should be considered if contamination with maternal blood is suspected When ISAGA is unavailable When only a single serum sample is available, in the beginning of pregnancy Strain isolation E. Rorman et al. / Reproductive Toxicology 21 (2006) 458–472 465 Table 1 (Continued) Test Matrix Results Interpretation Time Degree of expertise equired Other remarks Suggested use Cells Body fluids/tissue Positive/negative Presence of parasite 3–6 days Low sensitivity When available for a direct proof of infection PCR Body fluids/tissue Serum Positive/negative Presence of parasite’s DNA Fetal/newborn infection Several hours Very high reference center only Live parasites High High sensitivity Infrequent availability Amniotic fluid Western blot IgG, IgM a b c Identical/unidentical to maternal Ig 1 day High, reference center Confirmatory test or fetal/newborn infection EIA: enzyme immunoassay. Ig: immunoglobulin. IFA: indirect fluorescent assay. 4.3.2. Enzyme immunoassays (EIA) The most common laboratory tests for toxoplasmosis infection, also available as commercial kits and/or automated platforms, are EIA. These tests include: enzyme-linked immunosorbent assay (ELISA) and enzyme linked fluorescent immuno-assay (ELFA) which test for the presence of IgG and/or IgM antibodies specific for the parasite in human sera. EIA are useful as fast, low-cost screening tests and have been improved over the years to avoid false positive results due to non-specific detection of interfering factors such as rheumatoid factor and antinuclear antibodies. There is no standardization of these tests, which causes high variability in results obtained with different kits and/or in different laboratories. Consequently, and also as a result of the high incidence of false-positive results even in reference centers, the US Food and Drug Administration (FDA) issued a health advisory to physicians on July, 1997. The FDA recommends avoiding reliance of results obtained with any single commercial kit for the detection of toxoplasma-specific IgM, as the sole determinant of recent toxoplasma infection in pregnant women. In our experience at the Israeli National Toxoplasmosis Reference Center, during the years 1997–2002, in an average of 747 samples (range: 652–816) received annually for confirmation, only 17% ± 2.6% were indeed positive for T. gondii-specific IgM. It is therefore recommended that patient follow-up would be performed by a reference center, and that commercial kits would be locally evaluated to achieve the highest degree of accuracy and repeatability possible for screening tests. In general, when toxoplasma infection is suspected based on detection of specific IgM antibodies specimens are referred for confirmation by a reference center where SFDT, PCR and other advanced assays can be performed. 4.3.3. Immunosorbent agglutination assay test (IAAT) IAAT is highly specific in detection of anti-T. gondii IgM, IgA or IgE antibodies [79]. This assay utilizes the entire tachyzoite and is the most sensitive commercially available method [80–82]. Unfortunately, it is expensive, requires a high degree of expertise and is not automated. It is consequently seldom used in reference centers, usually in neonates suspected of having con- genital infection (where the expected levels of antibodies are very low) [74,83]. Toxoplasma-specific IgE antibodies can be detected by EIA or IAAT in sera of recently infected adults, congenitally infected infants, and children with congenital toxoplasmic chorioretinitis [84]. IgE detection is, however, ineffective in evaluating fetal or newborn samples where IgA tests are most informative. 4.3.4. Indirect fluorescent assay (IFA) The IFA was widely used to demonstrate T. gondii-specific antibodies: serially diluted serum samples are incubated with live, inactivated toxoplasma fixed to a glass slide. T. gondiispecific antibodies present in the serum would bind to the inactivated parasite, and the complex is then detected using fluorescein isothiocyanate-labeled anti-human Ig (or anti-IgG or anti-IgM). IFA is safer to perform and more economical than the SFDT. It appears to measure the same antibodies as the dye test, and its titers tend to parallel dye test titers [47,85]. However, the IFA interpretation is subjective and time consuming. False positive results may occur with sera containing antinuclear antibodies and rheumatoid factor [86], and false negative results of IFA for IgM may occur due to blockage by T. gondii-specific IgG [87]. 4.3.5. Avidity IgG avidity testing was developed by Hedman et al. and is based on the increase in functional affinity (avidity) between T. gondii-specific IgG and the antigen over time, as the host immune response (and specific B cell selection) evolves [88]. Dissociation of the antigen–antibody complexes reflects the lower avidity closer to primary infection. Pregnant women with high avidity antibodies are those who have been infected at least 3–5 months earlier, which makes the avidity test most useful and reliable in the first trimester when high-avidity is detected [89]. In one study, 35 out of 63 patients (55%) who were classified by toxoplasma-specific serology as having recent or borderline infection showed high avidity-antibodies and were therefore treated as chronic patients [90]. Lappaplainen et al. [91] were able to follow 13 women who showed high-avidity antibodies in the first trimester and confirmed that none of the born infants was found to be infected with T. gondii (as determined serologically 466 E. Rorman et al. / Reproductive Toxicology 21 (2006) 458–472 after birth). The avidity test is most important when only a single serum sample is available at the time when critical decisions must be made. To the best of our knowledge, commercial IgG avidity kits have been licensed in Europe but not in the US [92]. When avidity is low or borderline it may be misleading and a more careful interpretation of all laboratory tests results in conjunction with other clinical findings, should then be undertaken. Several studies have shown that this test is reliable and valuable in diagnosis of recent infection during early pregnancy [88,93–98]. Accurate and definitive serologic diagnosis of recently acquired toxoplasma infection is still difficult and depends on testing of more than one sample. Efforts to develop better diagnostic approaches continue based on antigens specifically expressed either during the primary phase (i.e. GRA7, GRA4) or the latent phase (i.e. GRA1) of infection. These antigens can be produced by recombinant DNA technologies and may lead to a more informative serologic diagnosis, based on a single serum sample [47,99,100]. 4.3.6. Animal and cell culture inoculation A definite laboratory confirmation of active toxoplasmosis infection (especially in immunocompromised patients and pregnant women) can be established by inoculation of body fluids or tissue into mice or cell culture [47]. Mice are injected intraperitoneally or subcutaneously with 10–30 ml of sediment from amniotic fluid or whole fetal blood. The mice are bled prior and 3–6 weeks following inoculation. Antibody detection by SFDT establishes infection and final proof is obtained by staining to demonstrate brain cysts [101]. Cell culture inoculation with amniotic fluid or blood uses indirect IFA to detect the parasite in monolayers within 3–6 days following inoculation [102]. When compared, inoculation of both blood and amniotic fluid from an infected fetus resulted in toxoplasma isolation from both cultures in 70% of cases. However, in 40% of the cases T. gondii isolation is successful in only one of the samples [100]. Derouin et al. [100] demonstrated similar sensitivities comparing cell culture and mice inoculation. Thulliez et al. [102] reported that the sensitivity of amniotic fluid cell culture inoculation is only 53% compared with 73% sensitivity in mice inoculation. Currently, the principle role for these methods may be confirmation of PCR as they are complex, expensive and relatively insensitive. [103]. 4.3.7. Molecular diagnosis Replacing fetal blood analysis, which is a high risk procedure for the fetus, with molecular evaluation of amniotic fluid has provided a low risk diagnosis of congenital toxoplasmosis. Polymerase chain reaction (PCR) is currently the most common molecular technique routinely used for diagnosis of toxoplasmosis, although, it has not yet been standardized. No attempts have been made to standardize either the sample preparation process or the PCR amplification itself, and numerous laboratories use multiple “in-house” methods of varying sensitivities and reliability [104,105]. Recently, a commercial PCR proficiency test became available. As in all diagnostic tests based on amplification of DNA, a few technical aspects are of crucial importance in achieving reliable results. Therefore, PCR based test should be carefully designed to include negative, positive and internal control, target DNA for amplification should be specific, sample preparation techniques should be perfected to extract minute parasite DNA [105] and to prevent cross contamination. In a small (5 laboratories) inter-laboratories comparative work [106] followed by a larger study (15 laboratories) [104] significant differences in test performances were obtained, including false negatives and false positives. These results should definitely urge optimization and standardization of the test. More recently, three PCR protocols were optimized prior to a comparative study, using three different targets: 18S ribosomal DNA, B1 gene and AF146527. No significant difference was observed between the results of the three protocols [107]. Chabbert et al. [108] used two different primer sets of the B1 gene to compare PCR performance followed by Southern blot, on various sample types (including amniotic fluid, blood and tissues). For amniotic fluid both PCR conditions produced similar results. The fragments produced by one of the primer sets had to be confirmed by specific hybridization, otherwise nonspecific results were obtained. The PCR product of the same amplification procedure was sequenced by Kompalic-Cristo and suspected of originating from human DNA, as predicted by bioinformatics analysis [109]. Different protocols influence the sensitivity and specificity of PCR assays. The specificity and positive predictive value of PCR tests on amniotic fluid samples is close to 100% [110,111]. However, the sensitivity of these PCR tests varies and estimated, based on a large number of studies, to be 70–80% [105]. One report showed that the sensitivity of PCR from amniotic fluid is affected by the stage of pregnancy in which maternal infection occurs: best sensitivity was detected when maternal infection occurred between 17 and 21 weeks of pregnancy [89,111,112]. In addition, treatment with anti-toxoplasma drugs may also affect the sensitivity [89,112]. However, the reliability of a PCR test performed on amniotic fluid prior to the 18th week of pregnancy requires further evaluation [110,111]. It should also be noted, that testing amniotic fluid for T. gondii was found to be effective about 4 weeks following infection, which is already during the parasitemic stage in the infected mother. Therefore, PCR test should not be performed in the absence of serologic or other clinical/sonographic data indicative of infection. In the last 4 years there have been reports on the use of Real Time PCR, a sensitive and specific technique, which enables rapid detection of amplification products as well as hybridization of amplicon-specific probes, similar to PCR followed by Southern blot analysis. The method, which will ultimately replace traditional PCR, enables an overall time for amplification and detection of less than two hours. In addition, cross contamination is prevented by elimination of the need to handle amplified amplicons. In Real Time PCR it is possible to perform a quantitative study and follow the parasite load, allowing determination of parasite count and its correlation with clinical symptoms and impact of treatment. The technique permits linear range over 6 logs of DNA concentrations [113,114]. E. Rorman et al. / Reproductive Toxicology 21 (2006) 458–472 The most popular target gene for PCR diagnosis of T. gondii is the 35-fold repetitive gene B1. A variety of primers have been used for amplification, some of which include nested primers. The second common locus is the single copy gene P30 also known as SAG1, which encodes for a surface antigen. Another PCR target is the 18S ribosomal DNA. As reviewed by Bastien [105], two other target loci have been examined but are currently not used by most laboratories. Recently, some laboratories have shown success in amplification of a DNA fragment, AF146527, which is repeated 200–300 times [89,113,114]. 4.4. Laboratory diagnosis of infants Laboratory diagnosis of Toxoplasma infection in infants is based on a combination of serologic tests, parasite isolation, and nonspecific findings [112]. When suspected, serologic follow-up of the newborn is recommended for the first year of life [90]. Evaluation for direct evidence as described above should be repeated as well during this period. Serologic tests should follow total (or IgG) T. gondii specific antibodies titer (taking into account that closely after birth these are maternal in origin, transferred through the placenta), IgM and IgA titers. Though passively transferred maternal IgG has a half life of approximately 1 month, it can still be detected in the newborn for several months, generally disappearing completely within one year [112]. Appearance of autonomous IgG antibodies in a congenitally infected newborn begins, in an untreated patient, about 3 months after birth. Anti-parasitic therapy may delay antibody production for about 6 months and, occasionally, may completely prevent antibodies production [86]. 4.4.1. Western blots Remington et al. introduced Western blots (using T. gondiispecific labeled antigens to detect antibodies, separated by electrophoresis and transferred to a membrane) to compare newborn versus maternal antibodies [115–117]. Western blotting could potentially separate maternal from fetal/newborn antibodies. The test is not widely used mainly because of its technical complexity and high price. 5. Treatment of congenital toxoplasmosis Anti T. gondii treatment initiation generally requires confirmatory laboratory tests in a reference center, followed by consultation with experts. Treatment is indicated in the following conditions: infection during pregnancy and congenital infection as well as infection of an immunocompromised host (e.g. HIV/AIDS) and in case of an invasive disease. In pregnant women and infected neonates, both symptomatic and asymptomatic, specific treatment of T. gondii infection is indicated immediately following established diagnosis. The combination of pyrimethamine, (adult dosage 25–100 mg/d × 3–4 weeks), sulfadiazine adult dosage 1–1.5 g qid × 3–4 weeks) and folinic acid (leucovorin, 10–25 mg with each dose of pyrimethamine, to avoid bone marrow suppression) is the basic treatment protocol recommended by the WHO [118] and CDC [119]. Other 467 drugs such as spiramycin (adult dosage 3–4 g/d × 3–4 weeks) and sometimes clindamycin are recommended in certain circumstances. Spiramycin is used to prevent placental infection; it is used in many European countries especially France, Asia and South America. In the US, spiramycin is currently not approved by the FDA but, available as an investigational drug, requiring special approval. Treatment with pyrimethamine and sulfadiazine to prevent fetal infection is contraindicated during the first trimester of pregnancy due to concerns regarding teratogenicity, except when the mother’s health is seriously endangered. During the first trimester sulfadiazine can be used alone. As recently reviewed by Montoya and Liesenfeld [112], treatment protocols vary among different centers. The effectivity of anti-T. gondii treatment is evaluated based on two criteria: rate of mother to child transmission and prevalence and severity of sequelae. The majority of the studies are retrospective or cohort studies of various populations and case definitions. The difference in study patterns and methodologies affects the reliability and validity of the results and thus prevents issuing further recommendations. Wallon et al. [120] reviewed studies comparing treated and untreated concurrent groups of pregnant women with proved or likely acute toxoplasma infection. Outcomes data of the offspring were reported. The results showed treatment to be effective in five studies but ineffective in four. Gras et al. [121] reported that the effect of prenatal pyrimethamine–sulfadiazine combination treatment on the cerebral and ocular sequelae of intrauterine infection with T. gondii was not beneficial in 181 children of infected mothers. Neto reported the outcome of patients with congenital toxoplasmosis who were all treated with pyrimethamine, sulfadiazine and folinic acid; of 195 patients 138 (71%) were asymptomatic until the age of 2 years. The authors suggest that for six patients with sequelae because of the delay in anti-toxoplasma treatment (6–14 months post diagnosis) the disease was not prevented [122]. Gratzl et al. [123] reported variable concentrations of spiramycin and its metabolites in serum and amniotic fluid of 18 pregnant women following treatment. All the drug concentrations were below the level reported to inhibit parasite growth in vitro. The authors suggested that the possible reasons being individual pharmatokinetic variability and patients’ treatment compliance. Gilbert et al. [124] reported the effect of prenatal treatment in 554 infected women and their offspring. In this study comparison of early versus late treatment and of combination treatment (pyrimethamine, sulfadiazine) with spiramycin or no-treatment, were all statistically insignificant. The possible interpretation is that delayed treatment initiation led to failure to prevent parasite transmission. Another European multicenter study comparing transmission rates and clinical outcomes in 856 mother–infant pairs, found no significant association between the outcome and the intensity of treatment protocol in pregnancy [125]. Bessieres et al. [126] studied the effect of treatment during pregnancy in a cohort of 165 women and found that cases could be identified during pregnancy as well as during the neonatal period. They also noted that T. gondii was less frequently isolated in women treated with pyrimethamine and sulfadoxine than in women treated with spiramycin only. Foulon et al. [127] reviewed the measures 468 E. Rorman et al. / Reproductive Toxicology 21 (2006) 458–472 6.1.1. Vaccine Development of a vaccine for toxoplasmosis can prevent human disease by immunization of human as well as animals (the source of infection). Both attenuated parasite and immunogenic antigens are considered as potential agents for vaccination. Live attenuated S48 strain is in use for vaccination of sheep in Europe and New Zealand but is unsuitable for human use due to its expense, short shelf life and most importantly, to the ability of the attenuated parasite to revert to a pathogenic strain [130–133]. Much of the work has been focused on SAG1, a surface antigen expressed on tachyzoites, in attempts to induce protective immune response (mainly T-helper response) when introduced to the host with various adjuvants [134–136]. Development of vaccine using antigens expressed by bradyzoites and oocytes is also under investigation[134,137]. State of Goias, Brazil as recommended by experts [127]. Screening of women should begin prior to conception with follow-up monthly tests during pregnancy to detect seroconverion. This is the basis for the French [138] screening program and the Austrian Toxoplasmosis Prevention Programs, both recommend routine serologic testing, in Austria three times during pregnancy: in the first, second and third trimesters and in France six times following the initial finding [139]. Treatment is recommended if one of the tests suggests definite or probable primary maternal infection [140]. In Massachusetts, USA, where there is low seroprevalence in the population, only newborns are screened for the presence of T. gondii-specific IgM [141]. IgM detection is followed by an extensive clinical evaluation and a one year treatment regimen combination of pyrimethamine and sulfadiazine [140]. A recent study screened 364,130 neonates in the United States for T. gondii specific IgM and confirmed 195 cases of congenital toxoplasmosis (1 in 1867). Moreover, a 7year follow-up of the treated patients revealed no symptoms or at least no progress of the disease. Based on these findings, the authors suggest including toxoplasmosis in neonatal screening programs [122]. In the United Kingdom a national committee concluded that no prenatal or neonatal screening for T. gondii should be performed, which brought out controversy among specialists [142]. A survey conducted in Italy reported 35/1000 pregnant women with primary T. gondii infection and recommended maternal screening during pregnancy rather than neonatal screening [143]. In Norway, screening of pregnant women was recommended until 1977 when the National Institute of Public Health discouraged it, following a large study that showed low (0.17 %) incidence of primary infection during pregnancy [144]. Two years following this change in policy, a study by Eskild et al. [145] showed that despite the recommendations, 81% of the pregnant women were still routinely tested for T. gondii-specific antibodies. In Finland, a cost-benefit analyses of screening programs for pregnant women as well as education programs revealed the beneficial effect of such programs in both low and high incidences of toxoplasmosis [146]. Cost-effectiveness of optional screening programs (no screening, pre-conception or neonates screening, frequency of tests during pregnancy) depends on local factors: incidence of congenital toxoplasmosis, available diagnostic and therapeutic services, and the population compliance with screening. It is important to promote public, as well as professional, knowledge regarding the disease, in order to effectively prevent, diagnose and treat congenital toxoplasmosis. In conclusion, it is highly recommended to educate the public and professionals to minimize risk of infection. Screening programs of women at childbearing age and upon gestation or at least newborn screening is highly effective for early treatment and prevention of sequelae. 6.2. Secondary prevention – screening Acknowledgments Routine toxoplasmosis screening programs for pregnant women have been established in France, in Austria and in the Dr. Irena Volovik Sub-district Health Officer, Hadera, Israel, for providing data of the presented case. of prevention of congenital toxoplasmosis and concluded that treatment during pregnancy significantly reduces sequelae and treatment of infected children has a beneficial effect when therapy is begun soon after birth. In conclusion, the efficacy of anti-T. gondii treatment in pregnancy is still an unsettled matter. It is difficult to find the effect of treatment when comparing the different studies because of: different treatment regimes and timing (for small groups of patients), the pharmacokinetics patterns of drugs (concentration in amniotic fluid and fetal CSF), patient (none) compliance with treatment and different methodologies of follow-up in each study. As concluded by Peyron et al. [128] and others, further large scale, carefully controlled studies are necessary in order to clarify this controversial issue. At present the anti-parasite treatment recommended for toxoplasmosis as outlined above, should be considered as the guideline for good medical practice. 6. Prevention 6.1. Primary prevention In the United States efforts at prevention of congenital toxoplasmosis have been primarily directed towards health education, focused to avoid personal exposure to the parasite (hygienic and culinary practice during pregnancy). In Poland, an extensive health education campaign, increased toxoplasmosis awareness and knowledge of preventive behaviour significantly within the 4 years of the reported study [129]. Many other countries have introduced educational programs aimed at reducing the incidence of congenital toxoplasmosis. Such programs depend on careful identification of unique target-populations and tailoring appropriate approaches of education. To evaluate the success of such programs it is important to measure incidence rate before onset and at pre-determined intervals after introducing the campaign. E. Rorman et al. / Reproductive Toxicology 21 (2006) 458–472 Mrs. R. Kaufman and Mrs. R. Avni for excellent laboratory work. References [1] Dubey JP, Lindsay DS, Speer CA. Structures of Toxoplasma gondii tachyzoites, bradyzoites, and sporozoites and biology and development of tissue cysts. Clin Microbiol Rev 1998;11:267–99. [2] Black MW, Boothroyd JC. Lytic cycle of Toxoplasma gondii. Microbiol Mol Biol Rev 2000;64:607–23. [3] Lekutis C, Ferguson DJ, Boothroyd JC. Toxoplasma gondii: identification of a developmentally regulated family of genes related to SAG2. Exp Parasitol 2000;96:89–96. [4] Lyons RE, McLeod R, Roberts CW. Toxoplasma gondii tachyzoitebradyzoite interconversion. Trends Parasitol 2002;18:198–201. [5] Manger ID, Hehl AB, Boothroyd JC. The surface of Toxoplasma tachyzoites is dominated by a family of glycosylphosphatidylinositolanchored antigens related to SAG1. Infect Immun 1998;66:2237–44. [6] Dubey JP, Miller NL, Frenkel JK. The Toxoplasma gondii oocyst from cat feces. J Exp Med 1970;132:636–62. [7] Coutinho SG, Lobo R, Dutra G. Isolation of Toxoplasma from the soil during an outbreak of toxoplasmosis in a rural area in Brazil. J Parasitol 1982;68:866–8. [8] Bahia-Oliveira LM, Jones JL, Azevedo-Silva J, Alves CC, Orefice F, Addiss DG. Highly endemic, waterborne toxoplasmosis in north Rio de Janeiro state, Brazil. Emerg Infect Dis 2003;9:55–62. [9] Benenson MW, Takafuji ET, Lemon SM, Greenup RL, Sulzer AJ. Oocyst-transmitted toxoplasmosis associated with ingestion of contaminated water. N Engl J Med 1982;307:666–9. [10] Bowie WR, King AS, Werker DH, Isaac-Renton JL, Bell A, Eng SB, et al. Outbreak of toxoplasmosis associated with municipal drinking water. The BC Toxoplasma Investigation Team. Lancet 1997;350:173–7. [11] Dumetre A, Darde ML. How to detect Toxoplasma gondii oocysts in environmental samples? FEMS Microbiol Rev 2003;27:651–61. [12] Jones JL, Lopez A, Wilson M, Schulkin J, Gibbs R. Congenital toxoplasmosis: a review. Obstet Gynecol Surv 2001;56:296–305. [13] Hoff EF, Carruthers VB. Is Toxoplasma egress the first step in invasion? Trends Parasitol 2002;18:251–5. [14] Barragan A, Sibley LD. Migration of Toxoplasma gondii across biological barriers. Trends Microbiol 2003;11:426–30. [15] Kasper LH, Mineo JR. Attachment and invension of host cell by Toxoplasma gondii. Parasitol Today 1994;10:82–5. [16] Suss-Toby E, Zimmerberg J, Ward GE. Toxoplasma invasion: the parasitophorous vacuole is formed from host cell plasma membrane and pinches off via a fission pore. Proc Natl Acad Sci USA 1996;93:8413–8. [17] Hakansson S, Morisaki H, Heuser J, Sibley LD. Time-lapse video microscopy of gliding motility in Toxoplasma gondii reveals a novel, biphasic mechanism of cell locomotion. Mol Biol Cell 1999;10:3539–47. [18] Mordue DG, Desai N, Dustin M, Sibley LD. Invasion by Toxoplasma gondii establishes a moving junction that selectively excludes host cell plasma membrane proteins on the basis of their membrane anchoring. J Exp Med 1999;190:1783–92. [19] Mordue DG, Hakansson S, Niesman I, Sibley LD. Toxoplasma gondii resides in a vacuole that avoids fusion with host cell endocytic and exocytic vesicular trafficking pathways. Exp Parasitol 1999;92:87–99. [20] Lecordier L, Mercier C, Sibley LD, Cesbron-Delauw MF. Transmembrane insertion of the Toxoplasma gondii GRA5 protein occurs after soluble secretion into the host cell. Mol Biol Cell 1999;10:1277–87. [21] Opitz C, Soldati D. ’The glideosome’: a dynamic complex powering gliding motion and host cell invasion by Toxoplasma gondii. Mol Microbiol 2002;45:597–604. [22] Sibley LD. Intracellular parasite invasion strategies. Science 2004;304:248–53. 469 [23] Barragan A, Sibley LD. Transepithelial migration of Toxoplasma gondii is linked to parasite motility and virulence. J Exp Med 2002;195:1625–33. [24] Su C, Howe DK, Dubey JP, Ajioka JW, Sibley LD. Identification of quantitative trait loci controlling acute virulence in Toxoplasma gondii. Proc Natl Acad Sci USA 2002;99:10753–8. [25] Weiss LM, Kim K. The International Congress on Toxoplasmosis. Int J Parasitol 2004;34:249–52. [26] Kissinger JC, Gajria B, Li L, Paulsen IT, Roos DS. ToxoDB: accessing the Toxoplasma gondii genome. Nucleic Acids Res 2003;31:234–6. [27] Bhopale GM. Pathogenesis of toxoplasmosis. Comp Immunol Microbiol Infect Dis 2003;26:213–22. [28] Sibley LD, Boothroyd JC. Virulent strains of Toxoplasma gondii comprise a single clonal lineage. Nature 1992;359:82–5. [29] Howe DK, Sibley LD. Toxoplasma gondii comprises three clonal lineages: correlation of parasite genotype with human disease. J Infect Dis 1995;172:1561–6. [30] Ware PL, Kasper LH. Strain-specific antigens of Toxoplasma gondii. Infect Immun 1987;55:778–83. [31] Kong JT, Grigg ME, Uyetake L, Parmley S, Boothroyd JC. Serotyping of Toxoplasma gondii infections in humans using synthetic peptides. J Infect Dis 2003;187:1484–95. [32] Ajzenberg D, Cogne N, Paris L, Bessieres MH, Thulliez P, Filisetti D, et al. Genotype of 86 Toxoplasma gondii isolates associated with human congenital toxoplasmosis, and correlation with clinical findings. J Infect Dis 2002;186:684–9. [33] Ferguson DJ, Pittilo RM. Toxoplasma gondii and the professor. Parasitol Today 1999;15:301–2. [34] Grigg ME, Bonnefoy S, Hehl AB, Suzuki Y, Boothroyd JC. Success and virulence in Toxoplasma as the result of sexual recombination between two distinct ancestries. Science 2001;294:161–5. [35] Su C, Evans D, Cole RH, Kissinger JC, Ajioka JW, Sibley LD. Recent expansion of Toxoplasma through enhanced oral transmission. Science 2003;299:414–6. [36] Volkman SK, Hartl DL, Parasitology. A game of cat and mouth. Science 2003;299:353–4. [37] Suzuki Y, Wong SY, Grumet FC, Fessel J, Montoya JG, Zolopa AR, et al. Evidence for genetic regulation of susceptibility to toxoplasmic encephalitis in AIDS patients. J Infect Dis 1996;173:265–8. [38] Mack DG, Johnson JJ, Roberts F, Roberts CW, Estes RG, David C, et al. HLA-class II genes modify outcome of Toxoplasma gondii infection. Int J Parasitol 1999;29:1351–8. [39] Herwaldt BL. Laboratory-acquired parasitic infections from accidental exposures. Clin Microbiol Rev 2001;14:659–88, table of contents. [40] Tenter AM, Heckeroth AR, Weiss LM. Toxoplasma gondii: from animals to humans. Int J Parasitol 2000;30:1217–58. [41] Jones JL, Kruszon-Moran D, Wilson M, McQuillan G, Navin T, McAuley JB. Toxoplasma gondii infection in the United States: seroprevalence and risk factors. Am J Epidemiol 2001;154:357–65. [42] Cook AJ, Gilbert RE, Buffolano W, Zufferey J, Petersen E, Jenum PA, et al. Sources of toxoplasma infection in pregnant women: European multicentre case–control study. European Research Network on Congenital Toxoplasmosis. BMJ 2000;321:142–7. [43] Aspinall TV, Marlee D, Hyde JE, Sims PF. Prevalence of Toxoplasma gondii in commercial meat products as monitored by polymerase chain reaction—food for thought? Int J Parasitol 2002;32:1193–9. [44] Lappin MR, Burney DP, Hill SA, Chavkin MJ. Detection of Toxoplasma gondii-specific IgA in the aqueous humor of cats. Am J Vet Res 1995;56:774–8. [45] Dubey JP. Duration of immunity to shedding of Toxoplasma gondii oocysts by cats. J Parasitol 1995;81:410–5. [46] Dubey JP. Sources of Toxoplasma gondii infection in pregnancy. Until rates of congenital toxoplasmosis fall, control measures are essential. BMJ 2000;321:127–8. [47] Dubey JP, Beattie CP. Toxoplasmosis of animals and man. Boca Raton: CRC Press; 1988. [48] Franklin DM, Dror Z, Nishri Z. The prevalence and incidence of Toxoplasma antibodies in pregnant women. Isr J Med Sci 1993;29:285–6. 470 E. Rorman et al. / Reproductive Toxicology 21 (2006) 458–472 [49] Teutsch SM, Juranek DD, Sulzer A, Dubey JP, Sikes RK. Epidemic toxoplasmosis associated with infected cats. N Engl J Med 1979;300:695–9. [50] Stagno S, Dykes AC, Amos CS, Head RA, Juranek DD, Walls K. An outbreak of toxoplasmosis linked to cats. Pediatrics 1980;65:706– 12. [51] Isaac-Renton J, Bowie WR, King A, Irwin GS, Ong CS, Fung CP, et al. Detection of Toxoplasma gondii oocysts in drinking water. Appl Environ Microbiol 1998;64:2278–80. [52] Kourenti C, Heckeroth A, Tenter A, Karanis P. Development and application of different methods for the detection of Toxoplasma gondii in water. Appl Environ Microbiol 2003;69:102–6. [53] Mead PS, Slutsker L, Dietz V, McCaig LF, Bresee JS, Shapiro C, et al. Food-related illness and death in the United States. Emerg Infect Dis 1999;5:607–25. [54] Lynfield R, Guerina NG. Toxoplasmosis. Pediatr Rev 1997;18:75–83. [55] Feigen RD, Adcock LM, Edwards MS. Fungel and protozoal infections (Toxoplasmosis). In: Fanaroff AA, Martin RJ, editors. Neonatal perinatal medicine disease of the fetus and infant. 5th ed. Mosby Year Book; 1992. p. 688–90. [56] Guerina NG. Congenital infection with Toxoplasma gondii. Pediatr Ann 1994;23:138–42, 47–51. [57] Avelino MM, Campos Jr D, do Carmo Barbosa de Parada J, de Castro AM. Pregnancy as a risk factor for acute toxoplasmosis seroconversion. Eur J Obstet Gynecol Reprod Biol 2003;108:19–24. [58] Dollfus H, Dureau P, Hennequin C, Uteza Y, Bron A, Dufier JL. Congenital toxoplasma chorioretinitis transmitted by preconceptionally immune women. Br J Ophthalmol 1998;82:1444–5. [59] Silveira C, Ferreira R, Muccioli C, Nussenblatt R, Belfort Jr R. Toxoplasmosis transmitted to a newborn from the mother infected 20 years earlier. Am J Ophthalmol 2003;136:370–1. [60] Chemla C, Villena I, Aubert D, Hornoy P, Dupouy D, Leroux B, et al. Preconception seroconversion and maternal seronegativity at delivery do not rule out the risk of congenital toxoplasmosis. Clin Diagn Lab Immunol 2002;9:489–90. [61] Lebech M, Joynson DH, Seitz HM, Thulliez P, Gilbert RE, Dutton GN, et al. Classification system and case definitions of Toxoplasma gondii infection in immunocompetent pregnant women and their congenitally infected offspring. European Research Network on Congenital Toxoplasmosis. Eur J Clin Microbiol Infect Dis 1996;15:799– 805. [62] El Ayoubi M, de Bethmann O, Monset-Couchard M. Lenticulostriate echogenic vessels: clinical and sonographic study of 70 neonatal cases. Pediatr Radiol 2003;33:697–703. [63] Gay-Andrieu F, Marty P, Pialat J, Sournies G, Drier de Laforte T, Peyron F. Fetal toxoplasmosis and negative amniocentesis: necessity of an ultrasound follow-up. Prenat Diagn 2003;23:558–60. [64] Crino JP. Ultrasound and fetal diagnosis of perinatal infection. Clin Obstet Gynecol 1999;42:71–80, quiz 174–5. [65] Safadi MA, Berezin EN, Farhat CK, Carvalho ES. Clinical presentation and follow up of children with congenital toxoplasmosis in Brazil. Braz J Infect Dis 2003;7:325–31. [66] Carvalheiro CG, Mussi-Pinhata MM, Yamamoto AY, De Souza CB, Maciel LM. Incidence of congenital toxoplasmosis estimated by neonatal screening: relevance of diagnostic confirmation in asymptomatic newborn infants. Epidemiol Infect 2005;133:485–91. [67] Remington JS, Desmonts G. Infectious Diseases of the Fetus and Newborn Infant. In: Remington JS, Klein JD, editors. Toxoplasmosis. 3rd ed. Philadelphia: WB Saunders; 1990. p. 89–195. [68] Freeman K, Oakley L, Pollak A, Buffolano W, Petersen E, Semprini AE, et al. Association between congenital toxoplasmosis and preterm birth, low birthweight and small for gestational age birth. BJOG 2005;112:31–7. [69] Swisher CN, Boyer K, McLeod R. Congenital toxoplasmosis. The Toxoplasmosis Study Group. Semin Pediatr Neurol 1994;1:4–25. [70] Vutova K, Peicheva Z, Popova A, Markova V, Mincheva N, Todorov T. Congenital toxoplasmosis: eye manifestations in infants and children. Ann Trop Paediatr 2002;22:213–8. [71] Wallon M, Kodjikian L, Binquet C, Garweg J, Fleury J, Quantin C, et al. Long-term ocular prognosis in 327 children with congenital toxoplasmosis. Pediatrics 2004;113:1567–72. [72] Potasman I, Davidovitch M, Tal Y, Tal J, Zelnik N, Jaffe M. Congenital toxoplasmosis: a significant cause of neurological morbidity in Israel? Clin Infect Dis 1995;20:259–62. [73] Bobic B, Sibalic D, Djurkovic-Djakovic O. High levels of IgM antibodies specific for Toxoplasma gondii in pregnancy 12 years after primary toxoplasma infection. Case report. Gynecol Obstet Invest 1991;31:182–4. [74] Pinon JM, Toubas D, Marx C, Mougeot G, Bonnin A, Bonhomme A, et al. Detection of specific immunoglobulin E in patients with toxoplasmosis. J Clin Microbiol 1990;28:1739–43. [75] Roberts A, Hedman K, Luyasu V, Zufferey J, Bessieres MH, Blatz RM, et al. Multicenter evaluation of strategies for serodiagnosis of primary infection with Toxoplasma gondii. Eur J Clin Microbiol Infect Dis 2001;20:467–74. [76] Sabin AB, Feldman HA. Dyes as microchemical indicators of a new immunity phenomenon affecting a protozon parasite (Toxoplasma). Science 1948;108:660–3. [77] Reiter-Owona I, Petersen E, Joynson D, Aspock H, Darde ML, Disko R, et al. The past and present role of the Sabin-Feldman dye test in the serodiagnosis of toxoplasmosis. Bull World Health Org 1999;77:929–35. [78] Rigsby P, Rijpkema S, Guy EC, Francis J, Das RG. Evaluation of a candidate international standard preparation for human antiToxoplasma immunoglobulin G. J Clin Microbiol 2004;42:5133–8. [79] Stepick-Biek P, Thulliez P, Araujo FG, Remington JS. IgA antibodies for diagnosis of acute congenital and acquired toxoplasmosis. J Infect Dis 1990;162:270–3. [80] Duffy KT, Wharton PJ, Johnson JD, New L, Holliman RE. Assessment of immunoglobulin-M immunosorbent agglutination assay (ISAGA) for detecting toxoplasma specific IgM. J Clin Pathol 1989;42:1291–5. [81] Ashburn D, Joss AW, Pennington TH, Ho-Yen DO. Specificity and usefulness of an IgE immunosorbent agglutination assay for toxoplasmosis. J Clin Pathol 1995;48:64–9. [82] Desmonts G, Naot Y, Remington JS, Immunoglobulin. Mimmunosorbent agglutination assay for diagnosis of infectious diseases: diagnosis of acute congenital and acquired Toxoplasma infections. J Clin Microbiol 1981;14:486–91. [83] Wong SY, Hajdu MP, Ramirez R, Thulliez P, McLeod R, Remington JS. Role of specific immunoglobulin E in diagnosis of acute toxoplasma infection and toxoplasmosis. J Clin Microbiol 1993;31:2952–9. [84] Remington PL, Anderson DE, Manering MC, Peterson EA, Anderson H. The PRECEDES Project: background and methods. Wis Med J 1990;89:695–6. [85] Araujo FG, Handman E, Remington JS. Use of monoclonal antibodies to detect antigens of Toxoplasma gondii in serum and other body fluids. Infect Immun 1980;30:12–6. [86] Wilson M, Jones JL, McAuley JB. Toxoplasma. In: Murray PR, Baron EJ, Jorgensen JH, Pfaller MA, Yolken RH, editors. Manuel of clinical microbiology, Vol. 2, 8th ed. ASM Press; 2003. p. 1970–80. [87] Remington JS, Araujo FG, Desmonts G. Recognition of different Toxoplasma antigens by IgM and IgG antibodies in mothers and their congenitally infected newborns. J Infect Dis 1985;152:1020–4. [88] Montoya JG, Liesenfeld O, Kinney S, Press C, Remington JS. VIDAS test for avidity of Toxoplasma-specific immunoglobulin G for confirmatory testing of pregnant women. J Clin Microbiol 2002;40:2504–8. [89] Remington JS, Thulliez P, Montoya JG. Recent developments for diagnosis of toxoplasmosis. J Clin Microbiol 2004;42:941–5. [90] Montoya JG. Laboratory diagnosis of Toxoplasma gondii infection and toxoplasmosis. J Infect Dis 2002;185(Suppl. 1):S73–82. [91] Lappalainen M, Koskiniemi M, Hiilesmaa V, Ammala P, Teramo K, Koskela P, et al. Outcome of children after maternal primary Toxoplasma infection during pregnancy with emphasis on avidity of specific IgG. The Study Group. Pediatr Infect Dis J 1995;14:354–61. [92] Alvarado-Esquivel C, Sethi S, Janitschke K, Hahn H, Liesenfeld O. Comparison of two commercially available avidity tests E. Rorman et al. / Reproductive Toxicology 21 (2006) 458–472 [93] [94] [95] [96] [97] [98] [99] [100] [101] [102] [103] [104] [105] [106] [107] [108] [109] [110] [111] [112] for toxoplasma-specific IgG antibodies. Arch Med Res 2002;33: 520–3. Liesenfeld O, Montoya JG, Kinney S, Press C, Remington JS. Effect of testing for IgG avidity in the diagnosis of Toxoplasma gondii infection in pregnant women: experience in a US reference laboratory. J Infect Dis 2001;183:1248–53. Pietkiewicz H, Hiszczynska-Sawicka E, Kur J, Petersen E, Nielsen HV, Stankiewicz M, et al. Usefulness of Toxoplasma gondii-specific recombinant antigens in serodiagnosis of human toxoplasmosis. J Clin Microbiol 2004;42:1779–81. Li S, Galvan G, Araujo FG, Suzuki Y, Remington JS, Parmley S. Serodiagnosis of recently acquired Toxoplasma gondii infection using an enzyme-linked immunosorbent assay with a combination of recombinant antigens. Clin Diagn Lab Immunol 2000;7:781–7. Aubert D, Maine GT, Villena I, Hunt JC, Howard L, Sheu M, et al. Recombinant antigens to detect Toxoplasma gondii-specific immunoglobulin G and immunoglobulin M in human sera by enzyme immunoassay. J Clin Microbiol 2000;38:1144–50. Li S, Maine G, Suzuki Y, Araujo FG, Galvan G, Remington JS, et al. Serodiagnosis of recently acquired Toxoplasma gondii infection with a recombinant antigen. J Clin Microbiol 2000;38:179–84. Nigro M, Gutierrez A, Hoffer AM, Clemente M, Kaufer F, Carral L, et al. Evaluation of Toxoplasma gondii recombinant proteins for the diagnosis of recently acquired toxoplasmosis by an immunoglobulin G analysis. Diagn Microbiol Infect Dis 2003;47:609–13. Daffos F, Forestier F, Capella-Pavlovsky M, Thulliez P, Aufrant C, Valenti D, et al. Prenatal management of 746 pregnancies at risk for congenital toxoplasmosis. N Engl J Med 1988;318:271–5. Derouin F, Mazeron MC, Garin YJ. Comparative study of tissue culture and mouse inoculation methods for demonstration of Toxoplasma gondii. J Clin Microbiol 1987;25:1597–600. Derouin F, Thulliez P, Candolfi E, Daffos F, Forestier F. Early prenatal diagnosis of congenital toxoplasmosis using amniotic fluid samples and tissue culture. Eur J Clin Microbiol Infect Dis 1988;7:423–5. Thulliez P, Daffos F, Forestier F. Diagnosis of Toxoplasma infection in the pregnant woman and the unborn child: current problems. Scand J Infect Dis Suppl 1992;84:18–22. Foulon W, Pinon JM, Stray-Pedersen B, Pollak A, Lappalainen M, Decoster A, et al. Prenatal diagnosis of congenital toxoplasmosis: a multicenter evaluation of different diagnostic parameters. Am J Obstet Gynecol 1999;181:843–7. Pelloux H, Guy E, Angelici MC, Aspock H, Bessieres MH, Blatz R, et al. A second European collaborative study on polymerase chain reaction for Toxoplasma gondii, involving 15 teams. FEMS Microbiol Lett 1998;165:231–7. Bastien P. Molecular diagnosis of toxoplasmosis. Trans R Soc Trop Med Hyg 2002;96(Suppl 1):S205–15. Guy EC, Pelloux H, Lappalainen M, Aspock H, Hassl A, Melby KK, et al. Interlaboratory comparison of polymerase chain reaction for the detection of Toxoplasma gondii DNA added to samples of amniotic fluid. Eur J Clin Microbiol Infect Dis 1996;15:836–9. Filisetti D, Gorcii M, Pernot-Marino E, Villard O, Candolfi E. Diagnosis of congenital toxoplasmosis: comparison of targets for detection of Toxoplasma gondii by PCR. J Clin Microbiol 2003;41:4826–8. Chabbert E, Lachaud L, Crobu L, Bastien P. Comparison of two widely used PCR primer systems for detection of toxoplasma in amniotic fluid, blood, and tissues. J Clin Microbiol 2004;42:1719–22. Kompalic-Cristo A, Nogueira SA, Guedes AL, Frota C, Gonzalez LF, Brandao A, et al. Lack of technical specificity in the molecular diagnosis of toxoplasmosis. Trans R Soc Trop Med Hyg 2004;98:92–5. Hohlfeld P, Daffos F, Costa JM, Thulliez P, Forestier F, Vidaud M. Prenatal diagnosis of congenital toxoplasmosis with a polymerase chain reaction test on amniotic fluid. N Engl J Med 1994;331:695–9. Romand S, Wallon M, Franck J, Thulliez P, Peyron F, Dumon H. Prenatal diagnosis using polymerase chain reaction on amniotic fluid for congenital toxoplasmosis. Obstet Gynecol 2001;97:296–300. Montoya JG, Liesenfeld O. Toxoplasmosis Lancet 2004;363:1965– 76. 471 [113] Homan WL, Vercammen M, De Braekeleer J, Verschueren H. Identification of a 200- to 300-fold repetitive 529 bp DNA fragment in Toxoplasma gondii, and its use for diagnostic and quantitative PCR. Int J Parasitol 2000;30:69–75. [114] Reischl U, Bretagne S, Kruger D, Ernault P, Costa JM. Comparison of two DNA targets for the diagnosis of Toxoplasmosis by real-time PCR using fluorescence resonance energy transfer hybridization probes. BMC Infect Dis 2003;3:7. [115] Robert-Gangneux F, Commerce V, Tourte-Schaefer C, Dupouy-Camet J. Performance of a Western blot assay to compare mother and newborn anti-Toxoplasma antibodies for the early neonatal diagnosis of congenital toxoplasmosis. Eur J Clin Microbiol Infect Dis 1999;18:648– 54. [116] Pinon JM, Dumon H, Chemla C, Franck J, Petersen E, Lebech M, et al. Strategy for diagnosis of congenital toxoplasmosis: evaluation of methods comparing mothers and newborns and standard methods for postnatal detection of immunoglobulin G, M, and A antibodies. J Clin Microbiol 2001;39:2267–71. [117] Tissot Dupont D, Fricker-Hidalgo H, Brenier-Pinchart MP, Bost-Bru C, Ambroise-Thomas P, Pelloux H. Usefulness of Western blot in serological follow-up of newborns suspected of congenital toxoplasmosis. Eur J Clin Microbiol Infect Dis 2003;22:122–5. [118] Drugs used in parasitic diseases, 2nd ed. Geneva: World Health Organization; 1995. [119] Chin J. Toxoplasmosis. In: Control of Communicable Disease Manual. 17th ed. Washington DC: American Public Health Association; 2000. p. 500–3. [120] Wallon M, Liou C, Garner P, Peyron F. Congenital toxoplasmosis: systematic review of evidence of efficacy of treatment in pregnancy. BMJ 1999;318:1511–4. [121] Gras L, Gilbert RE, Ades AE, Dunn DT. Effect of prenatal treatment on the risk of intracranial and ocular lesions in children with congenital toxoplasmosis. Int J Epidemiol 2001;30:1309–13. [122] Neto EC. Newborn screening for congenital infectious diseases. Emerg Infect Dis 2004;10:1068–73. [123] Gratzl R, Sodeck G, Platzer P, Jager W, Graf J, Pollak A, et al. Treatment of toxoplasmosis in pregnancy: concentrations of spiramycin and neospiramycin in maternal serum and amniotic fluid. Eur J Clin Microbiol Infect Dis 2002;21:12–6. [124] Gilbert RE, Gras L, Wallon M, Peyron F, Ades AE, Dunn DT. Effect of prenatal treatment on mother to child transmission of Toxoplasma gondii: retrospective cohort study of 554 mother-child pairs in Lyon, France. Int J Epidemiol 2001;30:1303–8. [125] Gilbert R, Dunn D, Wallon M, Hayde M, Prusa A, Lebech M, et al. Ecological comparison of the risks of mother-to-child transmission and clinical manifestations of congenital toxoplasmosis according to prenatal treatment protocol. Epidemiol Infect 2001;127:113–20. [126] Bessieres MH, Berrebi A, Rolland M, Bloom MC, Roques C, Cassaing S, et al. Neonatal screening for congenital toxoplasmosis in a cohort of 165 women infected during pregnancy and influence of in utero treatment on the results of neonatal tests. Eur J Obstet Gynecol Reprod Biol 2001;94:37–45. [127] Foulon W, Naessens A, Ho–Yen D. Prevention of congenital toxoplasmosis. J Perinat Med 2000;28:337–45. [128] Peyron F, Wallon M, Liou C, Garner P. Treatments for toxoplasmosis in pregnancy. Cochrane Database Syst Rev 2000:CD001684. [129] Pawlowski ZS, Gromadecka-Sutkiewicz M, Skommer J, Paul M, Rokossowski H, Suchocka E, et al. Impact of health education on knowledge and prevention behavior for congenital toxoplasmosis: the experience in Poznan, Poland. Health Educ Res 2001;16:493–502. [130] Letscher-Bru V, Pfaff AW, Abou-Bacar A, Filisetti D, Antoni E, Villard O, et al. Vaccination with Toxoplasma gondii SAG–1 protein is protective against congenital toxoplasmosis in BALB/c mice but not in CBA/J mice. Infect Immun 2003;71:6615–9. [131] Haumont M, Delhaye L, Garcia L, Jurado M, Mazzu P, Daminet V, et al. Protective immunity against congenital toxoplasmosis with recombinant SAG1 protein in a guinea pig model. Infect Immun 2000;68:4948–53. 472 E. Rorman et al. / Reproductive Toxicology 21 (2006) 458–472 [132] Nielsen HV, Lauemoller SL, Christiansen L, Buus S, Fomsgaard A, Petersen E. Complete protection against lethal Toxoplasma gondii infection in mice immunized with a plasmid encoding the SAG1 gene. Infect Immun 1999;67:6358–63. [133] Denkers EY, Gazzinelli RT. Regulation and function of T-cell-mediated immunity during Toxoplasma gondii infection. Clin Microbiol Rev 1998;11:569–88. [134] Bhopale GM. Development of a vaccine for toxoplasmosis: current status. Microbes Infect 2003;5:457–62. [135] Roque-Resendiz JL, Rosales R, Herion P. MVA ROP2 vaccinia virus recombinant as a vaccine candidate for toxoplasmosis. Parasitology 2004;128:397–405. [136] Mohamed RM, Aosai F, Chen M, Mun HS, Norose K, Belal US, et al. Induction of protective immunity by DNA vaccination with Toxoplasma gondii HSP70, HSP30 and SAG1 genes. Vaccine 2003;21:2852–61. [137] Buxton D, Innes EA. A commercial vaccine for ovine toxoplasmosis. Parasitology 1995;110(Suppl):S11–6. [138] Thulliez P. Screening programme for congenital toxoplasmosis in France. Scand J Infect Dis Suppl 1992;84:43–5. [139] Aspock H, Pollak A. Prevention of prenatal toxoplasmosis by serological screening of pregnant women in Austria. Scand J Infect Dis Suppl 1992;84:32–7. [140] Lopez A, Dietz VJ, Wilson M, Navin TR, Jones JL. Preventing congenital toxoplasmosis. MMWR Recomm Rep 2000;49:59– 68. [141] Hsu HW, Grady GF, Maguire JH, Weiblen BJ, Hoff R. Newborn screening for congenital Toxoplasma infection: five years experience in Massachusetts USA. Scand J Infect Dis Suppl 1992;84:59– 64. [142] Gilbert RE, Peckham CS. Congenital toxoplasmosis in the United Kingdom: to screen or not to screen? J Med Screen 2002;9:135–41. [143] Ricci M, Pentimalli H, Thaller R, Rava L, Di Ciommo V. Screening and prevention of congenital toxoplasmosis: an effectiveness study in a population with a high infection rate. J Matern Fetal Neonatal Med 2003;14:398–403. [144] Eskild A, Magnus P. Commentary: Little evidence of effective prenatal treatment against congenital toxoplasmosis––the implications for testing in pregnancy. Int J Epidemiol 2001;30:1314–5. [145] Eskild A, Fallas Dahl G, Melby KK, Nesheim BI. Testing for toxoplasmosis in pregnancy: a study of the routines in primary antenatal care. J Med Screen 2003;10:172–5. [146] Lappalainen M, Sintonen H, Koskiniemi M, Hedman K, Hiilesmaa V, Ammala P, et al. Cost-benefit analysis of screening for toxoplasmosis during pregnancy. Scand J Infect Dis 1995;27:265–72.