{"id":1957,"date":"2020-05-05T16:41:15","date_gmt":"2020-05-05T14:41:15","guid":{"rendered":"https:\/\/www.newslab.sk\/kazuistika-toxoplazmovej-meningoencefalitidy-s-fatalnym-koncom-u-hiv-pacienta\/"},"modified":"2020-05-05T16:45:41","modified_gmt":"2020-05-05T14:45:41","slug":"the-case-report-of-toxoplasmic-meningoencephalitis-with-fatal-outcome-in-hiv-patient","status":"publish","type":"post","link":"https:\/\/www.newslab.sk\/en\/the-case-report-of-toxoplasmic-meningoencephalitis-with-fatal-outcome-in-hiv-patient\/","title":{"rendered":"The case report of toxoplasmic meningoencephalitis with fatal outcome in HIV patient"},"content":{"rendered":"

*<\/strong>All tables, charts, graphs and pictures that are featured in this article can be found in the .pdf attachment at the end of the paper.<\/strong><\/span><\/p>\n

 <\/p>\n

\u00davod<\/strong><\/p>\n

Toxoplazm\u00f3za je zoonotick\u00e9 ochorenie sp\u00f4soben\u00e9 tkanivov\u00fdm parazitick\u00fdm prvokom Toxoplasma gondii<\/em>, ktor\u00e9ho definit\u00edvnym hostite\u013eom s\u00fa ma\u010dky. Parazit je celosvetovo roz\u0161\u00edren\u00fd a okrem \u010dloveka jeho hostite\u013emi s\u00fa r\u00f4zne teplokrvn\u00e9 \u017eivo\u010d\u00edchy. Toxoplasma gondii <\/em>parazituje intracelul\u00e1rne a u v\u00e4\u010d\u0161iny imunokompetentn\u00fdch os\u00f4b nesp\u00f4sobuje klinicky manifestn\u00e9 ochorenie, a\u017e 80 % pr\u00edpadov prebieha asymptomaticky. Naj\u010dastej\u0161ie postnat\u00e1lne z\u00edskan\u00e1 ak\u00fatna toxoplazm\u00f3za prebieha ako lymfoglandul\u00e1rna forma (zv\u00e4\u010d\u0161enie lymfatick\u00fdch uzl\u00edn v oblasti krku, v podpazu\u0161\u00ed a inguin\u00e1ch, ktor\u00e9 s\u00fa zvy\u010dajne nebolestiv\u00e9). Parazit v\u0161ak m\u00f4\u017ee sp\u00f4sobi\u0165 devastuj\u00face ochorenie v ur\u010dit\u00fdch skupin\u00e1ch pacientov, najm\u00e4 kongenit\u00e1lne infikovan\u00fdch det\u00ed, pacientov po org\u00e1nov\u00fdch transplant\u00e1ci\u00e1ch, u onkologick\u00fdch os\u00f4b a pacientov so z\u00edskan\u00fdm syndr\u00f3mom imunitnej deficiencie (AIDS).<\/p>\n

Kongenit\u00e1lna toxoplazm\u00f3za u naroden\u00fdch det\u00ed sp\u00f4sobuje hydrocefalus, mikrocef\u00e1liu a kalcifik\u00e1ty (tzv. tri\u00e1du pr\u00edznakov). Ku kongenit\u00e1lnej infekcii m\u00f4\u017ee d\u00f4js\u0165 v pr\u00edpade, ke\u010f je \u017eena v gravidite infikovan\u00e1 prv\u00fdkr\u00e1t. Frekvencia transplacent\u00e1rnych prenosov je ni\u017e\u0161ia na za\u010diatku tehotnosti, pri\u010dom v\u0161ak klinick\u00e1 z\u00e1va\u017enos\u0165 pre infikovan\u00fd plod v 1. trimestri je maxim\u00e1lna a m\u00e1 zl\u00fa progn\u00f3zu (abort \u010di chorioretinit\u00eddu). Pre o\u010dn\u00fa toxoplazm\u00f3zu s\u00fa pr\u00edzna\u010dn\u00e9 charakteristick\u00e9 l\u00e9zie v sietnici. Ve\u013emi nebezpe\u010dn\u00e9 s\u00fa reaktiv\u00e1cie latentnej \u010di chronickej infekcie u imunosuprimovan\u00fdch pacientov, kde b\u00fdva naj\u010dastej\u0161ie postihnut\u00e1 centr\u00e1lna nervov\u00e1 s\u00fastava a ochorenie sa mnohokr\u00e1t kon\u010d\u00ed fat\u00e1lne. Charakteristick\u00fdmi pr\u00edznakmi neurotoxoplazm\u00f3zy s\u00fa dif\u00fazna encefalopatia, meningoencefalit\u00edda, mozgov\u00e9 l\u00e9zie sprev\u00e1dzan\u00e9 boles\u0165ami hlavy, poruchami vedomia, teplotami a pneum\u00f3niami.<\/p>\n

Infikova\u0165 sa mo\u017eno aliment\u00e1rnou cestou po prehltnut\u00ed infek\u010dn\u00fdch \u0161t\u00e1di\u00ed (zelenina \u010di ovocie kontaminovan\u00e9 oocystami, nedostato\u010dne tepelne upraven\u00e9 m\u00e4so s tkanivov\u00fdmi cystami), transplacent\u00e1rne, krvnou transf\u00faziou a org\u00e1nov\u00fdmi transplant\u00e1tmi. Z epidemiologick\u00e9ho h\u013eadiska je v\u00fdskyt toxoplazm\u00f3zy na Slovensku vysok\u00fd, o \u010dom sved\u010d\u00ed pribli\u017ene 40 % IgG s\u00e9roprevalencia u na\u0161ich pacientov (Ondriska et al., 2003; Strh\u00e1rsky et al., 2009).<\/p>\n

V rutinnej diagnostike je zlat\u00fdm \u0161tandardom nepriama diagnostika, \u010di\u017ee d\u00f4kaz \u0161pecifick\u00fdch protil\u00e1tok proti T. <\/em>gondii <\/em>(IgG, IgM, IgA, reakcia v\u00e4zby komplementu pre d\u00f4kaz celkov\u00fdch protil\u00e1tok a aviditn\u00fd test pre stanovenie sily v\u00e4zby antig\u00e9n \u2013 protil\u00e1tka). S\u00e9rologick\u00e9 vy\u0161etrenie by malo v prvom rade zisti\u0165, \u010di je pacient infikovan\u00fd, a ak \u00e1no, v druhom kroku ur\u010di\u0165 \u0161t\u00e1dium infekcie. Detekcia DNA T.<\/em> gondii <\/em>pomocou PCR sa pova\u017euje za nenahradite\u013en\u00fa v diagnostike toxoplazm\u00f3zy u imunosuprimovan\u00fdch pacientov s AIDS, transplantovan\u00fdch a u \u010fal\u0161\u00edch imunokompromitovan\u00fdch os\u00f4b, pri o\u010dnej a kongenit\u00e1lnej toxoplazm\u00f3ze. Ve\u013emi d\u00f4le\u017eitou inform\u00e1ciou pri diagnostike suspektnej neurotoxoplazm\u00f3zy, o\u010dnej \u010di kongenit\u00e1lnej toxoplazm\u00f3zy je vy\u0161etri\u0165 okrem likvoru, o\u010dnej tekutiny \u010di plodovej vody paralelne aj s\u00e9rum pacienta. Spr\u00e1vne a v\u010dasn\u00e9 ur\u010denie \u0161t\u00e1dia toxoplazm\u00f3zy je rozhoduj\u00facim sign\u00e1lom na za\u010datie terapie (pyrimetam\u00edn, sulf\u00f3namidy a spiramyc\u00edn).<\/p>\n

Infekcii mo\u017eno predch\u00e1dza\u0165 v podobe prevent\u00edvnych opatren\u00ed, najm\u00e4 v dodr\u017eiavan\u00ed pr\u00edsnych hygienick\u00fdch n\u00e1vykov (um\u00fdvanie ovocia \u010di zeleniny pred konzumovan\u00edm, um\u00fdvanie r\u00fak po kontakte s p\u00f4dou, dostato\u010dn\u00e1 tepeln\u00e1 \u00faprava m\u00e4sa), ale i v s\u00e9rologickom skr\u00edningu rizikov\u00fdch skup\u00edn (tehotn\u00e9 \u017eeny a transplantovan\u00ed pacienti).<\/p>\n

 <\/p>\n

Klinick\u00e9 n\u00e1lezy a laborat\u00f3rna identifik\u00e1cia neurotoxoplazm\u00f3zy<\/h4>\n

Dokumentujeme ve\u013emi raritne diagnostikovan\u00fd pr\u00edpad neurotoxoplazm\u00f3zy u 60-ro\u010dn\u00e9ho HIV pacienta v \u0161t\u00e1diu AIDS. Pacient bol prijat\u00fd vo febru\u00e1ri 2019 na neurologick\u00e9 oddelenie nemocnice v Skalici z d\u00f4vodu nieko\u013ekomesa\u010dn\u00fdch febril\u00edt, respira\u010dn\u00fdch i mo\u010dov\u00fdch infekci\u00ed a prekonanej tromboflebit\u00eddy. Pri prijat\u00ed bol pacient mobiln\u00fd, pri vedom\u00ed, spolupracuj\u00faci, tlakovo a pulzovo stabilizovan\u00fd. V marci 2019 sa stav hospitalizovan\u00e9ho za\u010dal rap\u00eddne zhor\u0161ova\u0165, bol u neho zaznamenan\u00fd rozvoj ataxie, bradypsychizmu, komunikoval stru\u010dne, nie v\u017edy zrozumite\u013ene, \u010dasto vracal a mal epileptick\u00e9 z\u00e1chvaty. R\u00e1diol\u00f3govia pomocou CT a MR vy\u0161etren\u00ed mozgu detegovali mnohopo\u010detn\u00e9 lo\u017eiskov\u00e9 n\u00e1lezy (16 lo\u017e\u00edsk na perif\u00e9rii, obr\u00e1zok 1a \u2013 e<\/em><\/strong>) a CT vy\u0161etrenie brucha potvrdilo fok\u00e1lne l\u00e9zie (suspekt. MTS) na pe\u010deni. V mozgu bola lokaliz\u00e1cia multifok\u00e1lnych l\u00e9zi\u00ed supraa infratentori\u00e1lne, kortikosubkortik\u00e1lne so zasahovan\u00edm do bielej hmoty, corpus callosum, v \u013eavom talame, v pravom putamene, v mozo\u010dku s perifok\u00e1lnym ed\u00e9mom. Z laborat\u00f3rnych vy\u0161etren\u00ed bola dok\u00e1zan\u00e1 reaktivita na HIV, \u010do bolo n\u00e1sledne v NRC konfirmovan\u00e9 a potvrden\u00e9 ako HIV pozitivita. Absol\u00fatny po\u010det CD4+ T-lymfocytov klesol na hodnotu 0,11. Pacient bol n\u00e1sledne prelo\u017een\u00fd na Kliniku infektol\u00f3gie a geografickej medic\u00edny LF UK v Bratislave.<\/p>\n

Echinokokov\u00fa ani toxokarov\u00fa neuroinfekciu sme v parazitologickom oddelen\u00ed Medirex, a. s., nedok\u00e1zali. Pomocou real-time PCR sme v\u0161ak detegovali DNA Toxoplasma gondii <\/em>v likvore (obr\u00e1zok 2)<\/em><\/strong>, pri\u010dom k intratek\u00e1lnej produkcii protil\u00e1tok nedo\u0161lo a v s\u00e9re boli pr\u00edtomn\u00e9 iba protil\u00e1tky triedy IgG proti T.<\/em> gondii (obr\u00e1zok 3)<\/strong><\/em>. Na z\u00e1klade laborat\u00f3rnych i klinic- k\u00fdch v\u00fdsledkov sme stanovili suspektn\u00fd diagnostick\u00fd z\u00e1ver sved\u010diaci o neurotoxoplazm\u00f3ze.<\/p>\n

Napriek pod\u00e1vanej terapii (daraprim, emticitabinum\/tenofovir a darunavir) sa zdravotn\u00fd stav pacienta zhor\u0161oval. Vedomie bolo na \u00farovni somnolencie, do\u0161lo k strate re\u010di i pohyblivosti v\u0161etk\u00fdch kon\u010dat\u00edn. Aj pri komplexnej starostlivosti sa prehlbovala porucha vedomia i s respira\u010dnou insuficienciou, a\u017e pacient umrel d\u0148a 7. 4. 2019 (exitus letalis). Pitevn\u00fd n\u00e1lez sa taktie\u017e viac-menej prikl\u00e1\u0148al k diagnostick\u00e9mu z\u00e1veru toxoplazmovej meningoencefalit\u00edde.<\/p>\n

 <\/p>\n

Zhrnutie<\/h4>\n

Predstavili sme v porad\u00ed 4. pr\u00edpad neuroinfekcie sp\u00f4sobenej tkanivov\u00fdm parazitom T.<\/em> gondii <\/em>na Slovensku, ktor\u00fd sa v\u0161ak ako jedin\u00fd skon\u010dil fat\u00e1lne. Vzh\u013eadom na vysok\u00fd v\u00fdskyt toxoplazm\u00f3zy (40 %) v na\u0161ich podmienkach a n\u00e1slednej latentnej infekcie \u017eiada si toto ochorenie v\u00fdznamn\u00fa pozornos\u0165 najm\u00e4 z d\u00f4vodu reaktiv\u00e1cie tejto infekcie po\u010das imunosupresie (onkologick\u00e9 ochorenie, transplant\u00e1cie, AIDS, gravidita). Prezentovan\u00fd pr\u00edpad neurotoxoplazm\u00f3zy sp\u00f4sobenej oport\u00fannym parazitom poukazuje na nevyhnutnos\u0165 systematicky vy\u0161etrova\u0165 imunosuprimovan\u00e9 osoby (AIDS, pacienti v transplanta\u010dnom programe) na pr\u00edtomnos\u0165 toxoplazmovej infekcie.<\/p>\n

 <\/p>\n

POU\u017dIT\u00c1 LITERAT\u00daRA<\/strong><\/p>\n

    \n
  1. Garcia LS. Diagnostic medical parasitology. 5th ed., ASM Press, Washington, C. 2007; 1202 s.<\/li>\n
  2. Hurley RA, Taber KH. Latent Toxoplasmosis gondii: emerging evidence for influences on neuropsychiatric disorders, Journal of Neuropsychiatry and Clinical Neurosciences 2012; 24: 376-383.<\/li>\n
  3. Mehlhorn Encyclopedia of Parasitology, III. (Eds.), Springer (ed.), New York 2008; 1573 s.<\/li>\n
  4. Murray PR, Baron EJ, Jorgensen JH, et Manual of Clinical Microbiology. ASM press, Washington, D.C. 2007; 2399 s.<\/li>\n
  5. Ondriska F, Boldi\u0161 V, Garajov\u00e1 M, Mrva Klinick\u00e1 parazitol\u00f3gia 1. vyd. Bratislava UK Pr\u00edrodovedeck\u00e1 fakulta. 2016; 233 s<\/li>\n
  6. Ondriska F, Boldi\u0161 V, Reiterov\u00e1 Parazitol\u00f3gia pre v\u0161eobecn\u00fdch lek\u00e1rov, vyd. Edi\u010dn\u00fd rad pre v\u0161eobecn\u00e9ho lek\u00e1ra \u010d\u00edslo 5, Raabe, Bratislava, 2015; 5: 116 s.<\/li>\n
  7. Ondriska F, \u010cat\u00e1r G, Voz\u00e1rov\u00e1 The significance of complement fixation test in clinical diagnosis of toxoplasmosis. Bratisl Lek Listy 2003; 104, 189-196.<\/li>\n
  8. Parlog A, Schl\u00fcter D, Dunay IR. Toxoplasma gondii-induced neuronal alterations. Parasite Immunology 2015; 37, 159-170.<\/li>\n
  9. Schmidt DD, Roberts LS. Foundations of parasitology. Eight ed., McGraw-Hill Companies, York, 2009; 701 s<\/li>\n
  10. Strh\u00e1rsky J, Klement C, Hrub\u00e1 Seroprevalence of Toxoplasma gondii antibodies in the Slovak Republic. Folia Microbiologica 2009; 54: 553-558.<\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"

    *All tables, charts, graphs and pictures that are featured in this article can be found in the .pdf attachment at the end of the paper.   \u00davod Toxoplazm\u00f3za je zoonotick\u00e9 ochorenie sp\u00f4soben\u00e9 tkanivov\u00fdm parazitick\u00fdm prvokom Toxoplasma gondii, ktor\u00e9ho definit\u00edvnym hostite\u013eom s\u00fa ma\u010dky. Parazit je celosvetovo roz\u0161\u00edren\u00fd a okrem \u010dloveka jeho hostite\u013emi s\u00fa r\u00f4zne teplokrvn\u00e9 \u017eivo\u010d\u00edchy.<\/p>\n","protected":false},"author":7,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_mi_skip_tracking":false,"footnotes":""},"categories":[292],"tags":[1427,1426,1425,1424],"class_list":["post-1957","post","type-post","status-publish","format-standard","hentry","category-microbiology","tag-hiv-patient","tag-meningoencephalitis","tag-neurotoxoplasmosis","tag-toxoplasma-gondii-en","typ_clanku-casuistry"],"acf":{"abstrakt":"

    Description of the case<\/h4>\n

    In Slovakia, we document a very rare case of neurotoxoplasmosis in a 60-year-old HIV patient in the AIDS stage. The patient was hospitalized due to frequent fever, vomiting, epileptic seizures and consciousness disorders. Radiological examinations (CT and MR) confirmed the presence of multiple findings in the brain (16 foci in the periphery). In the parasitological laboratory (Medirex Ltd.), we had excluded neuroinfection caused by parasitic agents such as Toxocara <\/em>spp. and Echinococcus <\/em>spp. However, we confirmed neurotoxoplasmosis based on detection of Toxoplasma <\/em>gondii <\/em>DNA in the patient\u2019s cerebrospinal fluid and the presence of specific IgG antibodies in the patient\u2019s serum. There was no production of anti-toxoplasmic antibodies in the cerebrospinal fluid, possibly due to the immune deficit resulting from HIV status. Despite the appropriately indicated therapy, the patient\u2019s health deteriorated (loss of speech and mobility of all limbs), and the patient died within a few weeks.<\/p>\n

    Keywords: <\/strong>Toxoplasma <\/em>gondii<\/em>, neurotoxoplasmosis, meningoencephalitis, HIV patient<\/p>\n","casopis":[{"ID":1893,"post_author":"7","post_date":"2020-05-05 11:32:54","post_date_gmt":"2020-05-05 09:32:54","post_content":"

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    • The case report of toxoplasmic meningoencephalitis with fatal outcome in HIV patient<\/li>\r\n \t
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