|Year : 2012 | Volume
| Issue : 3 | Page : 121-122
Rare presentation of toxoplasmosis
Kalyani Dukkipati1, M. Rajarao2, M. Meera3, K. Shankar2
1 Department of Pathology, Sir Ronald Ross Institute of Tropical and Communicable Diseases/Osmania Medical College, Hyderabad, India
2 Department of General Medicine, Sir Ronald Ross Institute of Tropical and Communicable Diseases/Osmania Medical College, Hyderabad, India
3 Department of Microbiology, Sir Ronald Ross Institute of Tropical and Communicable Diseases/Osmania Medical College, Hyderabad, India
|Date of Web Publication||21-May-2014|
Dr Kalyani Dukkipati
Department of Pathology, Sir Ronald Ross Institute of Tropical and Communicable Diseases, Hyderabad - 500 044, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Toxoplasmosis is a parasitic disease caused by the protozoan Toxoplasma gondii and infects most genera of warm-blooded animals, including humans, but the primary host is the felid (cat) family. This infection may clinically resemble influenza, hence causing diagnostic dilemma. Here we report a rare case of toxoplasmosis in a male patient aged 21 years with healthy immune system presented with flu like symptoms and eosinophilic leukocytosis. There was no clinical suspicion of toxoplasmosis. Serological detection of antibody titers is useful and rapid technique in the diagnosis of toxoplasmosis. Toxoplasmosis should be included in the differential diagnosis of parasitic infestation with persistant eosinophilia and detection of antibody titers is the best guide to a clinician in the absence of clinical suspicion.
Keywords: Antibody titers, eosinophilia, toxoplasmosis
|How to cite this article:|
Dukkipati K, Rajarao M, Meera M, Shankar K. Rare presentation of toxoplasmosis. J Acad Med Sci 2012;2:121-2
| Introduction|| |
Toxoplasmosis is the commonest parasitic infestation and it is usually seen in immunocompromised host.  Serological antibody tests are mandatory for definitive diagnosis. 
Here we report a case of Toxoplasmosis in an immunocompetent individual, which is uncommon feature. In an endemic area it should be considered as one of the parasitic infestations.
| Case Report|| |
A male patient aged 21 years admitted in Sir Ronald Ross Institute of Tropical and Communicable Diseases, Hyderabad with symptoms of high grade fever with chills and rigors, headache, and myalgia since 15 days. On examination there were palpable lymph nodes and organomegaly. There was no other lesion elsewhere in the body. Hemogram was done and revealed normocytic, normochromic blood picture with marked eosinophilic leukocytosis (white blood cell (WBC) count 26,500/mm 3 with 65% differential of esinophils) with mild shift to left. The peripheral smear was negative for hemoparasites and abnormal cells [Figure 1]. Peripheral smear of blood done at night was also negative for microfilariae.
|Figure 1: Peripheral smear showing marked eosinophilic leukocytosis (Leishman, ×40)|
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Other tests included Widal test, stool culture, liver function tests, and ultrasound examination of abdomen, all of which were within normal limits. Human immunodeficiency virus (HIV) and hepatitis B surface antigen (HBsAg) were negative. The tests were repeated after using a course of antibiotic. Additionally, patient was investigated for Brucellosis by antibody test which was negative. Wuchereria antigen detection by rapid enzyme linked immunosorbent assay (ELISA) method was found negative. Serum immunoglobulin E (IgE) levels were markedly elevated (>3,000 IU/ml). Further in the quest for identifying the etiology for this case of pyrexia of unknown origin (PUO), antitoxoplasma antibodies were looked for. The patient tested positive for antitoxoplasma IgM antibodies (1.7 IU/ml) by ELISA method.
Patient had mild retinitis [Figure 2]. Patient was treated for toxoplasmosis and recovered from clinical illness and was discharged after 1 week of antibiotic therapy (doxy 500 mg BID for 7 days). On discharge the patient was put on Septran (trimethoprim 80 mg and sulfamethoxazole 400 mg) and Hetrazan (Diethyl carbamazapine) 100 mg TID for 3 weeks.
| Discussion|| |
Over half of the world's human population is estimated to carry toxoplasma infection.  So even in the absence of clinical suspicion, serological tests of antibody titers are mandatory for definitive diagnosis of toxoplasmosis.  Usually, it is seen in predominantly immunocompromised host, but in the present case, there were no predisposing factors and the patient has healthy immune system. The only feature that indicated the parasitic infestation in this case was persistent eosinophilia. Hence, careful search of parasite was done for this case and other causes of esinophilia were excluded prior to the final diagnosis. Serum IgE levels were markedly increased (3,000 IU/ml) and IgM antibodies were measured by the immune capture IgM-ELISA method and were positive for this case. This method avoids false positive results due to the presence of rheumatoid factor and antinuclear antibodies. As per the guidelines recommended by Food and Drug Administration (FDA), the serum of this patient was sent to toxoplasma reference laboratory and the results are awaited. A combination of serological tests is frequently required to establish whether an individual has been more likely infected in the distant past or has been recently infected. Other tests to detect the toxoplasmosis are IgG antibodies to discriminate between recently acquired and distant infection. IgA antibodies are detected in sera of acutely infected adults and congenitally infected infants. The duration of IgE seropositivity is less than with IgM or IgA antibodies and hence appears useful as an adjunctive method for identifying recently acquired infections.  Increased IgE level correlates with early acute inflammation or with a reactive form of toxoplasmosis. However, negative IgE test result does not exclude acute toxoplasmosis. 
The parasite can cause encephalitis and chorioretinitis. In this case the patient had mild retinitis.
Apart from these, histological demonstration and isolation of organism are required. Detection in human blood samples may also be achieved by using the polymerase chain reaction (PCR).  Differential diagnosis includes other parasitic infestations like trichinosis and central nervous system (CNS) lymphomas. Toxoplasmosis has been reported widely and studies have proved that the seroprevalence is high and varies with many factors. ,,,,,,
Toxoplasmosis generally presents with flu-like symptoms and is not clinically diagnostic as illustrated in the present case as well as in other studies where there was no clinical suspicion of toxoplasmosis. Presence of persistent eosinophilia may not be helpful in arriving at diagnosis, but it is one of the indications for further search for the parasite in the tissue and also to exclude other causes of eosinophilia. In cases where antibody titers are raised, the diagnosis of toxoplasmosis can be considered as was done in this case.
| Conclusion|| |
Serologiacal estimation of antibody titers in toxoplasmosis is rapid and useful guide to the clinician in arriving at a diagnosis. Toxoplasmosis is more common than usually thought. In endemic areas, Toxoplasma gondii should be included in the differential diagnosis of parasitic infestations with persistent eosinophilia. To the best of our knowledge, this is the first reported case of persistent eosinophilia in toxoplasmosis from south India. Hence, we are of opinion that reporting this case may help to spread awareness.
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[Figure 1], [Figure 2]