Fatal disseminated toxoplasmosis with congenital transmission in an African migrant (2008)

Migrants from HIV-endemic areas may be newly diagnosed with HIV in Western countries. A 27-year-old pregnant woman from sub-Saharan Africa presented with disseminated fatal toxoplasmosis and congenitally transmitted the parasite. Despite medical care, maternal infection was only diagnosed postmortem and diagnosis in the newborn was delayed. Problematic aspects of medical care in migrants in Western countries are discussed. In the 36th gestational week, a 27-year-old African women, living in a refugee settlement in a rural region of Germany, developed respiratory symptoms including cough, headache and mild fever, which were treated symptomatically. Persistent fever and dyspnea lead to hospitalization 10 days after initial consultation. Radiological examination revealed the beginning of bronchopneumonia and antibiotic therapy with ampicillin/sulbactam was started. Further on, she developed nausea, vomiting and septic temperatures. Chorioamnionitis was suspected and caesarean section was performed in the 38th week of gestation. Two days later, HIV testing revealed a presumptive positive result and ablactation was initiated. Three days after caesarean section, the patient developed a transitory psychotic syndrome and was transferred to the local intensive care unit. A cranial computed tomography (CT) scan revealed cerebral edema, widening of the fourth ventricle and multiple hypodense areas close to the ventricular system without contrast enhancement. Differential diagnosis on the basis of the CT findings included opportunistic infections caused by Mycobacterium tuberculosis, Toxoplasma gondii and herpes viruses. Cerebral edema did not allow lumbar puncture. Serological tests for opportunistic viral, bacteriological, fungal and parasitological pathogens revealed a positive result for anti-T. gondii IgG antibodies (>300 IE/ml) but not for IgM antibodies. The absolute CD4 T-cell count was 15 cells/μl and the CD4/CD8 ratio was 0.02. The viral load was not determined. Increasing intracranial pressure required ventricular drainage. Analysis of cerebrospinal fluid (CSF) showed a slight lymphocytic pleocytosis, enhanced lactate and protein content and low relative glucose levels, but did not reveal the presence of bacterial, viral or fungal pathogens (culture, PCR). PCR for the detection of T. gondii-specific DNA was not performed at this time. Based on the available results, neurotuberculosis was suspected and antituberculous therapy was initiated. The patient died 12 days after hospitalization, presenting a clinical picture of dissociated brain death. Postmortem examinations confirmed extensive meningoencephalitis. T. gondii tachyzoites were detected in the brain and myocardium by immunohistology. Molecular biological testing revealed T. gondii-specific DNA in CSF, brain, myocardium and lung, indicating cerebral and disseminated toxoplasmosis. After transfer of the 10-day-old child to the university hospital, congenital toxoplasmosis was diagnosed (chorioretinitis, T. gondii DNA positive in blood and CSF, neosynthesized T. gondii-specific antibodies) and treatment with pyrimethamine, sulfadiazine and folinic acid was started. HIV-DNA could not be detected. Antiviral prophylaxis was not initiated at that late time point. In the Western world, migrants originating from countries with a high prevalence of HIV and T. gondii infection such as sub-Saharan Africa account for an increasing portion of particularly heterosexually transmitted HIV infection [1,2]. Most of them are unaware of their HIV infection and often present with a delay for primary medical care or for antenatal care [1]. Several factors, such as restricted access to healthcare for migrants, uncertainty of their legal status, communication problems, fear of stigmatization, misunderstandings caused by cultural differences, and a lack of knowledge about public healthcare offers and treatment possibilities in Western countries, are supposed to influence healthcare uptake [3,4]. However, once a healthcare setting has been attended, differences in ethnic group or other sociodemographic factors do not influence the extent or quality of care provided [5]. It is rather the physician's experience in management of HIV patients that considerably affects the quality of care and treatment [6,7]. As in rural areas of Western countries, the prevalence of HIV infection is low and patients often seek care in urban centers, and comprehensive knowledge on diagnosis and treatment of HIV and AIDS may be missing [8]. In the present case, several disadvantageous factors accumulated: the patient's migrant status, pregnancy, delayed testing for HIV, advanced stage of HIV disease, initial presentation with uncharacteristic symptoms of reactivated toxoplasmosis resulting in misinterpretation as neurotuberculosis, and involvement of healthcare centers in a region where HIV patients are rarely seen. Lack of experience in the management of HIV also resulted in neglect of antiviral prophylaxis in the child, which fortunately did not show any signs of infection so far. The presented case of an African woman with fatal reactivated toxoplasmosis and congenital transmission underlines the need for intensified medical education of the migrant population on the prevention and care of HIV/AIDS. Healthcare facilities in regions with low HIV prevalence should be prepared for the specific medical needs and problems in this population group. The implementation of structures facilitating immediate contact and support from specialized centers might be a useful strategy. Acknowledgements We thank Gitina Fiedler, Antje Grosse and Angela Pohlisch for excellent technical support. Birgitta Schweickert, Andrea Loui and Oliver Liesenfeld contributed to analysis and interpretation of the data, writing and revising of the manuscript and gave final approval of the version to be published. Renate Bollmann, Olaf Kaufmann, Jost Kluttig, Cornelia Feiterna-Sperling and Ulrich Baumann contributed to analysis and interpretation of the data, revising of the manuscript and gave final approval to the version to be published.