Research Journal of Infectious Diseases

ISSN 2052-5958

Review

Open Access

Relevant aspects of human toxoplasmosis

Katia Denise S Bresciani1*, Andr Luiz B Galvo2, Amanda L de Vasconcellos2, Jos Antonio Soares3, Lucas Vinicius Shigaki de
Matos2, Julia Cestari Pierucci2, Luiz da Silveira Neto2, Tercilia Oliveira Rodrigues1, Italmar Teodorico Navarro4, Jancarlo Ferreira
Gomes5 and Alvimar J da Costa2
*Correspondence: bresciani@fmva.unesp.br

These authors contributed equally to this work.

1
UNESP, Universidade Estadual Paulista Julio de Mesquita Filho, Faculdade de Medicina Veterinria de Araatuba, Araatuba, So
Paulo, Brazil.
2
UNESP, Universidade Estadual Paulista Julio de Mesquita Filho, Faculdade de Cincias Agrrias e Veterinrias, UNESP, Jaboticabal,
So Paulo, Brazil.
3
FKB, Fundao Karnig Bazarian, Faculdades Integradas de Itapetininga, Itapetininga, So Paulo, Brazil.
4
UEL, Universidade Estadual de Londrina, Centro de Cincias Biolgicas, Londrina, Paran, Brazil.
5
UNICAMP, Universidade Estadual de Campinas, Institutos de Biologia e Computao, Campinas, So Paulo, Brazil.

Abstract

Considering the great importance that the infection by Toxoplasma gondii has in public health, the aim of this article was
to demonstrate some aspects about this disease in human being. This parasite can cause several behavioral changes and
many cases of reactivation of this disease are associated with Acquired Immunodeficiency Syndrome AIDS. Major
cases of human infections by T. gondii are assymptomatic and the main clinical manifestation in the acute phase of this
zoonosis is lymphadenopathy, usually in the cervical area. There may also be fever, night sweats, myalgia, maculopapular
rash lymphocytic atypia and chorioretinitis. The congenital and/or acquired chronic latent cerebral toxoplasmosis play an
important role in the development of some types of neurodegeneration, like Alzheimer disease and Down Syndrome. Humans
and animals should not consume raw or undercooked meat, unpasteurized or not boiled dairy products, water without
being treated and poorly washed fruits and vegetables. Educational programs focused on reducing T. gondii environmental
contamination are essential for the congenital infection control. Due to the severity of this kind of infection and its sequel,
it is critical that those responsible for the communitys health establish prevention programs to avoid such a situation,
obtaining results in the medium and long term, and particularly preserving the involved populations welfare. A lack or
incomplete prenatal treatment was identified as an important risk factor for congenital toxoplasmosis, reinforcing the need
of improvement of prenatal care. In this study was demonstrated the importance of implementing prevention programs to
guide pregnant women to prevent the infection. Preventive measures like information and health education; screening of
pregnant women and infants; limiting harm from risk behaviour; treatment of risk cases and vaccination are recommended.
Serum monitoring throughout pregnancy, so as detect cases of maternal seroconversion allowing for early maternal treatment
is also basic. Some countries have adopted control programs of human toxoplasmosis, however, this issue should be of world
attention, considering its relevant aspects of public health, requiring the establishment of community education campaigns
and monitoring of pregnant women in the pre and neonatal, especially in a preventive action to reduce the pathogenic effects
of this disease.
Keywords: Toxoplasma gondii, public health, parasitic control, congenital infection

Introduction

Toxoplasma gondii has great importance in public health.

Women in initial stages of gestation may undergo miscarriage,
premature birth, neonatal death and even the classical Sabins
Triad, characterized by retinochoroiditis, cerebral calcifications,
hydrocephaly or microcephaly [1,2].
This parasite can cause behavioral changes [3] and during
pregnancy cases of antenatal depression and anxiety have
been related [4-7].
Many cases of reactivation of this disease are associated
with Acquired Immunodeficiency Syndrome - AIDS, including
pregnant women [8], especially with brain abscess manifestation
[9-11].
Educational programs focused on reducing T. gondii environ-

mental contamination are essential for the congenital infection

control [7,12,13].

Human toxoplasmosis

Major cases of human infections by T. gondii are assymptomatic

and the main clinical manifestation in the acute phase of this
zoonosis is lymphadenopathy, usually in the cervical area. There
may also be fever, night sweats, myalgia, maculopapular rash
lymphocytic atypia [14] and also chorioretinitis [11].
In primary infection of immunocompetent patients,
microgranulomas with no necrosis of giant cells, in cases of
cervical lymphadenopathy, can be observed.
In hosts with immune deficiency, neonates and the ones
infected by the protozoan during intrauterine life, the findings

2013 Bresciani et al; licensee Herbert Publications Ltd. This is an Open Access article distributed under the terms of Creative Commons Attribution License
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Bresciani et al. Research Journal of Infectious Diseases 2013,

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may include necrotizing meningoencephalitis and systemic

aggravation. Lymphadenopathy-type Piringer Kuchinka and
encephalitis were particularly evident [15].
The continued T. gondii tachyzoites proliferation and
tissue destruction can occur in fetal brain even when there
is a marked maternal immune response including maternal
IgG [16].
Patients with autism spectrum disorders (ASD) and with
chronic toxoplasmosis have persistent neuroinflammation,
hypercytokinemia with hypermetabolism associated with
enhanced lipid peroxidation, and extreme changes in the
weight resulting in obesity [17].
The congenital and/or acquired chronic latent cerebral
toxoplasmosis play an important role in the development
of some types of neurodegeneration, like Alzheimer disease
and Down Syndrome [18].
The intermediate hosts, humans and animals, can acquire
the disease by eating raw or undercooked meat, infected with
tissue cysts, as well by the consumption of raw vegetables
and water contaminated with oocysts [19]. Tachyzoites of T.
gondii can be acquired by consuming unpasteurized milk, eggs,
blood transfusion, semen, organ transplantation, laboratory
accidents with biological material and by transplacental via
[14,19-24].
In its cycle, the protozoan shows two evolutionary forms
in the intermediate host: tachyzoites, structures of rapid
multiplication present in organic fluids in the acute phase, and
bradyzoites, confined in tissue cysts, especially in the central
nervous system and muscles, in the chronic infection. Oocysts,
the final product of sexual reproduction, are formed only in
the digestive tract of felids, definitive hosts that shed the
oocysts with their feces, where by means of sporogony they
become infective and extremely resistant to environmental
conditions [19,25-27].
The cats are probably the main sources of environmental
contamination, because, when infected, they release large
quantities of oocysts, allowing the continuity of the parasite
biological cycle [23]. Our research group noticed that T. gondii
oocysts are widely distributed on the soil of elementary
public schools in our region, likely constituting the main
contamination source for these children [12]. It was observed
that cat owners in a cohort of middle-aged UK women do
not have an increased risk of brain cancer, when compared
with non-cat owners [28].
Cases of enhanced maternal-fetal transmission of T.
gondii infection of HIV-infected women chronically infected
were described, which may have important public health
consequences, considering the increasing frequency of HIVinfection observed among human being around the world [8].
The prevalence of 3599 samples of the National Health
Survey 2000 (NHS-2000) and 2916 of the National Health and
Nutrition Survey 2006 (NHNS-2006) serum banks, obtained
from 198 year old subjects of both genders and all states
of Mexico was studied. Anti-T. gondii IgG antibodies were

doi: 10.7243/2052-5958-1-7

determined by ELISA and confirmed by western blot. National

crude prevalence was 60.1% and 62.6% for NHS-2000 and
NHNS-2006, respectively [29].
All soldiers before being deployed in jungle operations
should be tested for T. gondii antibodies and to receive
adequate health information about the routine use of
personnel filters to purify their water for consumption [13].
The tachyzoite, reaches the fetus by transplacental via,
causing different levels of damage severity, depending on
the virulence and/or lineage, on the strain of the mothers
immune response capacity and on the gestational period that
the woman presents, that can result, even, in fetal death or
severe clinical manifestations. Toxoplasmosis may manifest
months or even years later in children born with this parasitosis
and in these cases the most common manifestations are
retinocorioidite, cerebral calcifications, neuropathies and
microcephaly [4].
Studies demonstrated that chorioretinitis affected 18.9%
of children suffering from congenital toxoplasmosis despite
antenatal and neonatal screening associated with early
treatment. Long-standing follow-up is needed because the
first lesion can occur as late as 12 years after birth. Late lesions
were less often macular but nevertheless caused sometimes
visual impairment [6].
The demonstration of the occurrence of human
toxoplasmosis associated to the milk ingestion from proven
infected goats, is particularly important in rural and periurban areas where these animals are raised for the purpose
of production of milk for domestic consumption [30].
Contamination of municipal water reservoirs with a
significant amount of T. gondii oocysts can lead to epidemics,
as recorded in Canada, in 1995, or trigger outbreaks like the
one reported in 2001, in Santa Isabel do Iva, Paran State,
Brazil [31,32,33].

Control of human toxoplasmosis

Humans and animals should not consume raw or undercooked

meat, unpasteurized or not boiled dairy products, water
without being treated and poorly washed fruits and
vegetables [34]. Meat products from ovine and swine are
more contaminated with this parasite cysts, and these are
rarely found in bovine [9,14].
Monitoring of Toxoplasma infection in animals destined
for human consumption is a great challenge for human
toxoplasmosis prevention. In Spain, some people eat
horse meat and it was observed that many horses from
various regions of the country are serologically positive for
toxoplasmosis [35]. It was showed the impossibility of any
serological test asserting the absence of T. gondii in meat
and guarantee that undercooked lamb can be consumed
without risk for people [36,37].
As daily routine, the cleaning of catteries, with fecal
material removal is indicated, since, in dependence on the
environmental conditions, the T. gondii oocysts eliminated

Bresciani et al. Research Journal of Infectious Diseases 2013,

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by cats require at least 24 hours to sporulate and become

infectious. It is also important to cover or encircle sand tanks
for children recreation, especially when they are not in use,
to prevent the cats access [12,33].
Dishes and utensils should be washed with hot water after
contact with unwashed fruits, vegetables, unpasteurized
milk and seafood. Pregnant women and immunosuppressed
individuals need to wear gloves to get contact with the soil
or dumps, avoiding possible touches in cat feces [34].
A lack or incomplete prenatal treatment was identified
as an important risk factor for congenital toxoplasmosis,
reinforcing the need of improvement of prenatal care in Brazil
[5]. A 2009 survey in the United States showed that 87.7%
counsel patients about how to prevent toxoplasmosis [38].
In our studies, were interviewed 85 teachers about
toxoplasmosis and 67.06% (57/85) did not know about this
issue. Interviews were made with 30 teachers of 18 educators
from local elementary schools in Brazil and 28.33% did not
know anything about the topic [32]. One hundred and thirty
four elderly people, from the institutions, were interviewed
and 86.57% (116/134) were ignorant of the dissemination
ways [39]. There is a need of implanting programs of control
against human toxoplasmosis[39-43].
Its important to reinforce the importance of sanitation
control in industrial restaurants and also demonstrate the
need for improvement in quality control regarding vegetables
at risk for T. gondii oocyst contamination [44].
Strategies to work on muscle fluids offers a great potential
for toxoplasmosis studies on farm animals, especially for large
scale control studies. We cannot yet offer any serological test
asserting the absence of Toxoplasma in meat and offering the
guarantee that undercooked lamb can be consumed without
posing an unacceptable risk for people at risk and freezing
the meat remains necessary [36,37].
Prenatal screening is performed in Austria, France and
Slovenia and neonatal screening in the New England states of
the USA, parts of Brazil, Denmark and Ireland, but on-demand
examination for T. gondii antibodies are widely practiced in
many European countries [45].
Since 1975, in Austria, serological monitoring of pregnant
negative women until the third month of pregnancy
it is mandatory , and for suspected cases, treatment is
performed until four months of pregnancy with spiramycin
and piimetamina associated with sulfadiazine after three
months and three weeks [45,46].
In France, since 1978, T. gondii tests were established in
seronegative women. However, control measures are not
standardized in this country, and so there are divergence
between treatment protocols and diagnostic interpretation
of infection [47].
In some American states, only serological monitoring of
newborns for Toxoplasma IgM has been preconized, without
prenatal intervention [48]. The Guidelines for Prevention and
Treatment of Opportunistic Infections in HIV-Infected Adults

doi: 10.7243/2052-5958-1-7

and Adolescents, produced by Centers for Disease Control and

Prevention, National Institutes of Health, and HIV Medicine
Association of the Infectious Diseases Society of America,
contains detailed recommendation [49,50].
Considering the high prevalence of HIV infection in
the Kyrgyz Republic, personalized medical orientation as
well as treatment and prevention of T. gondii infection are
recommended, with special attention to health education for
those with lower economic and social status and less access
to information [51].
In Spain, due to the low incidence of toxoplasmosis
in pregnant women, there is no proper disease control
recommendation from health authorities, however, detailed
control program has been preconized by the Spanish Society
of Pediatric Infectious Diseases for the diagnosis and treatment
of congenital toxoplasmosis [52].
Early detection with repeated sorological examination
and the treatment of pregnant women can reduce the risk
of infection by T. gondii as observed in India [53].
Pregnant women in Al Hasas, Saudi Arabia, are substantially
vulnerable to toxoplasmosis infection because have no
sufficient knowledge for primary prevention of congenital
toxoplasmosis [54].
The most commonly therapy is the combination of
pyrimethamine and sulfadiazine and folinic acid [55]. In
Germany, spiramycin is given until the 16th week of pregnancy,
followed by at least 4 weeks of combination therapy with
pyrimethamine, sulfadiazine, and folinic acid independent of
the infection stage of the fetus and this treatment program was
efficient in mimimize transplacentary parasitic transmission
[56].
As future perspectives, vaccines development studies
against T. gondii have demonstrated that heterologous DNA
priming and recombinant adenovirus boost strategy may
provide protective immunity against T. gondii infection [57]
and multiantigenic DNA antigen pGRA7-ROP1 was more
effective in stimulating host protective immune responses
than separately injected single antigens, and that IL-12 serves
as a good DNA adjuvant [58].
It was possible to show the importance of implementing
prevention programs to guide pregnant women to prevent
the infection. Preventive measures like information and
health education; screening of pregnant women and infants;
limiting harm from risk behaviour; treatment of risk cases
and vaccination are recommended [38]. Serum monitoring
throughout pregnancy, so as detect cases of maternal
seroconversion allowing for early maternal treatment is also
basic [7,10].

Conclusions

Some countries have adopted control programs of human

toxoplasmosis, however, this issue should be of world attention,
considering its relevant aspects of public health, requiring
the establishment of community education campaigns and

Bresciani et al. Research Journal of Infectious Diseases 2013,

http://www.hoajonline.com/journals/pdf/2052-5958-1-7.pdf

doi: 10.7243/2052-5958-1-7

monitoring of pregnant women in the pre and neonatal,

especially in a preventive action to reduce the pathogenic
effects of this disease.
List of abbreviations

AIDS: Acquired Immunodeficiency Syndrome

T. gondii: Toxoplama gondii
HIV: Human Immunodeficiency virus

Competing interests

The authors declare that they have no competing interests.

Authors contributions
Authors
contributions

KDSB

ALBG

ALV

LVSM

JCP

JAS

JFG

AJC

Research concept and design

--

--

--

--

--

Collection and/
or assembly of
data

Data analysis and

interpretation

Writing the
article

Critical revision
of the article

--

--

--

--

--

Final approval of
article

--

--

--

--

--

--

--

--

Statistical
analysis

--

--

--

--

--

--

--

--

Acknowledgement and funding

To FAPESP for the financial support for this publication.

Publication history

EIC: Ishtiaq Qadri, King Abdul Aziz, University, Jeddah, Saudi Arabia.
Editor: Claudio A. Pereira, University of Buenos Aires, Argentina.
Received: 12-Jun-2013 Revised: 20-Aug-2013
Accepted: 02-Sep-2013 Published: 19-Sep-2013

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Citation:
Bresciani KDS, Galvo ALB, Vasconcellos ALd, Soares
JA, Matos LVSd, Pierucci JC, Neto LdS, Rodrigues TO,
Navarro IT, Gomes JF and Costa AJd. Relevant aspects
of human toxoplasmosis. Res J Infect Dis. 2013; 1:7.
http://dx.doi.org/10.7243/2052-5958-1-7