Case Report: Severe ARDS in a Pediatric Hematopoietic Stem-Cell Transplantation Recipient Caused by Disseminated Toxoplasmosis

Abstract

Toxoplasma gondii infection is a severe complication of hematopoietic stem-cell transplantation (HSCT) recipients that can remain unnoticed without a high clinical suspicion. We present the case of a 6-year-old patient with acute lymphoblastic leukemia and HSCT recipient who was admitted to the Pediatric Intensive Care Unit (PICU) on post-transplantation day +39 with fever, hypotension, severe respiratory distress and appearance of a lumbar subcutaneous node. She developed severe Acute Respiratory Distress Syndrome (ARDS) and underwent endotracheal intubation and early mechanical ventilation. Subsequently, she required prone ventilation, inhaled nitric oxide therapy and high-frequency oscillatory ventilation (HFOV). An etiologic study was performed, being blood, urine, bronchoalveolar lavage and biopsy of the subcutaneous node positive for Toxoplasma gondii by Polymerase Chain Reaction (PCR). Diagnosis of disseminated toxoplasmosis was established and treatment with pyrimethamine, sulfadiazine and folinic acid started. The patient showed clinical improvement, allowing weaning of mechanical ventilation and transfer to the hospitalization ward after 40 days in the PICU. It is important to consider toxoplasmosis infection in immunocompromised patients with sepsis and, in cases of severe respiratory distress, early mechanical ventilation should be started using the open lung approach. In Toxoplasma IgG positive patients, close monitoring and appropriate anti-infectious prophylaxis is needed after HSCT.

The Medical Relevance of Toxoplasma Infections in Terms of the Safety of Blood Recipients under Immunosuppression—A Meta-Analysis

“…The risk of developing the condition has been associated with organ transplants such as heart, liver, kidney, and stem cell transplants [ 25 ]. The prevalence of T. gondii infection among recipients of hematopoietic stem-cell transplantation ranges from 0.4% to 9% and is strongly associated with significant immunosuppression [ 4 ]. Cerebral toxoplasmosis is the most common clinical manifestation of the infection in immunocompromised patients, followed by the progression of pulmonary disease leading to acute respiratory distress syndrome and disseminated toxoplasmosis.…”

“…Cerebral toxoplasmosis is the most common clinical manifestation of the infection in immunocompromised patients, followed by the progression of pulmonary disease leading to acute respiratory distress syndrome and disseminated toxoplasmosis. However, due to the non-specific nature of the symptoms, a definitive diagnosis of Toxoplasma infection is sometimes only established through a post-mortem necropsy [ 4 ].…”

“…T. gondii is widespread and infects a significant proportion of the global population [ 2 , 3 ]. The infection is usually harmless and resolves independently [ 4 ]. However, individuals with weakened immune systems are at risk of developing severe toxoplasmosis.…”

Toxoplasmosis Seroprevalence among Hemodialysis Patients: A Case-Control Study

“…When symptoms develop, isolated cervical or occipital lymphadenopathy is the most common clinical presentation, often with a mild, brief influenza-like illness (Rauwolf et al, 2021). The infection normally resolves on its own and is not harmful (De La Mata Navazo et al, 2022).…”