Cerebral toxoplasmosis and Guillain‐Barré syndrome after allogeneic peripheral stem cell transplantation

Abstract

We report an unusual case of cerebral toxoplasmosis associated with Guillain-Barré syndrome (GBS) in a 25-year-old patient diagnosed with chronic myelogenous leukaemia (CML), who underwent a mismatched allogeneic peripheral stem cell transplantation (PSCT). On day +83 he started with fever, and 7 days later tremor, muscular weakness, diplopia, dysarthria, respiratory difficulty, and universal arreflexia appeared, compatible with GBS. As the patient had a positive cytomegalovirus (CMV) antigenemia, this was the aetiology suspected for his neurologic findings, but specific treatment failed to improve his clinical situation, and he died on day +123. Necropsy demonstrated cerebral toxoplasmosis and axonal degeneration of nerve roots compatible with the axonal form of GBS. Interestingly, the polymerase chain reaction (PCR) signal for Toxoplasma gondii in two different cerebrospinal fluid (CSF) samples had been negative. In addition, this case showed unique magnetic resonance imaging (MRI) abnormalities. We conclude that a negative PCR on CSF cannot exclude toxoplasmosis in a transplant patient, and we emphasise the importance of considering Toxoplasma as an aetiology of fever and neurological symptoms in the transplant setting.

Cerebral toxoplasmosis in an allogeneic peripheral stem cell transplant recipient: case report and review of literature

“…Therefore, for verification of toxoplasmosis, other non‐invasive methods such as PCR (of CSF or blood) are employed (2, 12). Although Khoury et al suggested that PCR of CSF might be of great value in this respect (2), our results, similar to another case report (8), did not support this notion. The importance of PCR of blood emphasized by Bretagne et al (14) was, in our case, also not confirmed.…”

“…The pleiomorphic manifestation of toxoplasmosis makes it difficult to obtain a definite diagnosis ante mortem (6). Hence, despite significant cerebral involvement, the diagnosis of cerebral toxoplasmosis was not made during life in a number of case reports (6–12). Moreover, adults in Western and Central Europe have a very high likelihood of having had contact with T. gondii , proven by positive Toxoplasma serology (13).…”

“…Another feature from the reported non‐specific findings in Toxoplasma encephalitis is a combination of elevated protein with parallel normal glucose level in CSF (6–8). The presented patient fulfilled these criteria.…”

Infectious Complications in Kidney Transplantation

“…Encephalitis is a serious and frequent complication (Lopez-Duarte et al, 2003). Peripheral neuropathy is common, taking a Guillain-Barré pattern in a recently reported case (Gonzalez et al, 2000). Chorioretinitis, similar to that seen in CMV infection, is frequently seen (Moshfeghi et al, 2004).…”

Toxoplasmosis and secondary Guillain‐Barré associated with ruxolitinib as graft‐versus‐host disease treatment

“…Guilláin‐Barré syndrome is an autoimmune polyneuropathy, triggered by infections such as toxoplasma, that has not been previously described to be associated with ruxolitinib. After starting ruxolitinib, severe lymphopenia, with T lymphocytes of 46/mcl and CD4 of 3/mcl and a decrease in natural killer cells, with an increase in the percentage of the bright population up to 25% of the total were observed.…”