Cerebral Toxoplasmosis in a Rheumatoid Arthritis Patient on Immunosuppressive Therapy

Abstract

Cerebral toxoplasmosis is a life-threatening infection most commonly found in immunocompromised hosts such as acquired immunodeficiency syndrome (AIDS) or transplant patients. However, it is not known to affect patients with chronic inflammatory disorders on immunosuppressive therapy. We describe the case of a 70-year-old female with rheumatoid arthritis (RA) on chronic therapy with methotrexate and infliximab, who presented to the hospital after two weeks of right-sided weakness. Imaging revealed bilateral ring-enhancing lesions in the basal ganglia (left greater than right). A diagnosis of cerebral toxoplasmosis was made on brain biopsy. Apart from the immunosuppressive therapy and owning a cat, she had no other risk factors for developing the infection. The patient's immunosuppressive medications were discontinued, and she was started on high-dose trimethoprimsulfamethoxazole (TMP-SMX). Upon literature review using PubMed, we found seven other published reports on similar cases of toxoplasmosis in RA patients on immunosuppressive therapy; however, there was a lack of recommendations for diagnosis, treatment, and prophylaxis in this patient population. With the growing use of immunosuppressive therapies in chronic inflammatory disorders, further data is needed regarding the management of toxoplasmosis in these patients. This case report is an investigation of the relationship between immunosuppressive medications in RA patients and cerebral toxoplasmosis and an exploration of the available recommendations for its management.

Cerebral Toxoplasmosis as an Uncommon Complication of Biologic Therapy for Rheumatoid Arthritis: Case Report and Review of the Literature

“…We treated our patient with PYR-SDZ but felt the need to adjust the immunosuppressive treatment to achieve better results. In fact, two of the other four case reports also discontinued immunosuppressive drugs: in one case, the patient showed improvement on follow-up [ 10 ] and in the other, the prognosis is unknown [ 7 ], as the patient was lost to follow-up after being transferred to a long-term care hospital. Concerning prophylaxis, our patient received TMP-SMZ after toxoplasmosis treatment to decrease the risk of reactivation.…”

“…The higher seroprevalence of toxoplasmosis in RA patients and the long-term use of immunosuppressive drugs in autoimmune disorders increase the likelihood of toxoplasmosis infection in RA patients. Interestingly, cerebral toxoplasmosis due to biologic therapy with tumor necrosis factor α (TNF-α) inhibitors in patients with RA has been scarcely reported in the literature [ 7 ].…”

Seropositivity of Toxoplasma gondii antibodies in rheumatoid arthritis patients under treatment with TNF-? antagonists

“…This is because immunosuppressive drugs are used to treat these illnesses, which makes patients more vulnerable to infections (12). There is a possibility that infliximab was the sole predisposing factor in RA patients; as a result, additional study into the need of pretesting and/or prophylaxis, particularly in the RA group, is required; and, lastly, more research into the relationship between infliximab and RA is required (13). T. gondii has also been shown in previous studies to enhance the production of interleukin 17 (IL-17) in patients, which are significant since this cytokine is implicated in the development of many autoimmune disorders, including RA (14).…”

COVID-19-associated opportunistic infections: a snapshot on the current reports

“…Toxoplasmosis: toxoplasmic retinochoroiditis [161,162], cerebral toxoplasmosis [163] Cryptococcosis: pneumonia and pulmonary infection [258,259], disseminated infection [260,261], meningitis [262,263], cutaneous infection [264] Pneumocystis jiroveci (carinii) pneumonia [265][266][267][268] Aspergillosis: allergic bronchopulmonary [269], pulmonary [270], sinus aspergillosis [271], central nervous system aspergillosis [272], disseminated [273] Candidiasis: systemic candidiasis [274], arthritis [275], oral candidiasis [276] Mucormycosis: cutaneous [277], gastric perforation [233], disseminated [278], sinusitis [279], pulmonary [280] Strongyloidiasis: hyperinfection [281] Tuberculosis (pulmonary) [282][283][284] CMV retinitis [285], disseminated CMV [286] IL-17A blockers (Ixekizumab) Toxoplasmosis: lymphadenopathy [164] reported species [43,[45][46][47][48]. Other reported Candida species were C. albicans, C. tropicalis, C. parapsilosis, C. orthopsilosis, and C. glabrata among COVID-19 patients [43,49].…”

“…Combination of pyrimethamine and sulfadiazine is the choice drug for toxoplasmosis treatment among nonpregnant women [149]. Reactivation of latent toxoplasmosis has been reported in a number of patients who received immunosuppressive therapy, such as corticosteroids [154][155][156][157][158], JAKs inhibitors [159,160], TNF-α blockers [161][162][163] and IL-17A blockers [164], and the most common sequels were ocular [154][155][156][160][161][162] and cerebral [157][158][159]163] toxoplasmosis. In a case-control study among 100 COVID-19 patients in Egypt, a significantly higher prevalence of toxoplasmosis was detected among mild to moderate COVID-19 patients than the healthy control group [165].…”