DISSEMINATED TOXOPLASMOSIS - UNUSUAL PRESENTATIONS IN THE IMMUNOCOMPROMISED HOST

Objective.--Owing to the increasing number of patients with acquired i mmunodeficiency syndrome and immuno-suppressed transplant patients, di sseminated Toxoplasma gondii has emerged as a potentially fatal pathog en. Common presentations include encephalitis, pneumonia, and myocardi tis. The objective of this report is to describe the clinical course, histologic features, and outcome in two immunocompromised patients wit h disseminated toxoplasmosis presenting with parasitemia and panniculi tis. Materials and Methods.--Two cases of disseminated toxoplasmosis p resenting with parasitemia (patient 1) and panniculitis (patient 2) we re retrieved from the clinical, surgical, and autopsy pathology archiv es of Vanderbilt University Medical Center, Nashville, Tenn. The histo logy and diagnostic approaches used are reported. Charts were reviewed for primary diagnosis, therapy protocols, clinical presentation of in fection, and outcome. Results.--Patient 1 developed a clinically unexp lained sepsis syndrome shortly after heart transplantation; T gondii p arasitemia was diagnosed by examination of peripheral blood smears. Th e diagnosis was confirmed at autopsy. Patient 2 was a child undergoing induction chemotherapy for lymphoma who developed rapidly progressive neurologic deterioration accompanied by a maculopapular skin rash; T gondii panniculitis was diagnosed retrospectively when histologic exam ination was combined with immunohistochemistry. Autopsies performed in both cases confirmed widely disseminated infection. Conclusions.--Dis seminated toxoplasmosis should be considered in the differential diagn osis of immunocompromised patients with culture-negative sepsis syndro me, particularly if combined with neurologic, respiratory, or unexplai ned skin lesions. Examination of Wright's-stained peripheral blood sme ars or antitoxoplasma immunoperoxidase studies of skin biopsies may be diagnostic and allow rapid initiation of antibiotic therapy. Autopsy findings contributed to both of our cases by documenting the widesprea d heavy parasite burden and demonstrating numerous diagnostic T gondii cyst forms.