Grand Rounds: Toxoplasmosis
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A Grand Rounds neurology presentation given on 15/08/2014 at the University of Glasgow Small Animal Hospital demonstrating the approach to Toxoplasmosis through a case report of a one-year-old castrated male cat initially presenting with hindlimb ataxia and paresis, weightloss, and pyrexia.
![‘Kenzie’ McLaren
• One-year-old castrated male British Shorthair
• One-day history of hindlimb ataxia and paresis
• 20% weightloss in 11 weeks
• Initial PE: unremarkable
• PCV low: 22% [29-45%]
• Pelvic radiography unremarkable
• Referred to neurology service](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)
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Grand Rounds: Toxoplasmosis
- 1. Toxoplasmosis A diagnosis of exclusion
- 2. ‘Kenzie’ McLaren • One-year-old castrated male British Shorthair • One-day history of hindlimb ataxia and paresis • 20% weightloss in 11 weeks • Initial PE: unremarkable • PCV low: 22% [29-45%] • Pelvic radiography unremarkable • Referred to neurology service
- 4. Summary of Findings • Pyrexia (39.3 to 40.3°C) • Initial stiff hindlimb gait • Reduced exercise tolerance: forelimbs became stiff to the point of collapse • Normal spinal reflexes, but some myoclonus • No proprioceptive deficits • Suggestive of a neuromuscular disorder DDx: neuropathy, myopathy or junctionopathy
- 5. Summary of Findings • Pyrexia (39.3 to 40.3°C) • Initial stiff hindlimb gait • Reduced exercise tolerance: forelimbs became stiff to the point of collapse • Normal spinal reflexes, but some myoclonus • No proprioceptive deficits DDx: neuropathy, myopathy or junctionopathy
- 6. Summary of Findings • Pyrexia (39.3 to 40.3°C) • Initial stiff hindlimb gait • Reduced exercise tolerance: forelimbs became stiff to the point of collapse • Normal spinal reflexes, but some myoclonus • No proprioceptive deficits • Initial CK and ACh-R antibody (pending) tests DDx: neuropathy, myopathy or junctionopathy
- 7. Electromyography (EMG) • Abnormal spontaneous muscle activity • Normal nerve conduction velocities • Normal repetitive nerve stimulation DDx: myopathy or junctionopathy
- 8. Problem List Neurological Ataxia Stiff gate Reduced exercise tolerance Myoclonus (EMG confirmed) Dx: Myopathy (idiopathic or secondary) DDx: Infectious, Autoimmune, Neoplastic Other Weightloss (too acute) Pyrexia Anaemia (rarely) CK elevated (84X upper ref.)
- 9. Haematology Erythrocytes • Low haematocritt • Polycythaemia • Haemaglobinaemia Leukocytes • Leukopaenia • Neutropaenia • Lymphopaenia
- 10. Blood Smear • Anaemia poorly regenerative • Howell-Jolly bodies in RBCs • Occasional poikilocytes • Mild toxic left shift • Pro-eosinophils containing basophilic granules • Occasional hyperchromatic lymphoid cells • Direct Coombs Test Negative DDx: chronic infectious, autoimmune, neoplastic
- 11. Biochemistry • Hypoproteinaemia • Low globulin levels • High AST (2X upper ref.) • High ALT (3X upper ref.) • High CK (now 180X upper ref.) • High fasting bile acids (2X upper ref.) – Need bile acid stimulation test DDx: myopathy, mild cholangiohepatitis
- 12. Biochemistry • Hypoproteinaemia • Low globulin levels • High AST (2X upper ref.) • High ALT (3X upper ref.) • High CK (now 180X upper ref.) • High fasting bile acids (2X upper ref.) – Need bile acid stimulation test DDx: myopathy, mild cholangiohepatitis
- 13. Thoracic Radiography Excessive mild bronchial pattern and cardiomegaly L R DDx: chronic bronchitis, early onset asthma DDx: myocarditis, HCM
- 14. Microbiology Report • Mucal swab taken from endotracheal tube due to respiratory noise during anaesthesia • Culture: Gram negative cocci & large rods • Sensitive to – Clavunated amoxicillins – Azithromycin – Doxycycline – Marbofloxacin
- 15. Problem List Neurological Ataxia Stiff gate Reduced exercise tolerance Myoclonus (EMG confirmed) Dx: Myopathy (idiopathic or secondary) Dx: Mild cholangiohepatitis (potentially) Dx: Chronic bacterial bronchitis DDx: Infectious, Autoimmune, Neoplastic Other Weightloss Pyrexia Poorly regenerative anaemia CK elevated (180X upper ref.) Elevated liver enzymes Cardiomegaly (DDx: myocarditis)
- 16. Feline Infectious Disease Panel • NEGATIVE: Feline Leukaemia Virus (FeLV) Antigen • NEGATIVE: Feline Immunodeficiency Virus (FIV) Immunofluorescent Assay • NEGATIVE: Feline Corona Virus (FCoV) Antibody Titre • POSITIVE: Toxoplasma Antibody Titre – IgG Seropositive (4X upper ref.)
- 17. Problem List Neurological Ataxia Stiff gate Reduced exercise tolerance Myoclonus (EMG confirmed) Dx: Myopathy Dx: Mild cholangiohepatitis (potentially) Dx: Chronic bacterial bronchitis Dx: Myocarditis (potentially) Dx: Chronic Toxoplasmosis (Infectious) Other Weightloss Pyrexia Poorly regenerative anaemia CK elevated (180X upper ref.) Elevated liver enzymes Cardiomegaly Explains secondary symptoms and disease
- 18. Initial Treatment • Pyrexia & Liver: IV fluids (0.9% saline) • Neutropaenia and Bronchitis: Augmentin 40 mg slow IV TID, then oral Synulox 50 mg BID • Toxoplasmosis: Clindamycin 25 mg BID
- 20. Continued Treatment & Monitoring • Clindamycin 25 mg BID for 4 weeks • Retest Toxoplasma antibody levels in 4 weeks • Recheck biochemistry and haematology • Ensure pulmonary infection has resolved and hepatic markers are within normal limits • Consider further cardiac evaluation
- 21. Toxoplasma gondii • Worldwide zoonosis • Obligate, intracellular parasitic protozoan • Only sexually reproduce in cats – the definitive host • Chronic infection can occur for the lifetime of the host, periodically rupturing cysts and re-encysting to increase numbers
- 22. Clinical Signs General Signs Anorexia Lethargy Pyrexia Weightloss Ataxia Specific Disease Bronchopneumonia Hepatitis Myocarditis Encephalitis Uveitis • Acute or chronic progression • Transplacental infection most severe • Poorer prognosis with hepatic or pulmonary signs
- 23. Life Cycle
- 24. Questions? Special thanks Kate Stalin Rodrigo Gutierrez Quintana Emma Roberts Katie Grove
Notas del editor
- Hypotonia = poor muscle tone OOH = out-of-hours Any way to find out the temperature, etc. that was monitored in the kennel?
- Myoclonus = involuntary muscle twitching Myasthenia gravis = type of junctionopathy (disease of the muscle or neuromuscular junction); autoimmune complexes block Ach-R function Only a small blood sample was attainable ACh-R Ab titre (80-96% sensitive) results take a few weeks to come back Neuropathy = clinical signs rule out due reduced exercise tolerance and lack of proprioceptive and reflex deficits
- Myoclonus = involuntary muscle twitching Myasthenia gravis = type of junctionopathy (disease of the muscle or neuromuscular junction); autoimmune complexes block Ach-R function Only a small blood sample was attainable ACh-R Ab titre (80-96% sensitive) results take a few weeks to come back Neuropathy = clinical signs rule out due reduced exercise tolerance and lack of proprioceptive and reflex deficits
- Myoclonus = involuntary muscle twitching Myasthenia gravis = type of junctionopathy (disease of the muscle or neuromuscular junction); autoimmune complexes block Ach-R function Only a small blood sample was attainable ACh-R Ab titre (80-96% sensitive) results take a few weeks to come back Neuropathy = clinical signs rule out due reduced exercise tolerance and lack of proprioceptive and reflex deficits
- Evaluates and records the electrical potential of skeletal muscle cells (depolarisation) Identifies neuromuscular diseases, assesses pain, kinesiology, and motor control disorders Myopathy more likely than a junctionopathy (myasthenia gravis) because of normal nerve conduction velocities and repetitive nerve stimulation THEN, they ran a gambit of bloodwork
- Howell-Jolly bodies = remnant DNA (suggests splenic damage) Poikilocytes = abnormal-shaped RBCs Toxic left shift = immature features still present in mature neutrophils with band neutrophils also present Pro-eosinophils containing basophilic granules = often seen in chronic granulocytic leukaemia CRONIC REGENERATIVE ANAEMIA (bone marrow exhausting)
- Cholangiohepatitis? Shunts? Need a bile acid stimulation test.
- Cholangiohepatitis? Shunts? Need a bile acid stimulation test.
- Is the first radiograph a VD or DV, is it marked incorrectly or does it need to be flipped? Congenital HCM based on age Chronic bronchitis or early onset asthma Vestigial 14th rib
- Resp. noise during anaesthetic; the 5 days of antibiotics should have cleared up the infection
- Titres can remain high years after exposure
- All of these diagnoses are possible secondary to chronic Toxoplasmosis in transplacentally-acquired infection.
- Do we need to retest of Abs can stay in the system years after infection?
- Image 1: http://www.businessinsider.com/how-insects-and-animals-are-turned-into-zombies-by-parasites-2012-12?op=1 Image 2: http://www.ufrgs.br/para-site/siteantigo/Imagensatlas/Protozoa/Toxoplasma.htm
- Change rat behaviour in the brain and make them attracted to cat urine. Image: http://cmr.asm.org/content/25/2/264.full.pdf
- Image: http://www.catchannel.com/images/articles/2-2008/catmouse-200px.jpg