Toxoplasmosis Organism-Specific Therapy 

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Toxoplasmosis is caused by the protozoan Toxoplasma gondii, typically when tissue cysts in undercooked meat or oocysts shed in cat feces are ingested. In the vast majority of individuals, infection is asymptomatic, as a competent immune system is sufficient to keep the organism in a latent tissue cyst state. However, if these cysts reactivate, encephalitis may occur. Rarely, primary infection is associated with acute cerebral or disseminated disease. Immunocompromised or pregnant individuals are at highest risk when infected. In immunocompetent/nonpregnant individuals, only supportive therapy is necessary unless severe symptoms persist. All treatments should be administered orally unless otherwise indicated.

Immunocompromised patients (HIV/AIDS or transplantation)  ^{[1, 2]}

Initial treatment: Continue for 6 weeks after resolution of symptoms and imaging results

Pyrimethamine 200 mg loading dose, followed by weight-based therapy (50 mg/day for < 60 kg, 75 mg/day for >60 kg) plus  sulfadiazine 15 mg/kg, 4 times daily plus leucovorin (folinic acid) 10-20 mg/day

For those who are sulfadiazine hypersensitive, clindamycin 300 mg 4 times daily or atovaquone 1500 mg twice daily (with food) are acceptable substitutions

Consider IV steroid therapy for the treatment of mass effect attributed to focal lesions or associated edema. Anticonvulsants should be administered to patients with a history of seizures and continued through the acute treatment (but not given without a history of seizures).

Maintenance: Lifelong or until there is immune recovery (CD4 >200 cells/uL for more than 6 months)

Trimethoprim-sulfamethoxazole 480-960 mg/day or

For those who are intolerant to sulfa, dapsone 50 mg/day plus  pyrimethamine 50 mg/week plus  folinic acid 25 mg/week or

Atovaquone 1500 mg PO q24h alone or  with pyrimethamine 25 mg plus folinic acid 10 mg PO q24h

Congenital toxoplasmosis  ^[3]

Maternal infection 3 months before conception or during pregnancy, before 18 weeks of gestation, or immunocompromised women suspected of having reactivated latent Toxoplasma infection:

Spiramycin: 1 g q8h with food

Maternal infection after 18 weeks of infection:

Pyrimethamine 50 mg q12h for 2 days followed by 50 mg/day

Sulfadiazine loading of 75 mg/kg followed by 50 mg/kg q12h

Folinic acid 10-20 mg/day until 1 week following cessation of pyrimethamine treatment

Congenital infection of the newborn:

Pyrimethamine 1 mg/kg q12h for 2 days, followed by 1 mg/kg/day for 6 months, followed by 1 mg/kg 3 times a week

Sulfadiazine 50 mg/kg q12h

Folinic acid 10 mg 3 times a week until 1 week after cessation of pyrimethamine treatment

Treatment duration: 1 year

Mofenson LM, Brady MT, Danner SP, et al. Guidelines for the Prevention and Treatment of Opportunistic Infections among HIV-exposed and HIV-infected children: recommendations from CDC, the National Institutes of Health, the HIV Medicine Association of the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the American Academy of Pediatrics. MMWR Recomm Rep. 2009 Sep 4. 58:1-166. [Medline]. [Full Text].

Seddon J, Bhagani S. Antimicrobial therapy for the treatment of opportunistic infections in HIV/AIDS patients: a critical appraisal. HIV AIDS (Auckl). 2011. 3:19-33. [Medline]. [Full Text].

Moncada PA, Montoya JG. Toxoplasmosis in the fetus and newborn: an update on prevalence, diagnosis and treatment. Expert Rev Anti Infect Ther. 2012 Jul. 10(7):815-28. [Medline].

Darvin Scott Smith, MD, MSc, DTM&H Adjunct Associate Clinical Professor, Department of Microbiology and Immunology, Stanford University School of Medicine; Chief of Infectious Diseases and Geographic Medicine, Department of Internal Medicine, Kaiser Permanente Medical Group

Darvin Scott Smith, MD, MSc, DTM&H is a member of the following medical societies: American Medical Association, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, International Society of Travel Medicine

Disclosure: Nothing to disclose.

Katherine J Wu, MS Graduate Student in Biological and Biomedical Sciences, Harvard University

Disclosure: Nothing to disclose.

Jasmeet Anand, PharmD, RPh Adjunct Instructor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Thomas E Herchline, MD Professor of Medicine, Wright State University, Boonshoft School of Medicine; Medical Consultant, Public Health, Dayton and Montgomery County (Ohio) Tuberculosis Clinic

Thomas E Herchline, MD is a member of the following medical societies: Alpha Omega Alpha, Infectious Diseases Society of America, Infectious Diseases Society of Ohio

Disclosure: Nothing to disclose.

Kelley Struble, DO Fellow, Department of Infectious Diseases, University of Oklahoma College of Medicine

Kelley Struble, DO is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Toxoplasmosis Organism-Specific Therapy 

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