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Received: 30 August 2020    Revised: 3 October 2020    Accepted: 22 October 2020

DOI: 10.1111/tid.13506

ORIGINAL ARTICLE

Toxoplasmosis after allogeneic hematopoietic stem cell

transplantation: Impact of serostatus-based management

Takahito Amikura1 | Taku Kikuchi1  | Jun Kato1 | Yuya Koda1 | Masatoshi Sakurai1 |

Rie Yamazaki1  | Kei Mikita2 | Masuho Saburi1,3 | Tomonori Nakazato1,4 |
Takehiko Mori1

1
Division of Hematology, Department
of Medicine, Keio University School of
Medicine, Tokyo, Japan
2
Department of Infectious Diseases, Keio
University School of Medicine, Tokyo, Japan
3
Department of Medical Oncology and
Hematology, Oita University Faculty of
Medicine, Oita, Japan
4
Department of Hematology, Yokohama
Municipal Citizen's Hospital, Yokohama,
Japan
Correspondence
Takehiko Mori, Division of Hematology,
Department of Medicine, Keio University
School of Medicine, 35 Shinanomachi,
Shinjuku-ku, Tokyo 160-8582, Japan.
Email: tmori@a3.keio.jp
Abstract
Toxoplasmosis caused by Toxoplasma gondii (T. gondii) is a serious infectious complica-
tion after allogeneic hematopoietic stem cell transplantation (HSCT). The incidence
of toxoplasmosis varies widely because of the variabilities of seroprevalence among
patient populations. The incidence and the optimal management of toxoplasmosis
after allogeneic HSCT in a patient population with a low seroprevalence have not
been fully evaluated. We conducted a single-center retrospective study evaluating
toxoplasmosis in Japanese patients who underwent allogeneic HSCT. Of the 728
evaluable patients, only 5 developed toxoplasmosis with a median onset of day 60
post-transplant (range, day 55-393). The cumulative incidence was 0.7% (95% CI:
0.3%-1.5%) at day 500 post-transplant. Four of the five patients succumbed due to
toxoplasmosis. The more recently treated 220 patients (not the earlier 508 patients)
were screened for the T. gondii serostatus, and prophylactic treatment with trimetho-
prim/sulfamethoxazole was applied. All five patients with toxoplasmosis were in the
unscreened group, and there was no case of toxoplasmosis after the introduction of
the screening and prophylactic treatment. Our results suggest that toxoplasmosis
after allogeneic HST is rare but can develop as a life-threatening complication even in
the populations with low seroprevalence, and that prophylactic treatment for sero-
positive patients could effectively prevent toxoplasmosis.

KEYWORDS

allogeneic hematopoietic stem cell transplantation, seroprevalence, serostatus, toxoplasmosis

1 |  I NTRO D U C TI O N post-transplant toxoplasmosis is well recognized and studied. In a

Toxoplasmosis is one of the potential life-threatening infectious
complications after allogeneic hematopoietic stem cell transplan-
tation (HSCT).1 Since most cases of toxoplasmosis are caused by
the reactivation of the parasite Toxoplasma gondii (T. gondii), its inci-
dence is dependent on the seroprevalence of the patient population.
In areas of high seroprevalence such as Europe and Latin America,
Takahito Amikura and Taku Kikuchi equally contributed to this manuscript.
prospective study performed in Europe, the incidence of T. gondii
reactivation detected by polymerase chain reaction (PCR) was 16%
in T. gondii-seropositive patients after allogeneic HSCT, and 38% of
reactivated patients developed invasive toxoplasmosis. 2 Because
of this reactivation incidence, physicians rarely encounter cases of
toxoplasmosis in patient populations with a low seroprevalence.
The universally used method to identify the patients at risk
for developing toxoplasmosis is the determination of the IgG anti-
body titer for T. gondii before transplantation, as recommended by

Transpl Infect Dis. 2020;00:e13506. wileyonlinelibrary.com/journal/tid |

© 2020 Wiley Periodicals LLC     1 of 5
https://doi.org/10.1111/tid.13506
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the updated ‘Guidelines for Preventing Infectious Complications TA B L E 1   Patient characteristics (N = 728)
among Hematopoietic Cell Transplantation Recipients: A Global Median age, years (range) 44 (11-68)
Perspective’ cosponsored by Center for International Blood and Gender
Marrow Transplant Research, National Marrow Donor Program, Male/female 421/307
European Blood and Marrow Transplant Group, American Society
Underlying diseases
for Blood and Marrow Transplant, Canadian Blood and Marrow
Acute myeloid leukemia 229
Transplant Group, Infectious Diseases Society of America, Society
Myelodysplastic syndrome 119
for Healthcare Epidemiology of America (SHEA), Association of
Acute lymphocytic leukemia 109
Medical Microbiology and Infectious Diseases, the Center for
Malignant lymphoma 101
Disease Control and Prevention, and the Health Resources and
3
Services Administration. In the present study, we retrospectively Chronic myelogenous leukemia 81

evaluated the incidence and characteristics of toxoplasmosis devel- Aplastic anemia 30

oping after allogeneic HSCT in Japanese patients, which are known Multiple myeloma 29
to have a low seroprevalence for T. gondii. We also examined the Others 30
impact of prophylactic management for toxoplasmosis (based on the Donor and stem cells
patients' serostatus) on the incidence of toxoplasmosis. Bone marrow/peripheral blood from related donor 151/84
Bone marrow/peripheral blood from unrelated 373/8
donor
2 |  PATI E NT S A N D M E TH O DS Cord blood from unrelated donor 112
GVHD prophylaxis
2.1 | Patients and study design Cyclosporine A-based 325
Tacrolimus-based 391
In this single-center retrospective study, we evaluated the cases of
Not available 12
the patients who underwent an allogeneic HSCT between January
1994 and December 2018 at the Division of Hematology of Keio Abbreviation: GVHD, graft-versus-host disease.

University Hospital (Tokyo) by using an institutional database based

on the Transplant Registry Unified Management Program (TRUMP) 4
and the patients' medical records. This study was approved by the
ethics committee of Keio University School of Medicine.
2.2 | Definition and management of toxoplasmosis
be switched to atovaquone (1500 mg/day). The dose of TMP/SMX
was adjusted mainly based on the renal function at discretion of the
treating physician. In seronegative patients, TMP/SMX was given in
the same manner for the prophylaxis of pneumocystis pneumonia,
but it could be switched to pentamidine inhalation or atovaquone at
the discretion of each treating physician.

The diagnosis of toxoplasmosis was made based on the presence of

clinical signs or findings consistent with known organ diseases such
as central nervous system (CNS) lesions in combination with the de-
tection of T. gondii by histology or PCR, and/or the detection of the
5
specific IgM antibody. The diagnosis of chorioretinitis was based
on the typical ophthalmological findings assessed by an experienced
ophthalmologist.
Until the time point at which our hospital experienced a pa-
6
tient with disseminated toxoplasmosis after allogeneic HSCT, the
screening test for the IgG antibody specific for T. gondii before trans-
plantation was not performed in any of the patients. After 2012, all
patients were screened for the serum IgG antibody by a commer-
cially available enzyme-linked immunosorbent assay kit (Bio-Rad
Laboratories). The patients who were confirmed to be seropositive
received prophylactic trimethoprim/sulfamethoxazole (TMP/SMX)
for 14 days (TMP, 320 mg/day) before transplantation, which was
restarted (TMP, 320 mg twice a week or 80 mg daily) promptly
after the patient's neutrophil count recovered and he or she could
tolerate eating. TMP/SMX was continued until all the immunosup-
pressants were discontinued. If TMP/SMX was intolerable, it could
2.3 | Statistical analysis
The probability of toxoplasmosis was estimated based on the cumu-
lative incidence curve to accommodate deaths without the devel-
opment of toxoplasmosis within 500 days after transplantation as
a competing event. Statistical analyses were performed with EZR,
which is a graphical user interface for R.7
3 | R E S U LT S
3.1 | Patients and incidence of toxoplasmosis
During the study period, 728 patients underwent an allogeneic
HSCT. The patient characteristics are summarized in Table 1. Among
the 728 patients, only five developed toxoplasmosis and were en-
rolled in the analyses. The cumulative incidence of toxoplasmosis
was 0.7% (95%CI: 0.3%-1.5%) at 500  days after transplantation
(Figure 1A).
AMIKURA et al. |
      3 of 5

F I G U R E 1   Cumulative incidence of (A) (B)

toxoplasmosis after allogeneic HSCT in (A)
all patients (n = 728) and (B) the patients 2.0 2.0

Cumulative incidence (%)

Cumulative incidence (%)

not screened for their Toxoplasma gondii
serostatus (n = 508)

1.0 1.0

0.0 0.0

0 100 200 300 400 500 0 100 200 300 400 500
Post-transplant days Post-transplant days

3.2 | Characteristics of toxoplasmosis patients
The characteristics of the five patients who developed toxoplasmosis
are shown in Table 2. All five patients underwent an allogeneic HSCT
for a hematological malignancy. The median age was 38 years. All
patients had concurrent acute or chronic graft-versus-host disease
(GVHD) and received systemic immunosuppressive agents including
steroid at the onset of toxoplasmosis. None of the five patients were
receiving the prophylactic agents against T. gondii. Except for dis-
seminated disease in case 4, the involved organ was the brain with or
without chorioretinitis. A pre-mortem diagnosis of the disseminated
disease could not be made, and the patient's autopsy revealed that
toxoplasmosis invaded the lungs, liver, heart, gallbladder, stomach,
esophagus, kidneys, and thyroid.6 All but one of the five patients
died because of toxoplasmosis.
3.3 | Impact of prophylactic intervention in
seropositive patients on toxoplasmosis
All five of the patients who developed toxoplasmosis underwent the
allogeneic HSCT before the introduction of serostatus screening and
prophylactic intervention at our hospital. We reanalyzed the cumu-
lative incidence of toxoplasmosis in the 508 patients without screen-
ing; it was 1.0% (95% CI: 0.4%-2.2%, Figure  1B). The introduction
of screening for the T. gondii serostatus identified 20 seropositive
patients among 220 patients. Pre- and post-transplant prophylactic
intervention with TMP/SMX was applied, and there was no case of
toxoplasmosis in these patients.
4 | D I S CU S S I O N
The results of this retrospective study demonstrated the incidence
of toxoplasmosis after allogeneic HSCT at 0.7% in a Japanese popu-
lation, most of them developed toxoplasmosis within 3 months after
their HSCT. Although the number of cases was small, most of the
patients (four of the five) died due to toxoplasmosis. Our findings
also suggest that our hospital's prophylactic approach for seroposi-
tive patients effectively prevented the occurrence of toxoplasmosis.
The incidence of toxoplasmosis is affected by the seroprevalence
of T. gondii in patient populations because toxoplasmosis is mostly
caused by the reactivation of T. gondii in patients who have already
been infected.8,9 Compared to the seroprevalence of regions such
as Europe, Latin America, and the Middle East, the seroprevalence
in Japan has been known to be low (5%-16%).10-13 Although such a
low seroprevalence results in the low incidence of toxoplasmosis, a
certain proportion of patients in Japan are seropositive for T. gondii
and at risk for developing life-threatening toxoplasmosis. In fact, 5
of the present 728 patients developed toxoplasmosis, and 4 of them

TA B L E 2   Characteristics of five cases of toxoplasmosis after allogeneic hematopoietic stem cell transplantation

Toxoplasmosis

Age Underlying Stem cell Immunosuppressive Onset Involved

Case (y) disease Donor type GVHD agents at onset (d) organs Outcome

1 38 CML Sibling Bone marrow Yes Cyclosporine A, steroid 55 Brain, Dead

chorioretina
2 57 ALL Sibling Bone marrow Yes Tacrolimus, steroid 393 Brain Dead
3 22 AML Unrelated Bone marrow Yes Tacrolimus, steroid 95 Brain Recovered
a
4 43 MDS Unrelated Bone marrow Yes Tacrolimus, steroid 60 Disseminated   Dead
5 14 ALL Unrelated Bone marrow Yes Tacrolimus, steroid 57 Brain Dead

Abbreviations: ALL, acute lymphoblastic leukemia; AML, acute myelogenous leukemia; CML, chronic myeloid leukemia; GVHD, graft-versus-host
disease; MDS, myelodysplastic syndrome.
a
Involved organs were the lungs, liver, heart, gallbladder, stomach, esophagus, kidneys, and thyroid, which was confirmed by autopsy.
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4 of 5       AMIKURA et al.
did not survive the devastating infection. These findings are consis-
14,15
tent with those of previous reports from Japan. There was only
one case of toxoplasmosis involving the lungs in our present study.
However, because of the difficulty in the accurate diagnosis of pul-
monary toxoplasmosis mimicking other more common pulmonary
diseases, the incidence of pulmonary toxoplasmosis could have been
underestimated.11,15 Although the seroprevalence of T. gondii is low
and thus the incidence of toxoplasmosis is low in Japan, there have
been several reports by Japanese investigators showing the ominous
prognosis of toxoplasmosis, especially disseminated disease, devel-
oping after allogeneic HSCT.11,15,16 Therefore, there is a specific
guideline of ‘Toxoplasmosis’ from Japan Society for Hematopoietic
Cell Transplantation presenting the details of the basic background
and epidemiology, prevention, and treatment of toxoplasmosis after
HSCT. In the guideline, prophylaxis using TMP/SMX is recommended
for seropositive patients.
Because of the high mortality rate, all possible efforts and at-
tempts should be made to prevent the reactivation of T. gondii after
allogeneic HSCT. First, the assessment of each patient's serostatus
before transplantation is an essential step to identify the risk of
toxoplasmosis; this is universally recommended.3 However, sporadic
reports have described the development of toxoplasmosis in sero-
negative patients, which might be explained by the false negativity
of the assay and/or transmission via stem cell grafts or blood prod-
uct transfusion.17,18 Secondly, the use of PCR of the peripheral blood
could be an option in seropositive patients for the early detection
of reactivated T. gondii, which should be followed by preemptive
treatment in reactivated cases. 2,8,19 However, a reliable PCR assay
for T. gondii is not necessarily available at all facilities. Prophylactic
treatment for seropositive patients is more accessible, although the
toxicities of agents used should be carefully monitored. In addition
to the seropositivity against T. gondii before transplantation and de-
tection of reactivation of T. gondii after transplantation, reported risk
factors for developing toxoplasmosis after HSCT included absence
of prophylaxis, allogeneic HSCT (vs autologous HSCT), cord blood,
haploidentical and unrelated mismatched donor transplantation,
low CD4+ cell count, myeloablative conditioning, use of total body
irradiation, and anti-thymocyte globulin.1,2 Among the risk factors,
absence of effective prophylaxis was shown to have a great impact
on the incidence of T. gondii reactivation or toxoplasmosis. 2,18 The
results of our present analyses also reinforced the importance of
prophylaxis and suggest that pre- and post-transplant prophylactic
treatment with TMP/SMX can effectively prevent the development
of toxoplasmosis. Since there has not been a prospective study to
establish the optimal prophylaxis against toxoplasmosis, such re-
search should be performed in the future.
Our study has several limitations to be taken into consideration.
The major limitations are the study's retrospective nature and the
limited number of cases of toxoplasmosis. In addition, the results
were obtained from a Japanese population with a low seropreva-
lence, which makes it difficult to compare our findings with results
from other regions. Another limitation is that the study period was
>20 years, and the practice of HSCT changed significantly over the
study period, which could affect the transplant outcomes. The other
limitation concerns the comparative evaluation of the efficacy of
our management in preventing toxoplasmosis because the patients'
serostatus before the introduction of the serostatus screening was
unknown.
In conclusion, regardless of the seroprevalence, screening for
T. gondii serostatus should be performed for the recipients of allo-
geneic HSCT, and an available prophylactic or preemptive approach
should be applied to the seropositive patients in order to prevent
the development of toxoplasmosis. A large-scale prospective study
is required to establish the most effective and feasible management
for toxoplasmosis developing after allogeneic HSCT.
C O N FL I C T O F I N T E R E S T
The authors declare that they have no conflict of interest.
AU T H O R S ' C O N T R I B U T I O N
TA and TK designed the study, collected, and analyzed the data,
and wrote the manuscript; JK, YK, MS, RY MS, and TN took care
of the patients, collected data, and provided important opinions;
KM provided important opinions; and TM took care of the patients,
designed the study, collected and analyzed the data, and wrote the
manuscript. All the authors read and approved the final version of
the manuscript.
ORCID
Taku Kikuchi  https://orcid.org/0000-0002-3210-7756
Rie Yamazaki  https://orcid.org/0000-0001-7489-4180
Takehiko Mori  https://orcid.org/0000-0002-8176-4760
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How to cite this article: Amikura T, Kikuchi T, Kato J, et al.
Toxoplasmosis after allogeneic hematopoietic stem cell
transplantation: Impact of serostatus-based management.
Transpl Infect Dis. 2020;00:e13506. https://doi.org/10.1111/
tid.13506