Toxoplasma Gondii Meningitis in Heart Transplant Recipient - An Atypical Presentation of Toxoplasmosis

Abstract

Background While toxoplasmosis is an uncommon infection in heart transplant recipients with a prevalence of 0.3% to 0.61%, meningitis is extremely uncommon. Case report A 39-year-old male 3 months post heart transplant presented with one day of fever, nausea, vomiting and headache. He was on standard immunosuppression and prophylaxis except a modified dosing of SMZ-TMP at 400-80 (half tablet, twice per week) due to adverse effects of renal dysfunction and hyperkalemia. Initial infectious work up was negative but altered mental status worsened with no focal deficits despite empiric broad spectrum antibacterial coverage. CT head was unremarkable and MRI could not be performed due to retained pacemaker leads. Lumbar puncture (LP) showed glucose of 35, WBC of 438 (neutrophils 53%, monocytes 37% and lymphocytes 10%) and protein 217. All cultures were negative while Toxoplasma PCR showed 513,000 copies. Pyrimethamine with folinic acid and sulfadiazine was started but had ongoing fluctuations of his mental status and on day 15 a repeat CT head showed hyperdensity along the right lateral ventricle ( Figure 1 ) likely due to hemorrhagic meningoencephalitis. Repeat LP revealed negative toxoplasma PCR but blood in the CSF. Oral SMZ-TMP dosing was increased and clindamycin added to the regimen with a final improvement of his clinical status leading to discharge with ongoing improvement with no residual neurological deficits. Discussion Recipients with negative serostatus for toxoplasmosis are at a high risk of clinical disease when they receive organ from a seropositive donor. (OR 15.12, CI 2.37-96.3). Our patient had no prior exposure while his donor was noted to have toxoplasma IgG. Current prophylaxis regimens do not factor such mismatches and probably need to.