Episode 40
40: Febrile Digest - Toxo + Transplant
Dr. Julie Steinbrink joins Sara to chat about toxoplasmosis screening and prevention in transplant as well as useful resources from the American Society of Transplantation
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Transcript
Hello everyone.
Sara Dong:Welcome to Febrile, a cultured podcast about all things infectious disease.
Sara Dong:I'm Sara, your host and a Med-Peds ID fellow.
Sara Dong:And I have a friend here with me today, Julie, welcome to the show.
Sara Dong:Can you tell everyone a little bit about yourself?
Julie Steinbrink:Hi Sara, thanks for having me.
Julie Steinbrink:My name is Julie Steinbrink.
Julie Steinbrink:I am an assistant professor in Infectious Diseases at Duke University.
Julie Steinbrink:I specialize in adult transplant infectious diseases, so my clinical care focuses on the management of infections in immunocompromised patients, including solid organ and bone marrow transplant patients.
Julie Steinbrink:You know, the, also those with hematologic malignancies.
Julie Steinbrink:I also do some research focusing on noninvasive diagnostics for different types of infectious diseases in immunocompromised patients.
Julie Steinbrink:Um, and so I'm very excited to be here.
Julie Steinbrink:Additionally, I serve as co-chair for the American Society of Transplantation, um, our Infectious Diseases Community of Practice Education workgroup.
Julie Steinbrink:And so I wanted to give a little bit of a plug for one of the initiatives that we're doing through the education work group.
Julie Steinbrink:We have a survey that we've created for our ID trainees, both adult and pediatric, including both our current trainees and recent graduates in the last five years.
Julie Steinbrink:And what we're really trying to do is better understand and improve upon the Transplant ID training curriculum.
Julie Steinbrink:So we want to characterize what are the educational experiences and needs that our ID trainees are having, especially for those who want to further careers in Transplant ID.
Julie Steinbrink:And so these data will add significantly to the existing knowledge that we have about Transplant ID training and help us to, kind of, identify gaps in training that are present and update our recommended, uh, curriculum, and really try to improve that and make it more cohesive for our trainees.
Julie Steinbrink:So we hope to have this survey live within the month and it'll be open for about four weeks.
Julie Steinbrink:You may see various methods of potential distribution.
Julie Steinbrink:We're sending out emails through the program directors, through my IDSA say listserv, um, the AST ID COP, our online hub, and you'll see some social media blasts for it as well.
Julie Steinbrink:But if you do see that present and you're a recent or current trainee, then, please feel free to engage.
Julie Steinbrink:It'll really help us out and help future trainees as well to improve upon their curriculum.
Julie Steinbrink:So thank you.
Sara Dong:Yeah, that's awesome.
Sara Dong:So we'll, we'll send everyone a reminder once we have the link and we'll actually mentioned a couple other resources that the ID Community of Practice has put together at the end, which has helped a lot of Febrile episodes.
Sara Dong:And I use them all the time.
Sara Dong:Um, so I feel very confident plugging those.
Sara Dong:You know, our current case based episodes in April and May are part of , uh, what we called the Curious Congenital Conundrums, which I hope everyone's listening to.
Sara Dong:We have some amazing international colleagues that have been joining for that series.
Sara Dong:And the most recent episode, number 39 called Seal of Approval, talks through the approach and challenges in a case with congenital toxoplasmosis.
Sara Dong:But one of the most awesome and fun parts about ID is that we get to learn about infections in a variety of hosts.
Sara Dong:And so I thought today we could talk a little bit about toxo in a different setting and transplant recipients, which I think people probably could guess by our introduction.
Sara Dong:So as a quick refresher, toxoplasma is a protozoal infection and transmission can be foodborne, zoonotic or congenital, but there's also human to human transmission on rare occasions through blood transfusion and organ transplant.
Sara Dong:And it's been estimated that anywhere up to probably half or so of the world's population has probably been exposed, although it's always kind of hard to get those figures.
Sara Dong:Um, so Julie, can you talk a little bit about screening for toxoplasmosis before transplant and the things that we are worried about in that setting?
Julie Steinbrink:Sure, definitely.
Julie Steinbrink:So toxoplasmosis in transplant recipients can be a manifestation of donor derived infection.
Julie Steinbrink:It can be reactivation of a latent infection in the recipient, or could also be a primary acute infection.
Julie Steinbrink:And so in the transplant space, we can see it both in our solid organ and in our stem cell transplant patients.
Julie Steinbrink:But I'm going to focus, of course, on the solid organ transplants for the purposes of this talk.
Julie Steinbrink:So screening of all of our organ donors and recipients is recommend.
Julie Steinbrink:The seronegative recipients of toxoplasma IgG positive donors have the highest risk of infection.
Julie Steinbrink:So those are, you know, so donor positive recipient, negative mismatch.
Julie Steinbrink:And the highest concern is for those who are heart transplant recipients because of the propensity of the Toxoplasma to want to encyst in that cardiac muscle.
Julie Steinbrink:And they can have up to a 75% risk of early post-transplant infection unless they received the appropriate antimicrobial prophylaxis.
Julie Steinbrink:And so this is particularly important in the first, you know, three months or so after transplant, when they have the highest levels of immunosuppression, so highest concern for potential transmission of infection.
Julie Steinbrink:Although the risk of transmission is highest or most concerning in our heart transplant recipients, we have to also consider it in our other non-cardiac transplant patients as well, particularly if they still have that donor positive recipient negative mismatch, and so increased recognition of this donor derived infection in non-cardiac transplant patients has led to a, more of a mandated toxoplasma IgG donor screening for all organs.
Julie Steinbrink:I was even part of like a multicenter study, where we looked at a couple of centers in the Southeast USA and the toxoplasma rates in our transplant patients.
Julie Steinbrink:And we found that, yes, we did have it in our cardiac transplant patients, but you actually also had it in the majority were actually in our non-cardiac transplant patients as well, and more frequently in the setting of rejection and then patients who did not receive appropriate antimicrobial prophylaxis at that time.
Julie Steinbrink:So I think some of that stems from the fact that as people become more aware of toxoplasma, they get appropriate prophylaxis maybe at the time of transplant, and that helps prevent in that acute setting.
Julie Steinbrink:But then down the road, people tend to maybe forget about their toxoplasma status.
Julie Steinbrink:And then they get augmented immunosuppression in the setting of allograft rejection and they don't get appropriate toxoplasma prophylaxis, and then that leads to downstream potential infections.
Julie Steinbrink:So those would probably be like the two biggest times to consider it would be like immediately after transplant, and then also when you're treating for rejection.
Sara Dong:And I thought maybe you could tell us a little bit about specifics about prophylaxis and how we can try to prevent infection, but also what are the things that we can counsel our patients on potentially avoiding infection.
Julie Steinbrink:Yeah, definitely.
Julie Steinbrink:So, as I mentioned, you want to have prophylaxis at times of high levels of immunosuppression.
Julie Steinbrink:You want to particularly consider it in your patients where there's the highest risk of transmission, so those mismatches.
Julie Steinbrink:The good news is that typically your common trimethoprim sulfa, uh, regimens that you use for Pneumocystis prophylaxis in these patients will also adequately, typically protect against toxoplasma as well.
Julie Steinbrink:And that can include, you know, three times a week regimen as well as their daily regimens as well.
Julie Steinbrink:Lower dose regiments are probably less likely to be effective.
Julie Steinbrink:Some centers though may potentially can use lower dose regimens for other center-specific reasons, or even consider adding things like pyrimethamine to it in particularly high risk combinations, if they were to have that medication available.
Julie Steinbrink:There's a little bit less data for other alternative regimens for toxoplasma prevention, like dapsone or atovaquone.
Julie Steinbrink:Um, there is some concern that there have been some breakthrough infections on atovaquone and so concerns for failure there.
Julie Steinbrink:Potentially some breakthrough infections on dapsone if you're using lower doses to make sure you're dosing that appropriately.
Julie Steinbrink:And other Pneumocystis regimens like pentamidine are not going to be effective against toxoplasma.
Julie Steinbrink:So something to take into consideration, you know, a lot of our patients get trimethoprim sulfa right after the time of transplant for their pneumocystis prophylaxis, but then they get switched off of it for various other reasons, you know, kidney injury or myelosuppression or other things.
Julie Steinbrink:And so you just have to keep in mind that if you're doing that and you're transitioning them to a different pneumocystis regimen, you potentially could be sacrificing their toxoplasma coverage as well.
Julie Steinbrink:So just something to consider.
Julie Steinbrink:The other thing that's a bit debatable as well is the duration of prophylaxis for these type of patients.
Julie Steinbrink:And again, that can be center dependent, depending on how endemic the infection is in your area.
Julie Steinbrink:What particular organ groups you're working on.
Julie Steinbrink:You can do between three to six months versus a year.
Julie Steinbrink:Sometimes they'll do a lifetime prophylaxis if you've got really high risk or cardiac transplant patients.
Julie Steinbrink:Um, and again, that can be a bit variable.
Julie Steinbrink:So I think that covers the first part of your question there that you're talking about, you know, pro uh, antimicrobial prophylaxis for these patients, but certainly there are other things you can do to counsel your patients on lifestyle interventions that can help prevent against like acquisition of new infection.
Julie Steinbrink:So we tell our patients about ways to try to avoid this, um, infection.
Julie Steinbrink:So trying to avoid eating raw or like under cooked meats and avoiding contact with surfaces that may have been contaminated by these undercooked meats, um, unless they've been thoroughly cleaned afterwards.
Julie Steinbrink:Untreated drinking water as well is something you want to avoid.
Julie Steinbrink:You know, given the concern for cats for transmission, we tell transplant patients to avoid, you know, contact with stray cats or kittens.
Julie Steinbrink:You know, if you don't know what their toxoplasma status is.
Julie Steinbrink:Um, telling our patients as best they can to avoid changing their cat litter boxes, or if they are going to change it, that they'd try to take appropriate precautions, including gloves and washing hands and considering, you know, wearing masks and things like that.
Julie Steinbrink:And they should still be changing the litter box daily or somebody in their house should be changing the litter box daily because it can take at least 24 hours for the parasite to become infectious after it shed in the cat feces, but in addition to, you know, undercooked meats and cats as potential methods of transmission, you also want to keep in mind that gardening can also be a potential risks.
Julie Steinbrink:Telling our patients that if they're going to be in contact with soil or sand, for things like gardening, that they take appropriate precautions again.
Julie Steinbrink:Uh, wearing gloves with appropriate hand washing after removal.
Julie Steinbrink:So we don't want transplant patients to change their entire lifestyles, but we just want them to be able to take in, you know, appropriate precautions to make sure that they can do those activities safely for them and for, uh, the rest of their family.
Sara Dong:Yeah.
Sara Dong:Um, and you know, I feel like sometimes toxo plasma gets a little bit forgotten on the differential.
Sara Dong:And I was wondering if you, you know, I know there's a variety of things we might see, but maybe you can mention some clues or clinical presentations that might make toxo come a little bit higher on your list or be considered a little bit more.
Julie Steinbrink:Yeah, definitely.
Julie Steinbrink:Um, I think the tricky thing is exactly what you said in toxoplasma for immunocompromised patients.
Julie Steinbrink:You can really see a variety of clinical presentations depending on where the infection manifests in that particular patient.
Julie Steinbrink:And so it can involve multiple organ systems.
Julie Steinbrink:You can have pneumonitis, encephalitis, chorioretinitis, you know, a number of different things.
Julie Steinbrink:And it really depends on the organ that's involved.
Julie Steinbrink:Um, a couple of things that you really want to think about and some of the main organs that are involved would be, one of the primary ones that I think about is pulmonary infection.
Julie Steinbrink:So patients will present with your typical respiratory symptoms, including fever, dyspnea, cough.
Julie Steinbrink:And typically when you look on their imaging, they'll see bilateral, oftentimes diffuse kind of infiltrates.
Julie Steinbrink:And so keeping that in mind.
Julie Steinbrink:Uh, CNS or central nervous system infection is another big one that I think about, especially once I've identified toxoplasma in other organ systems and they can present with, you know, a variety of different types of neurologic symptoms.
Julie Steinbrink:So if they're having an unexplained headache or encephalitis or seizures or other focal neurologic deficits.
Julie Steinbrink:You want to think about it and on their imaging, you'll typically see, you know, the buzzword is the multiple ring enhancing lesions, um, that you'll notice on their imaging.
Julie Steinbrink:And those are typically localized near the, to the basal ganglia area.
Julie Steinbrink:And so if you see that on imaging, that definitely raises high concern for toxoplasma CNS infection.
Julie Steinbrink:Um, of course, as I said, you know, the predilection for muscle, it can infect the hearts.
Julie Steinbrink:And so myocarditis you know, and congestive heart failure can be a presentation of that.
Julie Steinbrink:Although sometimes that can be difficult to distinguish, um, from like rejection or other things if you're looking at heart transplant patients, and so sometimes you'll need to look at biopsy in order to be able to do that.
Julie Steinbrink:Um, and then visual changes is another big one too, for the patients that have chorioretinitis.
Julie Steinbrink:Um, because then they might have, you know, again, vision changes, photophobia things.
Julie Steinbrink:And when you look at their retinal exam, you'll often see these like yellow to yellow, white lesions on their retina as well.
Julie Steinbrink:And those are kind of, that's kind of a red flag of toxoplasma infection.
Julie Steinbrink:So those would be some of the main manifestations that would kind of raise a little bit of a flag in my head.
Julie Steinbrink:And you should keep a vigilant eye out for toxo.
Julie Steinbrink:Um, especially, you know, I do agree that sometimes it does sort of fall a little bit to the back of the differential, but if you're, if you see any of these kinds of clinical syndromes and your other diagnostic workups, thus far as becoming unrevealing, then, you know, taking into consideration that patients and, you know, donor and recipient toxoplasma status, it should definitely be something that should be.
Sara Dong:Yeah.
Sara Dong:And so let's say we have one of those presentations and were a bit worried about acute toxo in a solid organ transplant patient.
Sara Dong:What is our diagnostic test of choice?
Sara Dong:What do we want to request?
Julie Steinbrink:Definitely.
Julie Steinbrink:We talked already a bit about serologic testing and, you know, while you can do IgG testing for toxoplasma for screening purposes, and you can do the IgM for some evidence of acute infection, but it has varying sensitivity and specificity.
Julie Steinbrink:So it's kind of not the best choice in this kind of situation.
Julie Steinbrink:If you're thinking about acute infection, particularly in immunocompromised patients.
Julie Steinbrink:Really if you can you really want to try to get a PCR, polymerase chain reaction testing, in these patients because that can really expedite diagnosis in these folks.
Julie Steinbrink:And what's nice is that you can do it from different bodily fluids, depending on what organ system you're concerned for infection.
Julie Steinbrink:So if you're concerned about CNS infection, you can get it off the CSF.
Julie Steinbrink:You can get it off of the blood, if you're concerned for disseminated infection.
Julie Steinbrink:If you're worried about the lungs, you can get it from the BAL fluid, you can get it from the vitreal fluid.
Julie Steinbrink:And so if you, depending on, if even if they just have a localized to an organ system, you can still get, try to get a PCR from that bodily fluid, if possible, and that can really help you make a diagnosis.
Julie Steinbrink:The nice thing about PCR testing is you can also quantitatively follow that as well, in addition to their clinical progress to determine how they're responding to treatment because their parasite loads, you know, theoretically be declining and, you know, while you're treating them with their appropriate therapy.
Julie Steinbrink:I think the PCR of the bodily fluids or blood would be your first choice and probably the least invasive.
Julie Steinbrink:Um, additionally of course, you know, one other gold standard would be, you know, if you had a biopsy and you were able to get that.
Julie Steinbrink:And then if you see, you know, the tachyzoites on a, you know, on a cardiac biopsy, when you're concerned for that, then that would also determine the presence of acute infection.
Julie Steinbrink:But obviously that's much more of an invasive procedure and not necessarily always as easy to be able to get in real time.
Sara Dong:You know, we're not going to dig too much into treatment today.
Sara Dong:We talked a bit about prevention, but I thought I could end by one last question about challenges and management for these infections, the medications that we use, if you have any thoughts or things that you've learned, um, when treating patients with toxoplasmosis who have a transplant in the past.
Julie Steinbrink:Yeah.
Julie Steinbrink:So, uh, typically, you know, the guideline driven recommendations for treatment would be if you're using your induction regimen with the pyrimethamine, your sulfadiazine, and your leucovorin typically for a minimum of six weeks and followed by their chronic suppressive therapy with a lower dose for a period of time, again, kind of outlined in the ID COP guidelines.
Julie Steinbrink:Um, of course there can be alternative regimens if you, if the patients either can't tolerate sulfas or if they can't get access to the drugs, you know, there can be other things.
Julie Steinbrink:Various kind of mix and match regimens.
Julie Steinbrink:Clindamycin and pyrimethamine or, you know, trimethroprin sulfa monotherapy, or potentially atovaquone monotherapy, kind of combinations of depending on that.
Julie Steinbrink:But, but those would not, those would kind of be second line, if for some reason, either they had an, a drug intolerance or they couldn't get access to the drugs that were available.
Sara Dong:All right.
Sara Dong:So I did want to mention a few resources before we finish up.
Sara Dong:And one, I sort of mentioned as we've come along, I hope most fellows have these bookmarked or saved.
Sara Dong:I, I actually have them all downloaded in a folder on my computer, but the AST ID Community of Practice has a collection of guidelines for, you know, toxoplasma is one of them, but various infections in transplant recipients.
Sara Dong:And so I always refer to these and in fact, many of the Febrile transplant based episodes, we've tried to structure in a way that reflects those guidelines.
Sara Dong:And so these are really great to get caught up on topics yourself, but I also think they're a really good resource to give to learners on your team if they're starting on a transplant rotation or aren't as familiar.
Sara Dong:Um, so for example, I'll put a link to the tissue and blood protozoa one that has toxoplasmosis in the Consult Notes, but I'm also put the link to the collection that has the other ones.
Sara Dong:In addition to this, there is an AST, it's kinda like a Zotero library, and so, you can go to the website, transplantid.net as well as on Twitter they're at @transplantIDnet.
Sara Dong:And this is an awesome, I guess I use the word crowdsource, but basically they see ID Community of Practice members have built this and maintained it and they have it sort of grouped into various clinical questions or topics that are related to transplant.
Sara Dong:And so it's a really great reference to find key resources, if you're in a, in a bind or maybe you're really busy, it's a fast way to find, find resources.
Sara Dong:And I don't know if you have any other thoughts on this Julie or other things you wanted to mention
Julie Steinbrink:No, that was great.
Julie Steinbrink:I think those are some of the top resources, you know?
Julie Steinbrink:Um, and I know that both trainees and faculty alike use both of those resources.
Julie Steinbrink:So, uh, yeah, those would be two of the top ones that I would plug, you know, the guidelines and then the additional articles to transplantID.net.
Julie Steinbrink:So thanks.
Julie Steinbrink:And, um, I'm also of course, going to give one more plug for our little survey that's going to be coming out, um, that, you know, we really, you know, again, in the spirit of improving, you know, education and training for our transplant ID trainees.
Julie Steinbrink:Please when you see that come out, um, feel free to engage and let us know.
Julie Steinbrink:We can get a better idea of where the gaps are in your transplant ID training.
Julie Steinbrink:So that way we can further develop a more comprehensive curriculum in the future.
Julie Steinbrink:So, uh, so thanks for that.
Julie Steinbrink:And thanks so much, Sara, for, for allowing me to be on here.
Julie Steinbrink:I really enjoyed myself.
Sara Dong:Yeah.
Sara Dong:Well, the last thing I was going to say is for those who are considering transplant or aren't sure, it's a very welcoming community.
Sara Dong:I've reached out to plenty of people, both, you know, where at my institution, but also elsewhere and a lot of times through AST.
Sara Dong:So if you're trying to learn more about transplant, just reach out really to anyone.
Sara Dong:I bet they would love to talk, talk your ear off about doing transplant.
Julie Steinbrink:I 100% agree with that.
Julie Steinbrink:Yeah.
Julie Steinbrink:Our AST, our ID Community of Practice loves welcoming people.
Julie Steinbrink:Even if you're inquiring, just kind of experimenting with transplant ID, we're welcomed to kind of, you know, bring you over to our dark side here.
Julie Steinbrink:And, uh, we, uh, we'd be welcome.
Julie Steinbrink:We'd love to be able to chat with you and it'd be able to talk more.
Julie Steinbrink:So thanks for bringing that up.
Sara Dong:All right.
Sara Dong:Well, thank you so much, Julie.
Julie Steinbrink:Thank you.
Julie Steinbrink:All right, everyone.
Julie Steinbrink:Thank you so much for listening.
Julie Steinbrink:Our next episodein the Curious Congenital Conundrum series will be out next week on Monday.
Julie Steinbrink:Uh, you can find Febrile on Twitter or at our website, febrilepodcast.com where you'll find links to all the mentioned articles from today's episode.
Julie Steinbrink:Thanks for listening.
