Pediatric Toxoplasmosis Workup

Updated: Sep 20, 2019
  • Author: Itzhak Brook, MD, MSc; Chief Editor: Russell W Steele, MD  more...
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Approach Considerations

The laboratory evaluation of congenital toxoplasmosis includes serology, polymerase chain reaction (PCR), and other tests that can confirm and evaluate the extent of the infection, and can establish baseline values prior to initiating antimicrobial treatment. T gondii can be recovered from clinical specimens; however, this requires additional time and is available only in some reference laboratories. [8]

Demonstration of T gondii in blood, body fluids (ie, peripheral blood, cerebrospinal fluid, urine), or tissues is evidence of toxoplasmosis infection (see the image below). Recovery or histologic demonstration of T gondii or T gondii nucleic acids from clinical specimens, accompanied by clinical and/or serologic findings, can establish the diagnosis of congenital toxoplasmosis. However, these methods are used less frequently than serological evaluations and may require tissue specimens.

Isolation by mouse inoculation of Toxoplasma from amniotic fluid or placental or fetal tissue is diagnostic of congenital infection. Lymphocyte transformation in response to Toxoplasma antigens indicates previous infection in adults. Detection of Toxoplasma antigens in blood or body fluids by means of enzyme-linked immunoassay (ELISA) or PCR indicates acute infection. A skin test showing delayed hypersensitivity to Toxoplasma antigens may be a useful screening test.

Laboratory tests include complete blood cell (CBC) count with differential, liver function tests, lumbar puncture, serum creatinine, urinalysis, urine viral culture for cytomegalovirus, serum quantitative immunoglobulin testing, and testing for other congenital infections such as cytomegalovirus, rubella, syphilis, congenital lymphocytic choriomeningitis virus syndrome, and Zika. [9]

Toxoplasma gondii trophozoites in tissue culture. Toxoplasma gondii trophozoites in tissue culture.

The Sabin-Feldman dye test is a sensitive and specific neutralization test. It measures IgG antibody and is the standard reference test for toxoplasmosis; however, it requires live T gondii and thus is not available in most laboratories. High titers suggest acute disease.

The indirect fluorescent antibody (IFA) test measures the same antibodies as the dye test. Titers parallel dye test titers. The IgM fluorescent antibody test can be used to detect IgM antibodies within the first week of infection, but titers fall within a few months. The double-sandwich IgM ELISA test is more sensitive and specific than other IgM detection tests.

The indirect hemagglutination test measures a different antibody than does the dye test. Titers tend to be higher and remain elevated longer.

The IgG avidity test may be able to discriminate acute from chronic infection better than alternative assays, such as assays that measure IgM antibodies, can. As is true for IgM antibody tests, the avidity test is most useful when performed early in gestation, because a chronic pattern occurring late in pregnancy does not rule out the possibility that the acute infection may have occurred during the first months of gestation. A 2-fold rise in serum IgG obtained at 3-week intervals is diagnostic.

IgA and IgE ELISA should be determined when the infant’s IgM titers are negative or equivocal. Determination of Toxoplasma-specific IgA or IgE is more sensitive (but not specific) than detection of IgM for congenital toxoplasmosis (approximately 90% vs 75-80%). Repeating the test at least 10 days after delivery can assist in making the diagnosis. IgM and IgA titers in an infant who is not infected (usually an infant with low positive IgM and IgA titers) decrease with time, whereas the levels  remain positive for weeks to months in an infant who was congenitally infected. [10]

Perform an amniocentesis at 20-24 weeks' gestation in suspected cases of congenital disease. Performing PCR assay testing on body fluids, including cerebrospinal fluid, amniotic fluid, bronchoalveolar lavage fluid, and blood, may be useful in establishing the diagnosis. [11]

Antibody levels in aqueous humor or cerebrospinal fluid obtained through a lumbar puncture may reflect local antibody production and infection at these sites.


Imaging Studies


Ultrasonography of the fetus to evaluate for evidence of congenital toxoplasmosis can be performed at 20-24 weeks' gestation. Abdominal ultrasound can assist in detecting intrahepatic calcifications as well as hepatosplenomegaly.

CT scanning

Computed tomography (CT) scanning of the brain is useful in cerebral toxoplasmosis. It can detect intracranial calcifications, ventriculomegaly, and hydrocephalus. In 70-80% of immunodeficient patients with Toxoplasma encephalitis, the CT scan reveals multiple bilateral, ring-enhancing cerebral lesions. Although multiple lesions are more common, finding a solitary lesion should not exclude Toxoplasma encephalitis. There is an approximately 80% likelihood that the disease is present in patients with AIDS who have detectable Toxoplasma IgG and multiple ring-enhancing lesions. Lesions are characteristically hypodense and tend to occur at the corticomedullary junction; they frequently involve the basal ganglia.

CT scanning frequently underestimates the number of lesions, although delayed imaging after a double dose of intravenous (IV) contrast material may improve the sensitivity of this imaging modality. An enlarging, hypodense lesion that does not enhance is a poor prognostic finding.

Improvement is seen in as many as 90% of patients with AIDS and Toxoplasma encephalitis after 2-3 weeks of treatment. Complete resolution lasts from 6 weeks to 6 months; peripheral lesions resolve more rapidly than do deeper ones. Radiographic response tends to lag behind clinical response.


Magnetic resonance imaging (MRI) is the preferred imaging modality to evaluate for lesions. The lack of exposure to radiation is another advantage. MRI has superior sensitivity, particularly if gadolinium is used for contrast. It can often depict lesions or more extensive disease not apparent on CT scans. Hence, MRI should be used as the initial imaging procedure when feasible and should always follow CT demonstration of a single lesion.

MRI depicts Toxoplasma encephalitis lesions as high-signal abnormalities on T2-weighted studies and reveals a rim of enhancement surrounding the edema on T1-weighted, contrast-enhanced images.

Smaller lesions usually completely resolve on MRI studies within 3-5 weeks, but lesions with a mass effect tend to resolve more slowly and leave a small, residual lesion.

Even characteristic lesions on CT or MRI are not pathognomonic of Toxoplasma encephalitis. The major differential diagnosis in patients with AIDS is CNS lymphoma, which appears with multiple enhancing lesions in 40% of cases.

When single lesions are depicted on MRI, the probability of Toxoplasma encephalitis falls and that of lymphoma rises. Brain biopsy findings are generally required to obtain a definitive diagnosis.

Other modalities

To evaluate patients with AIDS and focal CNS lesions, various positron emission tomography (PET) and radionuclide scans have been used, generally with minimal benefit over the above modalities.

Initial auditory brain steam responses and yearly audiological evaluation in the first 3 years of life are helpful.


Histologic Findings

The histopathology of toxoplasmosis varies with the immune status of the host. In the healthy host with acquired toxoplasmosis, the characteristic histopathology of the lymph node is diagnostic, despite the relative paucity of organisms present. Typical findings include reactive follicular hyperplasia, irregular clusters of histiocytes encroaching on the margins of germinal centers, and focal distention of sinuses with monocytoid cells. Necrosis, granuloma formation, microabscesses, and vasculitis do not occur. At autopsy of normal hosts, tissue cysts are noted as incidental findings in skeletal muscle and myocardium, invoking little inflammatory response.

In contrast, in patients who are immunodeficient and in children with severe congenital toxoplasmosis, tachyzoite proliferation is accompanied by tissue necrosis and an intense, usually monocytic, inflammatory response. In patients with AIDS, toxoplasmosis typically produces brain abscesses that have a characteristic appearance. A central avascular area is surrounded by a region of necrosis and inflammatory cells that may also contain free and intracellular tachyzoites. Outside of the region of inflammation are cysts.

Demonstration of tachyzoites in a tissue specimen is required for definitive diagnosis of active infection. The presence of multiple cysts near an inflammatory lesion makes the diagnosis highly likely. Stains used to detect tachyzoites or cysts include hematoxylin and eosin, periodic acid-Schiff, and Gomori-methenamine silver. Immunoperoxidase and fluorescein-conjugated antibody stains can also be used.

Wright-Giemsa staining of body fluid sediments of biopsy tissue touch preparations is a rapid and simple method for visualizing the organisms.