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Toxoplasmosis
A diagnosis of exclusion
‘Kenzie’ McLaren
• One-year-old castrated male British Shorthair
• One-day history of hindlimb ataxia and paresis
• 20% we...
Initial Presentation
Summary of Findings
• Pyrexia (39.3 to 40.3°C)
• Initial stiff hindlimb gait
• Reduced exercise tolerance: forelimbs becam...
Summary of Findings
• Pyrexia (39.3 to 40.3°C)
• Initial stiff hindlimb gait
• Reduced exercise tolerance: forelimbs becam...
Summary of Findings
• Pyrexia (39.3 to 40.3°C)
• Initial stiff hindlimb gait
• Reduced exercise tolerance: forelimbs becam...
Electromyography (EMG)
• Abnormal spontaneous muscle activity
• Normal nerve conduction velocities
• Normal repetitive ner...
Problem List
Neurological
Ataxia
Stiff gate
Reduced exercise tolerance
Myoclonus (EMG confirmed)
Dx: Myopathy (idiopathic ...
Haematology
Erythrocytes
• Low haematocritt
• Polycythaemia
• Haemaglobinaemia
Leukocytes
• Leukopaenia
• Neutropaenia
• L...
Blood Smear
• Anaemia poorly regenerative
• Howell-Jolly bodies in RBCs
• Occasional poikilocytes
• Mild toxic left shift
...
Biochemistry
• Hypoproteinaemia
• Low globulin levels
• High AST (2X upper ref.)
• High ALT (3X upper ref.)
• High CK (now...
Biochemistry
• Hypoproteinaemia
• Low globulin levels
• High AST (2X upper ref.)
• High ALT (3X upper ref.)
• High CK (now...
Thoracic Radiography
Excessive mild bronchial pattern
and cardiomegaly
L
R
DDx: chronic bronchitis, early onset asthma
DDx...
Microbiology Report
• Mucal swab taken from endotracheal tube
due to respiratory noise during anaesthesia
• Culture: Gram ...
Problem List
Neurological
Ataxia
Stiff gate
Reduced exercise tolerance
Myoclonus (EMG confirmed)
Dx: Myopathy (idiopathic ...
Feline Infectious Disease Panel
• NEGATIVE: Feline Leukaemia Virus (FeLV)
Antigen
• NEGATIVE: Feline Immunodeficiency Viru...
Problem List
Neurological
Ataxia
Stiff gate
Reduced exercise tolerance
Myoclonus (EMG confirmed)
Dx: Myopathy
Dx: Mild cho...
Initial Treatment
• Pyrexia & Liver: IV fluids (0.9% saline)
• Neutropaenia and Bronchitis: Augmentin 40
mg slow IV TID, t...
5-days Post-Treatment
Continued Treatment & Monitoring
• Clindamycin 25 mg BID for 4 weeks
• Retest Toxoplasma antibody levels in 4 weeks
• Rech...
Toxoplasma gondii
• Worldwide zoonosis
• Obligate, intracellular
parasitic protozoan
• Only sexually reproduce in
cats – t...
Clinical Signs
General Signs
Anorexia
Lethargy
Pyrexia
Weightloss
Ataxia
Specific Disease
Bronchopneumonia
Hepatitis
Myoca...
Life Cycle
Questions?
Special thanks
Kate Stalin
Rodrigo Gutierrez Quintana
Emma Roberts
Katie Grove
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Grand Rounds: Toxoplasmosis

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A Grand Rounds neurology presentation given on 15/08/2014 at the University of Glasgow Small Animal Hospital demonstrating the approach to Toxoplasmosis through a case report of a one-year-old castrated male cat initially presenting with hindlimb ataxia and paresis, weightloss, and pyrexia.

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Grand Rounds: Toxoplasmosis

  1. 1. Toxoplasmosis A diagnosis of exclusion
  2. 2. ‘Kenzie’ McLaren • One-year-old castrated male British Shorthair • One-day history of hindlimb ataxia and paresis • 20% weightloss in 11 weeks • Initial PE: unremarkable • PCV low: 22% [29-45%] • Pelvic radiography unremarkable • Referred to neurology service
  3. 3. Initial Presentation
  4. 4. Summary of Findings • Pyrexia (39.3 to 40.3°C) • Initial stiff hindlimb gait • Reduced exercise tolerance: forelimbs became stiff to the point of collapse • Normal spinal reflexes, but some myoclonus • No proprioceptive deficits • Suggestive of a neuromuscular disorder DDx: neuropathy, myopathy or junctionopathy
  5. 5. Summary of Findings • Pyrexia (39.3 to 40.3°C) • Initial stiff hindlimb gait • Reduced exercise tolerance: forelimbs became stiff to the point of collapse • Normal spinal reflexes, but some myoclonus • No proprioceptive deficits DDx: neuropathy, myopathy or junctionopathy
  6. 6. Summary of Findings • Pyrexia (39.3 to 40.3°C) • Initial stiff hindlimb gait • Reduced exercise tolerance: forelimbs became stiff to the point of collapse • Normal spinal reflexes, but some myoclonus • No proprioceptive deficits • Initial CK and ACh-R antibody (pending) tests DDx: neuropathy, myopathy or junctionopathy
  7. 7. Electromyography (EMG) • Abnormal spontaneous muscle activity • Normal nerve conduction velocities • Normal repetitive nerve stimulation DDx: myopathy or junctionopathy
  8. 8. Problem List Neurological Ataxia Stiff gate Reduced exercise tolerance Myoclonus (EMG confirmed) Dx: Myopathy (idiopathic or secondary) DDx: Infectious, Autoimmune, Neoplastic Other Weightloss (too acute) Pyrexia Anaemia (rarely) CK elevated (84X upper ref.)
  9. 9. Haematology Erythrocytes • Low haematocritt • Polycythaemia • Haemaglobinaemia Leukocytes • Leukopaenia • Neutropaenia • Lymphopaenia
  10. 10. Blood Smear • Anaemia poorly regenerative • Howell-Jolly bodies in RBCs • Occasional poikilocytes • Mild toxic left shift • Pro-eosinophils containing basophilic granules • Occasional hyperchromatic lymphoid cells • Direct Coombs Test Negative DDx: chronic infectious, autoimmune, neoplastic
  11. 11. Biochemistry • Hypoproteinaemia • Low globulin levels • High AST (2X upper ref.) • High ALT (3X upper ref.) • High CK (now 180X upper ref.) • High fasting bile acids (2X upper ref.) – Need bile acid stimulation test DDx: myopathy, mild cholangiohepatitis
  12. 12. Biochemistry • Hypoproteinaemia • Low globulin levels • High AST (2X upper ref.) • High ALT (3X upper ref.) • High CK (now 180X upper ref.) • High fasting bile acids (2X upper ref.) – Need bile acid stimulation test DDx: myopathy, mild cholangiohepatitis
  13. 13. Thoracic Radiography Excessive mild bronchial pattern and cardiomegaly L R DDx: chronic bronchitis, early onset asthma DDx: myocarditis, HCM
  14. 14. Microbiology Report • Mucal swab taken from endotracheal tube due to respiratory noise during anaesthesia • Culture: Gram negative cocci & large rods • Sensitive to – Clavunated amoxicillins – Azithromycin – Doxycycline – Marbofloxacin
  15. 15. Problem List Neurological Ataxia Stiff gate Reduced exercise tolerance Myoclonus (EMG confirmed) Dx: Myopathy (idiopathic or secondary) Dx: Mild cholangiohepatitis (potentially) Dx: Chronic bacterial bronchitis DDx: Infectious, Autoimmune, Neoplastic Other Weightloss Pyrexia Poorly regenerative anaemia CK elevated (180X upper ref.) Elevated liver enzymes Cardiomegaly (DDx: myocarditis)
  16. 16. Feline Infectious Disease Panel • NEGATIVE: Feline Leukaemia Virus (FeLV) Antigen • NEGATIVE: Feline Immunodeficiency Virus (FIV) Immunofluorescent Assay • NEGATIVE: Feline Corona Virus (FCoV) Antibody Titre • POSITIVE: Toxoplasma Antibody Titre – IgG Seropositive (4X upper ref.)
  17. 17. Problem List Neurological Ataxia Stiff gate Reduced exercise tolerance Myoclonus (EMG confirmed) Dx: Myopathy Dx: Mild cholangiohepatitis (potentially) Dx: Chronic bacterial bronchitis Dx: Myocarditis (potentially) Dx: Chronic Toxoplasmosis (Infectious) Other Weightloss Pyrexia Poorly regenerative anaemia CK elevated (180X upper ref.) Elevated liver enzymes Cardiomegaly Explains secondary symptoms and disease
  18. 18. Initial Treatment • Pyrexia & Liver: IV fluids (0.9% saline) • Neutropaenia and Bronchitis: Augmentin 40 mg slow IV TID, then oral Synulox 50 mg BID • Toxoplasmosis: Clindamycin 25 mg BID
  19. 19. 5-days Post-Treatment
  20. 20. Continued Treatment & Monitoring • Clindamycin 25 mg BID for 4 weeks • Retest Toxoplasma antibody levels in 4 weeks • Recheck biochemistry and haematology • Ensure pulmonary infection has resolved and hepatic markers are within normal limits • Consider further cardiac evaluation
  21. 21. Toxoplasma gondii • Worldwide zoonosis • Obligate, intracellular parasitic protozoan • Only sexually reproduce in cats – the definitive host • Chronic infection can occur for the lifetime of the host, periodically rupturing cysts and re-encysting to increase numbers
  22. 22. Clinical Signs General Signs Anorexia Lethargy Pyrexia Weightloss Ataxia Specific Disease Bronchopneumonia Hepatitis Myocarditis Encephalitis Uveitis • Acute or chronic progression • Transplacental infection most severe • Poorer prognosis with hepatic or pulmonary signs
  23. 23. Life Cycle
  24. 24. Questions? Special thanks Kate Stalin Rodrigo Gutierrez Quintana Emma Roberts Katie Grove

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