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Case Report

Pulmonary toxoplasmosis in simian immunodeficiency virus infected rhesus

monkey with irregular antiretroviral therapy - Case report
Jiaojiao Liu a, Hongwei Qiao b, Li Li a, Hongjun Li a,*
a
Beijing YouAn Hospital, Capital Medical University, Beijing, 100069, China
b
Institute of Laboratory Animal Sciences, Chinese Academy of Medical Sciences (CAMS), Comparative Medicine Center, Peking Union Medical College (PUMC),
Beijing, 100050, China
Received 23 July 2019; revised 27 February 2020; accepted 2 March 2020
Available online ▪ ▪ ▪

Abstract

We describe a case of simian immunodeficiency virus (SIV) infected rhesus monkey with irregular antiretroviral (ARV) therapy that was
finally diagnosed as pulmonary toxoplasmosis. So far, there are still rare reports on pulmonary toxoplasmosis for its non-specific clinical and
radiological abnormalities.
A Chinese origin rhesus monkey started to row loose stools on the 148th day after SIV-mac239 inoculation with irregular ARV therapy, and
improved after expectant treatment for five days. However, when the treatment was stopped, loose stools reappeared with inappetence. On the
157th day after inoculation, it became worse with reduced autonomous activity. Before its death, CT scan results showed a bilateral pulmonary
multiple lesion, characterized by ground-glass opacities, increase of lung markings, the affected lung segments and the obscure lung lobe. Lung
autopsy study validated the infection of toxoplasma gandii.
In this case, we verified the infection of toxoplasma gandii in SIV-mac239 rhesus monkey pathologically, which reflects the pathological
basis of infection imaging in return. We also found that pulmonary toxoplasmosis should be taken into consideration in HIV/AIDS patients with
a poor adherence or failure to ARV and with fever, loose stools and reduced autonomous activity.
© 2020 Beijing You’an Hospital affiliated to Capital Medical University. Production and hosting by Elsevier B.V. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Keywords: Simian immunodeficiency virus; Pulmonary toxoplasmosis; Irregular antiretroviral therapy

1. Introduction specific clinical symptoms and radiological abnormalities

Opportunistic infections, in regard to toxoplasmosis, are
perpetuatated factors of grievous health issue among immune-
comprised patients, especially those who are with HIV/AIDS
[1]. Pulmonary toxoplasmosis accounts for the second location
of extracerebral toxoplasmosis following the ocular form, with
40% of mortality without early diagnosis and expectant
treatment. The diagnosis is hard to realize because of the non-
* Corresponding author.
E-mail address: lihongjun00113@126.com (H. Li).
Peer review under responsibility of Beijing You'an Hospital affiliated to
Capital Medical University.
[2e4] (see Table 1).
With high morbidity and mortality, pulmonary toxoplas-
mosis was hard to be diagnosed but for traditional methods
such as serological examination and autopsy postmortem.
Currently, more and more diagnosis of pulmonary toxoplas-
mosis is realized by bronchoalveolar lavage (BAL) and lung
biopsy.
Pulmonary toxoplasmosis are often accompanied by
increased lymphocyte in the lung, especially CD8þ T-cell
counts, as a result, CD4þ/CD8þ ratio obviously decreased,
suppressing spleen proliferation [5].
The pathomechanism of pulmonary toxoplasmosis is
incompletely understood, one of the most acceptable hypoth-
esis is that Toxoplasma gondii can invade to pulmonary from

https://doi.org/10.1016/j.jrid.2020.03.001
2352-6211/© 2020 Beijing You’an Hospital affiliated to Capital Medical University. Production and hosting by Elsevier B.V. This is an open access article under
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Please cite this article as: Liu J et al., Pulmonary toxoplasmosis in simian immunodeficiency virus infected rhesus monkey with irregular antiretroviral therapy -
Case report, Radiology of Infectious Diseases, https://doi.org/10.1016/j.jrid.2020.03.001
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2 J. Liu et al. / Radiology of Infectious Diseases xxx (xxxx) xxx
Table 1
SIV-mac239 relevant laboratory examinations.
3 weeks prior to 0 day (Baseline)
inoculation
CD4þ T-cell count cells/mL 2023.23 1212.93
CD8þ T-cell count cells/mL 1631.63 767.68
CD4/CD8 ratio 1.24 1.58
WBC 10.1  109 5.8  109
HGB 150 137
IgG 11.16 8.36
IgM 0.79 0.2
Viral load copies/mL e e
Detailed legend: At the 12th week post inoculation, CD4þ T-cell count was reduced for three times while viral load was increased to 6.40  106 compared with
baseline. Relevant laboratory findings at different time points were showed.
other organs such as head through blood transportation [4].
However, cystica and tachyzoite can also be found in lung by
BAL in few cases [6]. So far, there is no definite acquirement
about pathological characteristic for reasons such as rare re-
ports and the diversities of pathological alterations.
2. Case report
A 5 year old Chinese origin rhesus monkey was infected
with SIV-mac239 to mimic HIV/AIDS patients especially with
neuropathological symptoms. Health screening (including
parasite screening) was employed to confirm that this rhesus
monkey was in healthy condition before being admitted to this
study. To effectively eliminate the possible infection of simian
T cell lymphotropic virus-I (STLV-I), simian type-D retrovirus
(SRV), or simian immunodeficiency virus (SIV), it also un-
derwent indirect immunoinfluscent assay (IFA). On March
2nd, SIV-mac239 was injected intravenously and MRI scans
were performed for the monkey (as base line data). Then it had
the same examination every other 12 weeks post virus inoc-
ulation until it was dead naturally. It also investigated by
laboratory examinations such as peripheral blood SIV RNA
viral load, plasma CD4þ T-cell counts, CD8þ T-cell counts,
white cell counts, IgG and IgM. These examinations were
conducted 3 weeks prior to inoculation (quarantine period),
the day ahead of the first MRI scan, 10 days post inoculation
and 4 weeks post inoculation respectively to confirm that an-
imal models were successfully prepared. The aforementioned
laboratory examinations were conducted before each MRI
scan. CT scans were performed to observe lung alterations
when the rhesus monkey before its death. In order to investi-
gate the effect of the antiretroviral therapy, subcutaneous
parenteral administration of Zidovudine (AZT) 100 mg/kg/day
and Didanosine (DDI) 50 mg/kg/day was conducted regularly
from the 4th week post inoculation. The antiretroviral therapy
was lasted less than one month. On the 148th day after SIV-
mac239 inoculation, this monkey started to row loose stools,
with normal spirituality, activity and diet. The loose stools
symptom was improved after expectant treatment for five
days. However, when the treatment was stopped, loose stools
reappeared with inappetence. On the 157th day after inocu-
lation, it became worse with reduced autonomous activity. The
Please cite this article as: Liu J et al., Pulmonary toxoplasmosis in simian immunodeficiency virus infected rhesus monkey with irregular antiretroviral therapy -
Case report, Radiology of Infectious Diseases, https://doi.org/10.1016/j.jrid.2020.03.001
10 days post 4 weeks post 12 weeks post
inoculation inoculation inoculation
663.23 771.54 488.89
850.29 989.15 384.95
0.78 0.78 1.27
4.5  109 3.6  109 5.3  109
123 122 102
8.81 9.27 11.33
0.21 0.18 0.85
1.01  108 5.06  106 6.40  106
last body temperature of this rhesus monkey was 39.9  C, and
the weight was 7.30 kg. Before its death, both T1WI and
T2WI of the rhesus monkey brain showed that there was no
focal neurological deficit (Fig. 1). After MRI scan, CT scan for
lung showed a bilateral pulmonary multiple lesions, charac-
terized by ground-glass opacities, increase of lung markings
and the affected lung segments and the obscure lung lobe, as
shown in Fig. 2. Lung biopsy result showed the infection of
toxoplasma gandii (Fig. 3).
3. Discussion and conclusion
Previous studies reported that toxoplasma infection was
commonly seen in HIV/AIDS patients in the form of toxo-
plasmosis infection of the brain [1]. However, toxoplasma can
further invade more organs in addition to brain, while the
immunity is heavily damaged. Lung is one of the most
vulnerable extracerebral organs with the most acute clinical
manifestations. However, our observations of SIV-infected
rhesus monkey of pneumonitis due to toxoplasma
suggest that reactivation may also initially take place in the
lungs, which is in accordance with the previous study in
human [7].
Here, we described one SIV-infected rhesus monkey with
poor adherence to ARV therapy and antibiotic prophylaxis and
finally diagnosed as pulmonary toxoplasmosis. Jorge N
Velasquez and colleagues have reported two cases in 2016
with poor adherence to highly active antiretroviral therapy
(HARRT) and diagnosed as pulmonary toxoplasmosis in
Argentina. The two patients were discharged from the hospital
after several days in good clinical and neurological condition
after regular treatment for T. gondii infection [2].
Pulmonary toxoplasmosis occurred in patients with
advanced immunodeficiency with decreased CD4þ T-cell
count, in this report the CD4þ T-cell count is 488.89 cells/mL,
far less than normal rhesus monkey (2130.27 cells/mL). Both
IgM and IgG antibodies increased in patients whose viral load
is high, as a result, those patients are becoming more and more
susceptible to opportunistic infections [8]. In this case, plasma
viral load was 6.4  106 copies/mL. Serological data showed
that the total number of B cells decreased significantly 2
weeks post inoculation, and then recovered. The changes in B
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J. Liu et al. / Radiology of Infectious Diseases xxx (xxxx) xxx 3

Fig. 1. T1weighted image A and T2 weighted image B of rhesus monkey brain indicated that no obvious focal neurological deficit. Detailed legend: There is no
obvious focal neurological deficit in T1WI or T2WI.

Fig. 2. Two CT slices A and B presented a bilateral pulmonary multiple lesions in the alveolar septa (red arrow head). Detailed legend: CT scan for lung showed a
bilateral pulmonary multiple lesions, characterized by ground-glass opacities, increase of lung markings and the affected lung segments and the obscure lung lobe.

cells were very similar to those reported in the literature [9],
and were consistent with changes in CD4þ T-cells in the an-
imal and pathological changes in lymphoid tissues. Moreover,
the reduction of B cells was selective, mainly to activate
memory B cells and tissue B cells. B cell control of virus
replication after HIV/SIV infection was necessary, and its
prepotency may be determined at the early stage of the
infection.
In conclusion, pulmonary toxoplasmosis is an acquired
infection. However, its definite pathomechanism is not
completely understood. The pulmonary toxoplasmosis is
correlated with hypoimmunity and irregular antiretroviral
therapy. In our case, we verify the imaging manifestations
pathologically, which reflects the pathological basis of infec-
tion imaging in return. While there is no specific clinical signs
in the pulmonary of this time point. It is high time that we
should set up independent animal model to longitudinally
study the pathomechanism and imaging characteristics of
pulmonary toxoplasmosis, which contribute to non-invasive
diagnosis and differential diagnosis, so as to realize early
detection, improving the chances of cure and decreasing the
mortality.

Please cite this article as: Liu J et al., Pulmonary toxoplasmosis in simian immunodeficiency virus infected rhesus monkey with irregular antiretroviral therapy -
Case report, Radiology of Infectious Diseases, https://doi.org/10.1016/j.jrid.2020.03.001
 + MODEL
4 J. Liu et al. / Radiology of Infectious Diseases xxx (xxxx) xxx
Fig. 3. Hematoxylin and eosin staining (  100) of lung resection showed that
toxoplasma was located in the alveolar septa (red arrow head). Detailed leg-
end:Hematoxylin and eosin staining (  100) of lung resection showed infil-
tration and exudation of inflammatory cells in broadening alveolar septa.
Toxoplasma was present in the alveolar septa.
Ethics statement
Our project was approved by Institutional Animal Care and
Use Committee (IACUC). The laboratory has been confirmed
by the Association for Assessment and Accreditation of Lab-
oratory Animal Care (AAALAC). All invasive steps were
conducted under a general anaesthesia and all possible mea-
sures were taken to alleviate animal suffering.
Funding
This work is supported by China National Science Foun-
dation (61936013, 81771806), National Science and Tech-
nology Major Project (2020ZX10001013).
Authors’ contributions
Jiaojiao Liu plays an important role in disposalling data and
composing a first manuscript. Hongwei.
Qiao helps with pathological diagnosis and laboratory data
collection. Li Li helps with image
describing. Hongjun Li is the corresponding authors and
responsible for providing the critical idea. All
the authors have read and ratified the final draft.
Acknowledgement
The authors would like to acknowledge the instrumental
and technical support of Multi-modal biomedical imaging
Please cite this article as: Liu J et al., Pulmonary toxoplasmosis in simian immunodeficiency virus infected rhesus monkey with irregular antiretroviral therapy -
Case report, Radiology of Infectious Diseases, https://doi.org/10.1016/j.jrid.2020.03.001
experimental platform, Institute of Automation, Chinese
Academy of Sciences.
Abbreviations
AIDS Acquired Immune Deficiency SyndromeSIV Simian
immunodeficiency virus
BAL Bronchoalveolar lavage
STLV-I Simian T cell lymphotropic virus-I
SRV Simian type-D retrovirus
IFA Indirect immunoinfluscent assay
MRI Magnetic resonance imaging
AZT Zidovudine
DDI Didanosine
ARV Antiretroviral
HARRT Highly active antiretroviral therapy
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