Combating Infection
Toxoplasmosis update
BY ELIZABETH HEAVEY, PHD, RN, CNM
S
OME AMERICANS EAT
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free-range animal meat for
perceived ethical and health
reasons. However, they
should be aware of some practical
concerns about possible subsequent
infections, such as toxoplasmosis,
that may occur from consuming
meat from animals that have access
to plants from contaminated soil,
contaminated water in the environ-
ment, or other infected animals.1
Caused by a parasite called
Toxoplasma gondii, toxoplasmosis has
infected over 22% of adults in the
United States.2 In some parts of the
world, including South America, the
Middle East, and Africa, infection
rates are over 90%.3,4 Most healthy
people who are infected develop an
asymptomatic chronic infection that
can later develop into a significantly
symptomatic one if immunosuppres-
sion occurs.2
Toxoplasmosis is a common
opportunistic infection in patients
with HIV/AIDS; therefore, at-risk
immunocompromised patients
require prophylaxis.5 Pregnant
women are also particularly vulner-
able to infection, which can be
transmitted to the fetus. Congenital
transmission accounts for between
500 and 5,000 cases of toxoplasmo-
sis in the United States each year.6
How infection occurs
T. gondii is an intracellular protozoan
parasite that can live in birds or
mammals. But in order to replicate,
the parasite needs to complete its
sexual life cycle in the intestinal tract
of cats.7,8 Cats become infected by
eating infected birds, mice, and other
small animals. Cat feces containing
62 l Nursing2018 l Volume 48, Number 7
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
parasitic oocysts can contaminate
a litter box, garden soil, drinking
water, or anything else with
which contaminated feces come
in contact.3 Cattle and other farm
animals that eat where cats defecate
are at risk for exposure.
Most humans contract the infection
through accidental consumption,
which can occur from eating un-
cooked or undercooked contaminated
meat, consuming uncooked or
unwashed fruits and vegetables
contaminated in soil, or drinking
contaminated water. The infection
can also be contracted indirectly from
Advise patients, especially
pregnant women, to wear
gloves when gardening and
to wash hands thoroughly
when done.
hands, counters, or cooking utensils
that weren’t washed adequately after
coming in contact with contaminated
food or another source of infection,
such as cat feces.
T. gondii isn’t usually passed
person-to-person, apart from the
transmission of the infection during
pregnancy to an unborn child. In rare
cases, infections occur from organ
transplantation and blood transfu-
sion.3 T. gondii DNA has been isolated
in male semen, and some studies
indicate that it can be sexually
transmitted from males to females.9
Cultural practices, sanitation, water
cleanliness standards, climate, and
host factors affect infection rates.6,9
Oocysts can remain infective for
longer periods in warm, wet climates.6
Signs and symptoms
Most people infected with T. gondii
remain asymptomatic, though some
may experience mild flulike signs and
symptoms, including lymphadenopa-
thy, fever, lethargy, fatigue, pharyngi-
tis, headache, and myalgia.2 Though
initially thought to be a largely
self-limiting infection in healthy,
nonpregnant adults, emerging
evidence links the presence of
T. gondii antibodies with the
development of schizophrenia,
suicidal ideation, dementia, addic-
tion, and autism.1,6,10,11
Even asymptomatic patients are at
risk for developing ocular disease,
particularly retinochoroiditis.2
Infected patients who are immuno-
compromised may develop signs and
symptoms of encephalitis, including
fever, confusion, loss of coordination,
headache, and seizures.2 In these
patients, toxoplasmosis can be fatal.12
Diagnosing toxoplasmosis
In immunocompromised patients,
signs and symptoms of toxoplasmo-
sis include acute onset of fever and
lymphadenopathy. Serologic testing
for T. gondii typically confirms the
diagnosis. The CDC recommends
Toxoplasma-specific immunoglobulin
G (IgG) testing first. If the patient is
IgG positive, he or she has been
infected at some point.13 IgM levels
can also be evaluated if determining
the timing of the infection is
important, as for pregnant patients.
Negative IgG and IgM results
generally rule out recent infection,
but repeat testing in 2 to 3 weeks is
recommended in patients who
present within a week of symptom
onset.8,13,14 IgG and IgM levels that
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are slightly elevated may indicate an
early acute infection or an infection
that occurred in the past 18
months.13 It may be possible to
directly observe the parasite in
serum, bronchoalveolar lavage
material, lymph node biopsy, tissue,
or cerebrospinal fluid.2,13
Population screening
Due to the low prevalence and high
rate of false-positive IgM screening
tests, routine serologic screening
isn’t recommended.3,14,15 All infants
born in the United States are
included in newborn screening
programs, but not all states include
T. gondii infection in these screening
panels. Although some state health
departments require reporting of
T. gondii infection, it’s not a nation-
What’s cooking from the CDC
To prevent food-borne infection with T. gondii, the CDC recommends using a food
thermometer to ensure that meat is thoroughly cooked. Warn patients not to sample
meat until it’s thoroughly cooked to a safe temperature, as follows:
• For whole cuts of meat (excluding poultry): Cook to at least 145° F (63° C) as
measured with a food thermometer placed in the thickest part of the meat.
Allow the meat to rest* for 3 minutes before carving or consuming.
• For ground meat (excluding poultry): Cook to at least 160° F (71° C); ground
meats don’t require a rest time.
• For all poultry: Cook to at least 165° F (74° C). Whole poultry should be
allowed to rest for 3 minutes before carving or consuming.
In addition, remind patients to peel or thoroughly wash fruits and vegetables
before eating them, and to wash cutting boards, dishes, counters, utensils,
and hands with hot soapy water after contact with raw meat, poultry, seafood,
or unwashed fruits or vegetables. Freezing meat for several days at tempera-
tures below 0° F (−17.8° C) also reduces the risk of infection, according to
the CDC.
*According to the United States Department of Agriculture, a rest time is “the amount of time the product
remains at the final temperature, after it has been removed from a grill, oven, or other heat source. During the
three minutes after meat is removed from the heat source, its temperature remains constant or continues to
rise, which destroys pathogens.”
Source: Centers for Disease Control and Prevention. Reduce risk from food. www.cdc.gov/parasites/
toxoplasmosis/prevent.html.

ally reportable disease.16,17

Immunosuppressed patients
should be tested routinely.5 Immu-
nosuppressed women should be
tested during pregnancy to facilitate
early detection and treatment of
primary maternal infection.6 Advise
women who aren’t pregnant and
experience an acute infection with
T. gondii to avoid pregnancy for 6
months after the primary infection.15
Treatment
Immunocompetent nonpregnant
adults infected with T. gondii will
usually mount an appropriate
immune response, making treatment
unnecessary. However, with severe
infections, pyrimethamine, sulfadia-
zine, and leucovorin may be admin-
istered for 2 to 4 weeks.2,8,18 Because
treatment doesn’t destroy tissue-based
parasitic cysts, patients should be
advised that even after treatment
they’ll be chronic carriers and illness
may recur, particularly if they become
immunocompromised.5 Previously
healthcare provider. Because the
parasite isn’t spread through routine
contact or airborne mechanisms,
standard precautions are appropriate
when caring for an infected patient
in a healthcare setting.3
Patients who are HIV-positive and
who test positive for T. gondii antibod-
ies should be treated for the infection
and maintained on a prophylactic
regimen even if they don’t have an
active infection.5 Without prophylac-
tic treatment, the risk of conversion to
active infection status can be as high
as 30% among HIV-infected patients,
particularly when the patient’s CD4
count is below 200 cells/mcL.5,12
Prevention
Teach patients the importance of
thoroughly cooking all meat before
consuming it. Inform them that
microwaving (which heats food
unevenly) and ordinary refrigeration
aren’t effective, but freezing meat to
below 0° F (-17.8° C) for several days
counters, and all cooking utensils that
have come in contact with raw meat
such as cutting boards, knives, and
bowls, and to wash all fresh fruits and
vegetables thoroughly before eating.3
Advise immunosuppressed and
pregnant patients not to clean or
change a cat’s litter box.2 Cats should
be kept indoors and litter boxes
cleaned regularly to decrease the risk
of infection, because the Toxoplasma
parasite doesn’t become infectious
until 1 to 5 days after being shed in a
cat’s feces.19 All pets should be fed
commercially available pet food or
well-cooked meat.3,5 Parents should
keep children’s sandboxes covered to
prevent cats from getting into them.3
Advise patients, especially pregnant
women, to wear gloves when
gardening and to wash hands
thoroughly when done. For more
disease prevention tips, see What’s
cooking from the CDC. ■
REFERENCES

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 Combating Infection
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RESOURCE
Opsteegh M, Kortbeek TM, Havelaar AH, van
der Giessen JW. Intervention strategies to reduce
human Toxoplasma gondii disease burden.
Clin Infect Dis. 2015;60(1):101-107.
Elizabeth Heavey is the Graduate Program Director and
Professor of Nursing at the State University of New
York, Brockport, and a member of the Nursing2018
Editorial Board.
The author has disclosed no financial relationships
related to this article.
DOI-10.1097/01.NURSE.0000534106.04143.54
www.Nursing2018.com