Postgrad Med J 1995; 71: 168-180 i) The Fellowship of Postgraduate Medicine, 1995 Short reports Postgrad Med J: first published as 10.1136/pgmj.71.833.168 on 1 March 1995. Downloaded from Toxoplasma gondii - an unusual cause of myocarditis in old age

N Chapman, WJ MacLennan, M Rahilly

Summary Case report We report the case ofan 86-year-old man who was admitted with congestive car- An 86-year-old man was admitted with a diac failure and chronic renal failure. He one-week history of breathlessness associated was previously known to have a thoracic with cough and mucopurulent sputum. There aortic aneurysm and chronic bronchitis. was a long history of recurrent episodes of There was no history of myocardial respiratory infection previously diagnosed as infarction but his heart failure was chronic bronchitis. Six months earlier he had assumed to be due to ischaemic heart been referred as an out-patient suffering from disease. Despite treatment of the heart hoarseness of several weeks' duration. It was failure the patient died. At post-mortem established that this was due to a left recurrent he was found to have Toxoplasma gondii laryngeal palsy associated with an aneursym of myocarditis. the thoracic aorta. At the same time it was noted that he had serum urea and plasma creatinine Keywords: Toxoplasma gondii, myocarditis, elderly concentrations of 2.5 mmol/l and 414 ltmol/l, respectively. There was no history of blood transfusions in the recent past, and no contact Introduction with cats or any other pet. On examination he was co-operative and well orientated. His Infection with Toxoplasma gondii, a coccidian fingers were clubbed, he was apyrexial and parasite, manifests itself in humans in a variety there was no lymphadenopathy. There was of fashions.1`' In recent years a particularly jugular venous congestion and considerable virulent form of the infection has emerged in sacral and lower limb oedema. His pulse was patients with a compromised immune system.4`9 regular at 80 beats per minute, his blood The syndrome represents reactivation of an pressure was 100/60 mmHg, and heart sounds infection often acquired years previously, in were normal. There was dullness and dimin- which bradyzoites have remained dormant in ished air entry at both lung bases. His liver was tissue cysts until immunosuppression activates enlarged to 5 cm below the right costal margin, http://pmj.bmj.com/ the infection.4 and was smooth and non-tender. There were Although the proportion of individuals with no focal neurological signs. Laboratory investi- a positive serological test for Tgondii increases gations showed a normal white cell count. The with age, there have been no reports of toxo- serum sodium was 146 mmol/l, potassium 6.3 plasmosis causing severe organ damage in mmol/l, bicarbonate 15 mmol/l, urea 39.7 mmol/l, elderly patients.2 It is for this reason that the and creatinine 607 mmol/l. Creatinine clear- present report of myocarditis due to Tgondii is ance was subsequently found to be 1.3 ml/min. on October 2, 2021 by guest. Protected copyright. of particular interest. An electrocardiograph (ECG) showed left bundle branch block and generalised T-wave inversion. Features noted on chest X-ray were cardiomegaly, bilateral pleural effusions, and a large thoracic aneurysm. There was no Department of Clinical features of Toxoplasma Pathology, University gondii infection evidence of lung consolidation. Medical School, Teviot The provisional diagnoses at this stage were Place, Edinburgh, UK Healthy children Asymtomatic; or malaise, chronic bronchitis, congestive cardiac failure, M Rahilly or adults fever and anterior cervical/ aortic aneurysm and chronic renal failure. suboccipital lymphadeno- He was treated with calcium resonium and Geriatric Medicine pathy. Uveitis (rare). parenteral frusemide. There was progressive Unit, City Hospital, Atypical lymphocytes on Edinburgh, UK blood film. deterioration in his condition and he died three N Chapman Pregnancy Fetal intracerebral days later. WJ MacLennan calcification, hydrocephalus and choroidoretinitis Autopsy Correspondence to Immuno- Brain, lung, heart involve- ProfWJ MacLennan suppressed ment Geriatric Medicine Unit, (eg, AIDS, Examination of his heart revealed marked City Hospital, transplant biventricular dilatation. There was only mod- Greenbank Drive, recipients, erate atherosclerosis of the coronary arteries Edinburgh EH10 5SB, UK elderly) and no evidence of an old or recent myocardial Accepted 8 September 1994 infarction. The left ventricular myocardium Toxoplasma gondii myocarditis 169

was-thinned to 0.9 cm on the anterior wall and to 0.7 cm on the posterior wall (normal 1.3- 1.5 cm). Microscopic examination of the myo-

cardium, with sections taken from the interat- Postgrad Med J: first published as 10.1136/pgmj.71.833.168 on 1 March 1995. Downloaded from rial septum and anterior and posterior walls of the left ventricle, revealed features of myocar- ditis with occasional myocytes containing Tgondii cysts (figures 1 and 2). A thoracic aneurysm, with a maximum diameter of 10 cm, had its origin 6 cm above the aortic valve and there was a small fusiform aneurysm of the abdominal aorta. The kidneys were shrunken and scarred. There was histological evidence of benign nephrosclerosis and pulmonary emphy- Figure 1 The myocardium contains a mononuclear sema, but no evidence of toxoplasmosis at inflammatory infiltrate composed of lymphocytes and either site. some macrophages. There is some interstitial oedema (H+E, x 100) Discussion This man presented with multiple pathologies consisting of congestive cardiac failure, an aortic aneurysm, chronic bronchitis and chronic renal failure. Even with the benefit of hind- sight, the most likely diagnosis was congestive cardiac failure due to ischaemic heart disease, with the chronic renal failure accentuating the fluid retention. Without a clear history of ischaemic heart disease the possibility of a cardiomyopathy should have been considered, but the autopsy diagnosis oftoxoplasmosis was completely unexpected. The probable explanation of the condition was reactivation of a latent infection acquired Figure 2 Toxoplasma cysts within myocytes (arrows). The lack of an inflammatory response sur- many years previously. There was no oppor- rounding the cysts is characteristic: rupture of a cyst tunity to use stored serum to check for toxo- incites an inflammatory reaction (H + E; x 400) plasma antibodies or for infection with human immuno-deficiency virus (HIV). There was nothing in the history ofthis octogenarian with severe respiratory disease to suggest that HIV infection was a real possibility.'0 In these due to toxoplasmosis. It remains uncertain circumstances it seems much more likely that what proportion ofcases of so-called idiopathic the reason for his immunosuppression was myocarditis is due to toxoplasma, but clearly http://pmj.bmj.com/ severe renal failure secondary to nephrosclero- some may be. A diligent search for toxoplasma sis. cysts in tissue sections is required in cases of An unanswered question in this patient re- apparently non-specific myocarditis. mains the precise cause of the pulmonary It should be noted that the diagnosis in this congestion. It is possible that it related to the case would not have been made without an toxoplasmosis, but an alternative is that it was autopsy since none of the ECG changes were due to the severe renal impairment. Most specific for myocarditis. The use ofautopsies as on October 2, 2021 by guest. Protected copyright. reports of myocarditis associated with toxo- an effective form of audit has been sadly plasmosis suggest that the clinical features are neglected in recent years. It is our policy to non-specific.5 request autopsies on all deaths occurring in our While there have been several reports of assessment unit. A review has recently estab- toxoplasma cysts in the myocardium, it is lished that this has been extremely effective in wrong to assume that their identification is reducing complacency and encouraging high easy, even in cases of myocarditis known to be standards of clinical practice.II

1 Remington RS, Jacobs L, Kaufman HE. Toxoplasmosis in 7 Luft BJ, Pomeroy JS. Toxoplasmic encephalitis in AIDS. the adult. N Engl J Med 1960; 262: 180-5. CGin Infect Dis 1992; 15: 211-22. 2 Ho-Yen DC. Toxoplasmosis in human: discussion paper. J 8 Pomeroy C, Falice GA. Pulmonary toxoplasmosis: a review. R Soc Med 1990; 83: 571-2. Clin Infect Dis 1992; 14: 863-970. 3 Joss AWL, Skinner LJ, Chatterton JMW, Chisholm SM, 9 Jautzke G, Sell M, Thalmann U, et al. Extracerebral Williams HD, Ho-Yen DC. Simultaneous serological toxoplasmosis in AIDS: histological and immunological screening for congenital cytomegalovirus and toxoplasma findings based on 80 autopsy cases. Pathol Res Pract 1992, infection. Public Health 1988; 102: 409-19. 45: 575-8. 4 Gellin BG, Soave R. Coccidian infections in AIDS. Toxo- 10 Regstag KE, Bignell CJ. Age is no barrier to sexually plasmosis, cryptosporidiosis and isosporiasis. Med Clin N acquired infection. Age Ageing 1991; 20: 377-8. Am 1992; 76: 205-34. 11 Paterson DA, Dorovitch MI, Farquhar DL, et al. Prospec- 5 Wreghitt TG, Hakim M, Gray JJ, et al. Toxoplasmosis in tive study of necropsy audit of geriatric inpatient deaths. J heart and heart and lung transplant recipients. J Clin Pathol Clin Pathol 1992; 45: 575-8. 1989; 42: 194-9. 6 Derouin F, Devergie A, Auber P, et al. Toxoplasmosis in bone marrow-transplant recipients: report of seven cases. Clin Infect Dis 1992; 15: 267-70.