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Toxoplasmosis following allogeneic hematopoietic stem cell transplantation

Bone Marrow Transplantation volume 31, pages 617–618 (2003)Cite this article

In the April (2) 2002, issue of Bone Marrow Transplantation Mele et al1 report two cases of toxoplasmosis and perform a review of the literature. Their extensive review effort is to be congratulated and probably includes most of the case reports or small case series reported during the period analyzed. The authors state that they found 110 cases of toxoplasmosis (again, mostly case reports or small case series) up to December 2000. However, they fail to cite and include in their review the studies published in this matter by the European Group for Blood and Marrow Transplantation Infectious Diseases Working Party (EBMT-IDWP). In the year 2000, the EBMT-IDWP described first the frequency of toxoplasmosis and strategy policies in 52 EBMT centers2 and later published the detailed description of 41 cases observed during a 5-year period in 15 of these centers.3 Most importantly, the EBMT-IDWP proposed a set of definitions of the diagnostic certainty of toxoplasmosis infections and disease (see Table 1). These definitions are now used within the registry to report in detail cases of toxoplasmosis in patients registered in the EBMT. Reporting the degree of certainty in which a case of toxoplsmosis has been diagnosed is important, since many cases can be classified only as possible or probable cases, and definite cases are often diagnosed only at autopsy. As an example, the first case described by Mele et al would be classified as a probable Toxoplasma disease, while the second case would be a definite case based on post-mortem findings only. In the review performed by these authors, however, they make no mention to the degree of certainty of the diagnosis in the individual reports, so the reader cannot be certain how many cases of possible, probable and definite disease are described.

Table 1 EBMT-IDWP definitions for toxoplasmosis after hematopoietic stem cell transplantation (from Martino et al3)
Full size table

Additionally, the authors perform statistical analyses comparing the characteristics of patients diagnosed during life vs post mortem. Such an analysis may be misleading, since their data set is not derived from a cohort of consecutive patients from a single or from multiple institutions, but rather from published reports. Undoubtedly, in such analyses there is a strong publication bias that must be taken into account when interpreting the results (in addition to the diagnostic uncertainty of many cases, as described above). As an example, the authors stress that disseminated infection was more common in cases diagnosed post mortem, and at the same time they conclude that mortality was higher in disseminated than cerebral toxoplasmosis. This statistical result is inevitable, since most cases of disseminated infection (80% according to the authors) were diagnosed at autopsy and not during life, which biases the mortality towards disseminated infections.

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References

  1. Mele A, Paterson PJ, Prentice HG et al. Toxoplasmosis in bone marrow transplantation: a report of two cases and systematic review of the literature. Bone Marrow Transplant 2002; 29: 691–698.

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  2. Martino R, Bretagne S, Rovira M et al. Toxoplasmosis after hematopoietic stem transplantation. Report of a five-year survey from the Infectious Diseases Working Party of the European Group for Blood and Marrow Transplantation (EBMT-IDWP). Bone Marrow Transplant 2000; 25: 1111–1113.

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  4. Costa JM, Munoz C, Kruger D et al. Quality control for the diagnosis of Toxoplasma gondii reactivation in SCT patients using PCR assays. Bone Marrow Transplant 2001; 28: 527–528.

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  1. Rodrigo Martino
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  2. Catherine Cordonnier
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For the European Group for Blood and Marrow Transplantation Infectious Diseases Working Party (EBMT-IDWP)

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Martino, R., Cordonnier, C. & For the European Group for Blood and Marrow Transplantation Infectious Diseases Working Party (EBMT-IDWP). Toxoplasmosis following allogeneic hematopoietic stem cell transplantation. Bone Marrow Transplant 31, 617–618 (2003). https://doi.org/10.1038/sj.bmt.1703914

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