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Letter to the Editor
Ventricular arrhythmia as the first manifestation of congenital toxoplasmosis
Arritmias ventriculares como forma de presentación de toxoplasmosis congénita
María Isabel Sanchez-Codeza,
Corresponding author
mscodez1990@gmail.com

Corresponding author.
, Moises Rodríguez-Gonzálezb,c, Ana Castellano-Martínezd,c, Pamela Zafra Rodrígueze
a Unidad de Gestión Clínica de Pediatría, Sección de Infectología Pediátrica, Hospital Universitario Puerta del Mar, Cádiz, Spain
b Unidad de Gestión Clínica de Pediatría, Sección de Cardiología Pediátrica, Hospital Universitario Puerta del Mar, Cádiz, Spain
c Instituto de Investigación e Innovación Biomédica de Cádiz (INiBICA), Unidad de Investigación Hospital Universitario Puerta del Mar, Cádiz, Spain
d Unidad de Gestión Clínica de Pediatría, Sección de Nefrología Pediátrica, Hospital Universitario Puerta del Mar, Cádiz, Spain
e Unidad de Gestión Clínica de Pediatría, Sección de Neonatología, Hospital Universitario Puerta del Mar, Cádiz, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Congenital toxoplasmosis &#40;CT&#41; is a rare entity&#46; In Spain&#44; the incidence of infection during pregnancy is 1&#46;9&#47;1000&#46; Most of the affected fetuses do not present symptoms at birth&#44; but up to 80&#37; develop serious sequelae&#44; especially ophthalmological and neurological disorders&#44; with cardiac involvement being unusual&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a male neonate&#44; with arrhythmic heartbeat and tachycardia of up to 200&#8239;bpm from birth&#44; without hemodynamic repercussions&#46; The obstetric background included late pre-term&#44; urgent cesarean section and birth weight of 2875&#8239;g&#46; The pregnant woman came from Equatorial Guinea and reported an uncontrolled pregnancy&#44; presenting a positive peripartum test for human immunodeficiency virus &#40;HIV&#41;&#44; without having received antiretroviral therapy before or during delivery&#46; The maternal serology revealed positive IgM and IgG &#40;low avidity&#41; for <span class="elsevierStyleItalic">Toxoplasma gondii &#40;T&#46; gondii&#41;</span>&#46; An electrocardiogram was performed&#44; which detected ventricular extrasystoles&#44; frequent in bigeminy&#46; The 24&#8239;h Holter monitoring showed ventricular extrasystoles in 38&#37; of the recording&#46; The echocardiogram and chest X-ray were normal&#46; Serial lab tests revealed leukopenia&#44; thrombocytopenia&#44; and hypertransaminasemia&#46; HIV C-reactive protein &#40;CRP&#41; test at 48&#8239;h of life was negative&#46; The TORCH serology &#40;toxoplasmosis&#44; rubella&#44; cytomegalovirus&#44; herpes simplex and HIV&#41; showed positive IgM and IgG for <span class="elsevierStyleItalic">T&#46; gondii</span>&#44; with a positive PCR of <span class="elsevierStyleItalic">T&#46; gondii</span> in blood and cerebrospinal fluid &#40;CSF&#41;&#46; The extension study in the CSF&#44; eye fundus&#44; transfontanelar ultrasound&#44; and cranial magnetic resonance imaging &#40;MRI&#41; showed no disorders&#46; The neonate was treated with pyrimethamine &#40;P&#58; 1&#8239;mg&#47;kg every 12&#8239;h&#44; the first 48&#8239;h&#59; then 1&#8239;mg&#47;kg&#47;day&#41;&#44; sulfadiazine &#40;S&#58; 100&#8239;mg&#47;kg&#47;day&#44; every 12&#8239;h&#41; and folinic acid &#40;FA&#58; 10&#8239;mg&#44; every 72&#8239;h&#41;&#46; He did not receive corticosteroids&#46; During the first week&#44; bouts of ventricular tachycardia&#44; up to 2&#8239;min long&#44; without hemodynamic repercussions were observed&#46; Propranolol was started &#40;up to 3&#8239;mg&#47;kg&#47;day&#41; with progressive disappearance of ventricular arrhythmias&#46; The child is currently 6 months old&#44; and presents adequate psychomotor and statutory development&#46; He is asymptomatic&#44; without ventricular arrhythmias or adverse effects with the same treatment&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Transplacental transmission is responsible for the CT&#46; The development of the disease is favored by the immunosuppression of the host&#46; Immunological immaturity and maternal HIV predisposed our patient&#46; Cardiac involvement in toxoplasmosis is uncommon &#40;33 cases since 1964&#59; no cases in CT as the one we present&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;5</span></a> It usually affects young and immunosuppressed adults &#40;chemotherapy&#44; HIV&#44; heart transplantation&#41;&#44; with highly variable presentation&#44; including sudden death&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The appearance of palpitations or syncope in these patients should alert to the possibility of severe arrhythmias&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Although the exact cardiac pathogenic mechanism is not known&#44; it seems to be related to an inflammatory hypersensitivity or autoimmune reaction&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3</span></a> In the congenital form&#44; the tachyzoites invasion of the myocardium develops into fibrosis and necrosis&#46; However&#44; in adults&#44; myocardial involvement occurs after the cysts rupture in a latent state&#44; often during healing in the chronic phase&#46; Our patient did not receive a cardiac MRI or endomyocardial biopsy &#40;EMB&#41;&#44; the <span class="elsevierStyleItalic">gold standard</span> diagnosis&#46; The validity of cardiac MRI is limited in children younger than 4 months due to its poor temporal-spatial resolution&#46; EMB is an invasive technique&#44; reserved for severe myocarditis with poor evolution&#46; There was only one case where the invasion of <span class="elsevierStyleItalic">T&#46; gondii</span> was identified in EMB&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The neonatal diagnosis in our patient was based on a history of gestational toxoplasmosis&#44; compatible serology&#44; and PCR in blood&#44; and CSF positive for <span class="elsevierStyleItalic">T&#46; gondii</span>&#46; The involvement of the conduction tissue of the heart which manifested as ventricular arrhythmias&#44; and which has previously been described in toxoplasmosis cases and is not justifiable by any other cause&#44; would explain the cardiac symptoms&#46; The response to antiparasitic agents is variable&#44; and null in cystic forms&#46; Some authors suggest steroid treatment due to its autoimmune basis&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Our patient was treated as a congenital form with P&#44; S and FA according to clinical guidelines&#44; and associating beta blockers as antiarrhythmic agents&#46; The cardiac prognosis for toxoplasmosis is not known exactly&#59; Of the 33 cases reviewed&#44; 10 had serious complications and 4 recurrent arrhythmias&#46; Incomplete elimination of the cystic forms&#44; their multiplication&#44; new rupture&#44; and inflammatory reaction explain the relapses&#44; and this emphasis the need for long-term cardiological follow-up of these patients&#46; So far our case has not presented recurrences&#46; CT can present exclusively as cardiac involvement&#44; a form not described to date&#46; Early treatment and adequate follow-up is essential to prevent the risk of serious arrhythmias and sudden death&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Thanks to</span><p id="par0020" class="elsevierStylePara elsevierViewall">Dr&#46; Fernando Baquero Artigao from La Paz University Hospital for sharing his experience in congenital toxoplasmosis&#46;</p></span></span>"
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