Sinusoidal obstruction syndrome associated with disseminated toxoplasmosis involving the liver after allogeneic hematopoietic stem cell transplantation: A case report.

Sinusoidal obstruction syndrome (SOS) is a fatal complication after hematopoietic stem cell transplantation (HSCT). Only a few complications after HSCT have been reported as risk factors for SOS, including sepsis. Here, we report the case of a 35-year-old male diagnosed with Philadelphia chromosome-positive acute lymphoblastic leukemia who underwent peripheral blood HSCT from a human leukocyte antigen-matched unrelated female donor in remission. Graft-versus-host disease prophylaxis contained tacrolimus, methotrexate, and low-dose anti-thymoglobulin. The patient was treated with methylprednisolone for engraftment syndrome from day 22. On day 53, he presented worsening fatigue, breathlessness, and abdominal pain in the right upper quadrant that had persisted for 4 days. Laboratory tests showed severe inflammation, liver dysfunction, and positive for Toxoplasma gondii PCR. He died on day 55. An autopsy showed SOS and disseminated toxoplasmosis. Hepatic infection with T. gondii was identified in zone 3 of the liver, which overlapped with the pathological features of SOS. In addition, the timing of the exacerbation of hepatic dysfunction coincided with the onset of systemic inflammatory symptoms and T. gondii reactivation. This rare case of toxoplasmosis is the first to suggest that hepatic infection with T. gondii is strongly associated with SOS after HSCT.

Prevalence and genotype of Toxoplasma gondii in stranded Hawaiian cetaceans.

Toxoplasma gondii is a significant threat to endangered Hawaiian wildlife including birds and marine mammals. To estimate the prevalence of T. gondii in stranded cetaceans from 1997 to 2021 in Hawai'i, we tested tissues from 37 stranded spinner dolphins Stenella longirostris and 51 stranded individuals that represented 18 other cetacean species. DNA from cetacean tissue extracts were screened using a nested polymerase chain reaction (PCR) assay targeting the Toxoplasmatinae internal transcribed spacer 1 of the nuclear ribosomal DNA. A positive result was obtained in 9 tissues examined for each of 2 spinner dolphins out of 525 tissue samples analyzed by PCR. The PCR-positive spinner dolphins had disseminated acute toxoplasmosis with necrosis, inflammation, and intralesional protozoal cysts and tachyzoites in multiple organs. Discrete positive immunostaining for T. gondii was observed in all tissues tested including the adrenal gland, brain, liver, and lung. Both positive spinner dolphins were negative for cetacean morbillivirus. The T. gondii genotyping was performed by restriction fragment length polymorphism (PCR-RFLP) based on 10 genetic markers. The PCR-RFLP analysis revealed the T. gondii belonged to PCR-RFLP-ToxoDB genotype #24, previously detected in wild pig Sus scrofa in O'ahu, bobcats Lynx rufus from Mississippi, USA, and chickens Gallus gallus from Costa Rica and Brazil. These cases represent the first report of this genotype in aquatic mammals and the second and third reports of fatal disseminated T. gondii infection in stranded spinner dolphins from Hawai'i. Nearshore species, like spinner dolphins, may be at increased risk of mortality from this parasite in marine coastal waterways via sewage systems, storm water drainage, and freshwater runoff.

Toxoplasma-induced hemophagocytic lymphohistiocytosis after haploidentical allogeneic stem cell transplantation.

Hemophagocytic lymphohistiocytosis (HLH) is a disorder of immune regulation, manifested by fever, pancytopenia, hyperferritiniemia, hypertriglyceridemia, and extensive hemophagocytosis involving the bone marrow and spleen. HLH can occur in adults with an underlying hematopoietic malignancy, or with systemic infections. HLH following hematopoietic stem cell transplantation (HSCT) is unusual, and the diagnosis may be challenging particularly because the diagnostic criteria in the HLH-2004 guidelines overlap with common post-transplant complications such as engraftment syndrome, graft-vs-host disease, and infections. HLH is commonly triggered by viral, bacterial and, less commonly, parasitic infections. Following HSCT, patients with latent Toxoplasma infection may develop systemic disease secondary to reactivation, and rarely this may lead to a HLH physiology, with a very high mortality rate. Herein we describe the successful management of disseminated toxoplasmosis associated with life-threatening HLH using tocilizumab and antimicrobial therapy.

Disseminated toxoplasmosis with atypical symptoms which developed with exacerbation of systemic lupus erythematosus.

Toxoplasma is a common parasite worldwide that mainly affects the brain, lungs and eyes. Although toxoplasmic encephalitis is a lethal disease without treatment, past case reports show most patients with systemic lupus erythematosus who developed toxoplasmic encephalitis were misdiagnosed and treated as neuropsychiatric systemic lupus erythematosus, which led to unfavorable outcomes. We herein describe a case of disseminated toxoplasmosis affecting all the above organs with atypical symptoms, which developed with exacerbation of systemic lupus erythematosus. She had initially manifested with retinochoroiditis without vitritis, mild cognitive impairment and an isolated lung mass. These are completely different from the classic symptoms of toxoplasmosis that have been reported in patients with HIV infection and/or those after hematopoietic transplantation. Our case, together with previously reported cases, suggests the manifestation of toxoplasmosis that develops in systemic lupus erythematosus patients can be different from that seen in conventional cases and varies between individual patients. Our case highlights both the difficulty in and the importance of diagnosing toxoplasmosis in patients with systemic lupus erythematosus and provides helpful information to identify this rare, devastating, yet treatable disease.

Genotyping of Toxoplasma gondii: DNA extraction from formalin-fixed paraffin-embedded autopsy tissues from AIDS patients who died by severe disseminated toxoplasmosis.

This study investigated the genetic features of Toxoplasma gondii isolated directly in autopsies of HIV-infected patients who died with severe disseminated toxoplasmosis. This retrospective analysis was conducted in a cohort of 15 HIV-infected patients with clinical and laboratory data. They had previous cerebral toxoplasmosis at least 6 months before the disseminated toxoplasmosis episode. The hypothesis was that they were infected with highly virulent parasites due to the condition in which they died. T. gondii genotyping was done directly in DNA extracted from 30 autopsy brain and lung samples (2 per patient) and mutilocus PCR-RFLP genotyping was done using 12 molecular markers. The 30 clinical samples were genotyped successfully in 8 or more loci and six suggestive genotypes were identified. One of them was Toxo DB #11, previously identified in different domestic animals and virulent in experimental animals. The other five suggestive genotypes identified in 14 patients were not described. TgHuDis1 was the most frequent and was determined in 8 patients. TgHuDis3 and TgHuDis5 were identified in two patients each. TgHuDis2 and TgHuDis4 have been identified in one patient each. These suggestive genotypes could be considered as virulent, since they caused severe tissue damage and had similar characteristics as Toxo # DB 11.

Disseminated toxoplasmosis Toxoplasma gondii in a wild Florida manatee Trichechus manatus latirostris and seroprevalence in two wild populations.

Marine mammals are important indicators for ecosystem health and serve as sentinel species for infectious agents including zoonoses. Histological examination of tissues from a stranded Florida manatee Trichechus manatus latirostris revealed protozoal cysts in the cerebrum and intrahistiocytic tachyzoites in the liver and caudal mesenteric lymph node. Disseminated Toxoplasma gondii infection was confirmed by immunohistochemistry and sequencing of the nuclear ribosomal internal transcribed spacer region of formalin-fixed tissues. The lack of baseline information on Florida manatees' exposure to this pathogen prompted a study into the seroprevalence of T. gondii in 2 separate geographic habitats in Florida, USA, during the winters from 2011-2014. Serum was collected during routine health assessments of 44 apparently healthy manatees from Crystal River (n = 26) on the west central coast of Florida and Brevard County (n = 18) on the east coast of Florida. Serum was screened for detection of T. gondii immunoglobulin G (IgG) antibodies via the modified agglutination test. Two animals from Crystal River from 2011 and 2012 (7.7%) and one animal from Brevard County from 2011 (5.6%) tested positive for T. gondii antibodies. Overall seroprevalence for T. gondii was low in the 2 sampled populations and may reflect a low seroprevalence or animal susceptibility. However, continued monitoring of this pathogen in aquatic ecosystems is warranted due to both possible anthropogenic sources and zoonotic potential.

Clinical features and outcomes in patients with disseminated toxoplasmosis admitted to intensive care: a multicenter study.

BACKGROUND: Characteristics and outcomes of adult patients with disseminated toxoplasmosis admitted to the intensive care unit (ICU) have rarely been described. METHODS: We performed a retrospective study on consecutive adult patients with disseminated toxoplasmosis who were admitted from January 2002 through December 2012 to the ICUs of 14 university-affiliated hospitals in France. Disseminated toxoplasmosis was defined as microbiological or histological evidence of disease affecting >1 organ in immunosuppressed patients. Isolated cases of cerebral toxoplasmosis were excluded. Clinical data on admission and risk factors for 60-day mortality were collected. RESULTS: Thirty-eight patients were identified during the study period. Twenty-two (58%) had received an allogeneic hematopoietic stem cell transplant (median, 61 [interquartile range {IQR}, 43-175] days before ICU admission), 4 (10%) were solid organ transplant recipients, and 10 (27%) were infected with human immunodeficiency virus (median CD4 cell count, 14 [IQR, 6-33] cells/µL). The main indications for ICU admission were acute respiratory failure (89%) and shock (53%). The 60-day mortality rate was 82%. Allogeneic hematopoietic stem cell transplant (hazard ratio [HR] = 2.28; 95% confidence interval [CI], 1.05-5.35; P = .04) and systolic cardiac dysfunction (HR = 3.54; 95% CI, 1.60-8.10; P < .01) within 48 hours of ICU admission were associated with mortality. CONCLUSIONS: Severe disseminated toxoplasmosis leading to ICU admission has a poor prognosis. Recipients of allogeneic hematopoietic stem cell transplant appear to have the highest risk of mortality. We identified systolic cardiac dysfunction as a major determinant of outcome. Strategies aimed at preventing this fatal opportunistic infection may improve outcomes.

Clinical Spectrum, Radiological Findings, and Outcomes of Severe Toxoplasmosis in Immunocompetent Hosts: A Systematic Review.

BACKGROUND: Accumulating evidence suggests that toxoplasmosis in immunocompetent hosts can be severe and life-threatening. METHODS: We performed a systematic review of severe toxoplasmosis cases in immunocompetent patients to gain insight into the epidemiology, clinical characteristics, radiological findings, and outcomes of these cases. We classified severe toxoplasmosis as cases with the symptomatic involvement of target organs (the lungs, central nervous system (CNS), and heart), disseminated disease, prolonged disease (>3 months), or a fatal outcome. Our primary analysis focused on cases published from 1985-2022 to avoid confounding with cases in AIDS patients. RESULTS: We identified 82 pertinent articles (1985-2022) with a total of 117 eligible cases; the top five countries for these cases were French Guiana (20%), France (15%), Colombia (9%), India (9%), and Brazil (7%). Overall, 44% (51/117) of cases had pulmonary involvement, 39% (46/117) CNS, 31% (36/117) cardiac, 24% (28/117) disseminated disease, 2% (2/117) had prolonged disease, and 8% (9/117) of patients died. More than one organ was involved in 26% (31/117) of cases. Eighty-four percent (98/117) of cases occurred in the context of a recent acute primary Toxoplasma infection; for the remaining, the exact timing of infection was unclear. Genotyping data were very sparse. Among those reporting genotyping data, 96% (22/23) were caused by atypical non-type II strains; one case was caused by a type-II strain. Only half of the cases reported risk factors. The most common risk factors were eating raw/undercooked meat or eating game meat (47% (28/60)), drinking untreated water (37% (22/60)), or living in a toxoplasmosis high-prevalence area (38% (23/60)). For the 51 pulmonary cases, the main clinical presentation was pneumonia or pleural effusions in 94% (48/51) and respiratory failure in 47% (24/51). For the 46 CNS cases, the main clinical presentation was encephalitis in 54% (25/46), meningitis in 13% (6/46), focal neurologic findings in 24% (11/46), cranial nerve palsies in 17% (8/46), Guillain-Barre syndrome or Miller Fisher syndrome in 7% (3/46), and Brown-Sequard syndrome in 2% (1/46) of cases; more than one clinical manifestation could also be present. Among the 41 CNS cases reporting the CNS imaging findings, 68% (28/41) had focal supratentorial lesions and 7% (3/41) had focal infratentorial lesions. Brain abscess-like/mass-like lesions were seen in 51% (21/41) of cases. For the 36 cardiac cases, the main clinical presentation was myocarditis in 75% (27/36), pericarditis in 50% (18/36), heart failure and/or cardiogenic shock in 19% (7/36), and cardiac arrhythmias in 22% (8/36); more than one manifestation could also be present. Illness was critical in 49% (44/90) of cases intensive care unit care was needed in 54% (29/54) of cases among those reporting this information, and 9 patients died. CONCLUSION: The diagnosis of severe toxoplasmosis in immunocompetent hosts can be challenging. Toxoplasmosis should be considered in the differential diagnosis of immunocompetent patients presenting with severe illness of unclear etiology with pulmonary, cardiac, CNS, or multiorgan involvement/failure, or prolonged febrile illness, even in the absence of common exposure risk factors or common manifestations of toxoplasmosis (e.g., fever, mononucleosis-like illness, lymphadenopathy, and chorioretinitis). Fatal outcomes can also rarely occur in immunocompetent patients. Prompt initiation of anti-Toxoplasma treatment can be lifesaving.

Disseminated Toxoplasmosis associated with Haemophagocytic Lymphohistiocytosis in a Patient with the Human Immunodeficiency Virus: A Case Report and Literature Review.

Disseminated toxoplasmosis associated with haemophagocytic lymphohistiocytosis (DT-HLH) is rare and difficult to diagnose compared to disseminated toxoplasmosis or HLH presenting alone. Because of the limited number of reported cases, the clinical characteristics and outcomes of DT-HLH are unknown. We report a case of DT-HLH in a human immunodeficiency virus (HIV)-infected patient who was successfully treated with early anti-toxoplasmic therapy and performed a comprehensive literature review. A 33-year-old Cameroonian woman was transferred to our hospital owing to HIV infection and encephalitis. Although she developed HLH, bone marrow biopsy did not reveal the cause. She was diagnosed as having DT-HLH via polymerase chain reaction testing of bone marrow biopsy tissue, blood, and cerebrospinal fluid. DT-HLH improved within the initial two weeks of treatment for toxoplasmosis (sulfamethoxazole-trimethoprim, trimethoprim 10 mg/kg/day and clindamycin 1,800 mg/day) before the introduction of antiretroviral therapy. To our knowledge, only eight cases of DT-HLH have been previously reported in the literature. Most patients died within three weeks of hospitalisation and were diagnosed by autopsy. Conversely, patients diagnosed antemortem were all treated and survived, including the currently reported patient. DT-HLH can lead to poor prognosis without early and proper treatment. Clinicians should consider toxoplasmosis in the differential diagnosis of HLH.

Rare Presentation of Toxoplasma Pneumonitis in the Absence of Neurological Symptoms in an AIDS Patient and Use of Next-Generation Sequencing for Diagnosis.

Toxoplasma gondii is a known cause of encephalitis in human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) patients. Toxoplasma pneumonitis is a manifestation of extracerebral toxoplasmosis and can be clinically indistinguishable from other opportunistic infections including Pneumocystis jirovecii pneumonia (PJP) and miliary tuberculosis. In this case report, Toxoplasma pneumonitis and disseminated toxoplasmosis was diagnosed using next-generation sequencing (NGS) and polymerase chain reaction (PCR) assessment. NGS can detect microbial cell-free DNA (cfDNA) circulating in the plasma of over 1,000 pathogens. This case is a rare presentation of Toxoplasma pneumonitis in the absence of neurological symptoms and we discuss the use of NGS of microbial cfDNA and PCR tests that may be utilized for the timely diagnosis of such challenging cases. LEARNING POINTS: Next-generation sequencing can help make a correct diagnosis and detect culture-negative opportunistic infections.Recognition of Toxoplasma pneumonitis as a rare presentation of disseminated toxoplasmosis.In cases of Toxoplasma pneumonitis, brain imaging should be conducted to rule out CNS involvement even in the absence of neurological symptoms.

Toxoplasma gondii infection in Amami spiny rat on Amami-Oshima Island, Japan.

The Amami spiny rat (Tokudaia osimensis) is an endangered rodent species that is endemic to the forests of Amami-Oshima Island, Kagoshima, Japan. In July 2018, a deceased adult male Amami spiny rat was found on the Yuwandake Mountain Trail on the south-central coast of Amami-Oshima Island. Histopathological observations revealed protozoan infections in the liver, lungs, and heart. Nested or semi-nested PCRs targeting the B1, SAG3, GRA6, and ROP18 genes successfully detected the genomic DNA of Toxoplasma gondii in the formalin-fixed and paraffin-embedded specimen. Sequence analyses of the SAG3, GRA6, and ROP18 genes suggested that the strain detected in the study specimen was related to the type II strain of T. gondii. This is the first confirmed case of T. gondii infection in an Amami spiny rat.

Clinical characteristics and computed tomography findings of pulmonary toxoplasmosis after hematopoietic stem cell transplantation.

The prognosis of pulmonary toxoplasmosis, including disseminated toxoplasmosis involving the lungs, following hematopoietic stem cell transplantation (HSCT) is extremely poor due to the difficulties associated with early diagnosis and the rapidly progressive deterioration of multiorgan function. In our institution, we identified nine cases of toxoplasmosis, representing incidences of 2.2 and 19.6 % among all HSCT recipients and seropositive HSCT recipients, respectively. Of the patients with toxoplasmosis, six had pulmonary toxoplasmosis. Chest computed tomography (CT) findings revealed centrilobular, patchy ground-glass opacities (n = 3), diffuse ground-glass opacities (n = 2), ground-glass opacities with septal thickening (n = 1), and marked pleural effusion (n = 1). All cases died, except for one with suspected pulmonary toxoplasmosis who was diagnosed by a polymerase chain reaction assay 2 days after the onset of symptoms. In pulmonary toxoplasmosis, CT findings are non-specific and may mimic pulmonary congestion, atypical pneumonia, viral pneumonitis, and bronchopneumonia. Early diagnosis and treatment is crucial for overcoming this serious infectious complication. Pulmonary toxoplasmosis should be considered during differential diagnosis in a recipient with otherwise unexplained signs of infection and CT findings with ground-glass opacities, regardless of the distribution.

A probable case of acquired toxoplasmosis presenting as pyrexia of unknown origin in an immunocompetent individual.

Disseminated toxoplasmosis presenting as a prolonged febrile illness is rare in immunocompetent individuals. We report a probable case of acquired toxoplasmosis in an immunocompetent woman who presented with fever of 6 months duration with lymphadenopathy and splenomegaly. The diagnosis was confirmed by serology and the presence of Toxoplasma gondii tachyzoites on bone marrow aspirate. The patient was successfully treated with pyrimethamine plus clindamycin.

Expressão gênica de citocinas em pacientes com toxoplasmose sintomática

Este estudo avaliou os níveis de expressão de mRNA de 9 citocinas empacientes com toxoplasmose ocular e disseminada. Foram analisadas 77 amostrasclínicas divididas em 4 Grupos. Foram incluídos no estudo amostras de autopsiasparafinadas de cérebro e pulmão provenientes de 11 pacientes com a coinfecçãotoxoplasmose disseminada e AIDS (Grupo I). As células mononucleares do sangueperiférico (PBMC) foram isoladas de 23 pacientes com toxoplasmose ocular (GrupoII) e 9 indivíduos com toxoplasmose crônica) (Grupo III). A seguir, as amostras dePBMC foram estimuladas in vitro com antígeno de Toxoplasma gondii. Os controlesnegativos (Grupo IV) foram constituídos por 7 amostras de PBMC de indivíduossoronegativos para toxoplasmose e 16 amostras de tecido parafinado (cérebro epulmão) de pacientes negativos para toxoplasmose e HIV. A expressão de mRNApara IFN-γ, TNF-α, TGF-β, IL-4, IL-6, IL-10, IL-12, IL-17 e, IL-27 foi determinadapor qPCR. Os resultados mostraram um aumento significativo dos níveis deexpressão de mRNA de IL-6 e IL-10 nos pacientes com toxoplasmose ocular.Esses pacientes também apresentaram menor expressão de mRNA de IFN-γ doque os indivíduos crônicos. Nos pacientes com a coinfecção toxoplasmosedisseminada e AIDS foram detectados níveis de expressão de mRNA de TGF-β eIL-6 no cérebro e pulmão. IL-6 foi significativamente menor do que o TGF-β. Até omomento, este é o primeiro estudo a investigar a resposta imune de pacientes comtoxoplasmose sintomática através do perfil de expressão de mRNA das citocinasde interesse.

This study evaluated levels of mRNA expression of 9 cytokines from patientswith ocular and disseminated toxoplasmosis. A total of 77 clinical samples wasanalyzed and they were divided into 4 Groups. The Group I was constituted ofautopsy samples (cerebral and pulmonary paraffin tissues) from 11 patients withdisseminated toxoplasmosis and AIDS. The peripheral blood mononuclear cells(PBMC) were isolated from 23 patients with ocular toxoplasmosis (Group II) and 9individuals with chronic toxoplasmosis (Group III). Next, PBMC samples werestimulated with in vitro with a crude Toxoplasma gondii antigen. Negative controls(Group IV) consisted of 7 PBMC from patients seronegative for toxoplasmosis and16 paraffin tissue samples (brain and lung) from patients negative for toxoplasmosisand HIV. mRNA expression for IFN-γ, TNF-α, TGF-β, IL-4, IL-6, IL-10, IL-12, IL-17and IL-27 was determined by qPCR. The results showed a significant increase inlevels of mRNA expression for IL-6, IL-10 and TGB-β in patients with oculartoxoplasmosis. These patients also had lower mRNA expression for IFN-γ thanthose chronic individuals. In patients with disseminated toxoplasmosis and AIDS,levels of mRNA expression for TGF-β and IL-6 were detected in the brain and lung.IL-6 was significantly lower than TGF-β. To date, this is the first study to investigatean immune response of patients with symptomatic toxoplasmosis through themRNA expression profile of the cytokines of interest.

Disseminated toxoplasmosis in an immunocompetent patient from Peruvian Amazon / Toxoplasmosis diseminada en un paciente inmunocompetente procedente de la Amazonía peruana

We report a case of severe toxoplasmosis in an immunocompetent patient, characterized by pneumonia, retinochoroiditis, hepatitis and myositis. Diagnosis was confirmed by serology, T. gondii in thick blood smear and presence of bradyzoites in muscle biopsy. Treatment with pyrimethamine plus sulfadoxine was successful but visual acuity and hip extension were partially recovered. This is the first case report of severe toxoplasmosis in an immunocompetent patient from Peru.

Reportamos un caso de toxoplasmosis severa en un paciente inmunocompetente caracterizado por neumonía, retinocoroiditis, hepatitis y miositis. El diagnóstico fue confirmado por serología, el hallazgo de T. gondii en gota gruesa y la presencia de bradizoitos en biopsia muscular. El tratamiento con pirimetamina mas sulfadoxina fue exitoso pero solo hubo una parcial recuperación de la agudeza visual y de la capacidad de extensión de la cadera. Este es el primer reporte de un caso de toxoplasmosis severa en el Perú.

Diagnosis of disseminated toxoplasmosis by polymerase chain reaction in bronchoalveolar lavage fluid of a patient with aids / Diagnóstico de toxoplasmose disseminada através de técnica de reação em cadeia da polimerase realizada no lavado bronco-alveolar de paciente com sida

Pulmonary toxoplasmosis is a challenging diagnosis in immunosuppressed patients with nonspecific clinical picture and radiologic findings. We present a case of pneumonia due to Toxoplasma gondii diagnosed by polymerase chain reaction (PCR) in the bronchoalveolar lavage (BAL) fluid of a patient with acquired immunodeficiency syndrome (AIDS). Coinfection with Pneumocystis jirovecii was found in the same specimen. Direct examination and culture for bacteria, mycobacteria and other fungus were negative. Despite the intensive management, respiratory compromise evolved rapidly, with the need for ventilatory support. Acute respiratory distress syndrome developed, and the patient died of multiple organ failure. This case illustrates that a high index of suspicion is necessary for diagnosis of pulmonary toxoplasmosis, a potentially fatal condition. Due to high diagnostic performance, PCR in BAL fluid should be included in the evaluation of immunosuppressed patients with nonspecific pulmonary diseases.

O diagnóstico de toxoplasmose pulmonar em pacientes imunossuprimidos é difícil, devido ao quadro clínico e aos achados radiológicos inespecíficos. Neste artigo, relatamos o caso de uma paciente com síndrome da imunodeficiência adquirida (SIDA), que apresentou pneumonia por Toxoplasma gondii diagnosticada através de reação em cadeia da polimerase (PCR) no lavado bronco-alveolar (LBA). A paciente apresentava co-infecção com Pneumocystis jirovecii. Os demais exames microbiológicos, como bacterioscópico, cultural para bactérias, micobactérias e fungos, foram negativos. Apesar do manejo intensivo, a paciente evoluiu com síndrome do desconforto respiratório agudo e óbito por falência múltipla dos órgãos. Este caso demonstra que um alto índice de suspeita clínica é necessário para o diagnóstico de pneumonia por Toxoplasma gondii. Devido ao seu desempenho diagnóstico, o PCR para Toxoplasma gondii no LBA deve ser incluído na avaliação de pacientes imunossuprimidos com quadros pulmonares inespecíficos.