Τι είναι η τοξοπλάσμωση
Είναι ανθρωποζωονόσος που οφείλεται στο πρωτόζωο τοξόπλασµα gondii, µε κύριο ξενιστή τη γάτα και ενδιάµεσους ξενιστές τα βοοειδή, αιγοπρόβατα κ.α. Ο άνθρωπος µολύνεται από κατανάλωση µη καλά ψηµένου κρέατος που περιέχει τους τροφοζωίτες του παρασίτου ή από επαφή µε περιττώµατα γάτας που περιέχουν τις ωοκύστεις του. Στη µητέρα η λοίµωξη διαδράµει ασυµπτωµατικά στο 80% – 90% των περιπτώσεων. Στο κύηµα µεταδίδεται µόνο κατά το στάδιο της παρασιταιµίας της µητέρας. Η κάθετη µετάδοση είναι δυνατή σ’ όλη τη διάρκεια της κύησης, αλλά οι συνέπειες στο κύηµα είναι τόσο σοβαρότερες όσο νωρίτερα κατά την κύηση νοσήσει η µητέρα.
Συχνότητα εμφάνισης
20-25% του ενήλικου πληθυσμού παρουσιάζουν αντισώματα από παλαιά λοίμωξη 0,5-1% περίπου των εγκύων γυναικών θα παρουσιάσουν πρόσφατη ενεργό λοίμωξη στην κύηση.
Τρόπος μετάδοσης
Άψητο ή όχι καλά ψημένο κρέας
Μολυσμένα λαχανικά και φρούτα
Επαφή με κόπρανα μολυσμένων γατών
Επίπτωση τοξοπλάσμωσης
Συνήθως δεν προκαλεί συμπτώματα ή σε αντίθετη περίπτωση η πάσχουσα μπορεί να παρουσιάσει κλινική εικόνα γρίπης.
Όταν κάποιος κολλήσει τοξοπλάσμωση, θεωρείται ότι λόγω ανάπτυξης αντισωμάτων είναι προστατευμένος για την υπόλοιπη ζωή του, με εξαίρεση τους ανοσοκατεσταλμένους ανθρώπους.
Στην εγκυμοσύνη, η τοξοπλάσμωση θεωρείται επικίνδυνη για το έμβρυο, μόνον όταν υπάρξει ενεργός πρωτολοίμωξη κατά τη διάρκεια της κύησης ή 2-3 μήνες πριν τη σύλληψη, όπου πλέον χρησιμοποιούμε τον όρο συγγενείς τοξοπλάσμωση.
Η πιθανότητα μετάδοσης στο έμβρυο και παράλληλα η πιθανότητα το προσβεβλημένο έμβρυο να νοσεί, είναι άμεσα εξαρτώμενη από την ηλικία κύησης στην οποία μολύνθηκε η μητέρα.
Τοξοπλάσμωση στην κύηση
Σε ένα σηµαντικό ποσοστό τα νεογέννητα µε ενδοµήτρια λοίµωξη από τοξόπλασµα είναι ασυµπτωµατικά, αλλά τα περισσότερα από αυτά θα εκδηλώσουν αργότερα µόνιµες βλάβες από τα µάτια ή το ΚΝΣ. Οι κλινικές µορφές εκδηλώνονται µε:
Αποβολή
Ενδομήτριο θάνατο
Εικόνα γενικευµένης νόσου µε εξανθήµατα (πορφυρικά και “blueberry muffin”), ηπατοσπληνοµεγαλία, ίκτερο, αναιµία, θροµβοπενία.
Προσβολή του ΚΝΣ (υδροκεφαλία ή µικροκεφαλία, σπασµοί, αυξηµένη τάση της µεγάλης πηγής και ενδοκρανιακές επασβεστώσεις), που είναι ιδιαίτερα συχνή και µπορεί να αποτελεί και τη µοναδική εκδήλωση της νόσου κατά τη γέννηση.
Οφθαλµική προσβολή (χοριοαµφιβληστροειδίτιδα, καταρράκτη, µικροφθαλµία).
Καθυστερηµένες εκδηλώσεις µπορεί να εµφανιστούν ακόµη και στις ασυµπτωµατικές περιπτώσεις. Συχνότερες είναι οι συνέπειες της χοριοαµφιβληστροειδίτιδας (νυσταγµός, στραβισµός, τύφλωση) και της προσβολής του ΚΝΣ (υδροκέφαλος, σπασµοί κ.λ.π.), νευρογενής βαρηκοΐα.
Εάν υποθετικά μία μητέρα μολυνθεί από τοξόπλασμα για πρώτη φορά στην κύηση, δεν σημαίνει αυτόματα ότι το έμβρυο θα μολυνθεί.
Σε γενικές γραμμές, μόνον 4/10 έμβρυα θα μολυνθούν. Τα περισσότερα έμβρυα που γεννιούνται με τοξοπλάσωση είναι ασυμπτωματικά κατά τη γέννηση αλλά είναι πιθανόν να αναπτύξουν συμπτώματα, αργότερα στην παιδική ή εφηβική ηλικία.
Διάγνωση τοξοπλάσμωσης
Η διάγνωση γίνεται με μία απλή αιμοληψία της μητέρας. Η εξέταση αίματος ανιχνεύει αντισώματα τοξοπλάσματος, τα οποία φυσιολογικά παράγονται από το σώμα για να καταπολεμήσουν τη λοίμωξη.
Ανάλογα με τον τύπο των αντισωμάτων που ανιχνεύονται και ανάλογα με το εάν τα επίπεδα τους αυξάνονται, παραμένουν σταθερά ή είναι πτωτικά, μπορεί να προσδιοριστεί ο χρόνος εμφάνισης της λοίμωξης (πρόσφατη ή παλαιά λοίμωξη).
Τι εξετάζουμε
IgG αντισώματα – θετικά σε παλαιά λοίμωξη
IgM αντισώματα – θετικά σε πρόσφατη λοίμωξη
Avidity test – ειδικό τεστ το οποίο προσδιορίζει με μεγάλη ακρίβεια το χρόνο λοίμωξης
Τι σημαίνει ένα αρνητικό τεστ
Ένα αρνητικό τεστ σημαίνει ότι η ασθενής δεν είχε ποτέ στη ζωή της λοίμωξη από τοξόπλασμα και ως εκ τούτου δεν έχει ανοσία και θα πρέπει να πάρει τις απαραίτητες προφυλάξεις πριν τη σύλληψη και κατά τη διάρκεια της κύησης.
Τι σημαίνει ένα θετικό τεστ
Σημαίνει ότι η ασθενής κάποια στιγμή στη ζωή της είχε λοίμωξη από τοξόπλασμα και ως εκ τούτου έχει ανοσία στο παράσιτο.
Περίπου μια στις τρεις έγκυες γυναίκες ανιχνεύονται θετικές.
Δεδομένου ότι τα τεστ αυτά είναι εξαιρετικά ευαίσθητα, ένα μικρό ποσοστό θα βρεθεί ψευδώς θετικό.
Σε κάθε περίπτωση θετικού τεστ στην κύηση, δηλαδή θετικά IgM αντισώματα,
θα πρέπει να γίνει περαιτέρω έλεγχος με την δοκιμασία avidity, μια πιο ειδικευμένη εξέταση αίματος η οποία θα προσδιορίσει το κατά πόσον πρόκειται πραγματικά για πρόσφατη λοίμωξη.
Πρόσφατη λοίμωξη
Πριν τη σύλληψη
Λοίμωξη 2-3 μήνες πριν τη σύλληψη συνοδεύεται από ποσοστό 1% μετάδοσης στο έμβρυο, αλλά εξαιρετικά υψηλό ποσοστό αποβολής εάν το έμβρυο μολυνθεί.
Στο πρώτο τρίμηνο
Πρωτολοίμωξη της εγκύου στην περίοδο αυτή συνοδεύεται από 15% πιθανότητα μετάδοσης στο έμβρυο.
Τα έμβρυα που προσβάλλονται στην περίοδο αυτή έχουνε υψηλή πιθανότητα αποβολής ή ανάπτυξης σοβαρών συμπτωμάτων, όπως υδροκεφαλία, εγκεφαλικές αποτιτανώσεις και αμφιβληστροειδοπάθειας.
Στο δεύτερο τρίμηνο
Λοίμωξη της εγκύου στην περίοδο αυτή συνοδεύεται από ποσοστό 25% μετάδοσης στο έμβρυο.
Λοίμωξη στην περίοδο αυτή σπάνια θα προκαλέσει αποβολή, αλλά τα προσβεβλημένα έμβρυα παραμένουν σε κίνδυνο ανάπτυξης σοβαρών ανωμαλιών.
Στο τρίτο τρίμηνο
Ο κίνδυνος μετάδοσης στην περίοδο αυτή αυξάνει και είναι περίπου 65%.
Η πλειονότητα των προσβεβλημένων εμβρύων θα είναι υγιή στη γέννηση αλλά αρκετά από αυτά μπορεί να παρουσιάσουν συμπτώματα αργότερα στη ζωή τους με συνηθέστερες τις οφθαλμικές βλάβες.
Συμπερασματικά, η πιθανότητα μετάδοσης είναι αντιστρόφως ανάλογη της πιθανότητας το έμβρυο να νοσήσει.
Κοινώς, νωρίς στην κύηση λιγότερα έμβρυα θα προσβληθούν αλλά με μεγαλύτερο ποσοστό να νοσήσουν, ενώ αντίστροφα σε πρωτολοίμωξη αργότερα στην κύηση, περισσότερα θα προσβληθούν και λιγότερα θα νοσήσουν.
Εξετάσεις για τοξοπλάσμωση
Εξέταση ρουτίνας της εγκύου για αντισώματα IgG & IgM
Θετικά IgG – παλαιά λοίμωξη και ανοσία της εγκύου
Θετικά IgM – πρόσφατη λοίμωξη
Σε θετικά IgM – συνιστάται avidity test για να εξακριβωθεί κατά πόσον όντως πρόκειται για πρόσφατη λοίμωξη και δεν είναι ψευδώς θετικά τα IgM αντισώματα.
high avidity – παλαιά λοίμωξη
low avidity – επιβεβαιώνει πρόσφατη λοίμωξη
Εάν low avidity, συνιστάται αμνιοπαρακέντηση για ανίχνευση του ιού στο αμνιακό υγρό μετά την 21η εβδομάδα.
Να σημειωθεί ότι από το αποτέλεσμα της αμνιοπαρακέντησης αξιολογείται το αρνητικό αποτέλεσμα, ενώ σε αντίθετη περίπτωση ένα θετικό αποτέλεσμα σημαίνει ότι το έμβρυο έχει προσβληθεί από τον ιό, χωρίς να μπορεί να πει το κατά πόσον το προσβεβλημένο έμβρυο όμως νοσεί (τα υπερηχογραφικά ευρήματα υποδηλώνουν το κατά πόσον το προσβεβλημένο έμβρυο νοσεί).
Θεραπεία
Σπυραμυκίνη
Το συγκεκριμένο αντιβιοτικό δίνεται προληπτικά σε εγκύους που βρέθηκαν θετικές σε πρόσφατη λοίμωξη και σκοπός αυτού είναι να μειώσει τον κίνδυνο μετάδοσης στο έμβρυο.
Η χρησιμότητα του είναι μόνον κατά της μείωσης της πιθανότητας μετάδοσης και όχι για θεραπεία του εμβρύου.
Ως εκ τούτου δεν μπορεί να αναστρέψει πιθανή βλάβη του εμβρύου.
Πυριμεθαμίνη & Σουλφοναμίδη
Ο συνδυασμός των δύο αυτών αντιβιοτικών, χρησιμοποιείται στις περιπτώσεις όπου αποδειγμένα υπάρχει λοίμωξη του εμβρύου με σκοπό να περιορίσουν τις πιθανές βλάβες αυτού.
Θεραπευτικό σχήµα συγγενούς τοξοπλάσµωσης
Ι. Συµπτωµατική νόσος : Ια. Για τους πρώτους 6 µήνες ζωής πυριµεθαµίνη µαζί µε σουλφαδιαζίνη και φυλινικό οξύ. Ιβ. Για το δεύτερο 6µηνο ζωής : σπειραµυκίνη για 4 εβδοµάδες, που εναλλάσσεται µε πυριµεθαµίνη + σουλφαδιαζίνη + φυλινικό οξύ για άλλες 4 εβδοµάδες, µέχρι το τέλος του πρώτου χρόνου ζωής.
ΙΙ. Ασυµπτωµατική νόσος : πυριµεθαµίνη + σουλφαδιαζίνη + φυλινικό οξύ για 6 εβδοµάδες που εναλλάσσεται µε σπειραµυκίνη για άλλες 6 εβδοµάδες, µέχρι το τέλος του πρώτου χρόνου ζωής.
Πρόληψη.
Προληπτικά, συνιστάται στην έγκυο η αποφυγή των εστιών µόλυνσης (γάτες) και της κατανάλωσης µη καλά ψηµένου κρέατος. Η νόσος στην έγκυο αντιµετωπίζεται µε χορήγηση σπειραµυκίνης πριν τη 16η εβδοµάδα της κύησης και µε συνδυασµό σπειραµυκίνης µε πυριµεθαµίνη µετά τη 16η εβδοµάδα και εφ΄ όσον υπάρχει υποψία προσβολής του κυήµατος. Η χορήγηση πυριµεθαµίνης αντενδείκνυται πριν τη 16η εβδοµάδα κύησης, γιατί είναι δυνητικά τερατογόνος. Πρόσφατα προτάθηκε εναλλακτικά η χορήγηση κοτριµοξαζόλης, αλλά δεν υπάρχουν ακόµη αρκετές µελέτες για την ασφάλεια και αποτελεσµατικότητά της.
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