In this case A 38 yo pregnant women with gestational age of 16 weeks went to the gynecologist with complaints of dizziness, muscle

stiffness, and painful swallowing. Previous pregnancy miscarried at 6 weeks of age. Result of Torch examination is she was diagnose (+) IgG Anti Toxoplasma, (+) IgM Anti Toxoplasma, (+) IgG Anti Rubella and (-) IgM Anti Rubella. Toxoplasmosis is an important zoonotic parasitic disease worldwide. Toxoplasma gondii (T. gondii) is a coccidian protozoan that multiplies only in living cells. About one-third of women who become acutely infected with T. gondii during pregnancy transmit the parasite to the fetus. T. gondii has a complex life cycle consisting of three stages: 1) tachyzoiteduring the acute stage of infection, this form of the parasite invades and replicates within cells; 2) bradyzoiteduring latent infections, this form of the parasite is present in tissue cysts; and 3) sporozoitethis form of the parasite is found in oocysts, which are environmentally resistant. Women infected with T. gondii before conception, with rare do not transmit the infection to their fetuses exception Women infected with T. gondii during pregnancy can transmit the infection across theplacenta to their fetuses (Jones J. L et al., 2001). In humans, the transplacental passage of tachyzoites from mother to fetur lead to congenital toxoplasmosis. If womanis infected during pregnancy tachyzoites can cross the placentaand infected the fetus. Serological evaluation and diagnosis of primary maternal infection during pregnancy we can use the case definition

Based on the interpretation table, pasient with (+) IgG Anti Toxoplasma, (+) IgM Anti Toxoplasma possible patien had acute infection or this false-positife IgM reaction.

If screening tests detect evidence of acute infection during pregnancy, treatment for the woman is initiated with spiramycin in an effort to prevent vertical transmission of the parasite to the fetus and for prophylactic use during pregnancy (Brunton, 2008; Montoya and Remington, 2008). In this study case, patient has 18 week gestational (16 week gestational) so that not recommended treatment with pyrimethamine and sulfadiazine. because pyrimethamine has potentially teratogenic if used earlier (Kaye, 2011). Result of screening test should be sent to reference laboratory for confirmatory testing to avoid false positive result in screening test.

Figure 3. procedure for confirmatory testing of positive IgM and IgG test results at a reference

laboratory (Montoya and Remington, 2008) Figure above shows the procedure for confirmatory testing of positive IgM and IgG test results at a reference laboratory. Polymerase chain reaction testing of amniotic fluid is the preferred method for providing confirmation of fetal exposure. This test should be performed at or after 18 weeks gestation and only in women with preliminary positive serologic results indicative of acute exposure (Jones et al, 2011). If fetal infection is confirmed by a positive result of PCR of amniotic fluid at 18 weeks of gestation or later, treatment with pyrimethamine, sulfadiazine, and folinic acid is recommended (if the patient is already receiving spiramycin, the recommendation is to switch to this combination because spiramycin does not generally cross the placenta) (Brunton, 2008). Obviously its important to take account of possible side effects of pyrimethamine. It inhibits the dihydrofolate reductase, which is important in the synthesis of folic acid. Supplement of folinic acid should be given with pyrimethamine to compensate for the reduction of folic acid caused by pyrimethamine. Pyrimethamine has also been associated with heart and kidney malformations in infants and may increase the risk of central nervous system cancer in childhood. Pyrimethamin and sulfadiazine also carry a risk of bone marrow suppression in both the mother and the infant. Moreover, it may reduce the severity of infection in a fetus because it delays transmission to a later time in gestation, when transmission is associated with less severe manifestations of infection. Instead, the combination of pyrimethamine and sulfadiazine is highly active against T. gondii and is widely used as a treatment to reduce the risk of clinical manifestation in infected children (Montoya and Remington, 2008). Recommendations for prevention of toxoplasmosis in pregnant women were as follows: Cook meat to well done or thoroughly to 67C (153F). Meat should not be pink in the center. Note that meat that is smoked, cured in brine, or dried may still be infectious

Avoid mucous membrane contact when handling raw meat Do not touch face or eyes while preparing food. Wash hands carefully after contact with raw meat Kitchen surfaces and utensils that have come in contact with raw meat should be washed wearing gloves Refrain from skinning or butchering animals Avoid contact with materials potentially contaminated with cat feces, especially when handling cat litter or gardening. Wearing gloves is recommended when these activities cannot be avoided and then wash hands thoroughly. The litter box should be changed daily becauseT. Gondii oocysts require several days to become infectious. Pregnant women should be encouraged to keep their cats inside and not adopt or handle stray cats. Cats should be fed only canned or dried commercial food or well-cooked table food, not raw or undercooked meats. Disinfect emptied cat-litter box with near-boiling water for 5 min before refilling Wash fruits and vegetables before consumption Avoid drinking water potentially contaminated with oocysts Pregnant women should wear gloves when gardening and during any contact with soil or sand because cat waste might be in soil or sand. After gardening or contact with soil or sand, hands should be washed thoroughly. (Jones et al, 2001; Montoya and Remington, 2008)

ositive results were found in IgG patients could be caused by patients had suffered infection Rubella virus before. Further her body produce antibodies memory (IgG) to against Rubella virus. so if reinfection occurs, the body will be ready to boost the immune system of an existing memory antibody.

DAPUS: Brunton, L., K. Parker, D. Blumenthal, and I. Buxton. 2008. Manual of Pharmacology and Therapeutics. USA: McGraw-Hill Companies, Inc. Montoyo, J. G. and J. S. Remington. 2008. Management of Toxoplasma gondii Infection during Pregnancy. Clinical Infectious Diseases, Vol. 47. p: 554-566 Kaye, A. 2011. Toxoplasmosis: Diagnosis, Treatment and Prevention in Congenitally Exposed Infants. Journal of Pediatric Health Care, Vol. 25, No. 6. p: 355-364 Jones, J. L. A. Lopez, M. Wilson, J. Schulkin and R. Gibbs. 2011. Congenital Toxoplasmosis: A Review. Obstetrical and Gynecological Survey, Vol. 56, No. 5. p: 296-305
(Jones, J. L., Adriana L., Marianna W., Jay S and Ronald G. 2001. Congenital Toxoplsmosis: A Review. Obstretical and Gynecological Survey. Vol. 150 No. 5). (Serranti D., D. Bounsenso and P. Valentini. 2011. Congenital toxoplasmosis treatment. European

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