CASE REPORT Serbian Journal of Dermatology and Venereology 2014; 6 (3): 113-119

DOI: 10.2478/sjdv-2014-0010

Cutaneous Manifestations of Toxoplasmosis: a Case Report

Sonya MARINA, Valja BROSHTILOVA, Ivo BOTEV, Dimitrina GULEVA,
Maria HADZHIIVANCHEVA, Assia NIKOLOVA, Jana KAZANDJIEVA
Department of Dermatology and Venereology, Medical University of Sofia, Bulgaria

*Correspondence: Maria Hadzhiivancheva, E-mail: [email protected]

UDC 616.5:616.993
OPEN

Abstract
Although toxoplasmosis is one of the most widely spread infections in the world, types that involve the skin are extremely
rare. However, skin lesions are not specific; moreover, they are quite diverse, which makes the diagnosis of cutaneous
toxoplasmosis rather difficult. Thus, differential diagnosis should include a number of other diseases. We present a case of
a 43-year-old immunocompetent man with multiple livid erythematous papules and nodules with yellowish discharge that
involved the skin of the body and the extremities. By using electro-chemiluminescence immunoassay, immunoglobulin G
antibodies to Toxoplasma gondii were detected in the serum, confirming the diagnosis of toxoplasmosis. The treatment with
pyrimethamine and trimethoprim-sulfamethoxazole led to complete resolution of skin lesions. In conclusion, although rare in
the dermatological practice, cutaneous toxoplasmosis should be considered in all patients presenting with lymphadenopathy,
non-specific skin eruptions, especially nodular and colliquative, blood eosinophilia and histological findigs revealing abundant
eosinophilic inflitrations.

Key words
Toxoplasmosis; Signs and Symptoms; Skin Manifestations; Pyrimethamine; Trimethoprim-Sulfamethoxazole Combination;
Treatment Outcome

T oxoplasmosis is a parasitic disease caused by the

protozoan Toxoplasma gondii, a tiny crescent shaped
parasite (1). There are 3 genotypes of T. gondii, which
2. Acquired infection - which is asymptomatic
in up to 90 % of patients. Cutaneous manifestations
are very rare. A small number of patients present with
cause different clinical manifestations and distribution. cervical lymphadenopathy and flu-like symptoms. It
The main reservoirs are Toxoplasma cysts found in is estimated that approximately one third of the world
the cat feces. However, other mammals including population is infected with T. gondii. Ocular disease, is
humans, can also be infected. The main mechanisms usually due to reactivation of fetal infection (1).
of transmission to humans include consumption of 3. Toxoplasmosis in immunocompromised
infected undercooked meat or ingestion of ova via patients - which is often a result of activation of a latent
contaminated food or water. Other possible mechanisms disease and clinical manifestations include papular and
of transmission are via organ transplantation (2, 3), nodular eruptions as well as encephalitis. It usually
blood transfusion (4) and transplacental transfer. The occurs in patients with defects of T-cell–mediated
parasites form cysts, usually found in the muscles, heart immunity, including patients with hematologic
and brain. They also invade the reticuloendothelial malignancies and transplantations, as well as human
system, as well as the endothelium of blood vessels immunodefficiency virus (HIV)-infected patients who
where they form granulomas and later necrosis. often develop encephalitis (1).
There are three main types of toxoplasmosis in
humans: Case Report
1. Fetal infection - which may result in severe A 43-year-old man complained of skin eruptions
brain damage, chorioretinitis or stillbirth; which appeared 3 years earlier. He noticed livid spots

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Serbian Journal of Dermatology and Venereology 2014; 6 (3): 113-119 Cutaneous Manifestations of Toxoplasmosis

and nodules on the skin of the lower extremities with

subsequent spreading to the skin of the body and arms,
accompanied by moderate itching.
The patient was in good health, afebrile, and
physical examination revealed no abnormalities.
Multiple livid erythematous papules with peripheral
scaling and livid nodules, some with central depression
expressing yellowish discharge, were observed on the
skin of the ears, body and upper and lower extremities
(Figures 1-3). Postlesional hyperpigmented macules were
also present. Two non-tender, soft lymph nodes 1.5 cm
in diameter were palpable in the inguinal regions.
Routine laboratory and other relevant tests were
within normal limitis, except for the white cell count
which showed leukocytosis with eosinophilia: total
white blood count 23.84 x109/L, with a differential
of: neutrophils 28%, lymphocytes 45.5%, eosinophils
19.2% (4.6 x109/L), monocytes 3.4%, basophils 1.5%.
A punch biopsy was performed and histological
examination revealed: hyperkeratosis, hypergranulosis,
and acanthosis of the epidermis (Figure 4a); in the
dermis and upper hypodermis, there was a thick
Figure 1. Before the therapy infiltrate, pronounced in the deep dermis (Figure 4b);

Figure 2. Before the therapy Figure 3. Before the therapy

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CASE REPORT Serbian Journal of Dermatology and Venereology 2014; 6 (3): 113-119

deep dermal infiltrate with numerous eosinophils, bone marrow examination was performed. The bone
histiocytes, lymphocytes, plasmocytes and foreign- marrow was normocellular with a myeloid to erythroid
body giant cells was also observed (Figure 4c); dermal ratio of 3:1; granulocytes of all stages maturation were
collagen appeared rough and fibrotic (Figure 4d), and seen; the blast cell count was under 5%; the eosinophil
a scaring tissue was present as well. However, T. gondii count was 5%; the megakaryocyte count was slightly
zoites were not found. increased. According to the hematologist, there were no
Due to the finding of a dense eosinophilic abnormalities suggesting a lymphoproliferative process.
infiltrate and an increased number of eosinophils in the Taking into account the patient’s complaints,
blood, the patient was examined by a hematologist and the appearance of lesions and laboratory test results,

Figure 4a Histopathology of the skin biopsy showed hyperkeratosis, hypergranulosis and acanthosis in the
epidermis (HE staining).
Figure 4b. Histopathology of the skin biopsy revealed a thick infiltrate in the dermis as well as in the upper
hypodermis, mostly pronounced in the deep dermis (HE staining)..
Figure 4c. Histopathology of the skin biopsy showed a deep dermal infiltrate with numerous eosinophils,
histiocytes, lymphocytes, plasmocytes and foreign-body giant cells (HE staining)..
Figure 4d. Histopathology of the skin biopsy revealed a rough and fibrotic dermal collagen and scaring tissue.
(HE staining)..

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Serbian Journal of Dermatology and Venereology 2014; 6 (3): 113-119 Cutaneous Manifestations of Toxoplasmosis

a parasitic disease was suspected. No intestinal parasites

were detected. Serologic testing for Echinococcus
granulosus antibodies was negative. However, by using
ECLIA (electro-chemiluminescence immunoassay),
immunoglobulin G (IgG) antibodies to Toxoplasma
gondii were detected in the serum with an elevated titer
of 598 IU/ml (normally < 1 IU/L). HIV testing was
negative. After consulting a parasitologist, treatment
with Daraprim® tbl (pyrimethamine) 2 x 25 mg/d and
Biseptol® (trimethoprim-sulfamethoxazole) 2 x 960
mg/d p.o. were initiated in three courses of 5 days
with 14-days intervals between them. The eruptions
resolved completely leaving scars and postinflammatory
hyperpigmented macules (Figures 5-12). One month
later, the titer of antibodies decreased significantly to
1:80.

Discussion
Although toxoplasmosis is a common infection, affecting
about 1/3 of the world population, it is asymptomatic
in most cases. T. gondii was first observed by Nicolle and
Manceaux in 1908 in a North African rodent, Ctenodactylus
gondii (5). In 1939, it was identified as the cause of severe
Figure 6. After the therapy congenital syndrome by Wolf, Cowan, and Paige (6).

Figure 7. After the therapy Figure 8. After the therapy

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CASE REPORT Serbian Journal of Dermatology and Venereology 2014; 6 (3): 113-119

Figure 9. After the therapy Figure 10. After the therapy

Pinkerton and Henderson were the first to describe Cutaneous toxoplsmosis is usually found in
cases of cutaneous toxoplasmosis in 1941 (7). Cutaneous patients with a compromised immune system, such
manifestations are rare, but quite diverse, ranging as transplanted patients or patients having acquired
from macular (8), papular (8), urticarial, hemorrhagic immunodeficiency syndrome (AIDS). Cutaneous
eruptions (9) to formation of nodules (10) and bullae. lesions are rarely observed in immunocompetent
Lesions resembling pityriasis lichenoides (11) and patients. In 2002, Bossi described acute disseminated
dermatomyositis (12, 13, 14) have been described. toxoplasmosis in 3 patients with normal immune system
Fernandez et al, have reported a case of erythrodermia in with maculo-papular rash and systemic symptoms (18).
cutaneous toxoplasmosis (15). Althouh demonstration of the organism in
Several cases with cutaneous nodular lesions in biopsy of lymph node, liver or spleen, bone marrow,
toxoplasmosis infection have been described by Midana or in cerebrospinal and ventricular fluid confirms
A, et al. (16) in 1970 for the first time. In 1989, Leblanc T, toxoplasmosis, the diagnosis is usually based on
et al. reported multinodular non suppurative panniculitis clinical evidence, and confirmed serologically (1).
in a 3 year-old boy (17). A case of cutaneous toxoplasmosis Up to now, only few cases of disseminated
characterized by nodular lesions in a HIV-positive patient cutaneous nodular toxoplasmosis in immuno-
has been reported recently (Fong et al., 2010) (10). competent patients have been described in the

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Serbian Journal of Dermatology and Venereology 2014; 6 (3): 113-119 Cutaneous Manifestations of Toxoplasmosis

Figure 11. After the therapy Figure 12. After the therapy
literature. We report a case of nodular cutaneous References
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diseases. The diagnosis was confirmed serologically. T, Breathnach S, Cox N, Griffiths C, editors. Rook’s Textbook of
The patient was treated with sulphonamides and Dermatology. 6th ed. Oxford: Blackwell Publishing Ltd; 2010. pp.
pyrimethamine (Daraprim) which as it has been 37.1-37.44.
2. Lee SA, Diwan AH, Cohn M, Champlin R, Safdar A. Cutaneous
reported act synergistically and are effective (1). toxoplasmosis: a case of confounding diagnosis. Bone Marrow
Transplant 2005;36(5):465-6.
Conclusion
Although rare in the dermatological practice,
cutaneous toxoplasmosis should be considered
in all patients presenting with lymphadenopathy,
non-specific skin eruptions, especially nodular and
colliquative, blood eosinophilia and histological
findings of abundant eosinophilic infiltrations.

Abbreviations
HIV - human immunodeficiency virus
CRP - C-reactive protein
ECLIA - electro-chemiluminescence
immunoassay
IgG - immunoglobulin G
AIDS - acquired immunodeficiency syndrome Figure 12. After the therapy

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CASE REPORT Serbian Journal of Dermatology and Venereology 2014; 6 (3): 113-119

3. Mayes JT, O`Connor BJ, Avery R, Castellani W, Carey acquired toxoplasmosis. Int J Dermatol 1999;38:372-4.
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transplantation. Clin Infect Dis 1995;21(3):511-5. casual relationship? Pediatr Med Chir 1989;11(2):197-203.
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Sci 1908;147:763–6. Dermatomyositis-like syndrome due to toxoplasma. Br J
6. Wolf A, Cowen D, Paige B. Human toxoplasmosis: Occurrence Dermatol 1979;101(5):589-91.
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animals. Science 1939;89(2306):226-7. presenting as erythroderma. Int J Dermatol 1994;33(2):129-30.
7. Pinkerton H, Henderson RG. Adult toxoplasmosis: a previously 16. Midana A, Zina G, Pileri A. Acquired toxoplasmosis in adults
unrecognized disease entity simulating the typhus-spotted fever with cutaneous papulo-nodular manifestations. Bull Soc Fr
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Kutane manifestacije toksoplazmoze − prikaz slučaja

Sažetak
Uvod. Iako toksoplazmoza predstavlja jednu od analiza isečka obolele kože je pokazala hiperkeratozu,
najrasprostranjenijih infekcija u svetu, varijante koje hipergranulozu i akantozu u epidermisu; u dermisu,
zahvataju kožu su ekstremno retke. Manifestacije na koži naročito u njegovom dubokom delu kao i u susednim
nemaju spefičan izgled, mogu biti raznolike, što svakako delovima hipodermisa, uočavao se gust infiltrat sačinjen
otežava dijagnozu i čini diferencijalnu dijagnozu veoma od brojnih eozinofilnih granulocita, limfocita, histiocita,
složenom. plazma ćelija i džinovskih ćelija tipa oko stranog
Prikaz slučaja. U ovom radu prikazujemo slučaj tela; kolagen je bio fibroziran, ožiljast, vlakna su bila
četrdesetrogodišnjeg muškarca sa promenama na koži umnožena, grube, neravne zadebljale strukture. Pomoću
u vidu multiplih papula i nodula iz kojih se spontano elektro-hemiluminiscentnog imunoeseja, u serumu je
i na pritisak cedio žućkast eksudat. Promene su bile utvrđen značajno povišen nivo imunoglobulina klase G
diseminovane po trupu i ekstremitetima, najizraženije na protiv Toxoplasma Gondii, na osnovu čega je postavljena
dorzumima oba stopala, potkolenicama i natkolenicama; dijagnoza toksoplazmoze. Nakon oralnog lečenja sa
nije bilo promene opšteg stanja niti febrilnosti. Promene pirimetaminom i trimetoprim-sulfametoksazolom, došlo
su počele da se javljaju tri godine ranije; u početku je do potpune regresije promena.
su bile lokalizovane na donjim ekstremitetima u vidu Zaključak. Iako je toksoplazmoza veoma retka u
tamnoljubičastih mrlja i čvorova, da bi se kasnje počele svakodnevnoj dermatološkoj praksi, na nju uvek treba
širiti i zahvatati i ostale delove tela. misliti kod pacijenata sa limfadenopatijom, nespecifičnim,
Relevantne laboratorijske i ostale analize bile su u najčešće nodularno-kolikvativnim promenama na koži,
granicama fizioloških vrednosti, jedino je u krvnoj slici kod kojih se u perifernoj krvi i u kožnim lezijama može
postojala leukocitoza sa eozinofilijom. Patohistološka dokazati povišen broj eozinofilnih granulocita.

Ključne reči
Toksoplazmoza; Znaci i simptomi; Kožne manifestacije; Pirimetamin; Trimetoprim-sulfometoksazol
kombinacija; Ishod terapije

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