Dr. med. Uwe Auf der Strasse

Case 2

Mrs. Kaja N. 22 J.

In 2012, at the age of 15, muscle and limb pain first appeared in the right hand and then in the whole body, the Toxoplasma IgG and IgM showed positive results: Toxoplasma IgG 1:256 (normal up to 1: 16) Toxoplasma IgM 1:1024 (normal up to 1:64), this indicated an acute Toxoplasmosis.  A Therapy was not carried out, as it was expected that the Toxoplasmosis would cease within a few weeks.  This is not an unusual approach, which shows that this disease is quite often underrated.

In contradiction to this expectation the symptoms began to increase in the beginning of 2013, now there was a constant pronounced fatigue, severe concentration disorder, nerve pain, sweating, impaired vision, depression and panic attacks as well as overanxiety, in addition to severe headaches and severe upper abdominal pain, the cause of which could not be clarified although all diagnostic measures such as gastroskopy, colonoscopy,  MRI and more were taken. Despite getting enough sleep, the previously good student could not recover, as the sleep was not restful. Although she had been a good student, she now  faced a real drop in performance at school.

 

Over the entire duration of the disease of 8 years, all laboratory tests except for the Toxoplasma antibody count yielded no abnormal results. An inflammation of the thyroid gland and rheumatic diseases were excluded, a PCO syndrome was suspected, but ultimately not confirmed. The leading diagnosis was "idiopathic hypersomnia" (= pathologically increased need for sleep), which does not explain many of the symptoms, and the corresponding medication did not lead to any improvement.

 

11/2019 the patient contacted me by phone and asked for advice. Considering the numerous symptoms that are typical of toxoplasmosis, I urgently recommended to perform a Toxoplasma LTT  - the result was, at 49.5 SI (positive from 3), significantly elevated. Due to other personal plans, therapy could not begin immediately. Ms. N. lives in Baden Württemberg, about 400 km away.    In 2/2020 she had an appointment our practice, and a doctor who would supervise the treatment and prescribe the medication had been found in her hometown.

A revolving therapy was prescribed from the beginning in order to avoid any adaptation of the parasites to the therapy. Daraprim 2 x 1 + Calciumfolinate 6,35mg 1 x 1 was prescribed throughout,  while  Cotrimoxazole 960mg 2 x 1,  Clindamycin 300mg 3 x 1 and   Clarithromycin 500

2 x 1 were switched every 5 days. 

A first worsening of symptoms set in and affected the psychological situation of Ms. N. severely - she suffered from massive fears, was very short tempered, even aggressive and desperate about the illness and herself. Such an effect had also been described by some other patients. Still,  also a decrease in fatigue and pain could be seen at the same time.  In such cases it is advisable to treat with a reduced dosis for a longer time. The therapy was reduced while maintaining the rotation: Daraprim 1 x 1 and Calciumfolinate 6,35 mg 1 x 1 were taken continuously, and the additional antibiotic  was  switched  every 5 days  (Cotrimoxazole 2 x 1 for 5 days, then Clinda-mycin 300 2 x 1 for 5 days and then Clarithromycin 250 2 x 1 for 5 days). The treatment was now tolerated much better, but above all Ms. N. was stabilised by her loving family.

 

Another problem arose from an allergic reaction to Cotrimoxazole. Sulfadiazine was not available at the time and Rovamycin would have been less effective against the neurological symptoms. This is why we switched to an alternating system: Daraprim 1x1 and Calciumfolinate 6,35 mg 1x1 were taken continuously for altogether 42 days,   Clindamycin 300 2x1 and Clarithromycin 250 2x1 were added and switched alternating  every 6 days. This was well tolerated and a continuous improvement of all symptoms could be observed as a result.  Such a 6-day alternating system is a compromise when a "full" revolving therapy cannot be prescribed.

 

 

 

            Checklist 

            Toxoplasmosis        Mr / Mrs.       Kaja N. 

                                                                                                                Fluctuation of

            Age: 22 years                 Duration:    8 years             symptoms   yes / No

                     Toxoplasma                        IgG            21,8 IU/ml               IgM            3,01 AU/ml

 

                 LTT 49,5 SI                         Date......…....26.2.2020                Date...............30.6.2020  

                 

                 Treatment:                         Revolving  Therapy             Alternating   Therapy

                

                 Tiredness                            0 1 2 3  4 5  6  7 8 9   X              0 1 X 4 5 6 7 8 9 10

               

                 Muscular pain                    0 1 2 3  4 5 6 7 8 X 10              0 1 X 4 5 6 7 8 9 10

               

                 Concentration -                  0 1 2 3  4 5 6 7 8 X 10              0 1 X 3  4 5 6 7 8 9 10

                 disorder

                 

                 Profuse sweating              0 1 2 3 4 5  6  7  X 9 10              X 1 2 3 4 5 6 7 8 9 10

                 

                 Shortness of breath           X 1 2 3 4 5 6 7 8 9 10               X 1 2 3 4 5 6 7 8 9 10

                 Listlessness /                     0 1 2 3 4 5 6 7 8 X 10               0 1 X 4 5 6 7 8 9 10

                 Exhaustion...............................................................................................................................

                 Irritability                            0 1 2 3 4 5  6  7 8 9    X              0 1 X 4 5 6 7 8 9 10

               

                 Visual disturbancy              0 1 2 3  4 5  6 X 8 9 10              0 1 X 4 5 6 7 8 9 10

               

                 Dizzyness                           X 1 2 3 4 5  6 7 8 9 10                X 1 2  3 4 5 6 7 8 9 10

               

                 Depressive moods             0 1 2 3 4 5  6  7  X 9 10                0  X 2  3 4 5 6 7 8 9 10

                 Anxieties                             0 1 2 3 4 5  6  7  X 9 10              X 1 2  3 4 5 6 7 8 9 10

                 Morning stiffnness             0 1 2 3 4 5  6  7  X 9 10               X 1 2  3 4 5 6 7 8 9 10

                 Oedema                               X 1 2 3 4 5 6 7 8 9 10             X 1 2 3 4 5 6 7 8 9 10

                 Sleeping disorder               0 1 2 3 4 5 6 7 8 9   X              X 1 2 3 4 5 6 7 8 9 10

                 Insecure gait                       X 1 2 3 4 5 6 7 8 9 10              X 1 2 3 4 5 6 7 8 9 10

                 impaired coordination..........................................................................................................

                 Pressure in upper              0 1 2 3  4 5 6 7 8 X 10             X 1 2 3 4 5 6 7 8 9 10

                 abdomen

                 

                 Headache                            0 1 2 3 4 5  6  7  X 9 10             0 X 2  3 4 5 6 7 8 9 10

                 Joint pains                          X 1 2 3 4 5  6 7 8 9 10             X 1 2 3 4 5 6 7 8 9 10

                 Swollen lymphnodes         X 1 2 3 4 5  6 7 8 9 10             1 2 3 4 5 6 7 8 9 10

                 

                 SCORE                          115                                    20

 

 

After 6 weeks the symptoms had been reduced significantly and we were able to switch to a relapse prophylaxis initially on 3 days, later on 2 days a week, switching the combination from week to week. After 3 1/2 months the therapy was successfully ended. Ms. N. was able to start vocational training, the previously feared drops in physical and psychological resilience were completely absent.  I quote from an email to one of the doctors:

 

“We have gone through 8 terrible years  ... our daughter can (now) live her life again without medication. The tiredness is gone, Kaja can work without falling asleep, drive a car, meet up with friends again. She has been given a new life, and with her the whole family. "

 

Comment: I can't add much more to this, except that I'm very grateful for such a result. There was no Fluctuation of symptoms, which means that the severe symptoms did not show any spontaneous ameliorations any more. At this stage of the disease  usually a gradually worsening of symptoms takes place which affects the health of the patient more and more with every year the disease is not treated.  The therapy of chronic Toxoplasmosis needs to be carefully monitored and adjusted. In this case dosages had to be reduced to minimise side effects and ultimately the therapy had to be switched to an alternating scheme due to allergic reaction to CoTrimoxazol.