Mr. Karsten D., 40 y.

Mr D. works in a strenuous social profession. In May 2023 he suffered from a long-lasting sore throat, from which he only recovered after taking antibiotics. Subsequently, however, his condition slowly deteriorated. He was often very tired and unbalanced and now suffered from sleeping disorder that he had never experienced before. The strong and well-trained man then developed unclear pain in his thigh and shoulder muscles and pain in his left knee, as well as morning stiffness.  

1/2024 Mr D. presented in the practice. The  Checklist Toxoplasmosis indicated a risk of chronic active toxoplasmosis with a score of 77, the Toxoplasma IgG was slightly elevated at 6.8 IU/ml (the reference value was lowered to  3.0 by the laboratory),  with  an  unremarkable  Toxoplasma  IgM, so without doubt  Mr D. is a Toxoplasma carrier.   The IgG antibodies for Chlamydia pneumophilae were slightly elevated at 9.3 U/ml (norm up to 9), the IgA antibodies were slightly less elevated at 8.4 U/ml (norm up to 9).  However, as there were hardly any symptoms typical of Chlamydia, there was no need for treatment in this respect. 

Note: As a rule, the antibody tests  for Chlamydia show good sensitivity and only rarely  a Chlamydia LTT result is positive if the corresponding Chlamydia antibody tests are negative. However, there are also occasional false positive or false negative results with these tests. Therefore,  as with Toxoplasma and Borrelia, a decision  for a treatment should never be made on basis of laboratory results alone; instead, the symptoms and laboratory diagnostics should be weighed up carefully.

The other laboratory results showed normal results, but the Toxoplasma LTT was clearly positive at 23.3 SI. Since a fluctuation of symptom intensities with ‘good’ and ‘bad’ days was still observed with regard to the Toxoplasmosis symptoms, only a dual therapy was initially prescribed.  This means that only 2 combination partners are required, which makes the therapy more simple, with a tendency to cause fewer side effects, but producing  also a somewhat weaker effect on the Toxoplasma. 

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In the simplest form of a dual therapy, clindamycin is taken 3 x 300 mg to 2 x 600 mg for 6 days, then nitrofurantoin 50-100mg 2 x 1 for 6 days, then clindamycin again in the same dosage for 6 days and then nitrofurantoin again for 6 days.  

Important note: Nitrofurantoin is generally very well tolerated, but in rare cases it can trigger side effects relating to the lungs, in which case it must be discontinued immediately.

Under this therapy, the Toxoplasma score improved well from 77 to 22 within 4 weeks, then, as in other cases, this therapy was only taken on 3 days a week (Mon/Wed/Fri, break on Saturday and Sunday) to prevent a relapse, and the antibiotic was changed from week to week. 

This dual therapy is basically quite simple and does not require Daraprim, which is why I like to use it for less severe cases.  In this case, however, it turned out, that the effect out was not complete.

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Although a good  result could be achieved during the 4 weeks of continuous treatment, the symptoms increased again within about 3 weeks under this relapse prophylaxis and the Toxoplasma score rose again to 38.   

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Note: A renewed increase of Toxoplasmosis symptoms during the relapse prophylaxis is rare, but            it requires a consequent and rapid response. 

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In consequence, the same revolving therapy  as in cases 1, 3, 4 and 5 was prescribed: Daraprim 25 mg 2 x 1 and calcium folinate 6.35 mg  1 x 1 were taken continuously. This was initially combined with Cotrimoxazol forte 2 x 1, after 5 days this was changed to Clarithromycine 500 2 x 1, after a further 5 days it was changed to Clindamycine 300 mg 3 x 1, then the scheme was repeated again. Due to side effects (nausea, loss of appetite),  Daraprim was reduced to 1 x 1 and  Clindamycine was reduced to 2 x 300 mg after a few days. The side effects subsided rapidly, while the Symptoms reduced again within a month and did not occur again during the following prophylaxis.

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