Long-Term Ocular Prognosis in 327 Children With Congenital Toxoplasmosis Martine Wallon, MD, MPH, PhD*; Laurent Kodjikian, MD, PhD‡; Christine Binquet, MD, PhD§; Justus Garweg, MD; Jacques Fleury, MD‡; Catherine Quantin, MD, PhD§; and Franc ¸ois Peyron, MD, PhD* ABSTRACT. Objective. Retinochoroiditis is the most frequent consequence of congenital toxoplasmosis. Early diagnosis and treatment are believed to reduce the risk of visual impairment. We report on the clinical evolution of ocular lesions and final visual function in a prospective cohort of congenitally infected children who were iden- tified during monthly maternal prenatal screening. Methods. The study included 327 congenitally in- fected children who were monitored for up to 14 years at the Croix Rousse Hospital in Lyon, France. Data on date of maternal infection; time and type of therapy; antena- tal, neonatal, and postnatal work-ups; and ocular status were analyzed. Results. All mothers but 52 had been treated. Py- rimethamine and sulfadiazine was given in utero to 38% of children and after birth to 72% of newborns. Fansidar was given for an average duration of 337 days in all but 2 children. After a median follow-up of 6 years, 79 (24%) children had at least 1 retinochoroidal lesion. In 23 (29%) of them, at least 1 new event had been diagnosed up to 10 years after detection of the first lesions: reactivation of an existing lesion (1 case), new lesion in a previously healthy location (19 cases), or both (3 cases). Fifty-five children had lesions in 1 eye; of the 45 children for whom final visual acuity data were available, 31 (69%) had normal vision. Twenty-four children had lesions in both eyes; of the 21 for whom final visual acuity data were available, 11 had normal vision in both eyes. None had bilateral visual impairment. Conclusions. Clinicians, parents, and elder children with congenital infection should be informed that late- onset retinal lesions and relapse can occur many years after birth but that the overall ocular prognosis of con- genital toxoplasmosis is satisfactory when infection is identified early and treated accordingly. Pediatrics 2004; 113:1567–1572; Toxoplasma gondii, congenital, ocular, eye, cohort, prenatal screening, prevention. ABBREVIATION. Ig, immunoglobulin. C ongenital toxoplasmosis results from the transplacental transmission of the protozoan Toxoplasma gondii. Most infected newborns have no clinical signs but are at risk of developing visual impairment as a result of retinochoroiditis in childhood or adolescence. 1,2 Ocular lesions have been reported in as many as 80% of untreated, con- genitally infected children. 3–6 The most effective ap- proach to prevent ocular lesions caused by congeni- tal toxoplasmosis remains controversial. Additional data are necessary to determine to what extent the available preventive options (prevention of maternal infection, early treatment of infection in pregnant women, preventive treatment of infected infants, or treatment of existing lesions) are effective in reduc- ing the risk of severe visual impairment. Because new lesions or recurrence of existing lesions may appear late after birth, long-term follow-up studies are necessary to estimate the definite ocular progno- sis. 7 The longest follow-up of children identified through detection of maternal infection in pregnancy is reported by Couvreur at al. 8 Of 172 children, 41 (24%) had at least 1 retinal lesion after a follow-up of 2 to 11 years despite a 12-month postnatal treatment with pyrimethamine and sulfadiazine. However, no data were available on visual acuity, and no clear distinction was made between detection of new le- sions and reactivation of existing lesions. We report on the clinical evolution of ocular lesions and the final visual function in a prospective cohort of 327 congenitally infected children who were identified through monthly prenatal screening, received a di- agnosis and were treated early according to a stan- dard protocol, and were monitored for 6 months up to 14 years. METHODS Patients Between 1988 and 2001, a total of 1506 consecutive pregnant women were monitored at the Croix-Rousse Hospital in Lyon, France, for an acute Toxoplasma infection detected during preg- nancy through the French prenatal screening program. Fifty-three pregnancies ended with spontaneous abortion (n  22), stillbirth (n  4), or termination as a result of suspected or proven fetal infection (n  27). The remaining 1453 pregnant women gave birth to 1466 live-born infants (26 twins), 1384 (94%) of whom could be followed up until infection was ruled out (1026 of 1384 [74%]) or confirmed (358 of 1384 [26%]). Among the 358 infected children, 31 were excluded because they had been followed up for 6 months at the study endpoint (March 31, 2002). The long-term study thus included 327 children. From the *Service de Parasitologie, Ho ˆ pital de la Croix-Rousse, Lyon, France; ‡Service d’Ophtalmologie, Ho ˆ pital de la Croix-Rousse, Lyon, France; §Service de Biostatistiques et d’Informatique Me ´dicale, Centre Hos- pitalier Universitaire, Dijon, France; and Department of Ophthalmology, University of Bern, Inselspital, Bern, Switzerland. Received for publication Oct 13, 2003; accepted Feb 2, 2004. Reprint requests to (M.W.) Service de Parasitologie, Ho ˆpital de la Croix- Rousse, 103 grande rue de la Croix-Rousse, 69004 Lyon, France. E-mail: martine.wallon@chu-lyon.fr PEDIATRICS (ISSN 0031 4005). Copyright © 2004 by the American Acad- emy of Pediatrics. PEDIATRICS Vol. 113 No. 6 June 2004 1567 by on June 8, 2010 www.pediatrics.org Downloaded from