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FeedbackToxoplasmosis, which results from infection with Toxoplasma gondii, causes more deaths in the United States than any other foodborne illness. Although toxoplasmosis is usually asymptomatic or mild (presenting with flu-like symptoms) in immunocompetent individuals, it may be serious in individuals with compromised immune systems, in pregnant individuals, and in infants infected congenitally. T. gondii is usually transmitted by the consumption of undercooked meat or accidental ingestion of cat feces (eg, while cleaning a litter box). Human-to-human transmission can occur congenitally from mother to fetus or, in rare instances, from blood transfusion or organ transplantation. Laboratory testing includes serology and molecular tests, and confirmatory testing generally must be performed by a specialized reference lab.
Quick Answers for Clinicians
Assays for immunoglobulin M (IgM) antibodies to Toxoplasma gondii lack specificity, which can result in false-positive serologic results, complicating the diagnosis of toxoplasmosis. Two specific situations suggest the possibility of false-positive results:
- Positive IgM and negative IgG: This result is highly suspect but is possible soon after infection, before IgG antibodies have had a chance to form. A second specimen should be collected 2 weeks after the first specimen and both specimens should be tested (the first specimen should be retested).
- Positive IgM and positive IgG: A second specimen should be collected and both specimens should be submitted to a reference lab that uses a different method from that used for the first test for detecting IgM antibodies.
Results of Toxoplasma gondii serology assays may be difficult to interpret correctly, and some tests (eg, immunoglobulin A [IgA] antibodies to T. gondii) are not commercially available. Initial serologic tests for both IgG and IgM antibodies are available through many labs, but clinicians should consider seeking confirmation testing through the Palo Alto Medical Foundation Toxoplasma Serology Laboratory, the reference laboratory for the CDC and U.S. Food and Drug Administration (FDA). Specialized testing at this laboratory includes IgA serology testing, IgE serology testing, IgG dye testing, IgG avidity testing, and differential agglutination testing.
No. Prenatal screening for toxoplasmosis presents many challenges, including low seroprevalence, a lack of standardization among diagnostic serologic tests, a low incidence of acute infection, and a high testing cost. Therefore, prenatal screening for toxoplasmosis in the United States should be limited to pregnant individuals who have HIV or are immunosuppressed.
Indications for Testing
Testing for toxoplasmosis should be considered in the following vulnerable groups:
- Pregnant individuals who are either immunocompromised or immunosuppressed, or who have symptoms of acute toxoplasmosis (ie, flu-like symptoms and blurred vision or photophobia)
- Immunocompromised individuals with symptoms of acute toxoplasmosis or reactivated disease (specifically, focal encephalitis that causes confusion, headache, motor weakness, and/or seizures)
- Neonates whose mothers experienced acute T. gondii infection during pregnancy
Laboratory Testing
Serology
Serology, using either indirect fluorescent antibody (IFA) tests or enzyme immunoassays (EIAs) such as enzyme-linked immunosorbent assays (ELISAs), is the most common diagnostic testing for toxoplasmosis. Both immunoglobulin G (IgG) antibodies, which indicate a past infection, and IgM antibodies, which indicate a more recent infection, may be assessed. Interpretation of IgM results may be complicated because IgM antibodies lack specificity and may be detected up to 18 months after infection.
If initial testing is not conclusive, additional testing (eg, IgA serology testing, IgE serology testing, IgG dye testing, IgG avidity testing, and differential agglutination testing) should be pursued at a specialized reference lab.
| Test Results | Possible Interpretations | Next Steps | |
|---|---|---|---|
| IgG | IgM | ||
|
Negative |
Negative |
No infection |
None |
|
Negative |
Positive |
Possible acute infection False-positive IgM |
Retest for both IgG and IgM antibodies on both the original and a second specimen If the result is the same, infection is unlikely |
|
Negative |
Equivocal |
Possible early acute infection False-positive IgM |
Retest for both IgG and IgM antibodies on a second specimen If the result is the same, infection is unlikely |
|
Positive |
Negative |
Infected for ≥6 mos |
None for the general population If patient is pregnant and gestation is ≥18 weeks, additional testing should be pursueda |
|
Positive |
Positive |
Possible infection in previous 12 mos False-positive IgM |
Send specimen to specialized reference lab for further testing If patient is pregnant, perform IgG avidity testa |
|
Positive |
Equivocal |
Infected for >1 yr False-positive IgM |
Retest for IgM on a second specimen If result is the same, send both specimens to specialized reference lab for additional testing |
|
Equivocal |
Negative |
Indeterminate |
Retest for IgG on either the same specimen or a second specimen |
|
Equivocal |
Positive |
Possible acute infection |
Retest for IgG and IgM on second specimen If the results are the same or if IgG is positive, send both specimens to specialized reference lab for additional testing |
|
Equivocal |
Equivocal |
Indeterminate |
Retest for IgG and IgM on second specimen |
|
aFor more information, see the Toxoplasmosis Serologic Testing for Pregnant Individuals algorithm. |
|||
Pregnant Individuals
If a pregnant individual tests positive for both IgG and IgM antibodies, an IgG avidity test should be performed to help differentiate between acute and past infection. If performed within the first 12-16 weeks of pregnancy, the results should be interpreted as follows:
- High IgG avidity rules out T. gondii infection acquired during pregnancy.
- Low IgG avidity does not rule out T. gondii infection acquired during pregnancy, but does not necessarily indicate recent infection.
If a pregnant patient with suspected toxoplasmosis has low IgG titers, a second sample may be tested 2-3 weeks later. An increase in antibody titer suggests acute infection.
If initial testing is not conclusive, samples should be sent to a specialized reference lab for further assessment. For more information about interpreting serologic tests during pregnancy, see the Toxoplasmosis Serologic Testing for Pregnant Individuals algorithm.
Neonates
When congenital toxoplasmosis is suspected in neonates, IgA antibody levels should be assessed, in addition to IgM levels, because IgA antibody testing is more sensitive than IgM antibody testing in infants. Because there are no FDA-approved commercial assays for IgA antibodies, testing should be performed at a specialized reference lab.
Immunocompromised Individuals
Serologic testing is not always reliable in immunocompromised individuals; therefore, test results should be considered in the context of clinical presentation and other testing performed (eg, polymerase chain reaction [PCR]). In patients with AIDS, for example, IgG antibodies are occasionally negative, and IgM antibodies are usually negative.
Nucleic Acid Detection
PCR testing of amniotic fluid may be useful in diagnosing congenital T. gondii infection.
PCR testing may also be useful in immunocompromised patients to assist in diagnosis, alongside serology and clinical presentation. However, a negative result does not rule out infection. In patients with HIV, PCR testing of cerebrospinal fluid (CSF) may be considered to diagnose toxoplasmic encephalitis, which is caused by reactivated T. gondii infection, although the utility of this test is limited by low sensitivity.
Immunohistochemistry
Immunohistochemistry (IHC) may also be used to diagnose T. gondii infection, although the use of IHC is limited because it may be difficult to obtain an appropriate specimen.
ARUP Laboratory Tests
Use to detect the present of IgM and IgG antibodies to T. gondii
Semi-Quantitative Chemiluminescent Immunoassay
Use to detect presence of IgM antibodies to T. gondii
Semi-Quantitative Chemiluminescent Immunoassay
Use to detect the presence of IgG antibodies to T. gondii
Semi-quantitative Chemiluminescent Immunoassay
Aids in the diagnosis of toxoplasmosis in infants
Test is performed at the Palo Alto Medical Foundation Toxoplasma Serology Laboratory
Semi-Quantitative Enzyme-Linked Immunosorbent Assay
May be useful in the diagnosis of toxoplasmosis, especially in fetuses at risk of congenital infection
Qualitative Polymerase Chain Reaction
Use to detect T. gondii in infected tissues
Immunohistochemistry
References
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CDC - Parasites - Toxoplasmosis (Toxoplasma infection)
U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Parasites - toxoplasmosis (Toxoplasma infection). [Last reviewed: Aug 2018; Accessed: Aug 2021]
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cdc - Parasites - toxoplasmosis:disease
U.S. Department of Health and Human Services. Centers for Disease Control and Prevention. Parasites – toxoplasmosis (Toxoplasma infection): disease. [Last reviewed: Sep 2018; Accessed: Aug 2021]
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CDC - DPDx - laboratory ID: toxoplasmosis
U.S. Department of Health and Human Services. Centers for Disease Control and Prevention. DPDx – laboratory identification of parasites of public health concern: toxoplasmosis. [Last reviewed: Nov 2020; Accessed: Aug 2021]
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PAMF - Dr. Jack S. Remington Laboratory
Palo Alto Medical Foundation. Dr. Jack S. Remington Laboratory for Specialty Diagnostics. [Accessed: Aug 2021]
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CDC - Parasites - toxoplasmosis: health professionals
U.S. Department of Health and Human Services. Centers for Disease Control and Prevention. Parasites - toxoplasmosis (Toxoplasma infection): Resources for health professionals. [Last reviewed: May 2020; Accessed: Aug 2021]
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American College of Obstetricians and Gynecologists. Practice bulletin no. 151: cytomegalovirus, parvovirus B19, varicella zoster, and toxoplasmosis in pregnancy. [published correction appears in Obstet Gynecol. 2016;127(2):405] [published correction appears in Obstet Gynecol. 2016;127(2):405]. Obstet Gynecol. 2015;125(6):1510-1525.
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Montoya JG, Remington JS. Management of Toxoplasma gondii infection during pregnancy. Clin Infect Dis. 2008;47(4):554-566.
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Maldonado YA, Read JS; Committee on Infectious Diseases. Diagnosis, treatment, and prevention of congenital toxoplasmosis in the United States. Pediatrics. 2017;139(2):e20163860.
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Kaplan JE, Benson C, Holmes KK, et al. Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. MMWR Recomm Rep. 2009;58(RR-4):1-207.
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