IntroductionApproximately a third of the population worldwide is chronically infected with Toxoplasma gondii. Pyrimethamine-based regimens are recommended for the treatment of toxoplasmosis.ObjectiveThe aim was to evaluate the safety profile of pyrimethamine-based treatment for the three main Toxoplasma manifestations: toxoplasmic encephalitis (TE), ocular toxoplasmosis, and congenital toxoplasmosis.MethodsPubMed, Cochrane Library, and Google Scholar databases were searched through August 1, 2016. Randomized, observational, prospective/retrospective, and cohort studies were eligible. Thirty-one studies were included with a total of 2975 patients. Of these, 13 were in congenital toxoplasmosis (n = 929), 11 in ocular toxoplasmosis (n = 1284), and seven in TE (n = 687). Across manifestations, adverse event (AE)-related treatment discontinuation and/or change in therapy involved ≤37% of patients and occurred in >55% of studies: 100% for ocular toxoplasmosis, 57.1% for TE, and 61.5% for congenital toxoplasmosis. The most commonly observed AEs were bone marrow suppression, dermatologic, and gastrointestinal (GI). The prevalence of bone marrow suppression-related AEs was ≤50% in congenital toxoplasmosis, ≤42.7% in TE, and ≤9.0% in ocular toxoplasmosis. The frequency of GI and dermatologic AEs were ≤100 and ≤11.1%, respectively, for ocular toxoplasmosis, ≤10.7 and ≤17.9% for TE, and ≤10.8 and ≤2.1% for congenital toxoplasmosis. Steven–Johnson syndrome was reported in two patients with ocular toxoplasmosis and one with TE.ConclusionThe AE profile associated with pyrimethamine-based treatments differed by each manifestation of toxoplasmosis and within a given manifestation. Hematologic AEs occurred across all manifestations indicating the importance of monitoring the blood of patients administered pyrimethamine-based regimens.

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Introduction: Infection with Toxoplasma gondii (T. gondii) causes the disease toxoplasmosis in humans and animals. Oral transmission alone may not explain the widespread distribution of this parasite over large species of host animals and geographic areas. Areas covered: Limited studies indicate the potential role of ticks in the distribution of T. gondii. The possibility of transmission of T. gondii has been demonstrated in Dermacentor variabilis, Dermacentor andersoni, Amblyomma americanum, Dermacentor reticulatus, Ixodes ricinus, Ixodes amblyomma, Amblyomma cajennense, Ornithodorus moubata and Haemaphysalis longicornis. Tick transmission of T. gondii, spread of ticks and pathogens by migratory birds and presence in the United States (US) of tick vectors of human and animal disease like Haemaphysalis longicornis indigenous to other parts of the world provide a possible mechanism for the widespread distribution of T. gondii, and a potentially expanding disease threat. Expert opinion: The evidence indicates that T. gondii is potentially an unrecognized tick-borne pathogen spreading toxoplasmosis, and that clinicians might consider toxoplasmosis in the differential diagnosis of tickborne diseases.