Fig. 45.7. Congenital toxoplasmosis showing interstitial pneumonitis in the medial aspects of the lung bases, as well as hepatosplenomegaly in an infant with generalized T. gondii infection.

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Hydrocephalus or microcephaly was a complication in 20% of Feldman's large series of patients. Obstructive hydrocephalus occurs when the glial nodules of T. gondii enlarge and obstruct the aqueduct or foramina. This may be demonstrated in the neonate by cranial ultrasonography, CT, or magnetic resonance imaging (MRI), or may be evident at autopsy. Plain radiographs of the skull show a large head, enlargement of the fontanelles, widening of the sutures, and accentuation of the convolutional impressions. If the infection has produced considerable destruction of the brain parenchyma, then cerebral atrophy and microcephaly may result.

There are no reports of calcifications in the spinal cord or canal in toxoplasmosis acquired congenitally. Infants with severe, generalized congenital toxoplasmosis frequently show evidence of interstitial pneumonia and hepatosplenomegaly (Fig. 45.7).

There are few findings on plain radiography in adult immunocompetent patients with acquired toxoplasmosis. In patients with acute symptoms, chest films may demonstrate interstitial pneumonia with peribronchial cuffing due to perihilar edema. A few patients have more significant thoracic disease, with more focal but still patchy areas of consolidation, especially in the lower lobes. The radiographic features are nonspecific and similar to a variety of atypical viral and other pneumonias.

The heart is not usually enlarged, but, when seen, cardiomegaly may be due to a pericardial effusion or to biventricular failure and congestive cardiomyopathy. Echocardiography will then enable one to determine the etiology and assess left ventricular function. Myocardial biopsy under sonographic guidance may be diagnostic. Pericardial effusions can be large and chronic, and pericardiocentesis may be both diagnostic and therapeutic. Serial echocardiography is important in the management of toxoplasmosis.