Most cases of toxoplasmosis in immunocompetent humans are asymptomatic, but 10% may have a mononucleosis-like illness of variable severity. Reported here are 14 cases of toxoplasmosis in returned travelers, two of whom required hospitalization. A trend toward lower seroprevalence of T gondii has been observed

in the United States and many European countries, with steady declines observed over the past few decades. T gondii seroprevalence declined from 14.1% to 9.0% from 1988 to 2004 among US-born persons ages 12–49.2 In France, estimated seroprevalence in pregnant women has fallen from 84% in the 1960s to 63% in 1999 to 44% in 2003.3 Foci of high prevalence exist check details in Latin America, parts of Eastern and Central Europe, the Middle East, parts of Southeast Asia and Africa (Figure 1).4 Prevalence rises with age, contact with cat feces or soil contaminated with cat feces, and eating undercooked meats. Rural origin is also associated with a higher prevalence in multiple studies, and at least one prior study has identified travel outside the developed world as a risk factor.4,5 We report 14 immunocompetent returned travelers with symptomatic primary toxoplasmosis, seen between January 1999 and February 2011. Twelve patients

were seen in the Department of Medicine clinics affiliated with the University of Utah, and two patients were seen in Montreal, Canada; each had positive IgM and IgG serologies on presentation. Regions of travel included Central America, South America, Africa, and France (see Table 1). The most common symptoms in this series were fatigue (93%) followed LY2606368 mouse by fever (71%) and headache (71%). This is slightly different from a series of 155 symptomatic very cases described in an outbreak in southern Brazil; the main symptoms were headache (87%), fever (82.5%), malaise (82.5%), and myalgia (80%).6 Another report of an outbreak in patrons of a riding stable in Atlanta, Georgia noted fever (89%), headache (84%), myalgia (60%), and anorexia (54%).7 This suggests toxoplasmosis should be considered

in the differential diagnosis of travelers with febrile illness or acute onset of fatigue, especially when EBV and CMV serologies are negative. A case series in returning travelers in Belgium found 4% of those with prolonged fever presented with mononucleosis like syndrome. Fifty percent of these had CMV, 22% had toxoplasmosis, 20% had EBV, and 8% had HIV.8 Prolonged fatigue, greater than 1 month, was noted in their series as in this series. The most common sign in this series was lymphadenopathy (71%), which is similar to the Brazilian series where lymphadenitis (75%) predominated as well. One patient had left periaortic lymphadenopathy seen on computed tomography, with the largest lymph node being 1.5 × 2 cm. Toxoplasma lymphadenopathy in this site has not been reported previously. Two patients in our series underwent surgical biopsy to confirm the diagnosis.