See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/43344267

Cerebral toxoplasmosis in a patient with acquired immunodeficiency syndrome

Article  in  Journal of the Pakistan Medical Association · April 2010

Source: PubMed

CITATIONS READS

11 122

3 authors, including:

Rohana Naqi Muhammad Azeemuddin

Dow University of Health Sciences Aga Khan University, Pakistan
18 PUBLICATIONS   52 CITATIONS    65 PUBLICATIONS   315 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Case Report View project

All content following this page was uploaded by Muhammad Azeemuddin on 02 June 2014.

The user has requested enhancement of the downloaded file.

Case Report

Cerebral toxoplasmosis in a patient with acquired immunodeficiency syndrome

Rohana Naqi, Muhammad Azeemuddin, Humera Ahsan
Department of Radiology, The Aga Khan University Hospital, Karachi.

Abstract last 2 months and unable to move his body, could not talk
and for last 4 days had fever and became disoriented and
Cerebral toxoplasmosis commonly affects patients
stuperous. There was no history of seizures. On
with advanced HIV immunodeficiency. Toxoplasmosis in
examination, patient was vitally stable, Glasgow Coma
patients who are immunocompromised can be severe and
Scale (GCS) 7/15, neck stiffness was present, left sided
debilitating in patients with Central Nervous System (CNS)
gaze, increased tone bilaterally, decreased bulk, reflexes
involvement and the condition may be fatal.
brisk and power 2/5 in all limbs was noted.
We report the case of a 40 years old man who was a
He underwent MRI brain with Gadolinium which
known case of HIV and presented with cerebral
showed multiple ring enhancing lesions of variable sizes in
toxoplasmosis. His Magnetic Resonance Imaging (MRI)
bilateral supra and infratentorial regions. Lesions were
scan showed multiple ring enhancing lesions with extensive
mainly located in the periventricular region as well as at the
surrounding oedema in supratentorial as well as
grey-white matter junction with extensive surrounding
infratentorial region. Lesions were mainly located in the
oedema. These were causing mass effect with midline shift.
periventricular region as well as at the grey-white matter
These lesions were enhancing in the periphery as well as a
junction and showed enhancement in the periphery as well
tiny nodule in their centre. Based on these findings, diagnosis
as a tiny nodular enhancement in the centre. Patient was
of cerebral toxoplasmosis was suggested (Figure-1).
started on Septran DS, empirically for toxoplasmosis and
steroids to reduce intracranial pressure. On follow up MRI Further information obtained from biological and
scan after 10 days there was a reduction in size, number and immunological studies showed raised neutrophils count,
enhancement of the masses with decrease in the positive Toxo IgG antibodies, positive serum HIV and
surrounding oedema. Patient was clinically stable, oriented raised C Reactive protein. CBC showed absolute
and his fever settled. He was discharged from hospital on lymphocyte count 7.8%. CSF analysis and CD4 cell count
same medication and advised to continue regular follow-up. were not done. Patient's chest X-ray and Ultrasounds were
unremarkable.
Introduction
Toxoplasmosis, a common mass lesion in patients with
acquired immune deficiency syndrome (AIDS), is caused by
ubiquitous parasite, toxoplasma gondii. Human infection
usually occurs via the oral or trans-placental route.1 In adults,
most T.gondii infections are subclinical, but severe infections
can occur in patients who are immunocompromised (A.I.D.S,
Malignancy). AIDS associated toxoplasma encephalitis
results from reactivation of chronic latent infection in more
than 95% of patients.2 In patients with AIDS seropositive for
T.gondii, the risk for cerebral toxoplasmosis approaches
30%.3 Drug therapy does not eradicate T.gondii, and lifelong
therapy to avoid relapse is often necessary.1
Toxoplasmosis is the most common cause of focal
brain lesions in patients with AIDS and frequently localizes to
the basal ganglia, although other sites in the brain and spinal Figure-1: (a) T1-Weighted Axial MR image showing multiple hypointense lesions
cord may be affected, multiple foci are seen more often.1 with perilesional edema. (b) T2-Weighted Axial MR image showing multiple
hyperintense lesions of varying sizes with marked surrounding vasogenic edema.
Case Report (c) Post contrast sagittal T1 image showing multiple lesions with enhancement in
the periphery and centre. (d) Post contrast coronal image showing multiple
A 40 years old male patient was diagnosed as HIV supratentorial and infratentorial ring enhancing lesions with eccentric nodules: the
"target sign". (e) Diffusion weighted axial MR image showing multiple ring
positive. Initially asymptomatic he had been bed bound for enhancing lesions of varying sizes.

316 J Pak Med Assoc

 Brain biopsy was deferred because of financial Discussion
constraints and the patient was started on Septran DS
Diagnosis of toxoplasmosis is made clinically,
empirically for toxoplasmosis and steroids to reduce
radiologically and by serology, histology or by molecular
intracranial pressure. He was also given Paracetamol,
methods. Toxoplasmosis associated with HIV infection
Clarithromycin and rehydrated with intravenous fluids.
manifest primarily as toxoplasmic encephalitis and is a
Follow-up MRI scan with Gadolinium performed frequent cause of focal CNS lesions. Characteristically,
after ten days re-demonstrated multiple ring enhancing toxoplasmic encephalitis presents with headache, altered
lesions of various sizes in supra and infratentorial region. mental status and fever. Most common focal neurological
These demonstrated mixed signals on T1, hyperintense on signs are motor weakness, speech disturbance. Patients can
T2-Weighted and Flair images. Post contrast images present with seizures, cranial nerve abnormalities, visual
showed peripheral and central enhancement. On field defects, sensory disturbances, cerebellar dysfunction,
Susceptibility Weighted images the lesion showed meningismus, movement disorders and neuropsychiatric
susceptibility effect. However on comparison with previous manifestations.4 Ocular and pulmonary diseases are the
MRI scan there was reduction in size, number and most common presentations in patients with cerebral
enhancement of the masses as well as the surrounding toxoplasmosis.5 Toxoplasmosis rarely presents as a rapidly
oedema. Lesions showed haemorrhagic component in them fatal form of diffuse encephalitis.
(Figure-2).
The most commonly used serologic tests to detect
Patient was clinically stable, oriented had started the presence of anti-T gondii IgG and IgM. IgG antibodies
taking orally and his fever settled. He was discharged from can be detected with the Sabin Feldman dye test (considered
hospital on same medication and advised to continue to be the gold standard). CSF from patients with
regular follow-up. toxoplasmic encephalitis may reveal mild pleocytic
mononuclear predominance and protein elevation.6
Polymerase chain reaction (PCR) based detection of
T.gondii DNA has sensitivity of 12-70 % and specificity of
100% in patients with toxoplasmic encephalitis.7
Toxoplasmosis can be diagnosed by isolation of T.gondii
from culture of body fluids (Blood, CSF, and
bronchoalveolar lavage fluids) or tissue biopsy.
The cranial imaging features on CT and MRI are not
pathognomonic, but their distribution or appearance may
have predictive value. MRI is the best initial screening
procedure for CNS toxoplasmosis. CT scan reveals
multiple, bilateral, hypodense contrast enhancing focal
brain lesions in 70-80% of patients. These lesions tend to
involve basal ganglia and hemispheric corticomedullary
junction. Contrast enhancement often shows a ring like
pattern surrounding the lesion. Toxoplasmic encephalitis
may less frequently present with single lesion or with no
lesion on CT scan.8
MRI is more sensitive and is the preferred imaging
technique especially in patients with focal neurological
abnormalities. Typical radiological findings comprise of
bilateral, multiple, ring enhancing lesions over basal
ganglia and corticomedullary junctions of cerebral
hemisphere. In approximately 14% of cases, the lesions are
solitary. Haemorrhage may be seen occasionally, a finding
that can help differentiate toxoplasmosis from lymphoma
Figure-2: (a): Follow up T1-Weighted axial MR Image shows multiple lesions with
mixed hypo and hyperintense signal and markedly reduced surrounding edema. (b) Post which typically does not bleed before treatment.
contrast axial MR image shows multiple ring enhancing lesions, reduced in size, Occasionally a small eccentric nodule rests alongside an
number and enhancement with markedly reduced surrounding edema. (c) Coronal Flair
post contrast image shows multiple enhancing lesions in supratentorial and infratentorial
enhancing ring; the "target sign" is highly suggestive of
region. (d) Diffusion weighted MR Image showing multiple ring enhancing lesions. toxoplasmosis. However, it is seen in less than 30% of

Vol. 60, No. 4, April 2010 317

 cases. Surrounding oedema and mass effect are present in lesions was also typical in our case. We used MRI to follow
varying degrees.8 up the case to see the response.
The most important differential diagnosis is CNS Primary prophylaxis should be considered in HIV
lymphoma. Features that favor the diagnosis of T.gondii patients with CD4 cell counts less than 200 and positive
encephalitis over CNS lymphoma include: subcortical Toxoplasma IgG titers. Prophylaxis can be discontinued
lesions, more than three lesions, absence of ependymal or when the patients CD4 cell count has returned to over 200
leptomeningeal involvement, marked perilesional oedema, for atleast 6 months.4
absence of hyper attenuation on non enhanced CT scans or HIV infected persons should be tested for baseline
slender uniform ring enhancing foci.9 Diffusion weighted IgG antibodies to Toxoplasma to detect latent infection with
imaging has been suggested to help differentiate between T. gondii. All HIV infected persons should be councelled
the two diseases, as lymphoma typically has restricted regarding exposure to toxoplasmic infection. (a) Avoid
diffusion. Unfortunately, toxoplasmosis demonstrates a eating raw or undercooked meat. (b) Wash hands after
wide range of diffusion characteristics which can overlap contact with raw meat. (c) Wash fruits and vegetables well.
with those of lymphoma.8 Increased uptake in SPECT or (d) Avoid handling cat's litter.10
PET can enhance the specificity for the detection of CNS
lymphoma. References
Brain biopsy showing tachyzoites or cyst provides a 1. Khan AN, Turnbull I, Al Okaili R. Toxoplasmosis, CNS. (Online) 2010.
Available from URL: http://emedicine.medscape.com/article/344706-
definitive diagnosis for toxoplasmosis encephalitis. overview.
Conservative approach is particularly helpful when the 2. Dahnert W. Radiology Review Manual. Central Nervous System, 5th ed.
lesion is surgically inaccessible. Combination of Philadelphia: Lippincott, Williams and Wilkins, 2003; pp 323-4.

Pyrimethamine /Sulfadiazine and folinic acid is considered 3. Edelman RR, Hesselink JR. Clinical Magnetic Resonance Imaging. Infectious
and inflammatory diseases, 3rd ed. Philadelphia: Saunders, Elsevier Co, 2006'
the standard regime for the treatment of toxoplasmosis pp 1274-6.
encephalitis.6 Short course of corticosteroids can be used in 4. Rathore MH. Neurological manifestations of HIV-Associated Infections
(Part-I). Infect Dis J 2005; 14: 51-6.
toxoplasmosis encephalitis patients with significant cerebral
5. Rabaud C, May T, Amiel C, Katlama C, Leport C, Ambroise-Thamas P, et al.
edema and elevated intracranial pressure. Toxoplasmosis Extracerebral toxoplasmosis in patients infected with HIV. A French National
will reoccur if therapy is discontinued.8 Survey. Medicine (Baltimore) 1994; 73: 306-14.
6. Montoya JG, Kovacs JA, Remington JS. Toxoplasma gondii. In : Mandell GL,
Empirical treatment for T.gondii should be started on Bennett JE, Dolin R. Principles and Practice of Infectious Diseases. 6th ed.
patients with multiple ring enhancing lesions on MRI, Philadelphia: Churchill Livingstone, 2005; pp 3170-98.
positive serology for Toxoplasma IgG, and absolute CD4 7. Parmley SF, Goebel FD, Remington JS. Detection of Toxoplasma gondii in
cerebrospinal fluid from AIDS patients by polymerase chain reaction. J Clin
count less than 200 cells/mm3.4 Microbiol 1992; 30: 3000-2.
If an empiric course of treatment is begun for 8. Smith AB, Smirniotopoulos JG, Rushing EJ. From the archives of the AFIP:
central nervous system infection associated with human immunodeficiency
toxoplasmosis without biopsy, then a repeat cranial study is virus infection: radiologic pathologic correlation. Radiographics 2008; 28:
recommended. If CT or MRI findings are unchanged, then 2033-58.
biopsy is indicated. Both CT and MRI may be used for 9. Dunn IJ, Palmer PE. Toxoplasmosis. Semin Roentgenol 1998; 33: 81-5.
follow up after treatment. In our case the appearance of the 10. No author listed. 1999 USPHS/IDSA guidelines for the prevention of
opportunistic infections in persons infected with Human Immunodeficiency
lesions was very characteristic as there were a number of Virus. US Public Health Service (USPHS) and Infectious Diseases Society of
"target Lesions" in the brain. Also the distribution of the America (IDSA). MMWR Recomm Rep 1999; 48: 1-59, 61-6.

318 J Pak Med Assoc

View publication stats