Recurrent Cerebral Toxoplasmosis in young patient

Case Presentation:

A 35-year-old woman was admitted with a headache and two episodes of seizures on background of HIV and previous cerebral toxoplasmosis. Collateral history from her husband revealed that she had stopped taking antiretroviral medications a year ago. On examination her Glasgow Coma Scale was 15/15 but she appeared lethargic and in distress. Systemic examination showed left upper limb weakness. There were no other neurological signs.

Inv estigations:

Urgent CT Head showed a vasogenic area in right frontal lobe with mass effect. This lesion was not present when compared to a CT from 10 years ago. Blood tests showed normal inflammatory markers and electrolytes. CD3, CD4 and CD8 counts were 242, 4 and 45 respectively. The cryptococcal antigen test and Cytomegalovirus DNA test were negative. HIV-1 RNA was 66200 copies/ml and HIV-1 viral load detected. Toxoplasma screen was positive.

Fu rther Imaging:

MRI head showed 9 ring enhancing lesions in both cerebral hemispheres with significant perilesional edema resulting in 8mm midline shift. To rule out the possibility of malignancy, CT CAP with contrast was performed which was normal.

Management:

She was commenced on Pyrimethamine, Clindamycin, Folinic acid, Dexamethasone and Levetiracetam. Her symptoms improved drastically. Neurosurgeons advised that she was not fit for neurosurgery due to spreading nature of lesions in the brain. She was also reviewed by Sexual health and HIV consultant who arranged outpatient follow-up. She was discharged on Co-trimoxazole prophylaxis.

Follow-up:

A follow-up MRI head with and without contrast was arranged which showed marked improvement of the extensive neuroinfection diagnosed previously.

Author(s): Ivana Lutchman

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