Neurotoxoplasmosis is an infection caused by Toxoplasma gondii, an intracellular protozoan that is often associated with immunocompromised patients, being rare in immunocompetent patients and often undetected. Toxoplasmosis is an obligate intracellular, food-borne parasite disease. It is transmitted through consumption of raw or uncooked meat contaminated by cat feces, the definitive host of oocytes and most individuals are infected inadvertently. This case underlines the need to perform appropriate tests and helps increase the knowledge about the diagnosis of this disease.
A 65-year-old female with a medical history of schizophrenia presented to our hospital with complaint of 2 weeks of agitation and aggressiveness and the day before arrival, she became sleepy, lethargic, stiff, and dragging her feet while ambulating. On examination, vitals were stable but appeared ill-looking, poorly groomed, altered mental status, speech disturbance with GCS of 8/15. Upon physical exam, Kernig and Brudzinski’s signs were positive and didn’t follow any commands. Upon laboratory work up patient had a WBC 24 x 10 3 bands 4% and neutrophil count 91%. Biochemical laboratory showed elevated ESR, CRP, and CPK. The patient was admitted with the diagnosis of suspected meningitis and was treated with broad-spectrum IV antibiotics and IV steroids to subside the inflammatory reaction. CT scan without contrast showed hypodensity at the right basal ganglia measuring approximately 5 mm. HIV and VDRL were reported negative and had no history of malignancy. A sample from lumbar puncture was sent for PCR analysis, CSF analysis showed elevated Toxoplasma gondii AB (IgM) 6.53 (normal value <0.90). Toxoplasma gondii antibody IgG 95.00 IU/mL (normal range < 7.20) and IgM 84.90 AU/mL (normal range <8.00) in blood were positive as well. Spinal culture reported no growth in 72 hrs. By the time the results of the antibody in the CSF and blood were reported, the patient recovered with current treatment, and close follow-up was planned to ensure resolution of the symptoms.
In an immunocompetent host, the probability of CNS infection by Toxoplasma gondii is low, and as a primary infection is rare in this group of patients. Therefore, the diagnosis is not usually considered initially. Our patient was probably exposed to Toxoplasma gondii due to direct ingestion of water contaminated with cat feces since she lived in inhumane conditions. Several methods are used for the diagnosis of Toxoplasmosis Gondii infection, but gold standard tests are enzyme-linked immunosorbent assay (ELISA) and indirect immunofluorescence assay (IFA) for detection of Toxoplasma-specific antibodies (IgG or IgM). When the diagnosis is made, treatment is rarely required for asymptomatic patients who are immunocompetent. Treatment with pyrimethamine, sulfadiazine, and folinic acid is usually reserved for patients who are immunocompromised and those patients who are immunocompetent who have severe or persistent symptoms. Counseling regarding risk factors can reduce the incidence and risk of acquiring the infection.
What will audience learn from your presentation?
- Explain how the audience will be able to use what they learn? The audience will be able to identify neurotoxoplasmosis in an immunocompetent patient
- How will this help the audience in their job? This will help by learning how to diagnose and identify this pathology in immunocompetent patient and how to manage the disease in a proper way
- Does this provide a practical solution to a problem that could simplify or make a designer’s job more efficient? Yes, this will teach other colleagues to understand more this pathology. Learn that infection with Toxoplasmosis may be subclinical or it may cause clinical signs and symptoms that vary according to the patient's immune status and their clinical situation. This case will provide knowledge about management and treatment and that neurotoxoplasmosis should be considered as an important diagnosis in immunocompetent patients with neurological findings