Title : An atypical presentation of CNS toxoplasmosis
Abstract:
Introduction: Toxoplasmosis is an infection caused by an intracellular protozoan parasite, Toxoplasma gondii. The central nervous system (CNS) or brain is one of the most commonly involved organs.
Neurological complications occur in nearly 40% patients with AIDS(Acquired Immunodeficiency Syndrome).
Clinical case: A 58 year old man, Hindu by religion and truck driver by profession presented with acute onset left lower limb weakness followed by upper limb weakness over 8 days. Upon admission, he was well oriented to time, place and person. His higher mental functions were intact. Eye examination was within normal limits, and his speech was normal. No abnormalities were found on cranial nerve examination. Tone was normal in all four limbs and power was about 4/5 on left side and 4+/5 on right sided limbs. Reflexes (ankle, knee, biceps and triceps) were 2+.
During his hospital stay, the patient developed ptosis of the right eye followed by weakness of right sided limbs. NCCT(Non-contrast Computerized Tomography)(Head) was done along with basic laboratory work-up. NCCT Head revealed an ill defined hypodense lesion involving right thalamus, right internal capsule and midbrain on the right side , reported as an infarct. MRI Brain (Plain+Contrast) was reported as subacute to chronic infarct or a granulomatous disease. Meanwhile, his ELISA report for HIV was reactive after a negative card test for same. CSF(Cerebrospinal Fluid) examination showed protein levels of 60mg/dl with 0 RBCs and WBCs. Cytopathology was negative for malignant cells. M.tuberculosis complex was not detected on Gene Xpert in CSF sample. Serology for Toxoplasma IgG antibody was done and was 17.9 IU/ml (ref: 0-2) His CD4+ count was 60 cells per microlitre. The patient was started on pyrimethamine and sulfadiazine and is currently under follow-up.
This case is being presented because of the following facts:
- As, HIV infection are becoming prevalent, CNS complications in HIV patients are encountered more in our clinical practice. This case presented as a mass lesion and if AIDS had been in our differential diagnosis, we would have considered toxoplasmosis.
- An acute stroke like presentation occurs in minority of patients.
