Title : Clinically diagnosed cerebral toxoplasmosis in an HIV-negative young farmer with rapid neurologic deterioration: A case report
Abstract:
Background: Cerebral toxoplasmosis is the most common opportunistic infection of the central nervous system in patients with advanced HIV infection but is rare in HIV-negative individuals. Its diagnosis is challenging because the clinical presentation and neuroimaging findings overlap with those of infectious, inflammatory, and neoplastic brain lesions. In resource-limited settings, the absence of advanced diagnostic modalities further complicates timely diagnosis. We report a fatal case of clinically diagnosed cerebral toxoplasmosis in an HIV-negative young farmer.
Case Description: A 23-year-old Filipino farmer presented with a 2-week history of progressively worsening headache, nausea, vomiting, malaise, and intermittent fever. He initially self-medicated with paracetamol, delaying medical consultation. He had daily farming exposure and cared for seven domestic cats, including routine cleaning of their litter boxes. On admission, he was stuporous (Glasgow Coma Scale score 10 [E2V3M5]) with a fixed dilated right pupil, sluggish left pupillary light reflex, spontaneous movement of all extremities, and nuchal rigidity. Contrast-enhanced cranial computed tomography revealed multiple bilateral ring-enhancing cerebral lesions with extensive vasogenic edema, ventricular compression, and a 0.6-cm midline shift. HIV serology was nonreactive, while Toxoplasma gondii IgG was positive and IgM was negative. Lumbar puncture was contraindicated because of impending brain herniation, and further diagnostic testing was unavailable. A presumptive diagnosis of cerebral toxoplasmosis was made based on the exposure history, neuroimaging findings, and serologic results. Despite treatment with intravenous mannitol, dexamethasone, and trimethoprim-sulfamethoxazole, he rapidly deteriorated and died on the second hospital day.
Discussion: This case highlights the importance of considering cerebral toxoplasmosis in HIV-negative patients with compatible epidemiologic exposure and multiple ring-enhancing brain lesions. When definitive diagnostic tests are unavailable, integrating clinical, radiologic, and serologic findings can support timely diagnosis and early empiric treatment.
