Ventriculitis and hydrocephalus: an unusual presentation of toxoplasmosis in an adult with human immunodeficiency virus
http://www.100md.com
《神经病学神经外科学杂志》
1 The Caldecot Centre, King’s Healthcare NHS Trust, London, UK
2 Department of Neurology, King’s College Hospital
3 Department of Neuroradiology, King’s College Hospital
Correspondence to:
Dr M Poulton
Consultant in HIV Medicine, The Caldecot Centre, King’s Healthcare NHS Trust, 15–22 Caldecot Road, London SE5 9RS, UK; Mary.Poulton@kingsch.nhs.uk
Keywords: HIV; hydrocephalus; toxoplasmosis; ventriculitis
A 33 year old African man presented with a history of fever, confusion, and headache. An magnetic resonance imaging (MRI) scan revealed hydrocephalus, marked enhancement within the ventricular walls, and extensive confluent T2-weighted/fluid attenuated inversion recovery (FLAIR), high signal around the 3rd and lateral ventricles, as well as within the splenium of the corpus callosum. Bilateral extra-ventricular drains were inserted. Cerebrospinal fluid (CSF) examination revealed: 28/mm3 lymphocytes, protein 2557 mg/l, glucose 1.8 mmol/l (serum 6.3 mmol/l), no organisms, and polymerase chain reaction (PCR) negative for tuberculosis (TB), cytomegalovirus (CMV), herpes simplex virus (HSV), and JC virus, but positive for Epstein-Barr virus (EBV). An human immunodeficiency virus (HIV)-1 enzyme-linked immunosorbent assay (ELISA) was positive with a CD4 count of 158/mm3. Serum CMV IgG and Toxoplasma IgG were positive consistent with previous exposure.
Treatment was commenced with anti-tuberculous medication, Aciclovir, and Ganciclovir. Despite this, he deteriorated and died a few days later. Post-mortem examination revealed extensive necrotising toxoplasmosis along the ventricular walls.
The radiological differential diagnosis of ventriculitis in HIV infection is usually that of TB, CMV, or lymphoma.1 In the context of HIV disease, lesions in the corpus callosum are most often seen in lymphoma and rarely in toxoplasmosis.2 Positive EBV PCR is also thought to be both highly sensitive and specific for primary central nervous system (CNS) lymphoma.3 Cerebral toxoplasmosis in the immunocompromised characteristically presents with mass lesions and although hydrocephalus is a common manifestation in congenital toxoplasmosis, it is rarely seen in adults.4 Our case stresses the importance that in HIV disease, neuroradiological and laboratory investigations can be grossly misleading, and that a trial of empirical anti-toxoplasmosis treatment should be considered for any CNS lesion in a deteriorating patient.
References
Guerini H, Helie O, Leveque C, et al. Diagnosis of periventricular ependymal enhancement in MRI in adults. J Neuroradiol 2003;30:46–50.
Lee HJ, Williams R, Kalnin A, et al. Toxoplasmosis of the Corpus Callosum: Another Butterfly. Am J Roetgenol 1996;166:1280–1.
Antinori A, Ammassari A, De Luca A, et al. Diagnosis of AIDS-related focal brain lesions: A decision-making analysis based on clinical and neuroradiologic characteristics combined with polymerase chain reaction assays in CSF. American Academy of Neurology 1997;48:687–94.
Lorberboym M, Wallach F, Estok L, et al. Rapid Differential Diagnosis of Cerebral Toxoplasmosis and Primary Central Nervous System Lymphoma by Thallium-201 SPECT. Journal of Nuclear Medicine 1996;37:1150–4.(T de Silva1, M Raychaudhu)
2 Department of Neurology, King’s College Hospital
3 Department of Neuroradiology, King’s College Hospital
Correspondence to:
Dr M Poulton
Consultant in HIV Medicine, The Caldecot Centre, King’s Healthcare NHS Trust, 15–22 Caldecot Road, London SE5 9RS, UK; Mary.Poulton@kingsch.nhs.uk
Keywords: HIV; hydrocephalus; toxoplasmosis; ventriculitis
A 33 year old African man presented with a history of fever, confusion, and headache. An magnetic resonance imaging (MRI) scan revealed hydrocephalus, marked enhancement within the ventricular walls, and extensive confluent T2-weighted/fluid attenuated inversion recovery (FLAIR), high signal around the 3rd and lateral ventricles, as well as within the splenium of the corpus callosum. Bilateral extra-ventricular drains were inserted. Cerebrospinal fluid (CSF) examination revealed: 28/mm3 lymphocytes, protein 2557 mg/l, glucose 1.8 mmol/l (serum 6.3 mmol/l), no organisms, and polymerase chain reaction (PCR) negative for tuberculosis (TB), cytomegalovirus (CMV), herpes simplex virus (HSV), and JC virus, but positive for Epstein-Barr virus (EBV). An human immunodeficiency virus (HIV)-1 enzyme-linked immunosorbent assay (ELISA) was positive with a CD4 count of 158/mm3. Serum CMV IgG and Toxoplasma IgG were positive consistent with previous exposure.
Treatment was commenced with anti-tuberculous medication, Aciclovir, and Ganciclovir. Despite this, he deteriorated and died a few days later. Post-mortem examination revealed extensive necrotising toxoplasmosis along the ventricular walls.
The radiological differential diagnosis of ventriculitis in HIV infection is usually that of TB, CMV, or lymphoma.1 In the context of HIV disease, lesions in the corpus callosum are most often seen in lymphoma and rarely in toxoplasmosis.2 Positive EBV PCR is also thought to be both highly sensitive and specific for primary central nervous system (CNS) lymphoma.3 Cerebral toxoplasmosis in the immunocompromised characteristically presents with mass lesions and although hydrocephalus is a common manifestation in congenital toxoplasmosis, it is rarely seen in adults.4 Our case stresses the importance that in HIV disease, neuroradiological and laboratory investigations can be grossly misleading, and that a trial of empirical anti-toxoplasmosis treatment should be considered for any CNS lesion in a deteriorating patient.
References
Guerini H, Helie O, Leveque C, et al. Diagnosis of periventricular ependymal enhancement in MRI in adults. J Neuroradiol 2003;30:46–50.
Lee HJ, Williams R, Kalnin A, et al. Toxoplasmosis of the Corpus Callosum: Another Butterfly. Am J Roetgenol 1996;166:1280–1.
Antinori A, Ammassari A, De Luca A, et al. Diagnosis of AIDS-related focal brain lesions: A decision-making analysis based on clinical and neuroradiologic characteristics combined with polymerase chain reaction assays in CSF. American Academy of Neurology 1997;48:687–94.
Lorberboym M, Wallach F, Estok L, et al. Rapid Differential Diagnosis of Cerebral Toxoplasmosis and Primary Central Nervous System Lymphoma by Thallium-201 SPECT. Journal of Nuclear Medicine 1996;37:1150–4.(T de Silva1, M Raychaudhu)