RESUMO
Four cases of people living with HIV/AIDS (PLWHA) with calcified cerebral toxoplasmosis associated with perilesional edema causing a single episode of neurological manifestations have recently been reported. Here, we describe the first detailed description of perilesional edema associated with calcified cerebral toxoplasmosis causing three episodes of neurological manifestations in a PLWHA, including seizures in two of them. These recurrences occurred over approximately a decade. Throughout this period, the patient showed immunological and virological control of the HIV infection, while using antiretroviral therapy regularly. This case broadens the spectrum of an emerging presentation of calcified cerebral toxoplasmosis, mimicking a well-described finding of neurocysticercosis in immunocompetent hosts.
Assuntos
Infecções por HIV , Neurocisticercose , Toxoplasmose Cerebral , Humanos , Toxoplasmose Cerebral/complicações , Toxoplasmose Cerebral/diagnóstico , Seguimentos , Infecções por HIV/complicações , Infecções por HIV/tratamento farmacológico , Neurocisticercose/complicações , Neurocisticercose/diagnóstico , Edema/etiologiaRESUMO
Due to their immunocompromised state, recipients of hematopoietic stem cell transplants (HSCTs) are at a higher risk of opportunistic infections, such as that of toxoplasmosis. Toxoplasmosis is a rare but mortal infection that can cause severe neurological symptoms, including confusion. In immunosuppressed individuals, such as those with acquired immunodeficiency syndrome (AIDS), toxoplasmosis can cause movement disorders, including hemichorea-hemiballismus. We present the case of a 54-year-old Caucasian male with a history of hypertension and JAK-2-negative primary myelofibrosis who underwent an allogeneic peripheral blood stem cell transplant from a related donor. After the development of acute changes in mental status, left-sided weakness, and left-sided hemichorea-hemiballismus post-transplant, the patient was readmitted to the hospital. Subsequent testing included an magnetic resonance imaging (MRI) of the brain, which revealed multiple ring-enhancing lesions around the thalami and basal ganglia, as well as a cerebrospinal fluid tap that tested positive for toxoplasmosis. The patient was initially treated with intravenous clindamycin and oral pyrimethamine with leucovorin. The completion of treatment improved the patient's mental status but did not improve his hemichorea-hemiballismus. This case illustrates an uncommon complication associated with central nervous system (CNS) toxoplasmosis in stem cell transplant recipients. Due to its rarity, cerebral toxoplasmosis in immunocompromised patients often remains undetected, particularly in HSCT patients who are immunosuppressed to improve engraftment. Neurological and neuropsychiatric symptoms due to toxoplasmosis may be misidentified as psychiatric morbidities, delaying appropriate treatment. Polymerase chain reaction (PCR) assays offer methods that are sensitive and specific to detecting toxoplasmosis and provide opportunities for early intervention.
Assuntos
Discinesias , Transplante de Células-Tronco Hematopoéticas , Toxoplasmose Cerebral , Humanos , Masculino , Toxoplasmose Cerebral/complicações , Toxoplasmose Cerebral/diagnóstico , Pessoa de Meia-Idade , Transplante de Células-Tronco Hematopoéticas/efeitos adversos , Transplante de Células-Tronco Hematopoéticas/métodos , Discinesias/etiologia , Coreia/etiologia , Hospedeiro Imunocomprometido , Imageamento por Ressonância Magnética/métodosRESUMO
BACKGROUND: The present case contributes to the limited literature on central nervous system involvement of blastic plasmacytoid dendritic cell neoplasm (BPDCN). CASE PRESENTATION : A 63-year-old male presented to the department of neurology with a three-day history of rapidly progressing headache, fatigue, and confusion. Physical examination revealed multiple bruise-like skin lesions. Initial laboratory workup raised suspicion of acute leukemia, and a brain computer tomography identified several hyperdense processes. A bone marrow biopsy gave the diagnosis BPDCN, a rare and aggressive hematologic malignancy derived from plasmacytoid dendritic cells with a poor prognosis. Lumbar puncture showed not only signs of BPDCN, but also cerebral toxoplasmosis, thus providing a differential diagnosis. Despite intensive systemic and intrathecal chemotherapy, the patient died 25 days later due to multi-organ failure. DISCUSSION: The exact incidence of BPDCN is unknown and perhaps underestimated but may account for 0.5 - 1% of all hematological malignancies. The median age at onset is 60 to 70 years, and most patients are men. Cutaneous lesions are the most frequent clinical manifestation at diagnosis. Other symptoms present at time of diagnosis or during disease progression include lymphadenopathy, splenomegaly and cytopenia caused by bone marrow involvement. Although the majority of BPDCN patients have no symptoms or signs of central nervous system involvement, plasmacytoid dendritic cells have been detected in the cerebrospinal fluid in more than 50%. CONCLUSIONS: This case highlights the importance of considering hematological malignancies as a differential diagnosis in patients developing acute neurological symptoms and raises suspicion of a possible association between toxoplasmosis and hematological malignancies.
Assuntos
Neoplasias Hematológicas , Transtornos Mieloproliferativos , Neoplasias Cutâneas , Toxoplasmose Cerebral , Células Dendríticas/patologia , Feminino , Neoplasias Hematológicas/diagnóstico , Neoplasias Hematológicas/patologia , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias Cutâneas/diagnóstico , Neoplasias Cutâneas/patologia , Toxoplasmose Cerebral/complicações , Toxoplasmose Cerebral/diagnóstico , Toxoplasmose Cerebral/patologiaRESUMO
Toxoplasmosis is a widespread parasitic disease. It is caused by an intracellular parasite Toxoplasma gondii. It can affect various tissues and organs, forming cysts and continuing to replicate within them. In people with intact immune system, tissue cysts remain in latent state throughout their whole life. However, in cases of cellular immunodeficiency the infection can be reactivated, which leads to secondary generalization of the process. People with HIV most commonly present with cerebral toxoplasmosis. Non-specific neuroimaging signs, as well as absence of pathognomonic symptoms and specific laboratory data lead to difficulties of cerebral toxoplasmosis diagnosis, particularly in the cases with a history of multiple sclerosis that has similar clinical symptoms and brain MRI data suggesting of tumefactive multiple sclerosis image. A clinical case of cerebral toxoplasmosis in a female patient with multiple sclerosis and HIV infection is described.
Assuntos
Infecções por HIV , Esclerose Múltipla , Toxoplasma , Toxoplasmose Cerebral , Feminino , Infecções por HIV/complicações , Humanos , Esclerose Múltipla/diagnóstico , Esclerose Múltipla/diagnóstico por imagem , Neuroimagem , Toxoplasmose Cerebral/complicações , Toxoplasmose Cerebral/diagnósticoRESUMO
Toxoplasma gondii is an opportunistic protozoan pathogen with a wide geographic distribution. The chronic phase of toxoplasmosis is often asymptomatic in humans and is characterized by tissue cysts throughout the central nervous system and muscle cells. T. gondii and other pathogens with tropism for the central nervous system are considered risk factors in the etiology of several neuropsychiatric disorders, such as schizophrenia and bipolar disorder, besides neurological diseases. Currently, it is known that cerebral toxoplasmosis increases dopamine levels in the brain and it is related to behavioral changes in animals and humans. Here we evaluate whether chronic T. gondii infection, using the cystogenic ME-49 strain, could induce behavioral alterations associated with neuropsychiatric disorders and glutamatergic neurotransmission dysfunction. We observed that the startle amplitude is reduced in the infected animals as well as glutamate and D-serine levels in prefrontal cortical and hippocampal tissue homogenates. Moreover, we did not detect alterations in social preference and spontaneous alternation despite severe motor impairment. Thus, we conclude that behavioral and cognitive aspects are maintained even though severe neural damage is observed by chronic infection of C57Bl/6 mice with the ME-49 strain.
Assuntos
Ácido Glutâmico/metabolismo , Transtornos Mentais/etiologia , Transtornos Mentais/metabolismo , Reflexo de Sobressalto , Serina/metabolismo , Toxoplasmose Cerebral/complicações , Toxoplasmose Cerebral/parasitologia , Animais , Comportamento Animal , Peso Corporal , Encéfalo/metabolismo , Encéfalo/parasitologia , Encéfalo/patologia , Hipocampo/metabolismo , Transtornos Mentais/diagnóstico , Transtornos Mentais/psicologia , Camundongos , Neurotransmissores/metabolismo , Córtex Pré-Frontal/metabolismo , Comportamento Social , ToxoplasmaRESUMO
Toxoplasma gondii is an intracellular protozoan parasite. Approximately 30% of the global population is infected by T. gondii. In chronically infected individuals, the parasite resides in tissue cysts, especially in the brain. There is a growing interest in the role of parasitologic agents in the causation of neuropsychological disorders. In this review, we have explained the interactions between Toxoplasma and its host, mechanisms, and consequences on neural and psychological diseases.
Assuntos
Transtornos Neurocognitivos/etiologia , Toxoplasma/patogenicidade , Toxoplasmose/complicações , Encéfalo/parasitologia , Doença Crônica , Interações Hospedeiro-Parasita , Humanos , Transtornos Neurocognitivos/parasitologia , Toxoplasmose/parasitologia , Toxoplasmose Cerebral/complicações , Toxoplasmose Cerebral/parasitologiaAssuntos
Infecções Oportunistas Relacionadas com a AIDS/complicações , Síndrome da Imunodeficiência Adquirida/complicações , Adenocarcinoma/diagnóstico , Neoplasias Encefálicas/diagnóstico , Toxoplasmose Cerebral/complicações , Infecções Oportunistas Relacionadas com a AIDS/diagnóstico por imagem , Infecções Oportunistas Relacionadas com a AIDS/patologia , Adenocarcinoma/patologia , Idoso , Neoplasias Encefálicas/patologia , Evolução Fatal , Feminino , Humanos , Imageamento por Ressonância Magnética , Toxoplasmose Cerebral/diagnóstico por imagem , Toxoplasmose Cerebral/patologiaAssuntos
Encéfalo/patologia , Retinite por Citomegalovirus/complicações , Infecções Oculares Virais/complicações , Infecções por HIV/complicações , HIV , Toxoplasmose Cerebral/complicações , Adulto , Anticorpos Antivirais/análise , Citomegalovirus/imunologia , Retinite por Citomegalovirus/diagnóstico , Infecções Oculares Virais/diagnóstico , Feminino , Infecções por HIV/diagnóstico , Humanos , Imageamento por Ressonância Magnética , Toxoplasmose Cerebral/diagnósticoRESUMO
Toxoplasma is a common parasite worldwide that mainly affects the brain, lungs and eyes. Although toxoplasmic encephalitis is a lethal disease without treatment, past case reports show most patients with systemic lupus erythematosus who developed toxoplasmic encephalitis were misdiagnosed and treated as neuropsychiatric systemic lupus erythematosus, which led to unfavorable outcomes. We herein describe a case of disseminated toxoplasmosis affecting all the above organs with atypical symptoms, which developed with exacerbation of systemic lupus erythematosus. She had initially manifested with retinochoroiditis without vitritis, mild cognitive impairment and an isolated lung mass. These are completely different from the classic symptoms of toxoplasmosis that have been reported in patients with HIV infection and/or those after hematopoietic transplantation. Our case, together with previously reported cases, suggests the manifestation of toxoplasmosis that develops in systemic lupus erythematosus patients can be different from that seen in conventional cases and varies between individual patients. Our case highlights both the difficulty in and the importance of diagnosing toxoplasmosis in patients with systemic lupus erythematosus and provides helpful information to identify this rare, devastating, yet treatable disease.
Assuntos
Lúpus Eritematoso Sistêmico/complicações , Infecções Oportunistas/complicações , Toxoplasmose Cerebral/complicações , Toxoplasmose Cerebral/diagnóstico , Adulto , Encéfalo/diagnóstico por imagem , Diagnóstico Diferencial , Feminino , Humanos , Pulmão/diagnóstico por imagem , Vasculite Associada ao Lúpus do Sistema Nervoso Central/complicações , Imageamento por Ressonância Magnética , Oftalmoscópios , Tomografia Computadorizada por Raios XAssuntos
Linfócitos T CD4-Positivos , Transplante de Células-Tronco Hematopoéticas , Linfopenia/diagnóstico , Linfopenia/etiologia , Toxoplasmose Cerebral/complicações , Toxoplasmose Cerebral/parasitologia , Biomarcadores , Encéfalo/diagnóstico por imagem , Encéfalo/parasitologia , Feminino , Transplante de Células-Tronco Hematopoéticas/efeitos adversos , Transplante de Células-Tronco Hematopoéticas/métodos , Humanos , Pessoa de Meia-Idade , Toxoplasmose Cerebral/diagnóstico , Transplante AutólogoRESUMO
Resumen En este artículo se describe el caso clínico de una mujer colombiana del sur del país con diagnóstico de infección intrauterina por Toxoplasma gondii y por los virus del chikungunya y del Zika. La mujer acudió al control prenatal en el segundo trimestre de su embarazo e informó que durante el primer trimestre había presentado síntomas indicativos de infección por el virus del Zika. Mediante reacción en cadena de la polimerasa (PCR) en líquido amniótico, se demostró infección por Toxoplasma gondii así como por los virus del chikungunya y del Zika. En las imágenes diagnósticas se observaron malformaciones del sistema nervioso central en el feto. A las 29 semanas de gestación se dio por terminado el embarazo mediante procedimiento médico.
Abstract We report a case of intrauterine infection by Toxoplasma gondii, Chikungunya and Zika viruses in a Colombian woman from the southern part of the country. The patient attended prenatal care in the second trimester of her pregnancy and she informed that in the first trimester she had presented with clinical symptoms compatible with Zika virus infection. Amniotic fluid PCR assays showed infection by T. gondii, chikungunya and Zika viruses. Diagnostic imaging showed fetal malformation of the central nervous system. At 29 weeks of gestation, pregnancy was terminated medically.
Assuntos
Adolescente , Feminino , Humanos , Gravidez , Complicações Infecciosas na Gravidez , Toxoplasmose Cerebral/complicações , Febre de Chikungunya/complicações , Infecção por Zika virus/complicações , Complicações Infecciosas na Gravidez/diagnóstico , Toxoplasmose Congênita/diagnóstico , Toxoplasmose Cerebral/diagnóstico , Febre de Chikungunya/diagnóstico , Infecção por Zika virus/diagnósticoRESUMO
Extracerebral toxoplasmosis, with pulmonary involvement and shock, is a rare form of toxoplasmosis in patients with advanced AIDS. It can mimic pneumocystosis, histoplasmosis, and disseminated tuberculosis, and should be considered in the differential diagnosis of causes of respiratory failure and fulminant disease in this group of individuals, especially in areas where the Toxoplasma gondii infection is highly prevalent and in those without proper use of antimicrobial prophylaxis. We report the case of a 46-year-old male patient who presented to the emergency department with uremia, requiring urgent dialysis. During the laboratorial investigation, the patient had confirmed HIV infection, with a low CD4+ peripheral T-cell count (74 cells/µL). During hospitalization, the patient presented drug-induced hepatitis due to trimethoprim/sulfamethoxazole in a prophylactic dose, requiring interruption of this medication. On the 55th day of hospitalization, the patient developed refractory shock and died. At the autopsy, disseminated toxoplasmosis with encephalitis and severe necrotizing pneumonia were diagnosed, with numerous tachyzoites in the areas of pulmonary necrosis.
Assuntos
Humanos , Masculino , Pessoa de Meia-Idade , Infecções Oportunistas Relacionadas com a AIDS/complicações , Encefalite Infecciosa/complicações , Pneumonia/complicações , Choque/complicações , Toxoplasmose Cerebral/complicações , Autopsia , Diagnóstico Diferencial , Evolução Fatal , Toxoplasma , Toxoplasmose/patologiaRESUMO
A 65-year-old woman with rheumatoid arthritis (RA) visited our hospital because of right facial sensory hypoesthesia. Cerebral toxoplasmosis was suspected on brain magnetic resonance imaging. We discontinued methotrexate for RA and started a sulfamethoxazole/trimethoprim (ST) mixture. Although ST treatment was interrupted because of adverse reactions, her prognosis was favorable. The Toxoplasma 18S rDNA gene was detected by nested-polymerase chain reaction (PCR) from blood and cerebrospinal fluid. Detecting the Toxoplasma 18S rDNA gene by nested-PCR is useful for the diagnosis and safer than a brain biopsy. In addition, the discontinuation of immunosuppressants may be recommended in patients compromised by those immunosuppressants.
Assuntos
Artrite Reumatoide/complicações , Reação em Cadeia da Polimerase , Toxoplasmose Cerebral/diagnóstico , Idoso , Artrite Reumatoide/tratamento farmacológico , DNA Ribossômico/análise , Feminino , Humanos , Imunossupressores/uso terapêutico , Metotrexato/uso terapêutico , Toxoplasma/genética , Toxoplasma/isolamento & purificação , Toxoplasmose Cerebral/complicações , Toxoplasmose Cerebral/tratamento farmacológico , Combinação Trimetoprima e Sulfametoxazol/uso terapêutico , Suspensão de TratamentoRESUMO
Cerebral toxoplasmosis is caused by the protozoan Toxoplasma gondii because of reactivation of latent tissue cysts in the Acquired Immunodeficiency Syndrome (AIDS) patients with severe immunosuppression. The objective of this study was to evaluate the benefit of co-trimoxazole in presumptive and prevention of cerebral toxoplasmosis in Human Immunodeficiency Virus (HIV)/AIDS patients at Bobo-Dioulasso Hospital in Burkina Faso from June 2012 to October 2014. ELISA and ELFA were performed on serum for the quantitative determination of IgG and IgM anti-T. gondii, respectively. The seroprevalence of toxoplasmosis was 29.3%. No IgM antibodies for T. gondii were found. Six patients with Toxoplasma-specific antibodies presented cerebral toxoplasmosis. All patients were infected by HIV-1 with the median of CD4+ T lymphocytes at 141 cells/µl. No patient was under antiretroviral therapy. No case of cerebral toxoplasmosis was noted in patients receiving co-trimoxazole in prevention. Presumptive treatment of cerebral toxoplasmosis with co-trimoxazole was effective in all patients with a significant clinical improvement in 83.3%. These results attest the benefit of cotrimoxazole in cerebral toxoplasmosis treatment in countries where drug resources are limited when sulfadiazine is not available. Ours finding highlight the importance of establishing toxoplasmosis chemoprophylaxis to HIV with severe immunosuppression patients and positive Toxoplasma serology.
Assuntos
Infecções por HIV/complicações , Toxoplasmose Cerebral/complicações , Toxoplasmose Cerebral/tratamento farmacológico , Combinação Trimetoprima e Sulfametoxazol/uso terapêutico , Adulto , Antibacterianos/economia , Antibacterianos/uso terapêutico , Burkina Faso/epidemiologia , Estudos Transversais , Feminino , Infecções por HIV/epidemiologia , Humanos , Imunoglobulina G/sangue , Imunoglobulina M/sangue , Masculino , Pessoa de Meia-Idade , Fatores Socioeconômicos , Toxoplasmose Cerebral/sangue , Toxoplasmose Cerebral/epidemiologia , Combinação Trimetoprima e Sulfametoxazol/economia , Adulto JovemAssuntos
Infecções por HIV/complicações , Toxoplasmose Cerebral/diagnóstico , Vasculite do Sistema Nervoso Central/diagnóstico por imagem , Adulto , Coinfecção , Infecções por Citomegalovirus/sangue , Infecções por Citomegalovirus/líquido cefalorraquidiano , Infecções por Citomegalovirus/complicações , Evolução Fatal , Feminino , Humanos , Imageamento por Ressonância Magnética , Tomografia Computadorizada por Raios X , Toxoplasmose Cerebral/complicações , Vasculite do Sistema Nervoso Central/complicações , Vasculite do Sistema Nervoso Central/etiologiaRESUMO
We report the case of a 40-year-old woman with a progressive right-sided hemiparesis. Standard MRI revealed a contrast-enhancing brain lesion within the left basal ganglia. Ffluoroethyl-L-tyrosine (F-FET) PET showed a distinct tracer uptake (lesion-to-brain ratio [LBR]: LBRmax = 2.03, LBRmean = 1.68) with a significant larger metabolic lesion volume than contrast-enhancement in MRI, indicating cerebral glioma. Surprisingly, histopathologic analysis demonstrated central nervous system toxoplasmosis with pronounced inflammatory reaction (reactive astrogliosis, microglia activation, macrophage, and T-lymphocyte infiltration), which was associated with strong LAT1/LAT2/CD98 expression. In conclusion, inflammatory brain lesions, such as cerebral toxoplasmosis, represent a potential pitfall of F-FET PET mimicking a brain tumor.
Assuntos
Síndrome da Imunodeficiência Adquirida/complicações , Proteínas Adaptadoras de Transdução de Sinal/metabolismo , Regulação da Expressão Gênica , Transportador 1 de Aminoácidos Neutros Grandes/metabolismo , Tomografia por Emissão de Pósitrons , Toxoplasmose Cerebral/diagnóstico por imagem , Tirosina/análogos & derivados , Adulto , Transporte Biológico , Neoplasias Encefálicas/diagnóstico por imagem , Diagnóstico Diferencial , Feminino , Humanos , Inflamação/patologia , Toxoplasmose Cerebral/complicações , Toxoplasmose Cerebral/metabolismo , Tirosina/metabolismoRESUMO
Central nervous system immune reconstitution inflammatory syndrome (CNS-IRIS), which occurs most often in HIV-infected patients, is an exacerbation of inflammatory reactions related to opportunistic infections as well as primary CNS malignancies both of which mostly occur in HIV-infected patients. However, differential diagnoses are challenging both clinically and radiologically. We describe a patient with CNS-IRIS due to toxoplasmosis whose 11C-methionine uptake suggested lymphoma but whose arterial spin-labelling MRI led to the correct diagnosis.