Investigation and Management of HIV Infected Patients with Suspected Focal Brain Lesion

Department of Internal Medicine, PMHC HIV infected patients frequently present with focal neurological signs suggesting a focal brain lesion (FBL), manifesting as fits, hemiplegia, confusion with localising signs and signs of meningeal irritation with focal signs. There is a tendency to treat patients empirically for toxoplasmosis. Whilst this is not wrong it is important to think more widely as toxoplasmosis is probably not the most common cause of FBL in our setting. Also patients are commonly started on toxoplasma treatment when their HIV status is unknown or their CD4 count is unknown. Again this s not wrong but efforts must be made to ensure the correct diagnosis has been made and that adjustments to treatment are made if necessary i.e. toxoplasmic encephalitis is not likely to be the cause of a patients symptoms if their CD4 count is >100. Below are listed a number of conditions and their features that may present as a FBL. Following this a brief guideline for investigation is proposed. All patients are assumed to have a positive HIV test. 1. Tuberculoma a. TB maybe present elsewhere CXR, sputum, lymphnodes b. CSF raised lymphocyte count, raised protein, reduced glucose c. CT brain with contrast hypodense or isodense round lesions, with irregular walls with variable thickness, mainly cortical location. Meningeal enhancement. Oedema and mass effect may be present. d. Respond to TB treatment 2. Toxoplasmic encephalitis a. Positive toxoplasma CFT b. CD4 < 100 cells / mm3 c. CT scan multiple hypodense lesions, rim enhancing, mainly in basal ganglia, some oedema d. Respond to toxoplasma treatment 3. Neurosyphilis a. CSF WR / TPHA positive 4. Neurocysticercosis a. CT scan regular thin walled, cystic lesions, ring enhancing. May see scolex. Maybe old calcified lesion. b. Positive serology 5. Cryptococcosis a. CSF India ink or cryptococcal antigen positive 6. Primary central nervous system lymphoma a. CT scan hyperdense lesions, no oedema, homogenous contrast enhancement, periventricular or subependymal in location. b. CD4 <100 cells/mm3 c. Atypical lymphocytes in CSF d. No response to TB or toxoplasma treatment 7. Progressive multifocal leucoencephalopathy a. CT scan lesions confined to white matter. Hypodense non-enhancing. Approach to diagnosis 1. Establish HIV status get CD4 count, search for TB, toxoplasma serology, WR 2. CT scan followed by lumbar puncture including WR/TPHA/India ink/CRAG 3. Based on above treat for most likely cause if no response revise diagnosis 4. If CT scan not immediately possible treat empirically for either TB or toxoplasmosis based on clinical findings. But be prepared to revise diagnosis depending on CD4, response to treatment or subsequent CT. Reference: Modi M, Mochan A, Modi G. Management of HIV associated focal brain lesions in developing countries. Quarterly Journal of Medicine. 2004;97:413-421