Cerebral Toxoplasmosis

in RSCM Hospital Jakarta

Darma Imran
Herlyani Khosama, Nurhayana Lubis, Widi
Widowati, Alifa Dimayanti, Jofizal Jannis
Department of Neurology RSCM Hospital - Indonesia University

New HIV-AIDS Cases in Cipto

Mangunkusumo Hospital, Jakarta
Female

1000

821

900
800

Year

700

2002

600

Male

Male Female

T otal

2003

400

13

128

301
301

330
29

330

2004
115 128 821

300
200
100

13

115

500

96

917

96 917

29

2002

2003

2004

POKDISUS
AIDS RSCM
Pokdisus
AIDS- FKUI
FKUI2004

Num ber of cases

Number of HIV Cases admitted in

Neurological Ward (inpatient) 2003-2006

189

200
150

98

100
50

16

26

1
2003

2
2004

0
3
2005

4
2006

Years

Department of Neurology RSCM Hospital - Indonesia University

AIDS related CNS Opportunistic Infection

in 203 Cases at RSCM Hospital Jan 2004 March 2006
Unknown
21%
Toxo
35%
Bacterial
5%

TBC
26%

Krypto
13%

Department of Neurology RSCM Hospital - Indonesia University

ALGORITHM - 1
APROACH TO CNS OPPORTUNISTIC COMPLICATION IN AIDS
RSCM Hospital, Jakarta

HIV seropositive, CD4 < 200 sel/uL

Fever, Headache, decreasing counsciousnes, clinical sign of intracranial
infection or SOL, progressive neurological signs and symptoms

Yes

Toxo

or

TB

CT / MRI:Focal brain lesion

or

Bacterial

two weeks or
less
Response

No

Lumbar Puncture

Cryptococcus, TB,
Bacterial, other

Brain biopsy (rare)

Failure

Reassesment
Clinical, radiologic, labs

Add treatment for TB

or Toxo or Bacterial
or others (CMV,PML)

Choosing between Toxo

TB Bacterial Absces

Empiric Anti Toxoplasmic

No history of toxo prophylaxis

Empiric Anti TB drug

CD4 > 200
Thorax photo : Miliar TB

Empiric Antibiotic for Bacterial Brain Absces

Neuroimaging study : compatible with bacterial
brain absces

ALGORITHM - 2
APROACH TO CNS OPPORTUNISTIC COMPLICATION IN AIDS

RSCM Hospital, Jakarta

WITH OUT CT SCAN / MRI

HIV seropositive, CD4 < 200 sel/uL
Fever, Headache, decreasing counsciousnes, clinical sign of intracranial
infection or SOL, progressive neurological signs and symptoms
Yes

Treatment A

Anti Toxoplasma OR

Focal neurologic sign

Treatment B

Lumbar
Puncture

Anti TB

Two weeks

Response

No

Failure

Add anti TB if previously received anti toxoplasma (vise versa)

Cryptococcal
TB
Bacterial inf

Aim

To review the clinical manifestations

and treatment response of Suspected
Cases of Cerebral Toxoplasmosis

Department of Neurology RSCM Hospital - Indonesia University

Methods
Retrospective data from January
2004 to January 2007
125 Suspected cases of cerebral
toxoplasmosis
Who received empiric antitoxoplasmic treatment

Department of Neurology RSCM Hospital - Indonesia University

300 cases
of AIDS Related Intracranial Complications
175 other cases

125
Suspected Cases of Cerebral Toxo

Received Empiric Treatment

89 Response

36 No Response

(Clinical Improvement)

(no clinical improvement)

Department of Neurology RSCM Hospital - Indonesia University

Neuroimaging Studies
Single lesion 20%
Multiple lesions 80%
Subcortical lesions
61 %

Contrast
examination
Without contrast : 9 %
Enhancement : 78 %

Department of Neurology RSCM Hospital - Indonesia University

Empiric anti Toxoplasmic

Treatment
2004
Pyrimethamine-sulfadoxine bid po
Drug allergy 34.2 %

Clindamycin 600 mg qd po

2005 - present
Pyrimethamine 200 mg load 75 mg/d
Clindamycin 600 mg qd po
Department of Neurology RSCM Hospital - Indonesia University

Patients Characteristics
N = 125

Patients

Percentage

110

88

Age

19 48 yr

(Mean 28)

IDU

102

82

Sex (Male)

CD4

0 172 cells/mm3 (Mean 39) (85 % below 100)

New HIV Diagnosis

107

86

Toxo IgG (N=84)

82

98

Hep C (N=37)

37

100

Pulmonary TB

41

33

Department of Neurology RSCM Hospital - Indonesia University

Clinical Manifestations
N = 125

Number of
patients
106

Percentage

Fever

59

47

Vomitus

48

39

GCS < 12

46

37

Seizure

46

37

Hemiparesis

60

48

Headache

85

GCS : Glasgow Coma Scale

Department of Neurology RSCM Hospital - Indonesia University

Outcome

Respon to anti-toxoplasmic treatment

Clinical improvement : 89 (71%)
No response : 36 (29%)
Clinical response in 7 days : 65 (73%)

Mortality rate : 31 %

Department of Neurology RSCM Hospital - Indonesia University

Outcome
N = 125
New HIV Dx
On HAART
Focal sign
Multiple lesions
GCS < 12
PulmonaryTB

Response
74
7
69
75
23
24

No Response P-value
33
2
22
29
13
17

NS
NS
NS
NS
0.00
0.03

Department of Neurology RSCM Hospital - Indonesia University

Conclusion

Clinical response to anti-toxoplasmic

treatment 71%
Glasgow coma scale below 12 on admission
have poor outcome
Patients with pulmonary tuberculosis tended
to have poor outcome.

Department of Neurology RSCM Hospital - Indonesia University

Thank you
darma_imran@cbn.net.id
Department of Neurology
RSCM Hospital University of Indonesia