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QJM: An International Journal of Medicine, 2016, 491–492

doi: 10.1093/qjmed/hcw044
Advance Access Publication Date: 29 March 2016
Clinical picture


Cerebral toxoplasmosis

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Central nervous system (CNS) toxoplasmosis occurs from re- lesion surrounded by wide hypermetabolic edematous areas
activation of disease in patients given immunosuppressive or compatible with primary brain neoplasm.
cytotoxic therapy or in patients with HIV infection. It is rare in Stereotactic brain biopsy revealed granulomatous inflamma-
immunocompetent individuals. We describe an immunocom- tion and immunohistochemical studies showed bradyzoides
petent patient with cerebral toxoplasmosis diagnosed by a brain and tachyzoides of Toxoplasma gondii in the brain parenchyma
biopsy. (Figure 1B). T. gondii antibodies (IgG) were positive and anti-HIV
A 60-year-old man presented with headache and left-sided antibodies were negative He was given co-trimoxazole for 3
numbness and weakness. He was diagnosed low-grade papil- months; his neurological features improved completely and a
lary tumor of urinary bladder 3 years ago. He was treated with repeated MRI study after 8 months showed apparent regression
transurethral resection of the tumor with post-resection instil- of the lesion with no pathological contrast enhancement.
lation of six-dose of mitomycin C. The patient recovered com- CNS toxoplasmosis is well described in HIV-infected patients
pletely and was followed-up without any treatment. who are not given prophylaxis. The infection is caused by an
On this admission, his sensorial and motor deficits were ap- intracellular protozoan parasite, T. gondii. The primary infection
parent on left face side, left arm and left leg. A cranial MRI re- in an immunocompetent host is usually asymptomatic and
vealed millimetric hypointense foci on T2-weighted images then it persists for the life. After being immunosuppressed (for
surrounded by a large vasogenic edematous area in right HIV-infected patients, especially when CD4 falls below 100
fronto-parietal white matter of the brain (Figure 1A). On T1- cells/ll), it reactivates.1 Typical radiology is multiple ring-
weighted images, there was ring and nodular contrast enhance- enhancing lesions. Definitive diagnosis is established by brain
ment of lesions. Complete blood count and biochemistry were biopsy; this invasive procedure is associated some morbidity. A
negative. A fluorodexyglucose positron emission tomography response to empirical treatment is accepted as diagnostic. A re-
described the same lesion as a hypermetabolic hypodense sponse to therapy is checked after 2–3 weeks and lack of clinical

Figure 1. (A) Axial T2-weighed image revealing milimetric hypointense foci surrounded by a large vasogenic edematous area in right fronto-parietal white matter of
the brain. (B) Intacellular bradyzoides (arrows) of T. gondii in glial cells of the brain (Hematoxylin & Eosin staining, 40).

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492 | QJM: An International Journal of Medicine, 2016, Vol. 109, No. 7

and/or radiologic improvement should raise the probability of Istanbul University, Istanbul, Turkey; S. Sahin and B. Oz,
an alternative diagnosis. Department of Pathology, Cerrahpasa Medical School Istanbul
A definitive diagnosis of cerebral toxoplasmosis requires University, Istanbul, Turkey. email:
compatible clinical features including headache, neurological
symptoms, and fever, and identification of ring-enhancing
mass lesion(s) by brain imaging, and detection of the organism
in a biopsy specimen.2
In immunocompetent individuals, the probability of cerebral 1. Luft BJ, Remington JS. Toxoplasmic encephalitis in AIDS. Clin
toxoplasmosis is very low3 and a presumptive diagnosis of cere- Infect Dis 1992; 15:211.
bral toxoplasmosis may not be considered in a patient with a 2. Panel on Opportunistic Infections in HIV-Infected Adults and
focal cerebral lesion. For the presented case, a cerebral metasta- Adolescents. Guidelines for the prevention and treatment of
sis from urinary bladder cancer was not likely. The tumor was opportunistic infections in HIV-infected adults and adoles-

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low-grade papillary and treated locally 3 years ago. The growth cents: Recommendations from the Centers for Disease Control
rate of these tumors is very slow and they rarely progress. The and Prevention, the National Institutes of Health, and the HIV
risk of invasion or metastasis is reported as zero.4 Medicine Association of the Infectious Diseases Society of
Although it is rare in immunocompetent individuals, cere- America.
bral toxoplasmosis should be considered in the differential adult_oi.pdf (7 February 2016, date last accessed).
diagnosis of ring-enhancing focal cerebral lesions. 3. Vastava PB, Pradhan S, Jha S, Prasad KN, Kumar S, Gupta RK.
MRI features of toxoplasma encephalitis in the immunocom-
Conflicts of interest: None declared. petent host: a report of two cases. Neuroradiology 2002;
Photographs and text from: R. Ozaras, B. Karaismailoglu, A. 4. Soloway MS. Expectant treatment of small, recurrent, low-
Vatan, Department of Infectious Diseases, Cerrahpasa Medical grade, noninvasive tumors of the urinary bladder. Urol Oncol
School Istanbul University, Istanbul, Turkey; Z. Hasiloglu, 2006; 24:58–61.
Department of Neuroradiology, Cerrahpasa Medical School