Case 33:  Headaches and Confusion

Case 33:  Headaches and Confusion

History
A 28-year-old black South African theatre nurse in London is admitted to the emergency
department complaining of headaches and confusion. Her headaches have developed over
the past 3 weeks and have become progressively more severe. The headaches are now persis-
tent and diffuse. Her friend who accompanies her says that she has lost 10 kg in weight over 6
months and has recently become increasingly confused. Her speech is slurred. While in the
emergency department she has a generalized tonic–clonic convulsion.

Examination
She is thin and weighs 55 kg. Her temperature is 38.5°C. There is oral candidiasis. There is no
lymphadenopathy. Examination of her cardiovascular, respiratory and gastrointestinal sys-
tems is normal. Neurological examination prior to her convulsion showed her to be disori-
ented in time, place and person. There were no focal neurological signs. Funduscopy shows
bilateral papilloedema.

INVESTIGATIONS
Normal

Haemoglobin 12.2 g/dL 11.7–15.7 g/dL

White cell count 12.1 × 109/L 3.5–11.0 × 109/L
Platelets 365 × 109/L 150–440 × 109/L
Sodium 126 mmol/L 135–145 mmol/L
Potassium 3.9 mmol/L 3.5–5.0 mmol/L
Urea 6.2 mmol/L 2.5–6.7 mmol/L
Creatinine 73 μmol/L 70–120 μmol/L
Glucose 5.6 mmol/L 4.0–6.0 mmol/L

A computed tomography (CT) scan is shown in Figure 33.1.

Figure 33.1  Computed tomography scan of

  the brain.

Questions
• What is the cause for this woman’s headaches, confusion and convulsions?
• What is the underlying diagnosis?
• How should this woman be further investigated and treated?
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ANSWER 33
This woman has cerebral toxoplasmosis secondary to HIV infection. This condition is caused
by the protozoan Toxoplasma gondii, which primarily infects cats but can also be carried
by any warm-blooded animal. In the West, 30–80 per cent of adults have been infected by
ingesting food or water contaminated by cat faeces or by eating raw meat from sheep or pigs
that contained Toxoplasma cysts. After ingestion by humans the organism divides rapidly
within macrophages and spreads to muscles and brain. The immune system rapidly controls
the infection, and the cysts remain dormant. The primary infection is generally asymptom-
atic but can cause an acute mononucleosis-type illness with generalized lympadenopathy
and rash. It may leave scars in the choroid and retina and small inflammatory lesions in the
brain. If the host then becomes immunocompromised, the organism starts proliferating,
causing toxoplasmosis. This is an AIDS-defining illness but is relatively rare in solid organ
transplant recipients. Cerebral toxoplasmosis usually presents with a subacute illness com-
prising fever; headache; confusion; convulsions; cognitive disturbance; and focal neurologi-
cal signs, including hemiparesis, ataxia, cranial nerve lesions, visual field defects and sensory
loss. Movement disorders are common due to involvement of the basal ganglia. CT or mag-
netic resonance imaging (MRI) will usually show multiple bilateral ring-enhancing lesions
predominantly located near the grey–white matter junction, basal ganglia, brainstem and
cerebellum. The clinical and radiological differential diagnoses include lymphoma, tubercu-
losis, Cryptococcus, secondary tumours and bacterial abscesses. Anti-toxoplasma IgG anti-
body is usually but not always positive in patients with toxoplasma encephalitis.
The other clues in this case to the diagnosis of HIV infection include the patient’s country of
origin, the weight loss and oral candidiasis. The headaches and papilloedema are caused by
raised intracranial pressure from the multiple space-occupying lesions. The hyponatraemia
is due to the syndrome of inappropriate antidiuretic hormone (ADH) secretion (SIADH)
consequent to the raised intracranial pressure.
This woman should be started on anticonvulsants to prevent further seizures. Treatment is
started with high-dose sulfadiazine and pyrimethamine together with folinic acid to prevent
myelosuppression. There should be a rapid clinical and radiological improvement. In cases
that have not responded within 3 weeks, a biopsy of one of the lesions should be considered.
Cerebral toxoplamosis is uniformly fatal if untreated, and even after treatment neurological
sequelae are common.
The patient should be counselled about HIV infection, and consent for an HIV test should
be obtained. Her HIV viral load and CD4 count should be measured and antiretroviral
drugs started. She should be advised to contact her previous sexual partners so that they
can be tested and started on antiretroviral therapy. She should also tell her occupational
health department so that the appropriate advice can be taken about contacting, testing and
reassuring patients. The risk of HIV transmission from an HIV positive healthcare worker to
a patient is very small.

KEY POINTS

• Toxoplasmosis is the most common opportunistic infection of the central nervous

system in patients with AIDS.
• Patients can present with headache, confusion, seizures and focal neurological deficits.
• The clinical and radiological response to treatment is usually rapid.

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