Case Report

Cerebral Toxoplasmosis
Presenter: dr. Ita Purwanti
Supervisor: Dr. dr. Jumraini Tammasse, Sp.S (K)`
 Patient’s Identity

Name : Mr. D
Age : 25 years old
Address : Makassar
Medical record : 912329
Date of addmision : June 11th 2020
Date of discharged : June 24th 2020
Hospital : Wahidin sudirohusodo
Anamnesis

 Headache and
double vison for
 No history of diabetes,
past 4 months
 Confused and hypertenson, and high
Chief complaint: cholesterol level.
Right side speak indistinctl
 No history of trauma
weakness since 2  Phlegm cough for
and tumor
weeks ago 2 months.

RSWS Hospital
11/07/2020
Siloam hospital
6-11/07/2020

Loss of consciousness
Diagnosed HIV infection
 General Physical Examination

• Blood pressure : 110/60 mmHg

• Heart rate : 84 beats/minute, regularly
• Respiratory rate : 24 times/minute
• Temperature: 37 degree celcius
• Head : Normocephaly
• Eye : Conjunctiva anemis (-/-), Sklera Ikteric (-/-)
• Neck : Carotid bruit (-)
• Cor : I-II heart sound regular, murmur (-), gallop (-)
• Pulmo : Bronchovesicular, rhonki (+/+), wheezing (-/-)
• Abdomen : Normal bowel sound, defance muscular (-),
organomegaly (-)
 Neurological Examination
• GCS : E4M6V5, VAS: 4-5
• Higher cortical function: disturbed
• Meningeal sign : neck stiffness (-), kernig sign (-/-)
• Cranial nerve : isochorous, Ø 2.5mm/2,5 mm, direct and
indirect light reflex positive/positive
• Other cranial nerves: right abducens nerve palsy, central type of right
facial nerve and hypoglossus nerve palsy
• Motor Function:

• Sensory: Hemihypesthesia dextra

• Autonomy: micturation: per catheter, defecation: normal
SUPPORTING EXAMINATION
 Laboratory
WBC 8.200 4.000-10.000/uL CD4 13 470-1298 U/L
RBC 4.290.000 4.000.000-6.000.000/uL HBs Ag Reactive Non reactive
HGB 12,6 12,0-16,0 g/dl Anti HCV Non Reactive Non reactive
PLT 303.000 150.000-400.000/Ul Kol. Total 241 200 mg/dl
HCT 37 37,0-47,0% Kol. HDL 33 L (>55) P (>56) mg/dl
Kol. LDL 181 <130 mg/dl
GDS 128 140 mg/dl
Trigliserida 145 200 mg/dl
Ureum 36 10-50 mg/dl
Kreatinin 0,58 L(<1,3);P(<1,1) mg/dl Anti TOXO IgG >300 <8 IU/ml
SGOT 18 <38 U/L
Anti TOXO IgM 0,09 < 0,65 COI
SGPT 19 <41 U/L
Anti Rubella IgG 80 <14 IU/ml
Natrium 135 136-145 mmol/l
Anti Rubella IgM 0,09 <1,2 COI
Kalium 4,2 3,5-5,1 mmol/l
Anti CMV IgG Tidak cukup <6 IU/ml
Clorida 105 97-111 mmol/l
Anti CMV IgM Tidak cukup <0,9 COI
Antibodi Non reactive Non reactive 04
COVID 19 Prokalsitonin <0,05 <0,05 mg/dl
Thorax X-ray

06/06/2020, Siloam Hospital

Conclusion: No abnormalities
04 were seen at
the present examination
Thorax CT-Scan

11/06/2020, RSWS
Conclusion: Right pneumonia
04 infection
suspect bacterial
Brain CT Scan Without Contras

06/06/2020, Siloam Hospital

Conclusion :
 Hypodens lesion in the basal ganglia, internal
capsula, thalamus to the left side pons
suggestive encephalitis DD/ SOL
 Midline shift to the right
04Hydrocephalus
 Multisinusitis
Brain CT Scan With Contras

06/06/2020, Siloam Hospital

Conclusion :
 An abses in the left thalamus, size +/- 1,8 X 1,6
X 2,1 cm, with sign of cerebritis
 04
Mild Midline shift to the right
 Obstructive hypertensive hydrocephalus
Working Diagnosis

Clinical diagnosis .

• Right Hemiparesis + Multiple Cranial Nerve Palsy + Cortical

Higher Function Impairment

Topis diagnosis

• Left Cerebral Hemisphere

Etiological diagnosis

• Susp. Cerebral Toxoplasmosis + HIV Infection Stage 4

Therapy
Infusion: Sodium Chloride 28 drops/ minute
• Citicholine 500mg/ 12 hours/ intravenous
• Mecobalamine 500mcg/ 24 hours/ intravenous
• Ranitidine 150mg/ 12 hours/ intravenous
• Dexamethasone 5mg/ 6 hours/ IV (tapp off/ 3day)

Tropical Infection:
• Ciprofloxacine 200mg/ 12 hours/ intravenous Plan:
• Metronidazole 500mg/ 8 hours/ intravena Check toxoplasma serology
• Nystatin drops 10gtt/8 hours/ oral Consult to Psychiatry and Clinical nutrition
• N-Ace 200mg/ 8 hours/ oral
• Vit. C 200mg/ 12 hours/ intravenous
FOLLOW UP
 Day 2
S: No Fever, Right side weakness, Headache,
Speech indistincly, Restless Therapy
Inadequate oral intake  Infusion: Sodium Chloride 28 drops/ minute
O:  Citicholine 500mg/ 12 hours/ intravenous
GCS : E4M6V5, VAS: 4-5  Mecobalamine 500mcg/ 24 hours/ intravenous
Higher cortical function: disturbed  Ranitidine 150mg/ 12 hours/ intravenous
Cranial nerve: right abdusenc nerve palsy, central type right  Dexamethasone 5mg/ 6 hours/ IV Day 2 (tapp off/
Facialis and Hypoglossus palsy 3day)
Motoric function: strength Tropical Infection treatment:
1 5
 Ciprofloxacine 200mg/ 12 hours/ intravenous
1 5 (Day 8)
 Metronidazole 500mg/ 8 hours/ intravena (Day 8)
MMSE Result : 17 (probable cognitive imparement)  Nystatin drops 10gtt /8 hours/ oral (Day 2)
A:  N-Ace 200mg/ 8 hours/ oral
1. RIGHT HEMIPARESIS + MULTIPLE CRANIAL NERVE PALSY +  Mycamine 100mg/ 24 hours/ oral (Day 2)
CORTICAL HIGHER FUNCTION IMPAIRMENT ECAUSA
Plan:
SUSPEK TOXOPLASMOSIS
2. HIV INFECTION STAGE IV Check toxoplasma sereology
3. ORAL CANDIDIASIS Consult to Psychiatry and Clinical nutrition
4. COMMUNITED ACQUIRED PNEUMONIA
 Day 5
Therapy
S: No Headache and Fever ,  Infusion: Sodium Chloride 28 drops/ minute
Right side weakness (improvement),  Citicholine 500mg/ 12 hours/ intravenous
Speech indistincly, Restless  Mecobalamine 500mcg/ 24 hours/ intravenous
Inadequate oral intake  Ranitidine 150mg/ 12 hours/ intravenous
O:  Dexamethasone 5mg/ 8 hours/ IV Day 2 (tapp off/ 3day)
GCS : E4M6V5 Tropical Infection treatment:
 Cotrimoxazole 960mg/ 24 hours/ oral (Day 1)
Higher cortical function: disturbed
 Pyrimethamine loading 200mg continued 25mg/ 8 hours/ oral (Day 1)
Cranial nerve: right abdusenc nerve palsy, central  Clindamycin 600mg/ 6 hours/ oral (Day 1)
type right facialis and hypoglossus palsy  ARV triple adult 1 tablet/ 24 hours/ oral (Day 1)
Motoric function: strength 2 5  Folic acid 20mg/ 24 hours/ oral
 Nystatin drops 10gtt/8 hours/ oral (Day 5)
2 5  N-Ace 200mg/ 8 hours/ oral
A:  Vit. C 200mg/ 12 hours/ intravenous
1. TOXOPLASMOSIS CEREBRI Clinical nutrition treatment:
2. HIV INFECTION STAGE IV  Zinc 20mg/ 24 hours/ oral
 B. Complex 2 tablets/ 8 hours/ oral
3. ORAL CANDIDIASIS
 Curcuma 40mg/ 8 hours/ oral
4. COMMUNITED ACQUAIRED PNEUMONIA  Pujimin 2 Capsuls/ 8 hours/ oral
5. ORGANIC MENTAL DISORDER Psychiatry treatment:
6. MODERATE ENERGY PROTEIN MALNUTRITION Olanzapine 5mg ½ tablet/ 24 hours/ oral
 Day 9
Therapy
 Infusion: Sodium Chloride 28 drops/ minute
S: Right side weakness (improvement),  Citicholine 500mg/ 12 hours/ intravenous
Speech indistincly , Restlessness decreases,  Mecobalamine 500mcg/ 24 hours/ intravenous
Oral intake was good  Ranitidine 150mg/ 12 hours/ intravenous
O:  Dexamethasone 5mg/ 12 hours/ IV Day 3 (tapp off/ 3day)
GCS : E4M6V5 Tropical Infection treatment:
 Cotrimoxazole 960 mg/ 24 hours/ oral (Day 5)
Higher cortical function: disturbed
 Pyrimethamine 25mg/ 8 hours/ oral (Day 5)
Cranial nerve: right abdusenc nerve palsy, central  Clindamicin 600mg/ 6 hours/ oral (Day 5)
type right facialis and hypoglossus palsy  Nystatin drops 10 gtt/ 8 hours/oral (Day 9)
Motoric function: strength 4 5  N-Ace 200mg/ 8 hours/ oral
 Vit. C 200mg/ 12 hours/ intravenous
4 5  ARV triple adult 1 tablet/ 24 hours/ oral (Day 5)
A:  Folic acid 20mg/ 24 hours/ oral
1. TOXOPLASMOSIS CEREBRI Clinical nutrition treatment:
2. HIV INFECTION STAGE IV  Zinc 20mg/ 24 hours/ oral
3. ORAL CANDIDIASIS  B. Complex 2 tabs/ 8 hours/ oral
4. COMMUNITED ACQUAIRED PNEUMONIA  Curcuma 40mg/ 8 hours/ oral
 Pujimin 2 Caps/ 8 hours/ oral
5. ORGANIC MENTAL DISORDER
Psychiatry treatment:
6. MODERATE ENERGY PROTEIN MALNUTRITION
 Olanzapine 5mg ½ tablet/ 24 hours/ oral
 Day 14
S: Right side weakness (improvement)
Therapy
Speech indistincly (improvement)
Infusion: Sodium Chloride 28 drops/ minute
Oral intake was good Citicholine 500mg/ 12 hours/ intravenous
O:
Mecobalamine 500mcg/ 24 hours/ intravenous
GCS : E4M6V5
Ranitidine 150mg/ 12 hours/ intravenous
Higher cortical function: disturbed
Dexamethasone 0,5mg/ 8 hours/ oral
Cranial nerve: right abdusenc nerve palsy, central
Tropical Infection treatment:
type right facialis and hypoglossus palsy
Cotrimoxazole 960 mg/ 24 hours/ oral (Day 10)
Motoric function: strength 4 5 Pyrimethamine 25mg/ 8 hours/ oral (Day 10)
Clindamicin 600mg/ 6 hours/ oral (Day 10)
4 5
Nystatin drops 10 gtt/ 8 hours/oral (14)
A: N-Ace 200mg/ 8 hours/ oral
1. TOXOPLASMOSIS CEREBRI Vit. C 200mg/ 12 hours/ intravenous
2. HIV INFECTION STAGE IV
ARV triple adult 1 tablet/ 24 hours/oral (Day 10)
3. ORAL CANDIDIASIS
Folic acid 20mg/ 24 hours/ oral
4. COMMUNITED ACQUAIRED PNEUMONIA
Plan:
5. ORGANIC MENTAL DISORDER
The patient may go home and control in the outpatient
6. MODERATE ENERGY PROTEIN MALNUTRITION
Final Diagnosis

Clinical diagnosis
.
• Right Hemiparesis + Multiple Cranial Nerve Palsy + Cortical Higher Function Impairment

Topis diagnosis

• Left Cerebral Hemisphere

Etiological diagnosis

• Cerebral Toxoplasmosis + HIV Infection Stage 4

Secunder Diagnosis

• ORAL CANDIDIASIS
• COMMUNITED ACQUAIRED PNEUMONIA
• ORGANIC MENTAL DISORDER
• MODERATE ENERGY PROTEIN MALNUTRITION
DISCUSSION
HIV Infection
The human immunodeficiency virus (HIV) targets the immune system and weakens people's
defense  against many infections. As the virus destroys and impairs the function of immune
cells, infected individuals gradually become immunodeficient. HIV can be diagnosed by laboratory
criteria (HIV antibody testing with rapid or laboratory based enzyme immunoassay)

• Asymptomatic, Persistent Generalized Lymphadenopathy

1
• Weight Loss < 10% Total Body Weight, Recurrent Respiratory
2 Infection, Dermatology Disorder

• Weight Loss > 10% Total Body Weight, Prolonged Diarrhea Or

3 Fever (>1 Month), Oral Candidiasis, Pulmonary TB, etc

• Extrapulmonary TB, CNS Toxoplasmosis, Herpes Infec-tion, CMV

4 Encephalitis, Cryptococcal Meningitis, HIV Dementia, PML, etc

World Health Organization. Who Case Definitions Of HIV For Surveillance And Revised Clinical Staging And Immunological
Classification Of HIV-Related Disease In Adults And Children. In Switzerland: World Health Organization; 2007. p. 8.
Neurological Complication of HIV

Tan I. L., Smith B. R., et al. HIV-associated opportunistic infections of the CNS. Lancet Neurl. 2012;11(7):605–17
Definition

• Toxoplasmosis has been one of the most common causes of secondary

CNS infections in patients with AIDS.
• It is caused by Toxoplasma gondii, a tiny, obligate, intracellular parasite.
• RSCM in 2011 found the incidence of toxoplasmosis at 48.5% of all 470
cases of opportunistic infections in HIV.

Aninditha, Tiara. Buku Ajar Neurologi. Vol. 1. Jakarta: Fakultas Kedokteran Universitas Indonesia, 2017
Patogenesis

Life cycle of Toxoplasma gondii

Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, Seventh Edition.2003 
 Patogenesis

McCaffery, Jessica N. “A Multi-Stage Plasmodium Vivax Malaria Vaccine Candidate Able to Induce Long-Lived Antibody Responses Against Blood Stage Parasites and Robust
Transmission-Blocking Activity.” Frontiers in Cellular and Infection Microbiology 9 (May 1, 2019): 135. https://doi.org/10.3389/fcimb.2019.00135.
Clinical Manifestation

Headache

Hemiparesis

Fever

Decreased consciousness

Seizures

Other neurological deficits

Aninditha, Tiara. Buku Ajar Neurologi. Vol. 1. Jakarta: Fakultas Kedokteran Universitas Indonesia, 2017
Supporting Examination

RADIOLOGY
• Head CT scan with contrast
: Ring enhancing lesion
with surrounding edema
• Head MRI with contrast :
Multiple ring enhancing or
solid lesion in basal ganglia

BIOPSY SEROLOGY
• Definitive diagnosis Positive IgM or IgG
• Worsened response antibody indicates
or failed 2-4 weeks of T.gondii in serum
empiric therapy

PCR
Good specificity
and sensitivity
but high cost

Sugianto, Paulus, and A. Rizal. Modul Infeksi. Malang: Kelompok Studi Neuroinfeksi PERDOSSI, 2019
Radiology Examination

 Usually multifocal ring enhancing, but it

can also be a solid lesion.
 Located in the basal ganglia, thalamus,
gray/ white junction, cerebral cortex and

PV white matter.
 MRI
• The lesions are hypointense on T1
and hyperintense on T2- weighted
images.
• A significant amount of edema
surrounds the lesions, appearing as
T1 hypointensity and T2 hyperintensity.

Aminoff MJ, Josephson SA, editors. Aminoff’s neurology and general medicine. Fifth edition. Amesterdam: Elsevier/AP; 2014. 1368 p.
Diagnosis in this case

Neurological Serology: Ig G > 300 IU/ ml

examination:
• High cortical function
inpairment
• Multiple cranial CD4: 13 U/L
nerve palsy
• Decreased motor and
sensory function

Anamnesis:
• Right side weakness,
headache, speech indistincly
and restless
• History of HIV infection
Radiology:
Presumptive • CT scan brain without contras: Hypodens
lesion in the basal ganglia, internal
diagnosis of capsula, thalamus to the left side pons
Cerebral suggestive encephalitis DD/ SOL
• CT scan brain with contras:An abses in the
Toxoplasmosis left thalamus, size +/- 1,8 X 1,6 X 2,1 cm,
with sign of cerebritis
 Palliative therapy
with steroid

Algorithm management of intracranial lesions in people with HIV-AIDS

Sugianto, Paulus, and A. Rizal. Modul Infeksi. Malang: Kelompok Studi Neuroinfeksi PERDOSSI, 2019
Management
DRUG DOSAGE
Sulfadiazine 1-2gram/ 6 hours In this Case:
(Tablet:500mg)  Combined Pyrimethamine + Clindamycin: anti
Pyrimethamine 200 mg loading dose, toxoplasmosis
continued 50mg/day  Trimetoprin-sulfamethoxazole: primer profilaksis
(BW ≤ 60 kg), 75mg/  Folinac acid: reduce antifolac from pyrimethamine
day (BW >60kg)  Methyl prednisolone: reduce edema
(Tablet: 25 mg)  Ranitidine: gastroprotector
Clindamycin 600mg/ 6 hours  Citicholine and mecobalamine: neuroprotector
(Tablet: 300mg) and neurotropic
Folinac Acid 10-20mg/ day  ARV: HIV infection
(Tablet: 5-10mg)  N-Ace + Ciprofloxacine: CAP
Trimetoprin- 960mg/ 12 hours  Nystatin drop: oral candidiasis
sulfamethoxazole (Tablet: 480mg)
 Olanzapine: mental disorder

Aninditha, Tiara. Buku Ajar Neurologi. Vol. 1. Jakarta: Fakultas Kedokteran Universitas Indonesia, 2017
Prognosis

Toxoplasmosis has a good prognosis with a mortality rate of 1-25% in cases that
do not get handled properly

In patients with immune deficiency, there is a possibility of recurrence if

prophylactic treatment is stopped

This patient has a good prognosis because there are improvements in clinical
symptoms and motor strength

Sugianto, Paulus, and A. Rizal. Modul Infeksi. Malang: Kelompok Studi Neuroinfeksi PERDOSSI, 2019
Thank You