Cerebral Toxoplasmosis in a patient with Pneumocystis: a case report
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Abstract
Acquired Immune Deficiency Syndrome, or AIDS, is characterized by a clinical condition in which the body's defenses suffer a gradual depletion, making it susceptible to a wide variety of infections. Among these, neurotoxoplasmosis is a characteristic opportunistic infection caused by Toxoplasma gondii. This infection generates numerous neurological deficits that can regress if early diagnosis and intervention are carried out. However, underdiagnosis of these cases due to incorrect management or inaccurate diagnosis leads to damaging and permanent results due to the expansive nature of the mass, which affects a wide range of organic functions. It is then associated with infection by Pneumocystis jirovecii, also characteristic of immunodeficient patients, demonstrating a synergism between the mechanisms that facilitate the infectious process. Because of the seriousness of these infections and their association, a clinical picture like this must be well visualized.
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References
Garcia HH. Parasitic Infections of the Nervous System. Continuum (Minneap Minn). 2021 Aug 1;27(4):943-962. doi: 10.1212/CON.0000000000000986. PMID: 34623099; PMCID: PMC8805156.
Ayoade F, Joel Chandranesan AS. HIV-1 Associated Toxoplasmosis. 2021 Sep 18. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–. PMID: 28722907.
Araujo, IR et al. Déficits motores e preditores de perda de mobilidade ao final da internação em indivíduos com neurotox-oplasmose. Fisioterapia e Pesquisa [online]. 2019, v. 26, n. 4, pp. 360-365. Disponível em: <https://doi.org/10.1590/1809-2950/18017926042019>. Epub 02 Dez 2019. ISSN 2316-9117. https://doi.org/10.1590/1809-2950/18017926042019.
Marcus C, Feizi P, Hogg J, et al. Imaging in Differentiating Cerebral Toxoplasmosis and Primary CNS Lymphoma With Special Focus on FDG PET/CT. AJR Am J Roentgenol. 2021;216(1):157-164. doi:10.2214/AJR.19.22629
Giovane RA, Lavender PD. Central Nervous System Infections. Prim Care. 2018 Sep;45(3):505-518. doi: 10.1016/j.pop.2018.05.007. Epub 2018 Jul 9. PMID: 30115337.
Abbasi Fard S, Khajeh A, Khosravi A, et al. Fulminant and Diffuse Cerebral Toxoplasmosis as the First Manifestation of HIV Infection: A Case Presentation and Review of the Literature. Am J Case Rep. 2020;21:e919624. Published 2020 Jan 26. doi:10.12659/AJCR.919
Marcus C, Feizi P, Hogg J, et al. Imaging in Differentiating Cerebral Toxoplasmosis and Primary CNS Lymphoma With Special Focus on FDG PET/CT. AJR Am J Roentgenol. 2021;216(1):157-164.
Elsheikha HM, Marra CM, Zhu XQ. Epidemiology, Pathophysiology, Diagnosis, and Management of Cerebral Toxoplasmosis. Clin Microbiol Rev. 2020;34(1):e00115-19. Published 2020 Nov 25. doi:10.1128/CMR.00115-19
Kaplan JE, Benson C, Holmes KK, et al. Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. MMWR Recomm Rep. 2009;58(RR-4):1-CE4.
Garcia HH. Parasitic Infections of the Nervous System. Continuum (Minneap Minn). 2021;27(4):943-962. doi:10.1212/CON.0000000000000986
Wang, Huiying, et al. "The imaging diagnostic criteria of AIDS-related cerebral toxoplasmosis in China." Radiology of In-fectious Diseases 7.3 (2020): 85-90.
Yenilmez E, Çetinkaya RA. Difference in Toxoplasma gondii Seroprevalence Rates Due to Low and High CD4 Counts in Patients with HIV/AIDS. Turkiye Parazitol Derg. 2019 Oct 7;43(Suppl 1):1-7. doi: 10.4274/tpd.galenos.2019.6457. PMID: 31587535.
Hryzhak IH. Invasion with Toxoplasma gondii can promote pneumocystis pneumonia in individuals with HIV/AIDS. Folia Parasitol (Praha). 2021 Jul 7;68:2021.018. doi: 10.14411/fp.2021.018. PMID: 34279242.
Mendez OA, Koshy AA. Toxoplasma gondii: Entry, association, and physiological influence on the central nervous system. PLoS Pathog. 2017 Jul 20;13(7):e1006351. doi: 10.1371/journal.ppat.1006351. PMID: 28727854; PMCID: PMC5519211.
BRASIL. Protocolo Clínico e Diretrizes Terapêuticas para Manejo da Infecção pelo HIV em Adultos. Brasília: Ministério da Saúde, 2018. 412 p. ISBN 978-85-334-2640-5
Vidal J. E. (2019). HIV-Related Cerebral Toxoplasmosis Revisited: Current Concepts and Controversies of an Old Disease. Journal of the International Association of Providers of AIDS Care, 18, 2325958219867315. https://doi.org/10.1177/2325958219867315
Luft, B. J., Conley, F., Remington, J. S., Laverdiere, M., Wagner, K. F., Levine, J. F., Craven, P. C., Strandberg, D. A., File, T. M., Rice, N., & Meunier-Carpentier, F. (1983). Outbreak of central-nervous-system toxoplasmosis in western Europe and North America. Lancet (London, England), 1(8328), 781–784. https://doi.org/10.1016/s0140-6736(83)91847-0
Vilaseca, J., Arnau, J. M., Bacardi, R., Mieras, C., Serrano, A., & Navarro, C. (1982). Kaposi's sarcoma and toxoplasma gondii brain abscess in a Spanish homosexual. Lancet (London, England), 1(8271), 572. https://doi.org/10.1016/s0140-6736(82)92086-4
Centers for Disease Control (CDC) (1982). Opportunistic infections and Kaposi's sarcoma among Haitians in the United States. MMWR. Morbidity and mortality weekly report, 31(26), 353–361.
Schlüter, D., & Barragan, A. (2019). Advances and Challenges in Understanding Cerebral Toxoplasmosis. Frontiers in im-munology, 10, 242. https://doi.org/10.3389/fimmu.2019.00242
Churchill, M., & Nath, A. (2013). Where does HIV hide? A focus on the central nervous system. Current opinion in HIV and AIDS, 8(3), 165–169. https://doi.org/10.1097/COH.0b013e32835fc601
Bednar, M. M., Sturdevant, C. B., Tompkins, L. A., Arrildt, K. T., Dukhovlinova, E., Kincer, L. P., & Swanstrom, R. (2015). Compartmentalization, Viral Evolution, and Viral Latency of HIV in the CNS. Current HIV/AIDS reports, 12(2), 262–271. https://doi.org/10.1007/s11904-015-0265-9
Montoya, J. G., & Liesenfeld, O. (2004). Toxoplasmosis. Lancet (London, England), 363(9425), 1965–1976. https://doi.org/10.1016/S0140-6736(04)16412-X
Wang, Z. D., Wang, S. C., Liu, H. H., Ma, H. Y., Li, Z. Y., Wei, F., Zhu, X. Q., & Liu, Q. (2017). Prevalence and burden of Toxo-plasma gondii infection in HIV-infected people: a systematic review and meta-analysis. The lancet. HIV, 4(4), e177–e188. https://doi.org/10.1016/S2352-3018(17)30005-X
Pappas, G., Roussos, N., & Falagas, M. E. (2009). Toxoplasmosis snapshots: global status of Toxoplasma gondii seroprevalence and implications for pregnancy and congenital toxoplasmosis. International journal for parasitology, 39(12), 1385–1394. https://doi.org/10.1016/j.ijpara.2009.04.003
Antinori, A., Larussa, D., Cingolani, A., Lorenzini, P., Bossolasco, S., Finazzi, M. G., Bongiovanni, M., Guaraldi, G., Grisetti, S., Vigo, B., Gigli, B., Mariano, A., Dalle Nogare, E. R., De Marco, M., Moretti, F., Corsi, P., Abrescia, N., Rellecati, P., Castagna, A., Mussini, C., … Italian Registry Investigative NeuroAIDS (2004). Prevalence, associated factors, and prognostic determinants of AIDS-related toxoplasmic encephalitis in the era of advanced highly active antiretroviral therapy. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, 39(11), 1681–1691. https://doi.org/10.1086/424877
d'Arminio Monforte, A., Cinque, P., Mocroft, A., Goebel, F. D., Antunes, F., Katlama, C., Justesen, U. S., Vella, S., Kirk, O., Lundgren, J., & EuroSIDA Study Group (2004). Changing incidence of central nervous system diseases in the EuroSIDA cohort. Annals of neurology, 55(3), 320–328. https://doi.org/10.1002/ana.10827
Coelho, L., Cardoso, S. W., Amancio, R. T., Moreira, R. I., Campos, D. P., Veloso, V. G., Grinsztejn, B., & Luz, P. M. (2014). Trends in AIDS-defining opportunistic illnesses incidence over 25 years in Rio de Janeiro, Brazil. PloS one, 9(6), e98666. https://doi.org/10.1371/journal.pone.0098666
Luft, B. J., Hafner, R., Korzun, A. H., Leport, C., Antoniskis, D., Bosler, E. M., Bourland, D. D., 3rd, Uttamchandani, R., Fuhrer, J., & Jacobson, J. (1993). Toxoplasmic encephalitis in patients with the acquired immunodeficiency syndrome. Members of the ACTG 077p/ANRS 009 Study Team. The New England journal of medicine, 329(14), 995–1000. https://doi.org/10.1056/NEJM199309303291403
Vidal, J. E., Hernandez, A. V., de Oliveira, A. C., Dauar, R. F., Barbosa, S. P., Jr, & Focaccia, R. (2005). Cerebral toxoplasmosis in HIV-positive patients in Brazil: clinical features and predictors of treatment response in the HAART era. AIDS patient care and STDs, 19(10), 626–634. https://doi.org/10.1089/apc.2005.19.626
Jellinger, K. A., Setinek, U., Drlicek, M., Böhm, G., Steurer, A., & Lintner, F. (2000). Neuropathology and general autopsy findings in AIDS during the last 15 years. Acta neuropathologica, 100(2), 213–220. https://doi.org/10.1007/s004010000245
Silva, A. C., Rodrigues, B. S., Micheletti, A. M., Tostes, S., Jr, Meneses, A. C., Silva-Vergara, M. L., & Adad, S. J. (2012). Neu-ropathology of AIDS: An Autopsy Review of 284 Cases from Brazil Comparing the Findings Pre- and Post-HAART (Highly Active Antiretroviral Therapy) and Pre- and Postmortem Correlation. AIDS research and treatment, 2012, 186850. https://doi.org/10.1155/2012/186850
Evaluation and management of intracranial mass lesions in AIDS. Report of the Quality Standards Subcommittee of the American Academy of Neurology. (1998). Neurology, 50(1), 21–26. https://doi.org/10.1212/wnl.50.1.21.