Original article | Volume 26, Article 185, 30 Mar 2017 | 10.11604/pamj.2017.26.185.9127

Ring enhancing lesions in the brain of an HIV infected patient: a diagnostic challenge

Joe James, Nallaveettil Kesavan Thulaseedharan

Corresponding author: Joe James, Department of Internal Medicine,Government Medical College Kozhikode

Received: 15 Feb 2016 - Accepted: 23 Feb 2016 - Published: 30 Mar 2017

Domain: Clinical medicine

Keywords: Cerebral toxoplasmosis, magnetic resonance imaging, HIV, basal ganglia, mild cognitive impairment, gait apraxia

©Joe James et al. Pan African Medical Journal (ISSN: 1937-8688). This is an Open Access article distributed under the terms of the Creative Commons Attribution International 4.0 License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Cite this article: Joe James et al. Ring enhancing lesions in the brain of an HIV infected patient: a diagnostic challenge. Pan African Medical Journal. 2017;26:185. [doi: 10.11604/pamj.2017.26.185.9127]

Available online at: https://www.panafrican-med-journal.com/content/article/26/185/full

Home | Volume 26 | Article number 185

Original article

Ring enhancing lesions in the brain of an HIV infected patient: a diagnostic challenge

Ring enhancing lesions in the brain of an HIV infected patient: a diagnostic challenge

Joe James1,&, Nallaveettil Kesavan Thulaseedharan1

 

1Department of Internal Medicine,Government Medical College Kozhikode

 

 

&Corresponding author
Joe James, Department of Internal Medicine,Government Medical College Kozhikode

 

 

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A 58-year old male presented with headache, unsteadiness of gait and cognitive decline in the form of loss of recent memory of 1-month duration. He also reported significant loss of weight. Neurological examination revealed short term memory loss and gait apraxia. There were no cerebellar signs or sensorimotor deficits. He was tested positive for HIV. MRI showed T2-FLAIR hyperintense lesions with edema in the left centrum semiovale (A), right basal ganglia (B) and right frontal corticomedullary junction (C). The corresponding lesions in T1 after gadolinium showed ring enhancement (D-F). His CD4 count was 70/µL. Serum IgG Toxoplasma was positive. He was started on pyrimethamine with sulfadiazine and anti-retroviral treatment and discharged. Toxoplasmosis is a parasitic infection caused by Toxoplasma gondii. CNS Toxoplasmosis is an important differential diagnosis in HIV patients presenting with neurological symptoms. Common presentations are headache, seizures, focal neurological deficits like hemiparesis or aphasia, and altered sensorium. Toxoplasmosis in AIDS is due to reactivation of previously acquired infection as immunity wanes, almost always when CD4 count is less than 100/µL. Multiple ring enhancing lesions in the corticomedullary junctions of frontal and parietal lobe, centrum semiovale and basal ganglia with edema and mass effect in an HIV patient is virtually diagnostic of toxoplasmosis. Ring enhancing lesions in the brain can also be seen in primary CNS lymphoma which often causes diagnostic confusion. An isolated ring enhancing lesion larger than 4cm in size or a positive serology for Ebstein-Barr virus in CSF favors lymphoma over toxoplasmosis.

 

 

Figure 1: MRI Brain in CNS Toxoplasmosis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Original article

Ring enhancing lesions in the brain of an HIV infected patient: a diagnostic challenge

Original article

Ring enhancing lesions in the brain of an HIV infected patient: a diagnostic challenge

Original article

Ring enhancing lesions in the brain of an HIV infected patient: a diagnostic challenge

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Cerebral toxoplasmosis

Magnetic resonance imaging

HIV

Basal ganglia

Mild cognitive impairment

Gait apraxia

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