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Acute Confusional State: A Manifestation of Toxoplasma and CMV Co-infection in HIV Patient.

Jehangir W, Sareen R, Sen S, Raoof N, Yousif A - N Am J Med Sci (2014)

Bottom Line: Imaging studies that were performed after stabilizing the patient revealed a ring-enhancing lesion in the brain and after further testing, a diagnosis of reactivated T. gondii with co-infection with CMV was made.Patients infected with T. gondii that are already immune-compromised deteriorate rapidly and the disease diagnosis poses several challenges.Since our patient was not on the required prophylactic medication to prevent infection with T. gondii, it was imperative to start treatment in a timely manner and to monitor the patient for any further decline in functioning.

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine, Raritan Bay Medical Center, Perth Amboy, New Jersey, USA.

ABSTRACT

Context: When dealing with a patient with HIV that presents with an altered mental status, there are various infections and disease etiologies a physician has to rule out that may play a role in complicating the inherent complex nature of HIV. Toxoplasma gondii (T. gondii) and cytomegalovirus (CMV) affect a large part of the world's population and lead to a varied and broad symptomatology depending upon the severity of HIV, the CD4 count and how early the infection is diagnosed.

Case report: We report an HIV+ patient in his early 50s and with a low CD4 count that presented with severe lethargy and confusion. Imaging studies that were performed after stabilizing the patient revealed a ring-enhancing lesion in the brain and after further testing, a diagnosis of reactivated T. gondii with co-infection with CMV was made. Patients infected with T. gondii that are already immune-compromised deteriorate rapidly and the disease diagnosis poses several challenges.

Conclusion: Clinicians have to be extremely careful about making a prompt diagnosis and initiate treatment without delay before the infection takes a deadly toll on the patient. Since our patient was not on the required prophylactic medication to prevent infection with T. gondii, it was imperative to start treatment in a timely manner and to monitor the patient for any further decline in functioning.

No MeSH data available.


Related in: MedlinePlus

MRI of the brain showing ring-enhancing lesions, largest measuring up to 3.4 × 1.9 cm in the left superior frontal lobe
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Figure 3: MRI of the brain showing ring-enhancing lesions, largest measuring up to 3.4 × 1.9 cm in the left superior frontal lobe

Mentions: Initially, the patient was treated with intravenous (IV) Vancomycin and Zosyn after being admitted to the intensive care unit. IV folic acid and thiamine were administered after considering the fact that the patient had been abusing alcohol for a long time and alcohol detox protocol was added to prevent delirium tremens and agitative behavior. Patient was also started on therapeutic dose of Lovenox for pulmonary embolism. Lumbar puncture was performed, which showed cerebrospinal fluid (CSF) protein 96 mg/dl, glucose 65 mg/dl, Mononuc 99% and PMN 1%. Acyclovir was started suspecting for herpes encephalitis. Rapid HIV test came out positive; viral load and Phenosense were ordered. Serology for HIV was found to be positive and CD4 count was noted to be 13. Magnetic resonance imaging (MRI) of the brain was done, which showed multiple bilateral supratentorial and infratentorial ring-enhancing lesions, measuring up to 3.4 × 1.9 cm in the left frontal lobe with extensive amount of vasogenic edema surrounding these lesions with a 4 mm rightward midline shift. These lesions exhibit peripheral ring-like low diffusivity, corresponding to the area of enhancement, without central low diffusivity, which is suspicious for toxoplasmosis [Figure 3]. Taking midline shift and saddle pulmonary embolism into consideration, the patient was transferred to a tertiary care center where he was found to be positive for CMV in CSF and T. gondii via PCR. He was treated with embolectomy for pulmonary embolism and CMV, and toxoplasmosis with resolution of his symptoms. He is currently being followed in our HIV clinic for HIV/AIDS management.


Acute Confusional State: A Manifestation of Toxoplasma and CMV Co-infection in HIV Patient.

Jehangir W, Sareen R, Sen S, Raoof N, Yousif A - N Am J Med Sci (2014)

MRI of the brain showing ring-enhancing lesions, largest measuring up to 3.4 × 1.9 cm in the left superior frontal lobe
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4215495&req=5

Figure 3: MRI of the brain showing ring-enhancing lesions, largest measuring up to 3.4 × 1.9 cm in the left superior frontal lobe
Mentions: Initially, the patient was treated with intravenous (IV) Vancomycin and Zosyn after being admitted to the intensive care unit. IV folic acid and thiamine were administered after considering the fact that the patient had been abusing alcohol for a long time and alcohol detox protocol was added to prevent delirium tremens and agitative behavior. Patient was also started on therapeutic dose of Lovenox for pulmonary embolism. Lumbar puncture was performed, which showed cerebrospinal fluid (CSF) protein 96 mg/dl, glucose 65 mg/dl, Mononuc 99% and PMN 1%. Acyclovir was started suspecting for herpes encephalitis. Rapid HIV test came out positive; viral load and Phenosense were ordered. Serology for HIV was found to be positive and CD4 count was noted to be 13. Magnetic resonance imaging (MRI) of the brain was done, which showed multiple bilateral supratentorial and infratentorial ring-enhancing lesions, measuring up to 3.4 × 1.9 cm in the left frontal lobe with extensive amount of vasogenic edema surrounding these lesions with a 4 mm rightward midline shift. These lesions exhibit peripheral ring-like low diffusivity, corresponding to the area of enhancement, without central low diffusivity, which is suspicious for toxoplasmosis [Figure 3]. Taking midline shift and saddle pulmonary embolism into consideration, the patient was transferred to a tertiary care center where he was found to be positive for CMV in CSF and T. gondii via PCR. He was treated with embolectomy for pulmonary embolism and CMV, and toxoplasmosis with resolution of his symptoms. He is currently being followed in our HIV clinic for HIV/AIDS management.

Bottom Line: Imaging studies that were performed after stabilizing the patient revealed a ring-enhancing lesion in the brain and after further testing, a diagnosis of reactivated T. gondii with co-infection with CMV was made.Patients infected with T. gondii that are already immune-compromised deteriorate rapidly and the disease diagnosis poses several challenges.Since our patient was not on the required prophylactic medication to prevent infection with T. gondii, it was imperative to start treatment in a timely manner and to monitor the patient for any further decline in functioning.

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine, Raritan Bay Medical Center, Perth Amboy, New Jersey, USA.

ABSTRACT

Context: When dealing with a patient with HIV that presents with an altered mental status, there are various infections and disease etiologies a physician has to rule out that may play a role in complicating the inherent complex nature of HIV. Toxoplasma gondii (T. gondii) and cytomegalovirus (CMV) affect a large part of the world's population and lead to a varied and broad symptomatology depending upon the severity of HIV, the CD4 count and how early the infection is diagnosed.

Case report: We report an HIV+ patient in his early 50s and with a low CD4 count that presented with severe lethargy and confusion. Imaging studies that were performed after stabilizing the patient revealed a ring-enhancing lesion in the brain and after further testing, a diagnosis of reactivated T. gondii with co-infection with CMV was made. Patients infected with T. gondii that are already immune-compromised deteriorate rapidly and the disease diagnosis poses several challenges.

Conclusion: Clinicians have to be extremely careful about making a prompt diagnosis and initiate treatment without delay before the infection takes a deadly toll on the patient. Since our patient was not on the required prophylactic medication to prevent infection with T. gondii, it was imperative to start treatment in a timely manner and to monitor the patient for any further decline in functioning.

No MeSH data available.


Related in: MedlinePlus