HIV Y TOXOPLASMOSIS CEREBRAL A PROPÓSITO DE UN CASO

Introducción: En Ecuador al igual que en el resto del mundo la infección por virus de inmunodeficiencia humana (VIH) constituye un problema de salud pública, con diagnósticos tardíos en fase avanzada del síndrome de inmunodeficiencia adquirida (SIDA), con toxoplasmosis cerebral una de las infecciones oportunistas más frecuentes que ocurre en pacientes con linfocitos CD4<200/µL. Objetivo: realizar diagnóstico precoz de toxoplasmosis cerebral en pacientes con SIDA y considerar como una verdadera emergencia a fin de disminuir la mortalidad de los pacientes inmunosuprimidos. Caso clínico: paciente de género masculino de 31 años, con antecedente de infección por HIV diagnosticado hace 19 días, con convulsiones tónico-clónicas generalizadas de tres meses de evolución, cefalea holocraneana de moderada intensidad, parestesias en hemicara derecha, asimetría comisura labial, tres días antes de su ingreso las crisis convulsivas se hacen diarias, repetitivas y se acompañan de fiebre, al examen físico disartria leve y monoparesia del miembro superior derecho, con biometría hemática con leucocitos 5270 mm3, IgG positiva anti-Toxoplasma gondii, linfocitosis discreta, pruebas de cuarta y tercera generación para HIV positivas, CD4 de 74/mm3, carga viral de 61500 copias/ml, resonancia magnética nuclear cerebral contrastada con lesiones intra-axilares corticales, con área hipointensa central, a nivel del lóbulo parietal izquierdo y occipital bilateral, se establece el diagnóstico de encefalitis toxoplásmica, indicándose tratamiento con trimetropin/cotrimoxazol, dexametosona y fármacos antirretrovirales con abacavir-lamivudina y lopinavir-ritonavir teniendo una buena evolución clínica. Conclusiones: El diagnóstico precoz de encefalitis toxoplásmica basado en criterios epidemiológicos, clínicos, de laboratorio y a la resonancia magnética, permitió buena respuesta al tratamiento empírico antitoxoplásmico. Palabras claves: Toxoplasmosis, infecciones oportunistas, encefalitis ABSTRACT Introduction: In Ecuador, as in the rest of the world, human immunodeficiency virus (HIV) infection constitutes a public health problem, with late diagnoses in an advanced phase of acquired immunodeficiency syndrome (AIDS), with cerebral toxoplasmosis one of the more frequent opportunistic infections that occur in patients with CD4 lymphocytes <100 / µL. Objective: to make an early diagnosis of cerebral toxoplasmosis in patients with AIDS and to consider it as a true emergency in order to reduce the mortality of immunosuppressed patients. Clinical case: a 31-year-old male patient, with generalized tonic-clonic seizures of three months of evolution, moderate intensity holocranial headache, paresthesia in the right side of the face, asymmetry of the labial commissure, three days before admission the seizures become daily, frequent and accompanied by fever, on physical examination mild dysarthria and monoparesis of the right upper limb, with hematic biometry with leukocytes 5270 mm3, discrete lymphocytosis, fourth and third generation tests for HIV positive, CD4 of 74 / mm3, viral load of 61,500 copies / ml, brain nuclear magnetic resonance with cortical intra-axillary lesions, with a central hypointense area, at the level of the left parietal lobe and bilateral occipital, the diagnosis of toxoplasmic encephalitis is established, indicating treatment with trimethropin / cotrimoxazole, dexamethasone and antiretroviral drugs with abacavir-lamivudine and lopinavir-ritonavir having a good clinical evolution. Conclusions: The early diagnosis of toxoplasmic encephalitis based on epidemiological, clinical, laboratory and magnetic resonance criteria, allowed a good response to empirical antitoxoplasmic treatment. Keywords: Toxoplasmosis, opportunistic infections, encephalitis

Risk factors of cerebral toxoplasmosis in HIV patients: A systematic review

Introduction. Cerebral toxoplasmosis is one of the diseases of the central nervous system that can occur in people with AIDS. Cerebral toxoplasmosis occupies third place among fatal diseases that can occur in people with AIDS. Prevalence of toxoplasmosis is about 25-30% of the world’s human population, and in Asia it is as high as 40%. Risk factors for developing cerebral toxoplasmosis is needed to be sought to to find out risk factors that triggers and acts as protective factors for toxoplasmosis cerebral in HIV-positive patients Methods. Two reviewers searched PubMed and Medline to identify cohort, case-control and cross-sectional studies. Two independent reviewers searched the databases, identified studies and extracted data. Inclusion and exclusion criteria were applied for the data screening. Results. Four studies were included. Two prospective cohort studies, one multicenter cohort study and one case control study. Age was not found to have a role as a risk factor. Gender was shown to have significant in one study (Male vs female OR 0.47 95% CI 0.25-0.88, p = 0.02). CD4 <100 increased the risk of toxoplasmosis by 27.94 times, while CD4 0-50 increased the risk by 10.82 times. HIV viral load > 100.000 was associated with 5.10 times higher to develop cerebral toxoplasma. Prophylaxis therapy using cotrimoxazole can reduce the risk of cerebral toxoplasmosis. Conclusion. Age, female sex, low CD4 cell count, and high HIV viral load increase the risk of cerebral toxoplasmosis, whereas ART therapy and prophylaxis with cotrimoxazole can reduce the risk.

Detection and treatment of cerebral toxoplasmosis in an aplastic pediatric post-allogeneic hematopoietic cell transplant patient: a case report

Background Cerebral toxoplasmosis infection presents with non-specific neurologic symptoms in immunocompromised patients. With lack of measurable adaptive immune responses and reluctance to sample affected brain tissue, expedient diagnosis to guide directed treatment is often delayed. Case presentation We describe the use of cerebrospinal fluid polymerase chain reaction and plasma cell-free DNA technologies to supplement neuroimaging in the diagnosis of cerebral toxoplasmosis in an immunocompromised pediatric patient following allogeneic hematopoietic cell transplantation for idiopathic severe aplastic anemia. Successful cerebral toxoplasmosis treatment included antibiotic therapy for 1 year following restoration of cellular immunity with an allogeneic stem cell boost. Conclusions Plasma cell-free DNA technology provides a non-invasive method of rapid diagnosis, improving the likelihood of survival from often lethal opportunistic infection in a high risk, immunocompromised patient population.

Social preference is maintained in mice with impaired startle reflex and glutamate/D-serine imbalance induced by chronic cerebral toxoplasmosis

Toxoplasma gondii is an opportunistic protozoan pathogen with a wide geographic distribution. The chronic phase of toxoplasmosis is often asymptomatic in humans and is characterized by tissue cysts throughout the central nervous system and muscle cells. T. gondii and other pathogens with tropism for the central nervous system are considered risk factors in the etiology of several neuropsychiatric disorders, such as schizophrenia and bipolar disorder, besides neurological diseases. Currently, it is known that cerebral toxoplasmosis increases dopamine levels in the brain and it is related to behavioral changes in animals and humans. Here we evaluate whether chronic T. gondii infection, using the cystogenic ME-49 strain, could induce behavioral alterations associated with neuropsychiatric disorders and glutamatergic neurotransmission dysfunction. We observed that the startle amplitude is reduced in the infected animals as well as glutamate and D-serine levels in prefrontal cortical and hippocampal tissue homogenates. Moreover, we did not detect alterations in social preference and spontaneous alternation despite severe motor impairment. Thus, we conclude that behavioral and cognitive aspects are maintained even though severe neural damage is observed by chronic infection of C57Bl/6 mice with the ME-49 strain.

Anisocoria, An Unusual Physical Exam Finding Leading to a Concurrent Diagnosis of Cerebral Toxoplasmosis and HIV/AIDS

Cerebral toxoplasmosis is the most common opportunistic central nervous system (CNS) infection, affecting patients with advanced/untreated acquired immunodeficiency syndrome (AIDS). Cerebral toxoplasmosis is caused by the parasite Toxoplasma gondii typically and it usually occurs in immunecompromised patients with a CD4 count below 100cell/microL [1,2]. Left untreated, symptomatic patients can progress to coma within days to weeks, significantly increasing rates of this population’s morbidity and mortality. Cerebral toxoplasmosis is rarely encountered before the diagnosis of HIV infection is established, which is why seemingly benign neurological complaints can be easily overlooked.

Clinical and prognostic features of cerebral toxoplasmosis in HIV-infected patients in Lubumbashi, Democratic Republic of the Congo

Introduction: Cerebral toxoplasmosis is the main opportunistic infection of the central nervous system (CNS) during in human immunodeficiency virus (HIV)-infection. The purpose of this study is to describe current epidemiologic, clinical, diagnostic, and prognostic features of cerebral toxoplasmosis during HIV-infection in hospital setting in Lubumbashi. Methods: This descriptive and analytic study examined the records of 21 HIV-positive patients with cerebral toxoplasmosis. Data were collected over 36 months (from January 2015 to December 2017) at the HIV/AIDS Center of Excellence in Lubumbashi (Democratic Republic of the Congo). Results: Twenty-one patients on 4,283 followed for HIV-infection completed the diagnostic criteria (a prevalence of 0.5%) with a sex ratio (M / F) of 1.3 and a mean age of 41.0±6 years. Major clinical manifestations were fever (100%), headaches (100%), motor deficit (61.9%), intracranial hypertension (47.6%), seizures (47.6%), and disorders of consciousness (42.9%). Cerebral imaging studies (4 Computed tomography scan) were performed and showed hypodensities with peripheral enhancement by cockade in 75% of the cases. The mean CD4 T-cell counts was 180.6±161.9 cells / mm3. Co-trimoxazole was the main anti-toxoplasma drug in all cases. The lethality rate was 42.9%. Conclusion: Early detection and primary prevention in HIV-infected patients remain essential to improve the prognosis and survival of these patients.

Autoantibodies Against Ubiquitous and Confined Antigens in Patients With Ocular, Neuro-Ophthalmic and Congenital Cerebral Toxoplasmosis

Toxoplasma gondii infection can trigger autoreactivity by different mechanisms. In the case of ocular toxoplasmosis, disruption of the blood-retinal barrier may cause exposure of confined retinal antigens such as recoverin. Besides, cross-reactivity can be induced by molecular mimicry of parasite antigens like HSP70, which shares 76% identity with the human ortholog. Autoreactivity can be a determining factor of clinical manifestations in the eye and in the central nervous system. We performed a prospective observational study to determine the presence of autoantibodies against recoverin and HSP70 by indirect ELISA in the serum of 65 patients with ocular, neuro-ophthalmic and congenital cerebral toxoplasmosis. We found systemic autoantibodies against recoverin and HSP70 in 33.8% and 15.6% of individuals, respectively. The presence of autoantibodies in cases of OT may be related to the severity of clinical manifestations, while in cases with CNS involvement they may have a protective role. Unexpectedly, anti-recoverin antibodies were found in patients with cerebral involvement, without ocular toxoplasmosis; therefore, we analyzed and proved cross-reactivity between recoverin and a brain antigen, hippocalcin, so the immunological phenomenon occurring in one immune-privileged organ (e.g. the central nervous system) could affect the environment of another (egg. the eye).