Cerebral toxoplasmosis with neurological co-infection in people living with AIDS/HIV: results of a prospective cohort in São Paulo, Brazil

Abstract

Background Concomitant neurological diseases in people living with HIV/AIDS (PLWHA) is a challenging subject that has been insufficiently evaluated by prospective clinical studies. The goal of the present study was to identify the clinical characteristics and outcomes of PLWHA with cerebral toxoplasmosis and neurological co-infections. Methods We conducted a prospective observational cohort study at a tertiary teaching center in São Paulo, Brazil, from January to July 2017. Hospitalized PLWHA aged ≥ 18 years with cerebral toxoplasmosis were consecutively enrolled. A standardized neurological examination was performed at admission and weekly until discharge or death. Diagnosis and treatment followed institutional routines; neuroradiology, molecular diagnosis, neurosurgery, and the intensive care unit (ICU) were available. The main outcomes were neurological coinfections and in-hospital death. Results We included 44 (4.3%) cases among 1,032 hospitalized patients. The median age was 44 (interquartile range [IQR]: 35–50) years, and 50% (n = 22) of the patients were male. The median CD4+ T lymphocyte count was of 50 (IQR: 15–94) cells/mm3. Multiple lesions on computed tomography were present in 59% of the cases. Neurological coinfections were diagnosed in 20% (n = 9) of the cases, and cytomegalovirus was the most common etiology (encephalitis: n = 3; polyradiculopathy: n = 2). Longer hospital stays (30 versus 62 days; p = 0.021) and a higher rate of ICU admissions (14% versus 44%; p = 0.045) were observed among PLWHA with neurological coinfections in comparison to those without them. The rate of in-hospital mortality was of 13.6% (n = 6) (coinfection group: 33%; no coinfection group: 8.6%; p = 0.054). Conclusion Neurological c-infections were common among PLWHA with cerebral toxoplasmosis, and cytomegalovirus was the main copathogen. The group of PLWHA with neurological co-infections underwent longer hospital stays and more frequent intensive care unit admissions. Additionally, this group of patients tended to have higher in-hospital mortality rate.

Cytomegalovirus retinitis in hospitalized people living with HIV in the late antiretroviral therapy era in São Paulo, Brazil

“…Of 65 studies ( n = 20 280 PLWHIV), only 5 studies ( n = 2836 patients) were from Latin America. 20 Low prevalence of CMV retinitis was reported in Latin America (<5% in Brazil and Peru) 20,27 and in Africa (<3%) 24 in the ART era. In contrast, maintenance of high prevalence has been reported in Asia (∼15%).…”

Case Report: Calcified Cerebral Toxoplasmosis Associated with Perilesional Edema in People Living with HIV/AIDS: Case Series of a Presentation Mimicking Neurocysticercosis

“…In contrast, cerebral toxoplasmosis continues to be the most common neurological opportunistic disease at Instituto de Infectologia Em ılio Ribas, São Paulo, Brazil, representing 36% of all hospitalized patients in a recent prospective observational cohort study. 9 In this study, only one (0.8%) case of neurocysticercosis was identified in PLWHA. Neurocysticercosis and HIV infection are endemic in South America and a potential interaction was expected.…”

Molecular diagnosis of opportunistic infections in the central nervous system of HIV-infected adults in Manaus, Amazonas

“…Similarly, a Ghana study reported 25% (21/84) of HIV-positive patients testing positive for T. gondii through molecular diagnosis ( 24 ). Telles et al ( 16 ) found T. gondii as the most commonly detected pathogen in CSF samples (36%) in a São Paulo study. Frequent neurological manifestations in patients with confirmed T. gondii DNA included headache (66.7%), limb paresis (28.5%), lowered levels of consciousness, aphasia (23.8%), and seizures (19%).…”

“…For people with HIV, their AIDS status is closely linked to opportunistic infections that can induce neurological diseases. Despite the widespread distribution of ART in Brazil, there persists a notable prevalence of opportunistic neurological diseases ( 16 ). Our study revealed that 36.7% of cerebrospinal fluid samples from HIV-positive patients with neurological manifestations contained opportunistic pathogens.…”

“…A study in São Paulo’s reference center reported a 2.4% (6/248) prevalence of cytomegalovirus detection, defining them as CMV encephalitis patients with CD4+ T-cell counts <50 cells/mm 3 ( 29 ). Another prospective observational cohort study in a Brazilian tertiary health center, involving 105 PLWHA, identified CMV as the third most frequent pathogen (12%), responsible for encephalitis, polyradiculitis, and/or retinitis ( 16 ).…”