Cerebral Toxoplasmosis Mimicking Subacute Meningitis in HIV-Infected Patients; a Cohort Study from Indonesia

Abstract

BackgroundHIV-associated subacute meningitis is mostly caused by tuberculosis or cryptococcosis, but often no etiology can be established. In the absence of CT or MRI of the brain, toxoplasmosis is generally not considered as part of the differential diagnosis.Methodology/Principal FindingsWe performed cerebrospinal fluid real time PCR and serological testing for Toxoplasma gondii in archived samples from a well-characterized cohort of 64 HIV-infected patients presenting with subacute meningitis in a referral hospital in Indonesia. Neuroradiology was only available for 6 patients.At time of presentation, patients mostly had newly diagnosed and advanced HIV infection (median CD4 count 22 cells/mL), with only 17.2% taking ART, and 9.4% PJP-prophylaxis. CSF PCR for T. Gondii was positive in 21 patients (32.8%). Circulating toxoplasma IgG was present in 77.2% of patients tested, including all in whom the PCR of CSF was positive for T. Gondii. Clinically, in the absence of neuroradiology, toxoplasmosis was difficult to distinguish from tuberculosis or cryptococcal meningitis, although CSF abnormalities were less pronounced. Mortality among patients with a positive CSF T. Gondii PCR was 81%, 2.16-fold higher (95% CI 1.04–4.47) compared to those with a negative PCR.Conclusions/SignificanceToxoplasmosis should be considered in HIV-infected patients with clinically suspected subacute meningitis in settings where neuroradiology is not available.

Caspase-11 Modulates Inflammation and AttenuatesToxoplasma gondiiPathogenesis

“…We also observed significant differences in leptomeningitis following T. gondii infection (Figures 6(c) and 6(d) ). Leptomeningitis refers to inflammation associated with the subarachnoid space in the brain and has been previously associated with T. gondii infection in humans [ 34 , 35 ]. Leptomeningitis developed in all of the T. gondii infected mice.…”

“…The underlying cause of this highly serious presentation of toxoplasmosis in humans is unknown. However, the condition appears to occur more often in the context of immunosuppression or attenuated innate immune responses [ 34 , 35 ].…”

Toxoplasmic encephalitis associated with meningitis in a heart transplant recipient

“…Autopsy findings confirmed the existence of necrotizing cerebritis with Toxoplasma cysts and trophozoites . A more recent study in Indonesia revealed that 21 of 64 cases (33%) of HIV‐infected patients with meningitis (clinical symptoms plus CSF abnormalities) had positive specific PCR for T. gondii in CSF .…”

Cerebral Toxoplasmosis in an HIV-Negative Patient: A Case Report

“…A key feature of T. gondii pathogenesis is the ability of the parasite to cross formidable biological barriers in the infected host and enter tissues such as the brain, eye, and placenta. Chronic asymptomatic infection affects 30% -50% of the global population with host cells of the parasitic cyst located mainly in the central nervous system (2). Cerebral toxoplasmosis typically presents as cerebral mass lesions with headache, confusion, fever, lethargy, seizures, cranial nerve palsies, psychomotor changes, hemiparesis, and/or ataxia (3).…”