Hemichorea-Hemiballismus as a Presentation of Cerebritis from Intracranial Toxoplasmosis and Tuberculosis

Abstract

Background: There is limited literature documenting hemichorea-hemiballism (HCHB) resulting from co-infection of toxoplasmosis and tuberculosis (TB) in acquired immunodeficiency syndrome (AIDS). Toxoplasmic abscess is the most common cause while TB is a rare etiology. Case Description: We describe a 24-year-old male with AIDS-related HCHB as the presentation of cerebritis on the right subthalamic nucleus and cerebral peduncle from intracranial toxoplasma and TB co-infection. Antimicrobials and symptomatic therapy were given. Marked improvement was seen on follow-up. Discussion: HCHB may be the initial presentation of intracranial involvement of this co-infection in the setting of AIDS and is potentially reversible with timely management. Highlights: Hemichorea-hemiballismus (HCHB) may be an initial presentation of intracranial involvement of concomitant toxoplasmosis and tuberculosis causing focal cerebritis in the contralateral subthalamic nucleus and cerebral peduncle, particularly in the setting of human immunodeficiency virus infection. Acquired immunodeficiency syndrome-related HCHB is potentially reversible with timely diagnosis and treatment.

Neuropsychiatric Symptoms in Cerebral Toxoplasmosis with Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS): Case Report

“…Hemichorea associated with toxoplasmosis of the brain is generally reversible if diagnosed and treated early. [15] In our case, the patient with right hemichorea received therapy with cotrimoxazole 960 mg/24 hours together with antipsychotics. The patient's clinical condition improved within a few days and the patient was planned for outpatient care.…”

Case report: 29-year-old male with Hemichorea-hemiballismus as the initial manifestation caused by cerebral Toxoplasmosis with diagnostic of HIV without treatment

“…10 Typically, it manifests as a late complication in patients with fewer than 200 CD4 T cells/μl. 3,4 The clinical presentation of cerebral toxoplasmosis is nonspecific but often involves subacute neurologic symptoms and signs. Common presentations include headaches, fever, seizures, focal neurologic deficits, cranial nerve palsies, visual disturbances, confusion, and psychomotor or behavioral changes.…”

“…Although both conditions share a similar pathophysiology, ballism manifests with proximal, high-amplitude movements, while chorea is characterized by more distal, lower amplitude movements. 3 Berger et al were the first to report involuntary movements in AIDS in 1984. 5 In 1986, Navia et al conducted an extensive study involving 27 patients with cerebral toxoplasmosis complicating acquired immune deficiency syndrome.…”

Overview of management of infection-related movement disorders with focus on specific-infections

“…Toxoplasmosis is responsible for more than 50 % cases of HCHB cases in patients with HIV. Other causes identified are infarct secondary to zoster vasculitis, histoplasma, JC virus infection and tuberculosis [103] , [104] . Treatment of CNS toxoplasmosis ( Table 1 ) is by sulfadiazine, pyrimethamine and leucovorin and includes induction phase for 6 weeks followed by a continuation phase till CD4 count is maintained > 200 cells/microL for at least 6 months on HAART [105] .…”