Non tuberculous mycobacteria and toxoplasma co-infection of the central nervous system in a patient with AIDS

Abstract

New-onset seizures are frequent manifestations in patients infected with Human Immunodeficiency Virus (HIV). We describe the clinical and radiological findings in an 25yr old AIDS patient presenting with new onset seizures as the primary manifestation of cerebral toxoplasmosis and Non Tuberculous Mycobacterial [NTM] co-infection. Cranial computed tomography showed a subtle ventricular dilatation whereas magnetic resonance imaging disclosed prominent temporal horn. Toxoplasma tachyzoites and rapidly growing mycobacteria were recovered from CSF. Seizures were complex partial in nature and refractory to antiepileptic therapy. Key-Words: Non tuberculous Mycobacteria, toxoplasmosis, HIV, seizures. Case ReportA 25 year old male came into the fold of our care in May 2008, in an unconscious state along with involuntary movements and complex partial seizures involving the right upper limb and the right side of face, for the past 3 days. History revealed presence of low grade evening fever with remission during the night spread over the last 6 months. He was treated for pulmonary tuberculosis 3 years back and the ATD regimen was duly completed. He had a history of exposure to commercial sex. There was no history of weight loss, oral or genital ulcers, headache, vomiting or visual disturbances and no past history suggestive of a seizure disorder.The general survey revealed enlarged cervical lymph nodes and hyperpigmented papules and plaques, distributed over all four limbs (Figure 1). All his vitals were within normal range. A detailed CNS examination revealed rigidity of both right upper and lower limbs. The deep reflexes were exaggerated on the right side while the plantar response was bilaterally flexor. There was no involvement of the cranial nerves, sensory or autonomic systems. The bladder and bowel control was unaffected. Ophthalmoscopy was within normal limits. Meningeal signs were positive. Abdominal exam revealed a firm nontender hepatomegaly. All other systems were apparently unaffected.Baseline investigations documented normal haemogram, blood sugar, urea and creatinine values. The Liver Function Test showed a serum bilirubin level of 0.6mg/dL (direct bilirubin of 0.4mg/dL), total protein of 8.3mg/dL (albumin 3.7mg/dL, globulin 4.3mg/dL), SGOT 108IU, SGPT 76IU and Alkaline Phosphate 430 IU. An ultrasound of abdomen revealed enlarged liver size with normal echo-texture. He was tested positive for Anti HIV -1 antibodies (ELISA),which was confirmed by western blot. His CD4 count was 46 cells / cumm. CT and MRI scans were essentially normal except for enlarged ventricles (Figures 2 and 3). The CSF study revealed a cell count of 5 cells/ cumm (all lymphocytes). The sugar and protein level in CSF were 38mg/dL and 84 mg/dL respectively. A smear drawn from CSF showed plenty of acid fast bacilli by ZN staining and toxoplasma tachyzoites on Giemsa stain.We initiated CAT 2 antitubercular regimen along with pyrimethamine and co-trimoxazole. He was also started on IV phenytoin and oral oxcarbamazepine was added to his anti...

Coinfección por Mycobacterium malmoense y Mycobacterium tuberculosis en paciente con el síndrome de inmunodeficiencia humana

“…La coinfección entre MNT y Mycobacterium tuberculosis es bastante infrecuente, los casos descritos generalmente se desarrollan en pacientes inmunodeficientes, particularmente en pacientes VIH/ sida. En nuestro laboratorio se realizó el primer reporte de esta inusual infección entre Mycobacterium gastri y Mycobacterium tuberculosis produciendo ambos patología respiratoria en un paciente sida (23)(24)(25) .…”

Central nervous system infection caused by Mycobacterium houstonense: A case report

“…Meanwhile, it is not helpful to distinguish nervous system infections caused by NTM from other infection types, such as tuberculous infections, on radiological images. Some NTM-CNS infections could present with hydrocephalus or brain atrophy, which is unexplained and not age-related ( 6 , 7 ), radiological images may also show nodular basal enhancement in NTM-CNS infection ( 8 ). On the basis of these radiological and clinical manifestations, as well as the mNGS CSF result in the second hospital, this patient was considered to have a CNS infection caused by M. houstonense , which is an NTM.…”