SESSION TITLE: Infectious Disease Student/Resident Case Report Posters III
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM
INTRODUCTION: Toxoplasmosis is the most common parasitic opportunistic infection of the central nervous system (CNS) in AIDS patients who are not on appropriate prophylaxis. Extra-cerebral sites may be involved with or without CNS toxoplasmosis. Pulmonary involvement is uncommon but is second to the CNS as the major site of disease. Although toxoplasmosis accounts for less than 1% of the pulmonary complications of HIV infection, it has a documented mortality of 55%.
CASE PRESENTATION: A 41-year-old African-American female presented to the hospital with a two day history of altered mental status. On admission, her vitals were unremarkable. Her examination was significant for a confused female who was oriented to person only, but otherwise in no obvious distress. Respiratory findings were significant for decreased breath sounds throughout. Her rapid HIV test was positive with an absolute CD4+ lymphocyte count of 7 cells/µL. CNS Toxoplasmosis was eventually diagnosed as evidenced by 1) Computed tomography (CT) of the brain showing numerous ring-enhancing lesions with the dominant mass in right basal ganglia 2) Positive cerebrospinal fluid Toxoplasma DNA polymerase chain reaction and serum Toxoplasma IgG antibody. Treatment was commenced with pyrimethamine and sulfadiazine. A CT scan of her chest showed diffuse multiple nodular lesions throughout both lung fields, the largest being 3 cm in the superior left lobe. Throughout her hospital stay she demonstrated no respiratory symptoms or hypoxia. She had three sputum smears that were negative for acid-fast bacilli. A bronchoalveolar lavage showed non-budding, spheric, thick-walled structures filled with small round microorganisms that were consistent with the cyst form of Toxoplasma gondii as well as tachyzoites. The cytology and silver stain for Pneumocystis jerovicii were negative. After receiving 10 days of treatment for CNS toxoplasmosis, a repeat CT chest showed significant improvement in nodules, with the largest now measuring 2cm. She significantly improved and was discharged to complete her treatment as outpatient.
DISCUSSION: Pulmonary toxoplasmosis may present without significant symptoms and have atypical chest imaging. These patients may also have extra-pulmonary manifestations of toxoplasmosis.
CONCLUSIONS: Clinicians need to have heightened awareness of this entity as it affects the rapidly growing number of immunocompromised patients. This would avoid a poor outcome in an otherwise treatable cause of diffuse lung disease in an immunosuppressed host.
Reference #1: Oksenhendler E, et al Toxoplasma gondii pneumonia in patients with the acquired immunodeficiency syndrome. Am J Med. 1990 May;88(5N):18N-21N
Reference #2: Evans TG, Schwartzman JD. Pulmonary toxoplasmosis: Semin Respir Infect. 1991 Mar;6(1):51-7
Reference #3: Pomeroy C, Filice Pulmonary toxoplasmosis: a review GA Clin Infect Dis. 1992 Apr;14(4):863-70
DISCLOSURE: The following authors have nothing to disclose: O'Dene Lewis, Babak Shokrani, Doshi Saumil, Marc Phillpotts
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