CEREBRAL TOXOPLASMOSIS IN TUBERCULOSIS/HIV CO-INFECTED PATIENTS

Abstract

The problem of cerebral toxoplasmosis in tuberculosis/HIV co-infected patients remains poorly understood.
Purpose of the study. To reveal of diagnostics and treatment features in tuberculosis/HIV co-infected patients with cerebral toxoplasmosis.
Material and methods. Twenty tuberculosis/HIV co-infected patients with cerebral toxoplasmosis were examined. All patients were diagnosed with active tuberculosis, they received anti-tuberculosis chemotherapy. Treatment of toxoplasmosis was performed with biseptol in combination with macrolides (clarithromycin, azithromycin) or clindamycin.
Results and discussion. Most patients had CD4 content less than 78 cells/mm3 (median 34.0 cells/mm3). Disseminated pulmonary tuberculosis with damage of lymph nodes was diagnosed in 16 persons. Patients complained of extremities weakness (9 persons), headache (7 persons), convulsions and gait disorders (5 persons). At a neurologic examination 16 had symptoms of cranial nerves irritation, 10 persons – rigidity of the occipital muscles and a positive Kernig symptom. From 11 studies of the cerebrospinal fluid normal protein content were determined in 8 persons, glucose – in 7, cellular elements – in 8 persons, 10 patients had negative Nonne-Apelta test. The normal composition was observed in 2 patients. Two-sided toxoplasmic abscesses were found in 17 patients, the others were single, in size 45-65 mm. Diagnosis of cerebral toxoplasmosis was verified in vivo in 17 patients, the rest was an autopsy finding. 12 of 20 patients died in hospital, generalized tuberculosis was found on an autopsy, there were no signs of tuberculous meningoencephalitis. 9 patients were on antiretroviral therapy, the median of treatment before this was 43 days. Two cases of immune reconstitution inflammatory syndrome, leading to the death of patients, were recorded, the remaining patients continued treatment, which led to a partial regression of symptoms and changes in the brain. The case of successful treatment of disseminated tuberculosis and cerebral toxoplasmosis is presented.
Conclusions. Most of tuberculosis/HIV co-infected patients developed the cerebral toxoplasmosis having CD4 content less 78 cells/mm3, the pulmonary tuberculosis with damage of lymph nodes was diagnosed. Patients complained of extremities weakness and headache (9 and 7 persons), every fourth was disturbed by convulsions and unsteady gait. In 16 the symptoms of cranial nerves irritation were determined, in 10 – meningeal signs. The normal content of protein, glucose, and cellular elements was detected in the majority of patients. Treatment of toxoplasmosis and tuberculosis/HIV co-infection is a complex task, the key to success is timely diagnosis and antiretroviral therapy.