Abstract
Cerebral toxoplasmosis is a life-threatening infection most commonly found in immunocompromised hosts such as acquired immunodeficiency syndrome (AIDS) or transplant patients. However, it is not known to affect patients with chronic inflammatory disorders on immunosuppressive therapy. We describe the case of a 70-year-old female with rheumatoid arthritis (RA) on chronic therapy with methotrexate and infliximab, who presented to the hospital after two weeks of right-sided weakness. Imaging revealed bilateral ring-enhancing lesions in the basal ganglia (left greater than right). A diagnosis of cerebral toxoplasmosis was made on brain biopsy. Apart from the immunosuppressive therapy and owning a cat, she had no other risk factors for developing the infection. The patient’s immunosuppressive medications were discontinued, and she was started on high-dose trimethoprim-sulfamethoxazole (TMP-SMX). Upon literature review using PubMed, we found seven other published reports on similar cases of toxoplasmosis in RA patients on immunosuppressive therapy; however, there was a lack of recommendations for diagnosis, treatment, and prophylaxis in this patient population. With the growing use of immunosuppressive therapies in chronic inflammatory disorders, further data is needed regarding the management of toxoplasmosis in these patients. This case report is an investigation of the relationship between immunosuppressive medications in RA patients and cerebral toxoplasmosis and an exploration of the available recommendations for its management.
Highlights
Toxoplasmosis is one of the most prevalent infections worldwide, affecting an estimated one-third of the world’s population [1]. This infection is caused by Toxoplasma gondii, an intracellular protozoan parasite that is usually acquired during childhood and adolescence, and primarily transmitted to humans through ingestion of infectious oocytes, typically from infected cat feces or undercooked meat from an infected animal [2]
As serologic testing cannot differentiate between a reactivated vs latent infection, most definitive diagnoses are made via polymerase chain reaction (PCR) of the cerebral spinal fluid (CSF) or brain biopsy [1,3]
Taking into account the lack of data on this subject, there could be potential benefits from serologic testing prior to the initiation of immunosuppressive therapy such as tumor necrosis factor-a (TNF-a) inhibitors. This case report highlighted the potential role that immunosuppressive therapy plays in human immunodeficiency virus (HIV)-negative, nontransplant immunocompromised patients diagnosed with toxoplasmosis
Summary
Toxoplasmosis is one of the most prevalent infections worldwide, affecting an estimated one-third of the world’s population [1]. As serologic testing cannot differentiate between a reactivated vs latent infection, most definitive diagnoses are made via polymerase chain reaction (PCR) of the cerebral spinal fluid (CSF) or brain biopsy [1,3] Treatment of this infection is typically pyrimethamine and sulfadiazine for at least six weeks; other medications can be used, such as trimethoprim-sulfamethoxazole (TMP-SMX) or clindamycin [3]. One week after the onset of her initial weakness, she had begun to suffer from minor falls due to the right hemiparesis Her family was present at the bedside and noted that they had observed a mild left-sided facial droop and slurred speech several days before. MRI of the brain with and without contrast revealed bilateral ring-enhancing lesions in the basal ganglia (left larger than right) with surrounding vasogenic edema and mild mass effect on the left lateral ventricle from the larger lesion as shown in Figures 2, 3. The patient was stabilized and transitioned to a long-term acute care hospital with a six-week total course of high-dose TMP-SMX
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