Ring-Enhancing Brain Lesion in a Man with Acquired Immunodeficiency Syndrome

Abstract

RESENTATION 46-year-old Hispanic man with acquired immunodefiiency syndrome (AIDS) and a history of cryptococcal eningitis presented with new-onset simple partial seizures. e had noticed 2 weeks of progressive weakness and numbess of his right arm for which his highly active antiretroiral therapy (HAART) had been discontinued. He denied ny fever, weight loss, changes in his vision, or headache. n examination, the patient had oral thrush, was unable to ift his right arm against gravity, had some weakness in his ight leg, and sensation was decreased on the right side of is body. Head computed tomography (CT) scan with conrast and a brain magnetic resonance image (MRI) showed ring-enhancing lesion in the left posterior frontal lobe with urrounding edema, without midline shift (Figures 1 and 2). erebral spinal fluid (CSF) analysis was within normal imits. No growth of bacteria, mycobacteria, or fungus was oted. Tests for Epstein Barr virus, herpes simplex virus, ytomegalovirus DNA, and the cryptococcal antigen were egative. The patient’s CD4 count was 182 cells/mm and he viral load was 400 copies/mm. He was found to have icrocytic anemia with a hemoglobin of 8.4. His urinalysis evealed 4-10 red blood cells/hpf. Toxoplasma gondii serolgy returned positive for immunoglobulin G and negative or immunoglobulin M. Based on the patient’s head CT ndings, he was started on treatment for central nervous ystem toxoplasmosis and a bacterial brain abscess. Beause he showed no clinical improvement and a repeat head T showed an increase in the size of the lesion, the patient nderwent a brain biopsy. What is the diagnosis?