Spinal toxoplasmosis in a young man with undiagnosed HIV infection

Abstract

Spinal cord lesions are potentially devastating conditions leading to reduced mobility, loss of functional independence, and even ventilator dependence, dictated by the level of injury. Tissue diagnosis is paramount to differentiate between primary brain tumours such as ependymomas and glioblastomas, infarction, infection and demyelination. We present the case of a 30-year-old gentleman with subacute neck pain, nausea and evolving right upper limb weakness and paraesthesiae. MRI-spine demonstrated an intramedullary cervical spine mass with associated oedema, thought to represent an ependymoma. Open tissue biopsy revealed numerous bradyzoites on haematoxylin & eosin staining, subsequently confirmed by directed polymerase chain reaction testing as Toxoplasma gondii. Detailed immunological work-up led to a diagnosis of HIV infection, with detection of HIV antibodies and HIV-1 p24 antigen, an HIV-1 viraemia (log 6.33 copies/mL) and low CD4 count (16 cells/mL). Toxoplasmosis is the most common central nervous system infection in HIV patients not receiving appropriate prophylaxis.1 It may occur in up to 30% of such patients who are seropositive for Toxoplasma gondii,2 typically manifesting when CD4+ counts fall below 100 cells/mm3.3 This case highlights the importance of close collaboration between histopathology, microbiology and infectious diseases specialists in diagnosis of a spinal cord infection with associated HIV infection. 1.Porter SB, Sande MA. Toxoplasmosis of the central nervous system in the acquired immunodeficiency syndrome. N Engl J Med 1992; 327: 1643–8.2.Grant IH, Gold JW, Rosenblum M, et al. Toxoplasma gondii serology in HIV-infected patients: the development of central nervous system toxoplasmosis in AIDS. AIDS 1990; 4: 519–21.3.Kaplan JE, Benson C, Holmes KK, et al. Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents. MMWR Recomm Rep 2009; 58: 1–207.