Fulminant toxoplasmosis presenting as isolated myelitis

Toxoplasmose fulminante se apresentando como mielite isolada

A 29-year-old male patient with an untreated HIV infection for seven years presented with a two-month history of neck pain, progressive left-hand weakness and numbness. Physical examination showed C5-C6 territory hypoesthesia and urinary bladder retention. A spinal MRI (Figure 1) showed a single contrast-enhanced lesion at C4-C6 level, cerebrospinal fluid analysis showed 3.6 white blood cells/mm³ and a positive IgG for toxoplasma. Despite empiric treatment, the disease progressed locally and to the brainstem. Autopsy (Figure 2) showed disseminated CNS toxoplasmosis.

Figure 1
(A) Sagittal T2-weighted cervical spine MRI showing a heterogeneous mass-occupying lesion in the spinal cord (red arrow) with longitudinal edema from the medulla to T2 (blue arrows). The same lesion in T1-weighted MRI without (B) and with contrast (C). Note the heterogeneous contrast enhancement of the lesion (red arrows on B and C).

Figure 2
Autopsy findings showing: (A) macroscopic brain appearance with necrosis of brainstem and loss of connection between it and cerebellum. Histological evaluation with hematoxylin and eosin stain showed vast areas of liquefactive necrosis (lower magnification, B) and some T. gondii bradyzoites at higher magnification (arrow, C).

Toxoplasmosis is the most common CNS infection in patients with AIDS, but isolated spinal cord involvement is rare1. Prompt empiric treatment for toxoplasmosis should be considered in all patients2.

References

• Vyas R, Ebright J. Toxoplasmosis of the spinal cord in a patient with AIDS: case report and review. Clin Infect Dis. 1996 Nov;23(5):1061-5. https://doi.org/10.1093/clinids/23.5.1061
  » https://doi.org/10.1093/clinids/23.5.1061
• García-García C, Castillo-Álvarez F, Azcona-Gutiérrez JM, Herraiz MJ, Ibarra V, Oteo JA. Spinal cord toxoplasmosis in human immunodeficiency virus infection/acquired immunodeficiency syndrome. Infect Dis. 2015 May;47(5):277-82. https://doi.org/10.3109/00365548.2014.993421
  » https://doi.org/10.3109/00365548.2014.993421

Publication Dates

• Publication in this collection
  10 Jan 2020
• Date of issue
  Dec 2019

History

• Received
  22 Mar 2019
• Reviewed
  02 June 2019
• Accepted
  16 July 2019