Toxoplasmosis: Difference between revisions
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==Background== | ==Background== | ||
*Most common cause of focal encephalitis in patients with AIDS | *Most common cause of focal encephalitis in patients with AIDS | ||
*Risk at CD4 < 100 and not on prophylaxis | |||
==Clinical Features== | ==Clinical Features== | ||
*[[Headache]] | |||
*[[Fever]] | |||
*[[Focal neurologic deficits]] | |||
*[[altered mental status]] | |||
*[[Seizures]] | |||
==Diagnosis== | ==Differential Diagnosis== | ||
*Head CT | *Lymphoma | ||
**Shows multiple subcortical lesions | **More commonly single lesion in the periventricular white matter or corpus callosum | ||
*Cerebral TB | |||
**Characteristic inflammatory appearance with isodense exudate filling basal cisterns | |||
*[[Fungal infection]] | |||
{{HIV associated conditions}} | |||
==Evaluation== | |||
*[[Head CT]] without contrast | |||
**Shows multiple subcortical lesions with predilection for basal ganglia | |||
**Contrast usually not needed; if obtained, will show ring enhancing lesions | **Contrast usually not needed; if obtained, will show ring enhancing lesions | ||
*CSF | *[[CSF]] | ||
**Helpful but high rate of false negatives | **Helpful but high rate of false negatives | ||
*Serology not generally helpful since antibodies common in general population | |||
==Management== | |||
== | ===[[Antibiotics]]=== | ||
{{Toxoplasmosis Antibiotics}} | |||
===Steroids=== | |||
* | *Consider [[dexamethasone]] 4mg IV q6hr for significant edema or mass effect | ||
== | ===Folinic Acid=== | ||
''Administer if the treatment regimen includes Leucovorin'' | |||
*[[Folinic acid]] 10mg PO QD x6–8wk | |||
* | |||
==Disposition== | ==Disposition== | ||
*Admit | *Admit | ||
== | ==References== | ||
<references/> | |||
[[Category:ID]] | [[Category:ID]] | ||
Latest revision as of 09:28, 28 January 2018
Background
- Most common cause of focal encephalitis in patients with AIDS
- Risk at CD4 < 100 and not on prophylaxis
Clinical Features
Differential Diagnosis
- Lymphoma
- More commonly single lesion in the periventricular white matter or corpus callosum
- Cerebral TB
- Characteristic inflammatory appearance with isodense exudate filling basal cisterns
- Fungal infection
HIV associated conditions
- HIV neurologic complications
- HIV pulmonary complications
- Ophthalmologic complications
- Other
- HAART medication side effects[1]
- HAART-induced lactic acidosis
- Neuropyschiatric effects
- Hepatic toxicity
- Renal toxicity
- Steven-Johnson's
- Cytopenias
- GI symptoms
- Endocrine abnormalities
Evaluation
- Head CT without contrast
- Shows multiple subcortical lesions with predilection for basal ganglia
- Contrast usually not needed; if obtained, will show ring enhancing lesions
- CSF
- Helpful but high rate of false negatives
- Serology not generally helpful since antibodies common in general population
Management
Antibiotics
Immunocompetent
Antibiotics only needed if patient has severe symptoms
- Pyrimethamine 200mg PO one dose (for loading) THEN 50mg PO q24hrs x4wks AND
- Leucovorin 10mg PO q24hrs AND
- Sulfadiazine 1g PO q6hrs
Immunosprepressed
- TMP/SMX 5mg/kg IV q12hrs OR
- Pyrimethamine 200mg PO one dose (for loading) THEN 75mg PO q24hrs x4-8wks AND Leucovorin 25mg PO q24hrs PLUS
- Sulfadiazine 1500mg PO q6hrs OR
- Clindamycin 600mg PO or IV q6hrs OR
- Azithromycin 12000mg PO q24hrs OR
- Atovaquone 1500mg PO q12hrs
Pregnant
- Spiramycin 1 g orally every 8 hours[2]
- If amniotic fluid is positive treat with 3 weeks of pyrimethamine (50 mg/day orally) + sulfadiazine (3 g/day orally in 2-3 divided doses)
- Alternate with a 3-week course of Spiramycin 1 g 3 times daily OR
- Pyrimethamine (25 mg/day orally) and sulfadiazine (4 g/day orally) divided 2 or 4 times daily until delivery AND
- Leucovorin 10-25 mg/day orally to prevent bone marrow suppression
Steroids
- Consider dexamethasone 4mg IV q6hr for significant edema or mass effect
Folinic Acid
Administer if the treatment regimen includes Leucovorin
- Folinic acid 10mg PO QD x6–8wk
Disposition
- Admit
References
- ↑ Gutteridge, David L MD, MPH, Egan, Daniel J. MD. The HIV-Infected Adult Patient in The Emergency Department: The Changing Landscape of the Disease. Emergency Medicine Practice: An Evidence-Based Approach to Emergency Medicine. Vol 18, Num 2. Feb 2016.
- ↑ Paquet C, Yudin MH. Toxoplasmosis in pregnancy: prevention, screening, and treatment. J Obstet Gynaecol Can. Jan 2013;35(1):78-9.