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. 2013;7(1):e1994.
doi: 10.1371/journal.pntd.0001994. Epub 2013 Jan 10.

Cerebral toxoplasmosis mimicking subacute meningitis in HIV-infected patients; a cohort study from Indonesia

A Rizal Ganiem  1 , Sofiati Dian, Agnes Indriati, Lidya Chaidir, Rudi Wisaksana, Patrick Sturm, Willem Melchers, Andre van der Ven, Ida Parwati, Reinout van Crevel
Affiliations

Cerebral toxoplasmosis mimicking subacute meningitis in HIV-infected patients; a cohort study from Indonesia

A Rizal Ganiem et al. PLoS Negl Trop Dis. 2013.

Abstract

Background: HIV-associated subacute meningitis is mostly caused by tuberculosis or cryptococcosis, but often no etiology can be established. In the absence of CT or MRI of the brain, toxoplasmosis is generally not considered as part of the differential diagnosis.

Methodology/principal findings: We performed cerebrospinal fluid real time PCR and serological testing for Toxoplasma gondii in archived samples from a well-characterized cohort of 64 HIV-infected patients presenting with subacute meningitis in a referral hospital in Indonesia. Neuroradiology was only available for 6 patients. At time of presentation, patients mostly had newly diagnosed and advanced HIV infection (median CD4 count 22 cells/mL), with only 17.2% taking ART, and 9.4% PJP-prophylaxis. CSF PCR for T. Gondii was positive in 21 patients (32.8%). Circulating toxoplasma IgG was present in 77.2% of patients tested, including all in whom the PCR of CSF was positive for T. Gondii. Clinically, in the absence of neuroradiology, toxoplasmosis was difficult to distinguish from tuberculosis or cryptococcal meningitis, although CSF abnormalities were less pronounced. Mortality among patients with a positive CSF T. Gondii PCR was 81%, 2.16-fold higher (95% CI 1.04-4.47) compared to those with a negative PCR.

Conclusions/significance: Toxoplasmosis should be considered in HIV-infected patients with clinically suspected subacute meningitis in settings where neuroradiology is not available.

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Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Figure 1
Figure 1. CSF characteristics according to causative pathogen.
CSF cell count (A), protein concentration (B) and CSF∶blood glucose ratio (C) for cases with confirmed toxoplasmosis (•), crypotoccococis (▪), and tuberculosis (▴). Toxo = toxoplasmosis; crypto = cryptococcosis; TB = TB meningitis.
Figure 2
Figure 2. Kaplan Meier survival estimates.
Patients with available long term follow up data: Toxoplasmosis (n = 14), Cryptococcosis (n = 13), TB meningitis (n = 14), no diagnosis (n = 13).
See this image and copyright information in PMC

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