Delayed Cerebral Toxoplasmosis in a Kidney Transplant Patient: a Case Report

Abstract

Cerebral toxoplasmosis is often life-threatening in an immunocompromised patient due to delayed diagnosis and treatment. Several differential diagnoses could be possible only with preoperative brain images of cerebral toxoplasmosis which show multiple rim-enhancing lesions. Due to the rarity of cerebral toxoplasmosis cases in Korea, the diagnosis and treatment are often delayed. This paper concerns a male patient whose cerebral toxoplasmosis was activated 21 years post kidney transplantation. Brain open biopsy was decided to make an exact diagnosis. Cerebral toxoplasmosis was confirmed by immunohistochemistry and PCR analyses of the tissue samples. Although cerebral toxoplasmosis was under control with medication, the patient did not recover clinically and died due to sepsis and recurrent gastrointestinal bleeding.

Keywords: Cerebral toxoplasmosis; PCR; brain open biopsy; kidney transplantation; multiple rim-enhancing lesion.

Fig. 1

Comparison of brain MRI between (A) at the ER visit and (B) 6 weeks after treatment. (A) Initial brain MRI showed multiple rim-enhancing lesions and miliary nodules. (B) Six weeks after treatment, rim-enhancing lesions disappeared with treatment-related changes.

Fig. 2

Histological photomicrographs. (A) the lesion showed extensive coagulative necrosis (Hematoxylin Eosin (HE)×100). (B) Several tiny dot or crescent-like tachyzoites (arrows) and degenerated cysts-containing bradyzoites were found in the necrotic tissue (HE×400). (C) Obliterative vasculitis with lymphoid cuffing was prominent in the peripheral part of the abscess (HE×100). (D) Immunohistochemistry for Toxoplasma gondii showed positive reaction in the organisms inside the blood vessels and surrounding tissue (×400).

Fig. 3

PCR result on Toxoplasma gondii P30(SAG1) gene. Lane 1 indicated the sample of the patient. Lane P indicated the positive control.