Case Report Toxoplasmosis of the spinal cord in an immunocompromised patient: case report and review of the literature Medullary toxoplasmosis in an immunosuppressed patient: Case report and literature review Carolina Rodríguez * 1 Martínez2 Ernesto Guillermo Bolívar3, Sandra Edwin Sánchez4 Carrascal4 1 University del Valle. Hospital Universitario del Valle. Department of Internal Medicine. Cali, Colombia. 2 Universidad del Valle and Free University. Valle University Hospital, Department of Internal Medicine. Cali, Colombia. 3 Free University, Department of Internal Medicine. Cali, Colombia.
4 Universidad del Valle. Valle University Hospital, Department of Pathology. Cali, Colombia * Corresponding Author: E-mail address: arpicaro@hotmail. com (Rodriguez C), emarbui@gmail. com (Martinez E), lunasa12@hotmail. com (Sandra Sanchez). © 2013 Universidad del Valle. This is an open-access article distributed under the terms of the Creative Commons Attribution License, Which Permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are the Credited. Article history: Received: 22 February 2012 Received in revised form 15 March 2012, Accepted: 16 August 2013 Available online 30 December 2013 Abstract We, HEREIN, describes an HIV-positive patient With toxoplasmosis of the spinal cord.
We Also Carried out a comprehensive literature review of this topic, with emphasis on the diagnostic tools and therapeutic approach. Keywords: Spinal cord toxoplasmosis, central nervous system, myelopathy in immunocompromised patient Summary the case of an HIV seropositive patient diagnosed with spinal toxoplasmosis in conjunction with the review of the literature of the few cases to date, with emphasis on key diagnostic and therapeutic approach is presented. Keywords: Toxoplasmosis spinal cord, central nervous system, myelopathy in immunocompromised patient Introduction Toxoplasmosis is the first cause of intracranial lesions Associated to neurological deficit in HIV / AIDS¹. ACCORDING to geographic location, the frequency varies between 3 and 50% of These Patients. The risk factor strongly related to this MOST infection is CD4-positive lymphocyte count below 200 / mm3, and Especially below 50 / mm3 3-6. Described locations are extracerebral With less frequency, in less than 11% of the cases2,6, with myelitis due to Toxoplasma being an uncommon condition, with only 19 cases in medical literature, only seven of Which Have Been confirmed in living patients1,3. Herein, we present the case of an HIV-infected patient diagnosed With myelitis due to Toxoplasma confirmed by biopsy, and review the published literature reviews on this condition. Literature search in PubMed was Carried out, Medline, LILACS, and SciELO databases by using the terms: Toxoplasma, toxoplasmosis, medullary, medullary, spinal, myelitis, myelopathy. Descriptions in Spanish and Inglés Were Considered of toxoplasmosis infection due to spinal cord in adult Among Patients.
Two cases Described in French Were included. Case description: The case was presented in the Internal Medicine Service at Hospital Universitario Emergency del Valle in Cali, Colombia. Clinical data was Collected from the medical chart and signed informed consent was Obtained from the patient for publication ITS. This was a 40 year-old, Latin American, heterosexual, male patient, with history of HIV infection diagnosed seven years ago. The patient was under treatment antiretroviral. His past medical history revealed an episode of cerebral toxoplasmosis five years ago, diagnosed through positive IgG for Toxoplasma and suggestive clinical presentation and imaging scan. This former episode was Treated With standard dose of pyrimethamine and sulfadiazine and images with good clinical response, followed by prophylaxis with Trimethoprim sulfamethoxazole intermittent. The patient presented to emergency room at our hospital with a two-year history of evolution of lumbar pain of moderate to severe intensity, Associated to diminished strength in the lower limbs, more pronounced on the lower right limb, with compromise of the urinary sphincter During last months. The CD4 count was 60 cells / mm3 and the viral load was 55. 110 copies / mL. Physical exam revealed a patient in good nutritional condition, bedridden, with neurological deficit Characterized by plegia in lower right limb, with greater compromise in distal roots of L3, L4, L5 and paresis and in the lower left limb. Further exam Showed lack of bilateral Achilles and patellar reflex. Sensitivity was unaltered.
The CSF extension not suitable for exam Resulted cell count due to sample coagulation, with glucose of 6 mg / dL, proteins of 4,100 mg / dL, and LDH of 274 U / L. Magnetic resonance imaging (MRI) of thoracolumbar spine With gadolinium (Figs. 1A, 1B) Showed an expansive lesion, with affectation of the distal medullary cone, isointense on T1 to spinal cord, heterogeneous intensity, and areas of hyperintensity on T2. The lesion extended from T10 to T12 and presented peripheral enhancement in relation to contrast With a probably infectious inflammatory process, suggesting toxoplasmosis as first Possibility. Surgical exploration was Conducted of the medullary cone, finding a thickened and hardened epiconus, with arachnoid and healthy skin, a tough avascular fibrous intra-axial lesion, from Which Were samples taken. The pathological study acute vasculitis Identified With granulomatous component, extensive necrosis, and tachyzoites Compatible with toxoplasmosis (Fig. 2). Special stains and cultures for acid fast bacilli and fungi Were negative. The immunohistochemical study was positive for Toxoplasma (specific monoclonal antibody Against Toxoplasma gondii – Dako) (Fig. 3). The PCR studies in CSF for herpes simplex virus types 1 and 2, Epstein-Barr virus, Mycobacterium tuberculosis, and cytomegalovirus Were negative. Electromyography of the four limbs provided abnormal results, with electrophysiological evidence of engine and distal axonal polyneuropathy sensitivity in lower limbs. The plasma folate and vitamin B12 levels Were usual.
The patient received second-line treatment7 with Trimethoprim sulfamethoxazole at a dose of 10 mg / kg / d IV and clindamycin 1,200 mg IV every 6 hours, According to the availability in the institution, with adequate tolerance. Clinical improvement was Observed With partial recovery of neurological deficit accomplishing His Déambulation with a walker aid at eight weeks of treatment, leaving him with a sequel of a right foot drop. Discussion: vacuolar myelopathy is a common condition With medullar compromise in HIV-positive Patients, found in over 30% of autopsies prior the start of the era of antiretroviral therapy1. Other causes and possible Described broadly differential diagnoses to bear in mind include HTLV I or II, herpes simplex 1 or 2, varicella zoster, cytomegalovirus, syphilis, and tuberculosis, Among the infections; and lymphoma or nutritional deficiencies, Among the non-infectious causes6 To date, only 18 cases Have Been Described of myelitis due to Toxoplasma diagnosed histologically, via biopsy or autopsy, or through successful therapeutic trials Within the context of a consistent clinical condition (Table 1 ). From the epidemiological point of view, These Were almost all of Patients male gender (90%), Between the third and fourth decade of life. All the cases Described Have Been Associated to immunodeficiency, Which only in three of These was not related to HIV. The symptoms Described in MOST of the cases are lumbar pain, loss of function With engine Especially in lower limbs compromise (70%), bladder dysfunction (55%), specific and sensitive alteration With medullar level (75%). One patient presented Brown-Sequard syndrome. In all cases in Which to cerebrospinal fluid study was Conducted, Alterations Were found, with Increased protein levels being The most common finding, with values up to 2. 2 g / dL. The Toxoplasma IgG antibody was positive in all but one of the Patients EVALUATED. Magnetic resonance imaging (MRI) With gadolinium was the preferred diagnostic imaging method, with enhanced intra-medullar solitary lesions as The most frequent findings. The Most Frequently compromised segment was the thoracic (55%) and cerebral simultaneous and medullar Involvement was established in half the cases described1,3.
All the cases Were Patients immune suppressed, with the vast majority being HIV-positive With One case Among These Suspected toxoplasmosis as a result medullary Immune Response of Inflammatory Syndrome (IRIS) 2. With regards of treatment, similar courses of antibiotics to standard Considered for Those Were Given cerebral toxoplasmosis. , According to current guidelines, Variable Obtained results are as sulfadiazine pyrimethamine With the first option, with early diagnosis factor being the best prognosis for complete recovery of These patients4. No special mention of using steroids to the Associated antibiotic regime was found, two, Although Their use in cases Have Been Described With success. In our case, steroid treatment was administered During the first eight weeks of treatment, with good relative response in Spite of the late diagnosis. More studies are needed to recommend this strategy in the future and determine the adequate manner for follow up and assessment of These Patients. table 1 Conclusion In Spite of the few cases Described in the literature, myelitis due to Toxoplasma gondii Could be a condition more common than thought. By being a treatable disease Whose prognosis Improves With early diagnosis, toxoplasmosis must be Considered in the differential approach of all HIV-positive Patients With suggestive clinical history, presence of medullar Involvement During magnetic resonance study (especially if it is a solitary lesion), in With positive IgG antibody combination Toxoplasma. Timely treatment can result in the patient’s significant improvement. Conflict of interest: The authors declare there is not That conflict of interest That Could be perceived as prejudicing the impartiality of the information reported almost.
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