Syntax Literate: Jurnal Ilmiah Indonesia p�ISSN:
2541-0849 e-ISSN: 2548-1398
Vol. 8, No.
3, Maret 2023
CEREBRAL
TOXOPLASMOSIS IN AN IMMUNOCOMPETENT PATIENT WITH CONFIRMED COVID-19 POSITIVE
Monica Fradisha, Dewi Nareswari
Faculty of Medicine, Sebelas Maret University
Email: [email protected]
Abstract
A case of a 30 years-old male patient, diagnosed with cerebral
toxoplasmosis, confirmed HIV, with positive COVID-19. Once he came to the
emergency department with a chief complaint of left upper and lower limbs weakness
progressing for two days. The patient appeared malnourished and was afebrile and assessed to be
well hydrated. He was alert but drowsy and had speech difficulty. �A focused neurologic examination was performed and revealed a loss
of nasolabial fold indicating facial nerve palsy. Neck stiffness was present
and there was reduced motoric power in the left upper and lower limb of 2/5,
with positive Babinski sign and Chaddock sign. According
to brain CT, showed vasogenic cerebral edema and midline shift. Further
laboratory exams showed positive IgG antibodies for Toxoplasma, with a titer
exceeding 300 IU/ml, positive serum HIV, with CD4 cell count below 200cell/mm3.
Complete
blood count study highlighted low haemoglobin and elevated white cell count. He
tested positive for COVID-19 by nasopharyngeal swab RT-PCR. Chest CT were done
and revealed features of viral pneumonia with ground glass opacity appearance. In
summary, we present a patient with cerebral involvement of toxoplasmosis
possibly facilitated by pre-existing immunodeficiency as an opportunistic
infections of HIV, and with COVID-19 complicated as acute infections.
This case report reinforces a potential role for other comorbidities, rather
than HIV infection as regards SARS-CoV-2 infection outcomes. For better assessment
we need to do MRI.
Keywords: Cerebral Toxoplasmosis, HIV, AIDS,
COVID-19
Introduction
Toxoplasmosis
encephalitis is an opportunistic infection that usually affects the central
nervous system of immunocompromised patients. Toxoplasma encephalitis (ET) or
toxoplasma encephalitis (TE) is the most common etiology of intracranial
infection that appears as space-occupying lesions in the brain in HIV patients.
Toxoplasma seroprevalence in Indonesia is very high and has been reported as
high as 80% in the healthy Indonesian population (Sahimin et al., 2017).
Most
of toxoplasmosis in HIV patients occurs due to reactivation of chronic
infection and manifests as ET. Clinical symptoms in ET generally have a
subacute onset with the most common symptoms and signs complaining are headache
(85%), hemiparesis (48%), fever (47%), decreased consciousness (37%), and
seizures (37%).
Majority
of patients with cerebral toxoplasmosis present with focal neurological
abnormality and positive anti toxoplasma antibody titer. Toxoplasma
gondii is a ubiquitous, intracellular protozoan parasite that causes
cosmopolitan zoonotic infection. Acute T gondii infection is usually subclinical
in most immunocompetent individuals, and it is very rarely associated with
severe clinical manifestations. On the other hand, cerebral toxoplasmosis is
caused almost exclusively due to reactivation of latent brain cysts and can
cause devastating consequences in host immunocompromised patients, particularly
in people living with HIV/AIDS. If untreated, cerebral toxoplasmosis is
uniformly fatal (Ram et al., 2022).
The
risk of severe disease in HIV-patients compared with that observed in the general
population of COVID-19 patients. People who are living with human immunodeficiency
virus/acquired immune deficiency syndrome (HIV/AIDS) have been reported to
suffer worse during the COVID-19 pandemic because of the disruption in
healthcare system (Gervasoni et al., 2020). Comorbidities of chronic diseases, especially in terms of
multimorbidity, appear to be the factor of COVID-19-related deaths. Extra
preventive measurement is required for individuals with comorbidities,
including people with immunocompromised such as HIV/AIDS. Wariness over the
increasing risk of COVID-19 for people with HIV/AIDS is based on the assumption
that the people is prone to immunosuppression. It is a concern in population
with poorly controlled HIV infection, where worse outcome of COVID-19 is
expected (Karmen-Tuohy et al., 2020).
Herein,
we reported a rare case of coinciding COVID-19 in an HIV patient with cerebral toxoplasmosis.
Toxoplasma infection has been widely recognized as the major cause of focal
brain lesions that is commonly attributed to the reduction of antiparasitic
T-cell activities in HIV-AIDS patients (Bintari & Sugianto, 2021).
Research Method
Research method in this study is descriptive
study that provides detailed information about an individual case, usually
involving a rare or unique condition, treatment, or situation. The purpose of a
case report is to contribute to the general understanding of a particular
phenomenon or to highlight new or unusual aspects of a case that can lead to
further research (Cohen, 2006).
Select a case, Identify
a unique or rare case that warrants further examination. This could be a
patient with an unusual presentation of a disease, a rare condition, or a novel
treatment approach. Then conduct a literature review, research existing
literature on the topic to understand the current state of knowledge and to
identify any gaps or inconsistencies (Ahn, 2017). This will provide context for your case report
and help you understand how your case contributes to the existing body of
knowledge. Obtain consent and ethical approval, If
your case report involves a human subject, obtain informed consent from the
patient or their legal guardian, ensuring they understand the purpose of the
study and how their information will be used. Additionally, if required by your
institution or the journal you plan to submit your case report to, obtain
ethical approval from the appropriate institutional review board or ethics
committee (Wild et al., 2005).
Collect data, Gather
detailed information about the case, including patient history, symptoms, diagnostic
tests, treatments, and outcomes. Depending on the case, this may involve
reviewing medical records, interviewing the patient or their caregivers, and
consulting with other healthcare professionals involved in the case. Analyze
data, Carefully examine the collected data to identify patterns, relationships,
or anomalies that can help explain the case (O�Mahony, Blank, Zallman,
& Selwyn, 2005). This may involve comparing the case to similar
cases in the literature or considering alternative explanations for the
observed outcomes. Then write the case report, Organize
your findings into a structured format, typically including sections such as
introduction, case presentation, discussion, and conclusion.
Result and Discussion
A 30-year-old male patient presented
to the emergency department with a chief complaint of left upper and lower
limbs weakness progressing for two days (Magalh�es &
Sampaio‐Rocha‐Filho, 2022). He was alert but drowsy and had speech
difficulty. The patient appeared malnourished and was afebrile and assessed to
be well hydrated. His blood pressure 110/80 mmHg, heart rate 88 beats/minute,
respiratory rate 18 breaths/minute, and oxygen saturation of 97% on
supplemental oxygen 3 liters/minute. A focused neurologic examination was
performed and revealed a loss of nasolabial fold indicating facial nerve palsy.
Neck stiffness was present and there was reduced motoric power in the left
upper and lower limb of 2/5, with positive Babinski sign and Chaddock sign.
He underwent brain CT which showed vasogenic
cerebral edema and midline shift. Further laboratory exams showed positive IgG
antibodies for Toxoplasma, with a titer exceeding 300 IU/ml, positive serum
HIV, with CD4 cell count below 200 cell/mm3. Complete blood count study
highlighted low hemoglobin and elevated white cell count. He tested positive
for COVID-19 by nasopharyngeal swab RT-PCR. Chest CT were done and revealed
features of viral pneumonia with ground glass opacity appearance.
The patient was treated initially
with intravenous cephalosporins and antiprotozoal medications. He also received
intravenous corticosteroid to help reduce cerebral edema. He was also started
on seizure prophylaxis, to prevent SOL. To treat SARS-CoV-2 infection, he received
loading and maintenance dose of Favipiravir. He also got Cotrimoxazole 1x960mg
by nasogastric tube, Prednisone and Levofloxacin.
�
Figure 1
Axial brain CT scan without IV contrast
The yellow arrow is edema vasogenic
in frontal area, and the green one is basal ganglia. SOL suspected. After 14
days of hospitalization, he was discharged in relatively good condition and
advised to self-quarantine at home for another 7 days.
Diagnose
These symptoms, clinical findings, imaging, in
this patient we diagnosed with Encephalitis toxoplasmosis, SARS-CoV-2
infection, Epilepsy symptomatic, AIDS.
Discussion
Contact with T. gondii is common worldwide and
it occurs through direct ingestion of food or water contaminated with oocysts
in cat faeces, transplacental infection, transfusion
or organ transplantation. Toxoplasmosis in patients who are immunocompromised
can be life threatening. Toxoplasmosis can occur as a result of reactivation of
chronic disease and commonly attacks the central nervous system. The most commonly
found neurological signs are motor weakness, speech disturbances, cranial nerve
abnormalities and movement disorders.� A
recent retrospective study, showed there is no differences in the infection
rate and severity on COVID-19 regarding HIV infection, nevertheless, the
effects of COVID-19 on patients with acquired immunodeficiency syndrome
required further investigations (H�rter et al., 2020).
Complementary to the syndromic diagnosis, 3
aspects are relevant to establish the most probable aetiologies
of expansive focal brain lesions in HIV-AIDS: (1) local neuroepidemiology
(i.e., tuberculomas is usually more
common than primary central nervous system lymphoma [PCNSL] in low- and
middle-income countries); (2) degree of immunosuppression (i.e., lymphocyte CD4
count <200 cells/mm3 suggests opportunistic diseases; PCNSL usually occurs
with lymphocyte CD4 count <50 cells/mm3); and (3) individual clinical,
laboratorial, and neuroradiological features (Nagarakanti, Okoh,
Grinberg, & Bishburg, 2021).
In clinical practice, severe
immunocompromised HIV-AIDS (lymphocyte CD4 count <200 cells/mm3) with
compatible clinical and radiological findings of cerebral toxoplasmosis should
receive anti-toxoplasma therapy. Early suspicion and prompt treatment during
the initial phase of cerebral toxoplasmosis reduce the risk of neurological
sequelae and death. If no clinical and radiological improvement is seen within
10 to 14 days of anti-toxoplasma therapy, alternative diagnoses to cerebral
toxoplasmosis should be considered.
Based on PNPK Kemenkes
2020 with the reference base consolidated guidelines on the use of
antiretroviral drugs for treating and preventing HIV infection 2016 from WHO.
HIV patients with CD4 <100cells/μL and
positive toxoplasma serology should receive primary prophylaxis, cotrimoxazole
960mg once daily, which is also effective as prophylaxis of pneumocystis jirovecii pneumonia (PCP) (Susila, Subronto, &
Marthias, 2022).
ET prophylaxis can be discontinued in
adult patients who have received ARVs and CD4 >200cells/�L for 3 consecutive
months. Since providing continuous prophylaxis has little benefit in preventing
toxoplasmosis, has the potential for toxicity and drug interactions, and can
create drug-resistant pathogens, in addition to cost considerations.
Studies using molecular docking showed that
lamivudine could be effective against SARS-CoV-2 by downregulating RNA
dependent RNA polymerase. Basically, treatment of COVID-19 is primarily based
on the experience against similar viruses such as severe acute respiratory
syndrome coronavirus (SARS-CoV), Middle East
respiratory syndrome coronavirus (MERS-CoV), HIV dan
influenza (Bintari & Sugianto,
2021).
Conclusion
We present a patient with cerebral involvement
of toxoplasmosis possibly facilitated by pre-existing immunodeficiency, and
with COVID-19 complicated as acute infections. This case report reinforces a
potential role for other comorbidities, rather than HIV infection as regards SARS-CoV-2
infection outcomes. For better assessment we need to do MRI. This disease
remains the most common cause of expansive brain lesions and causes high
morbidity and mortality in persons with advanced immunosuppression,
particularly from low- and middle-income countries.
Cerebral toxoplasmosis presents a wide spectrum
of clinical and neuroradiological manifestations and a timely high index of
suspicion is vital. Anti-toxoplasma therapy is an important component of the
diagnostic approach to expansive brain lesions in HIV-AIDS patients. Local
neuroepidemiology, the degree of immunosuppression, and individual clinical,
laboratory, and neuroradiological features are important for the timely
evaluation of alternative diagnoses. Studies are urged to develop a proper
treatment for people living with HIV/AIDS who are also suffering from COVID-19.
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