Fulminant toxoplasmosis presenting as isolated myelitis

https://doi.org/10.1590/0004-282X20190171 IMAGES IN NEUROLOGY Fulminant toxoplasmosis presenting as isolated myelitis Toxoplasmose fulminante se apresentando como mielite isolada Leonardo Favi BOCCA1, Alexandre Israel Kochi SILVA1, Carlos Roberto Veiga KIFFER2, Sergio CAVALHEIRO1, Paulo Eduardo Tavares de OLIVEIRA1, João Norberto STAVALE3, Linus Jan NO3, Franz Jooji ONISHI1 A 29-year-old male patient with an untreated HIV infection for seven years presented with a two-month history of neck pain, progressive left-hand weakness and numbness. Physical examination showed C5-C6 territory hypoesthesia and urinary bladder retention. A spinal MRI (Figure 1) showed a single contrast-enhanced lesion at C4-C6 level, cerebrospinal fluid analysis showed 3.6 A white blood cells/mm3 and a positive IgG for toxoplasma. Despite empiric treatment, the disease progressed locally and to the brainstem. Autopsy (Figure 2) showed disseminated CNS toxoplasmosis. Toxoplasmosis is the most common CNS infection in patients with AIDS, but isolated spinal cord involvement is rare1. Prompt empiric treatment for toxoplasmosis should be considered in all patients2. B C Figure 1. (A) Sagittal T2-weighted cervical spine MRI showing a heterogeneous mass-occupying lesion in the spinal cord (red arrow) with longitudinal edema from the medulla to T2 (blue arrows). The same lesion in T1-weighted MRI without (B) and with contrast (C). Note the heterogeneous contrast enhancement of the lesion (red arrows on B and C). 1 Universidade Federal de São Paulo, Departamento de Neurologia e Neurocirurgia, São Paulo SP, Brasil; 2 Universidade Federal de São Paulo, Departamento de Medicina, São Paulo SP, Brasil; 3 Universidade Federal de São Paulo, Departamento de Patologia, São Paulo SP, Brasil. https://orcid.org/0000-0003-4809-0159; Alexandre Israel Kochi Silva https://orcid.org/0000-0001-8541-949X; Leonardo Favi Bocca https://orcid.org/0000-0003-1122-0693; Sergio Cavalheiro https://orcid.org/0000-0002-9750-0508; Paulo Eduardo Carlos Roberto Veiga Kiffer https://orcid.org/0000-0002-5196-4753; João Norberto Stavale https://orcid.org/0000-0002-9141-0106; Linus Jan No Tavares de Oliveira https://orcid.org/0000-0002-5641-5104 https://orcid.org/0000-0002-3036-7626; Franz Jooji Onishi Correspondence: Franz Jooji Onishi; Disciplina de Neurocirurgia da UNIFESP; Rua Napoleão de Barros, 715, 6º andar, São Paulo SP, Brasil; E-mail: Conflict of interest: There is no conflict of interest to declare. Received 22 March 2019; Received in final form 02 June 2019; Accepted 16 July 2019. 901 A B C Figure 2. Autopsy findings showing: (A) macroscopic brain appearance with necrosis of brainstem and loss of connection between it and cerebellum. Histological evaluation with hematoxylin and eosin stain showed vast areas of liquefactive necrosis (lower magnification, B) and some T. gondii bradyzoites at higher magnification (arrow, C). References 1. 902 Vyas R, Ebright J. Toxoplasmosis of the spinal cord in a patient with AIDS: case report and review. Clin Infect Dis. 1996 Nov;23(5):1061-5. https://doi.org/10.1093/clinids/23.5.1061 Arq Neuropsiquiatr 2019;77(12):901-902 2. García-García C, Castillo-Álvarez F, Azcona-Gutiérrez JM, Herraiz MJ, Ibarra V, Oteo JA. Spinal cord toxoplasmosis in human immunodeficiency virus infection/acquired immunodeficiency syndrome. Infect Dis. 2015 May;47(5):277-82. https://doi.org/10.3109/00365548.2014.993421  (...truncated)