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Chapter 22 : Toxoplasmosis of the Central Nervous System

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Abstract:

This chapter focuses on the pathogenesis, diagnosis, and management of central nervous system (CNS) toxoplasmosis. The latest epidemiological trends are discussed, and special attention is given to recently developed diagnostic modalities including laboratory techniques and newer neuroimaging modalities. The lesions associated with toxoplasmosis vary in size, characteristics, and location. Typical lesions of toxoplasmosis are characterized histopathologically by three zones. In patients with AIDS, toxoplasmosis is almost always due to reactivation of previously acquired infection. Manifestations of toxoplasmosis in the AIDS population are primarily those of CNS dysfunction and usually reflect the multiple abscesses that are present. Given the high seroprevalence of toxoplasmosis, positive serology is not helpful in distinguishing reactivation from quiescent infection and is not very useful in ruling in active Toxoplasma infection. The locations of lesions adjacent to cerebrospinal fluid (CSF) pathways, e.g., periventricular as well as subependymal spread or ventricular encasement, are characteristic of primary CNS lymphoma (PCNSL), rather than toxoplasmosis. Thallium-201 single photon emission computed tomography (Tl-SPECT), fluorodeoxyglucose positron emission tomography (FDG-PET), and magnetic resonance spectroscopy have all been studied as methods to differentiate PCNSL from other causes of focal brain lesions, specifically toxoplasmosis. For patients who have not received HAART, primary prophylaxis and maintenance therapy need to be continued indefinitely due to the high risk of acute toxoplasmic encephalitis (TE) and relapse of TE, respectively.

Citation: Brown K, Skiest D. 2009. Toxoplasmosis of the Central Nervous System, p 313-329. In Goodkin K, Shapshak P, Verma A (ed), The Spectrum of Neuro-AIDS Disorders. ASM Press, Washington, DC. doi: 10.1128/9781555815691.ch22

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FIGURE 1

Life cycle of (Adapted with permission from .)

Citation: Brown K, Skiest D. 2009. Toxoplasmosis of the Central Nervous System, p 313-329. In Goodkin K, Shapshak P, Verma A (ed), The Spectrum of Neuro-AIDS Disorders. ASM Press, Washington, DC. doi: 10.1128/9781555815691.ch22
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Image of FIGURE 2
FIGURE 2

Postmortem brain showing a lesion of untreated toxoplasmosis involving the basal ganglia. There is significant surrounding edema and mass effect with compression of the ipsilateral ventricle. (Reprinted with permission from .)

Citation: Brown K, Skiest D. 2009. Toxoplasmosis of the Central Nervous System, p 313-329. In Goodkin K, Shapshak P, Verma A (ed), The Spectrum of Neuro-AIDS Disorders. ASM Press, Washington, DC. doi: 10.1128/9781555815691.ch22
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Image of FIGURE 3
FIGURE 3

Giemsa stain (magnification, × 1,000) of brain biopsy specimen from a patient with CNS toxoplasmosis. Tissue cyst containing multiple bradyzoites (arrow). The surrounding area reveals numerous tachyzoites (arrowheads). (Photomicrograph is courtesy of Dennis Burns.)

Citation: Brown K, Skiest D. 2009. Toxoplasmosis of the Central Nervous System, p 313-329. In Goodkin K, Shapshak P, Verma A (ed), The Spectrum of Neuro-AIDS Disorders. ASM Press, Washington, DC. doi: 10.1128/9781555815691.ch22
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Image of FIGURE 4
FIGURE 4

T1-weighted gadolinium-enhanced MRI revealing a large enhancing lesion of toxoplasmosis. There is surrounding edema and mass effect with midline shift.

Citation: Brown K, Skiest D. 2009. Toxoplasmosis of the Central Nervous System, p 313-329. In Goodkin K, Shapshak P, Verma A (ed), The Spectrum of Neuro-AIDS Disorders. ASM Press, Washington, DC. doi: 10.1128/9781555815691.ch22
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Image of FIGURE 5
FIGURE 5

T1-weighted gadolinium-enhanced MRI revealing multiple ring-enhancing lesions of toxoplasmosis.

Citation: Brown K, Skiest D. 2009. Toxoplasmosis of the Central Nervous System, p 313-329. In Goodkin K, Shapshak P, Verma A (ed), The Spectrum of Neuro-AIDS Disorders. ASM Press, Washington, DC. doi: 10.1128/9781555815691.ch22
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Image of FIGURE 6
FIGURE 6

Management algorithm for diagnosis of focal enhancing lesion(s) in an AIDS patient. SPECT-Tl-201, Tl-SPECT; PET, positron emission tomography with fluorodeoxyglucose.

Citation: Brown K, Skiest D. 2009. Toxoplasmosis of the Central Nervous System, p 313-329. In Goodkin K, Shapshak P, Verma A (ed), The Spectrum of Neuro-AIDS Disorders. ASM Press, Washington, DC. doi: 10.1128/9781555815691.ch22
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Tables

Generic image for table
TABLE 1

Clinical manifestations of CNS toxoplasmosis in AIDS

Citation: Brown K, Skiest D. 2009. Toxoplasmosis of the Central Nervous System, p 313-329. In Goodkin K, Shapshak P, Verma A (ed), The Spectrum of Neuro-AIDS Disorders. ASM Press, Washington, DC. doi: 10.1128/9781555815691.ch22
Generic image for table
TABLE 2

Results of CSF analyses by PCR for diagnosis of TE

Citation: Brown K, Skiest D. 2009. Toxoplasmosis of the Central Nervous System, p 313-329. In Goodkin K, Shapshak P, Verma A (ed), The Spectrum of Neuro-AIDS Disorders. ASM Press, Washington, DC. doi: 10.1128/9781555815691.ch22
Generic image for table
TABLE 3

Indications for brain biopsy in patients with AIDS and enhancing focal lesions

Citation: Brown K, Skiest D. 2009. Toxoplasmosis of the Central Nervous System, p 313-329. In Goodkin K, Shapshak P, Verma A (ed), The Spectrum of Neuro-AIDS Disorders. ASM Press, Washington, DC. doi: 10.1128/9781555815691.ch22
Generic image for table
TABLE 4

Treatment and prophylaxis for acute CNS toxoplasmosis

Citation: Brown K, Skiest D. 2009. Toxoplasmosis of the Central Nervous System, p 313-329. In Goodkin K, Shapshak P, Verma A (ed), The Spectrum of Neuro-AIDS Disorders. ASM Press, Washington, DC. doi: 10.1128/9781555815691.ch22

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