American Journal of Emergency Medicine xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Intracranial toxoplasmosis presenting as panhypopituitarism in an immunocompromised patient Abstract A 37-year-old man presented with worsening headache, vomiting, and right-sided weakness over the last few weeks. A head computed tomography showed a left hemispheric posterior medial parietal lobe lesion with surrounding edema. Further imaging with magnetic resonance imaging showed multiple enhancing mass lesions. The largest lesion measured 2.4 cm within the left occipital parietal region (Figure A and B). Laboratory data showed reactive HIV antibodies, confirmed by Western blot. An absolute CD4 count was 22 cells/μL. Other laboratory test results showed low sodium, thyrotropin, FT4, FT3, cortisol levels, corticotropin, luteinizing hormone, and testosterone. Based on these findings, the brain lesions were believed to be causing his panhypopituitarism. A brain biopsy confirmed the presence of Toxoplasma gondii by polymerase chain reaction. The patient was started on pyrimethamine and clindamycin for toxoplasmosis treatment, and azithromycin and sulfamethoxazole/trimethoprime for appropriate prophylaxis. He was also started on hormone supplementation. His symptoms were completely resolved at the time of discharge. A 37-year-old Sudanese man presented with worsening headache, nausea, vomiting, right-sided weakness, and tingling in both upper and lower extremities over the last few weeks. His medical history was significant for squamous cell carcinoma of the penis and epididymitis. Physical examination showed right-sided sensory and motor deficits. Otherwise, his physical examination result was unremarkable. A computed tomography was obtained that showed a left hemispheric posterior medial parietal lobe lesion with surrounding edema. Further imaging with magnetic resonance imaging showed multiple intraaxial enhancing mass lesions with a predominantly gray-white junction with their location highly suggestive of intracranial metastasis. The largest lesion measured 2.4 cm within the left occipital parietal region (Figure A and B). Laboratory data showed reactive HIV antibodies, confirmed by Western blot. HIV antibody viral load was 330004, with an absolute CD4 count of 22 cells/μL. Other
laboratory test results showed low sodium, thyrotropin, FT4, FT3, cortisol levels, corticotropin, and luteinizing hormone. His testosterone levels were also low. Based on these findings, the brain lesions were believed to be causing his panhypopituitarism. A brain biopsy confirmed the presence of Toxoplasma gondii by polymerase chain reaction. No cellular findings were consistent with lymphoma or metastasis. The patient was started on pyrimethamine and clindamycin for toxoplasmosis treatment, and azithromycin and sulfamethoxazole/ trimethoprime for appropriate prophylaxis. He was also started on hormone supplementation. His symptoms were completely resolved at the time of discharge. Toxoplasmosis is the most common central nervous system infection in patients with AIDS not receiving prophylaxis, with the probability of developing toxoplasmosis about 30&% with a CD4 count less than 100 cells/μL. Toxoplasmosis most frequently presents with central nervous system involvement, with signs and symptoms including headache, fever, and focal neurologic deficits upon the area of involvement; but extracerebral disease can also occur. Treatment is with antimicrobial therapy directed against the T gondii, as well as antiretroviral therapy. Shadi Hamdeh MD ⁎ Anum Abbas MBBS Jessica Fraker J.E. Lambrecht MD, Pharm D Creighton University School of Medicine, Department of Internal Medicine Omaha, NE, USA ⁎ Corresponding author. Creighton University School of Medicine Department of Internal Medicine, 601, N30th St, Suite 5850 Omaha NE, USA, 68131. Tel.: +1 816 726 6039 E-mail address: [email protected]
http://dx.doi.org/10.1016/j.ajem.2015.04.071
0735-6757/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Hamdeh S, et al, Intracranial toxoplasmosis presenting as panhypopituitarism in an immunocompromised patient, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.04.071
2
S. Hamdeh et al. / American Journal of Emergency Medicine xxx (2015) xxx–xxx
Figure. Magnetic resonance imaging showing numerous bilateral intraaxial T2/fluid-attenuated inversion recovery hyperintense lesions with significant enhancement. The largest appears in the left parieto-occipital area measuring 2.3 × 2.4 cm with significant perilesional edema that crosses through the splenium of the corpus callosum into the right occipital lobe (A and B).
Please cite this article as: Hamdeh S, et al, Intracranial toxoplasmosis presenting as panhypopituitarism in an immunocompromised patient, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.04.071
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Intracranial toxoplasmosis presenting as panhypopituitarism in an immunocompromised patient Abstract A 37-year-old man presented with worsening headache, vomiting, and right-sided weakness over the last few weeks. A head computed tomography showed a left hemispheric posterior medial parietal lobe lesion with surrounding edema. Further imaging with magnetic resonance imaging showed multiple enhancing mass lesions. The largest lesion measured 2.4 cm within the left occipital parietal region (Figure A and B). Laboratory data showed reactive HIV antibodies, confirmed by Western blot. An absolute CD4 count was 22 cells/μL. Other laboratory test results showed low sodium, thyrotropin, FT4, FT3, cortisol levels, corticotropin, luteinizing hormone, and testosterone. Based on these findings, the brain lesions were believed to be causing his panhypopituitarism. A brain biopsy confirmed the presence of Toxoplasma gondii by polymerase chain reaction. The patient was started on pyrimethamine and clindamycin for toxoplasmosis treatment, and azithromycin and sulfamethoxazole/trimethoprime for appropriate prophylaxis. He was also started on hormone supplementation. His symptoms were completely resolved at the time of discharge. A 37-year-old Sudanese man presented with worsening headache, nausea, vomiting, right-sided weakness, and tingling in both upper and lower extremities over the last few weeks. His medical history was significant for squamous cell carcinoma of the penis and epididymitis. Physical examination showed right-sided sensory and motor deficits. Otherwise, his physical examination result was unremarkable. A computed tomography was obtained that showed a left hemispheric posterior medial parietal lobe lesion with surrounding edema. Further imaging with magnetic resonance imaging showed multiple intraaxial enhancing mass lesions with a predominantly gray-white junction with their location highly suggestive of intracranial metastasis. The largest lesion measured 2.4 cm within the left occipital parietal region (Figure A and B). Laboratory data showed reactive HIV antibodies, confirmed by Western blot. HIV antibody viral load was 330004, with an absolute CD4 count of 22 cells/μL. Other
laboratory test results showed low sodium, thyrotropin, FT4, FT3, cortisol levels, corticotropin, and luteinizing hormone. His testosterone levels were also low. Based on these findings, the brain lesions were believed to be causing his panhypopituitarism. A brain biopsy confirmed the presence of Toxoplasma gondii by polymerase chain reaction. No cellular findings were consistent with lymphoma or metastasis. The patient was started on pyrimethamine and clindamycin for toxoplasmosis treatment, and azithromycin and sulfamethoxazole/ trimethoprime for appropriate prophylaxis. He was also started on hormone supplementation. His symptoms were completely resolved at the time of discharge. Toxoplasmosis is the most common central nervous system infection in patients with AIDS not receiving prophylaxis, with the probability of developing toxoplasmosis about 30&% with a CD4 count less than 100 cells/μL. Toxoplasmosis most frequently presents with central nervous system involvement, with signs and symptoms including headache, fever, and focal neurologic deficits upon the area of involvement; but extracerebral disease can also occur. Treatment is with antimicrobial therapy directed against the T gondii, as well as antiretroviral therapy. Shadi Hamdeh MD ⁎ Anum Abbas MBBS Jessica Fraker J.E. Lambrecht MD, Pharm D Creighton University School of Medicine, Department of Internal Medicine Omaha, NE, USA ⁎ Corresponding author. Creighton University School of Medicine Department of Internal Medicine, 601, N30th St, Suite 5850 Omaha NE, USA, 68131. Tel.: +1 816 726 6039 E-mail address: [email protected]
http://dx.doi.org/10.1016/j.ajem.2015.04.071
0735-6757/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Hamdeh S, et al, Intracranial toxoplasmosis presenting as panhypopituitarism in an immunocompromised patient, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.04.071
2
S. Hamdeh et al. / American Journal of Emergency Medicine xxx (2015) xxx–xxx
Figure. Magnetic resonance imaging showing numerous bilateral intraaxial T2/fluid-attenuated inversion recovery hyperintense lesions with significant enhancement. The largest appears in the left parieto-occipital area measuring 2.3 × 2.4 cm with significant perilesional edema that crosses through the splenium of the corpus callosum into the right occipital lobe (A and B).
Please cite this article as: Hamdeh S, et al, Intracranial toxoplasmosis presenting as panhypopituitarism in an immunocompromised patient, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.04.071
