POKDISUS AIDS RSCM - FKUI 2004. N. Female. Male. Year. 29. 301. 330. 2003.
96. 821. 917. 2004. 13. 115. 128. 2002. New HIV-AIDS Cases in Cipto.
Cerebral Toxoplasmosis in RSCM Hospital Jakarta
Darma Imran Herlyani Khosama, Nurhayana Lubis, Widi Widowati, Alifa Dimayanti, Jofizal Jannis Department of Neurology RSCM Hospital - Indonesia University
New HIV-AIDS Cases in Cipto Mangunkusumo Hospital, Jakarta Female
1000
821
900 800
Year
700
2002
600
Male
Male Female
T otal
2003
400
13
128
301 301
330 29
330
2004 115 128 821
300 200 100
13
N
115
500
96
917
96 917
29
0
2002
2003
2004
POKDISUS AIDS RSCM Pokdisus AIDS- FKUI FKUI2004
Num ber of cases
Number of HIV Cases admitted in Neurological Ward (inpatient) 2003-2006
189
200 150
98
100 50
16
26
1 2003
2 2004
0 3 2005
4 2006
Years
Department of Neurology RSCM Hospital - Indonesia University
AIDS related CNS Opportunistic Infection in 203 Cases at RSCM Hospital Jan 2004 – March 2006 Unknown 21% Toxo 35% Bacterial 5%
TBC 26%
Krypto 13%
Department of Neurology RSCM Hospital - Indonesia University
ALGORITHM - 1 APROACH TO CNS OPPORTUNISTIC COMPLICATION IN AIDS RSCM Hospital, Jakarta
HIV seropositive, CD4 < 200 sel/uL Fever, Headache, decreasing counsciousnes, clinical sign of intracranial infection or SOL, progressive neurological signs and symptoms
Yes
Toxo
or
TB
CT / MRI:Focal brain lesion
or
Bacterial
two weeks or less Response
No
Lumbar Puncture
Cryptococcus, TB, Bacterial, other
Brain biopsy (rare)
Failure
Reassesment Clinical, radiologic, labs
Add treatment for TB or Toxo or Bacterial or others (CMV,PML)
Choosing between Toxo – TB – Bacterial Absces
Empiric Anti Toxoplasmic – No history of toxo prophylaxis
Empiric Anti TB drug – CD4 > 200 – Thorax photo : Miliar TB
Empiric Antibiotic for Bacterial Brain Absces – Neuroimaging study : compatible with bacterial brain absces
ALGORITHM - 2 APROACH TO CNS OPPORTUNISTIC COMPLICATION IN AIDS
RSCM Hospital, Jakarta
WITH OUT CT SCAN / MRI HIV seropositive, CD4 < 200 sel/uL Fever, Headache, decreasing counsciousnes, clinical sign of intracranial infection or SOL, progressive neurological signs and symptoms Yes
Treatment A
Anti Toxoplasma OR
Focal neurologic sign
Treatment B
Lumbar Puncture
Anti TB
Two weeks
Response
No
Failure
Add anti TB if previously received anti toxoplasma (vise versa)
• Cryptococcal • TB • Bacterial inf
Aim
To review the clinical manifestations and treatment response of Suspected Cases of Cerebral Toxoplasmosis
Department of Neurology RSCM Hospital - Indonesia University
Methods Retrospective data from January 2004 to January 2007 125 Suspected cases of cerebral toxoplasmosis Who received empiric antitoxoplasmic treatment
Department of Neurology RSCM Hospital - Indonesia University
300 cases of AIDS Related Intracranial Complications 175 other cases
125 Suspected Cases of Cerebral Toxo
Received Empiric Treatment 89 Response
36 No Response
(Clinical Improvement)
(no clinical improvement)
Department of Neurology RSCM Hospital - Indonesia University
Neuroimaging Studies Single lesion 20% Multiple lesions 80% Subcortical lesions 61 %
Contrast examination •Without contrast : 9 % •Enhancement : 78 %
Department of Neurology RSCM Hospital - Indonesia University
Empiric anti Toxoplasmic Treatment 2004 Pyrimethamine-sulfadoxine bid po – Drug allergy 34.2 %
Clindamycin 600 mg qd po
2005 - present Pyrimethamine 200 mg load 75 mg/d Clindamycin 600 mg qd po Department of Neurology RSCM Hospital - Indonesia University
Patients Characteristics N = 125
Patients
Percentage
110
88
Age
19 – 48 yr
(Mean 28)
IDU
102
82
Sex (Male)
CD4
0 – 172 cells/mm3 (Mean 39) (85 % below 100)
New HIV Diagnosis
107
86
Toxo IgG (N=84)
82
98
Hep C (N=37)
37
100
Pulmonary TB
41
33
Department of Neurology RSCM Hospital - Indonesia University
Clinical Manifestations N = 125
Number of patients 106
Percentage
Fever
59
47
Vomitus
48
39
GCS < 12
46
37
Seizure
46
37
Hemiparesis
60
48
Headache
85
GCS : Glasgow Coma Scale Department of Neurology RSCM Hospital - Indonesia University
Outcome
Respon to anti-toxoplasmic treatment – Clinical improvement : 89 (71%) – No response : 36 (29%) – Clinical response in 7 days : 65 (73%)
Mortality rate : 31 %
Department of Neurology RSCM Hospital - Indonesia University
Outcome N = 125 New HIV Dx On HAART Focal sign Multiple lesions GCS < 12 PulmonaryTB
Response 74 7 69 75 23 24
No Response P-value 33 2 22 29 13 17
NS NS NS NS 0.00 0.03
Department of Neurology RSCM Hospital - Indonesia University
Conclusion
Clinical response to anti-toxoplasmic treatment 71% Glasgow coma scale below 12 on admission have poor outcome Patients with pulmonary tuberculosis tended to have poor outcome.
Department of Neurology RSCM Hospital - Indonesia University
Thank you
[email protected] Department of Neurology RSCM Hospital – University of Indonesia