Cerebral Toxoplasmosis in RSCM Hospital Jakarta

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