Dunphy Louise, Palmer Bret, Chen Fabian, Kitchen Joanne
Department of Acute Medicine, Royal Berkshire NHS Foundation Trust, Reading, UK
Department of HIV Medicine, Royal Berkshire Hospital, Reading, UK.
BMJ Case Rep. 2021 Jan 18;14(1):e237120. doi: 10.1136/bcr-2020-237120.
Individuals with HIV may present to the emergency department with HIV-related or HIV-unrelated conditions, toxicity associated with antiretroviral therapy or primary HIV infection (seroconversion). In individuals with HIV infection, central nervous system toxoplasmosis occurs from reactivation of disease, especially when the CD4+ count is <100 cells/μL, whereas in those taking immunosuppressive therapy, this can be either due to newly acquired or reactivated latent infection. It is a rare occurrence in immune-competent patients. Vertical transmission during pregnancy can manifest as congenital toxoplasmosis in the neonate and is often asymptomatic until the second or third decade of life when ocular lesions develop. Toxoplasmosis is an infection caused by the intracellular protozoan parasite and causes zoonotic infection. It can cause focal or disseminated brain lesions leading to neurological deficit, coma and death. Typical radiological findings are multiple ring-enhancing lesions. Histopathological examination demonstrating tachyzoites of and the presence of nucleic material in the spinal cerebrospinal fluid (CSF) confirms the diagnosis. The authors present the case of a 52-year-old male UK resident, born in sub-Saharan Africa, with a 3-week history of visual hallucinations. He attended the emergency department on three occasions. Laboratory investigations and a CT head were unremarkable. He was referred to psychological medicine for further evaluation. On his third presentation, 2 months later, a CT head showed widespread lesions suggestive of cerebral metastasis. Dexamethasone was initiated and he developed rigours. An MRI head showed multiple ring-enhancing lesions disseminated throughout his brain parenchyma. CSF analysis and serology confirmed the diagnosis of HIV and toxoplasmosis, respectively. His CD4 count was 10 and his viral load (VL) was 1 245 003. He was then initiated on Biktarvy 50 mg/200 mg/25 mg, one tablet daily, which contains 50 mg of bictegravir, 200 mg of emtricitabine and tenofovir alafenamide fumarate equivalent to 25 mg of tenofovir alafenamide. After 3 months of antiretroviral therapy, his HIV VL reduced to 42. However, his abbreviated mental test remained at 2/10. Despite presenting with neurocognitive impairment and being born in a HIV prevalent region, an HIV test was not offered. This case highlights missed opportunities to request HIV serology and raises awareness that cerebral toxoplasmosis can occur as the first manifestation of HIV. Prompt diagnosis and early initiation of antiretroviral therapy reduces morbidity and mortality in this patient cohort.
感染艾滋病毒的个体可能因与艾滋病毒相关或无关的病症、抗逆转录病毒疗法相关的毒性反应或原发性艾滋病毒感染（血清转化）而前往急诊科就诊。在艾滋病毒感染个体中，中枢神经系统弓形虫病是由疾病重新激活引起的，尤其是当CD4+细胞计数<100个/μL时；而在接受免疫抑制治疗的个体中，这可能是由于新获得的或重新激活的潜伏感染所致。在免疫功能正常的患者中，这种情况很少见。孕期垂直传播可表现为新生儿先天性弓形虫病，通常在生命的第二个或第三个十年出现眼部病变之前没有症状。弓形虫病是由细胞内原生动物寄生虫引起的感染，可导致人畜共患感染。它可引起局灶性或播散性脑损伤，导致神经功能缺损、昏迷和死亡。典型的放射学表现是多个环形强化病灶。组织病理学检查显示弓形虫速殖子以及脊髓脑脊液（CSF）中存在核酸物质可确诊。作者报告了一例52岁男性英国居民的病例，该患者出生于撒哈拉以南非洲，有3周的视幻觉病史。他三次前往急诊科就诊。实验室检查和头颅CT均无异常。他被转介到心理医学科进行进一步评估。2个月后他第三次就诊时，头颅CT显示广泛病变，提示脑转移。开始使用地塞米松后，他出现寒战。头颅MRI显示多个环形强化病灶散布于整个脑实质。脑脊液分析和血清学检查分别确诊为艾滋病毒和弓形虫病。他的CD4细胞计数为10，病毒载量（VL）为1 245 003。随后开始给他服用比克恩丙诺片50mg/200mg/25mg，每日一片，该片剂含有50mg比克替拉韦、200mg恩曲他滨和相当于25mg替诺福韦艾拉酚胺的富马酸替诺福韦二吡呋酯。经过3个月的抗逆转录病毒治疗，他的艾滋病毒病毒载量降至42。然而，他的简易精神状态检查评分仍为2/10。尽管该患者有神经认知障碍且出生在艾滋病毒流行地区，但当时并未进行艾滋病毒检测。该病例突出了错过进行艾滋病毒血清学检测的机会，并提高了人们对弓形虫病可能作为艾滋病毒首发表现的认识。及时诊断并尽早开始抗逆转录病毒治疗可降低该患者群体的发病率和死亡率。
