Smadja D, Fournerie P, Cabre P, Cabie A, Olindo S
Service de Neurologie, Hôpital Pierre Zobda-Quitman, Fort-de-France.
Presse Med. 1998 Sep 12;27(26):1315-20.
Non-viral opportunistic infections involving the central nervous system in AIDS patients most commonly result from toxoplasmic encephalitis (TE). Combination pyremethamin (pyr)/sulfadiazine (sulf) is the mainstay treatment for TE, but many patients experience severe adverse events occasionally requiring discontinuation of this antitoxoplasmic medication. This investigation assessed the effects of an open, prospective trial of alternative trimethroprim/sulfamethoxazole: cotrimoxazole (CTX) therapy for TE in AIDS patients.
The subjects were 18 AIDS patients with a first presumptive attack of TE (Group 1) and 9 relapsing patients, including 6 out of Group 1 (Group 2). We gave CTX as a therapy at the dose of 960 mg four times a day for 48 hours, then 960 mg three times a day for two weeks, followed by 960 mg twice daily until computed tomography showed complete disappearance of active TE lesions. Life-long maintenance therapy consisted to CTX 960 mg daily.
Group 1: Seventeen patients improved clinically and achieved complete resolution on computed tomography scars over a mean period of 33 days (range: 21-56). Only one patient was withdrawn from the study at day 18 due to a severe skin rash. Neither serious hematologic nor liver toxicity were observed. Under maintenance therapy, 7 patients relapsed after an average duration of 15.5 months. Relapses were precipitated either by poor compliance (5/7) or erronenous CTX protocol (2/7). Group 2: There were 15 relapses affecting 9 patients who were treated successfully with CTX. CTX was discontinued in one relapsing patient who experienced a Stevens-Johnson syndrome on day 13. This patient had previously experienced cutaneous intolerance to sulfadiazine.
A relative low dose regimen of CTX appears to be strongly efficient and safe treatment for toxoplasmic encephalitis in AIDS. Such a study is of particular interest for developing countries where TE is highly prevalent, given the wide availability of CTX which could be proposed as an economic first line therapy.
艾滋病患者中枢神经系统的非病毒性机会性感染最常见于弓形虫脑炎（TE）。乙胺嘧啶（pyr）/磺胺嘧啶（sulf）联合用药是TE的主要治疗方法，但许多患者会出现严重不良事件，偶尔需要停用这种抗弓形虫药物。本研究评估了一项开放性、前瞻性试验中，用替代药物甲氧苄啶/磺胺甲恶唑：复方新诺明（CTX）治疗艾滋病患者TE的效果。
受试者为18例首次疑似发作TE的艾滋病患者（第1组）和9例复发患者，其中6例来自第1组（第2组）。我们给予CTX治疗，剂量为960mg，每日4次，持续48小时，然后960mg，每日3次，持续两周，随后960mg，每日2次，直至计算机断层扫描显示活动性TE病变完全消失。终身维持治疗为每日960mg CTX。
第1组：17例患者临床症状改善，计算机断层扫描瘢痕在平均33天（范围：21 - 56天）内完全消退。仅1例患者在第18天因严重皮疹退出研究。未观察到严重血液学或肝脏毒性。在维持治疗期间，7例患者平均15.5个月后复发。复发原因要么是依从性差（5/7），要么是CTX方案错误（2/7）。第2组：9例接受CTX成功治疗的患者出现15次复发。1例复发患者在第13天出现史蒂文斯 - 约翰逊综合征，停用了CTX。该患者之前对磺胺嘧啶有皮肤不耐受。
相对低剂量的CTX方案似乎是治疗艾滋病患者弓形虫脑炎的高效且安全的方法。鉴于CTX广泛可得，可作为经济的一线治疗方案，对于TE高度流行的发展中国家而言，这样的研究尤为重要。
