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  #1  
Old 06-26-2011
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CT Scan Seizure and Ring Enhancement CT scan in HIV patient!

A 39-year-old man presents to the emergency department after a tonic-clonic seizure. He has a history of human immunodeficiency virus (HIV) infection and has not taken any antiretroviral therapy. On arrival, he is afebrile and disoriented to place and time. A head computed tomography (CT) scan is performed and shows two ring enhancing, spherical lesions at the corticomedullary junction. What is the most appropriate next step in the management of this patient?

Answer Choices
A. Amphotericin B
B. Brain biopsy
C. Fluconazole
D. Pyrimethamine and sulfadiazine
E. Serology for antitoxoplasma antibodies
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  #2  
Old 06-26-2011
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Toxoplasmosis

D. Pyrimethamine and sulfadiazine
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Old 06-26-2011
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The most common infection which manifest with ring enhancing lesion is Toxoplasmosis. The answer is D.Pyrimethamine and sulfadiazine.

However lymphoma of the CNS is also in the differential diagnosis because it manifests as ring enhancing lesion but you must treat toxoplasmosis first, if the lesions do not shrink you perform a biopsy to confirm the diagnosis.

Last edited by Sadalssud; 06-26-2011 at 10:32 AM. Reason: grammar mistake =P
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Old 06-26-2011
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pyrimethamine and sulfadiazine
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Old 06-26-2011
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Agree. And follow up 2 weeks later. Response to therapy confirms Toxoplasmosis and rules out lymphoma.
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Old 06-26-2011
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still no right answer
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Old 06-26-2011
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It is E in that case.. but I am not agree with that, because almost 90% of the people is toxoplasmosis positive!
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Old 06-26-2011
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besides toxoplasmosis ...i think cryptoccocus could appear like this...so fluconazole amphotericin i dont think it coulb an option...

I m btween Serology for antitoxoplasma antibodies and biopsy
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Default D

I'll go with D
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Old 06-27-2011
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D??
i dont think HIV patiet would test postive for antibodies or he wouldnt get such a disease
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Old 06-27-2011
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D brain enhancing lesion in HIV either toxoplasmosis or lymphoma


we should go for trial of therapy first if no improvement after 2 weeks then look for lymphoma


source Kaplan notes IM page 230

even if you tell me this wrong answer i will choose it on exam
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Quote:
Originally Posted by kemoo View Post
D brain enhancing lesion in HIV either toxoplasmosis or lymphoma


we should go for trial of therapy first if no improvement after 2 weeks then look for lymphoma


source Kaplan notes IM page 230

even if you tell me this wrong answer i will choose it on exam
me too i choose it but still wrong answer
i post it because i want to be sure it is wrong q
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Quote:
Originally Posted by miss patho View Post
me too i choose it but still wrong answer
i post it because i want to be sure it is wrong q
I had a similar question today, and the answer is Pyrimethamine and sulfadiazine.

Why?:

Amphotericin B is the treatment against Cryptococcus neoformans which USUALLY causes meningitis not CNS lesions.

Brain biopsy is reserved when you do not have a response to your treatment, in order to diagnose a CNS lymphoma, another cause of ring enhancing lesion.

Fluconazole is the treatment against Cryptococcus neoformans after you finish the IV amphotericin B at the hospital. (outpatient treatment)

Serology has a trick: Most of the people have antibodies against toxoplasma, however, people who is in a severe immunodeficiency could have a false negative in the test. Therefore the treatment is first.
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Old 06-27-2011
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What's correct answer? Thanks

Yes I would have gone with D -treatment for toxoplasmosis too.
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Option E (Serology for antitoxoplasma antibodies) is correct. The probability of multiple ring-enhancing lesions being toxoplasmosis in a patient not taking trimethoprim-sulfamethoxazole (TMP-SMX) rises to 90% if the patient's serology demonstrates antitoxoplasma antibodies. The test is not specific for current infection, but lifelong exposure. Toxoplasmosis of the CNS in HIV patients typically is a reactivation. If the toxoplasma antibodies are not present, the likelihood drops and brain biopsy must be strongly considered prior to starting anti-infective therapy.

Option A (Amphotericin B) is incorrect. Amphotericin is used in the management of patients with cryptococcosis, which presents as a meningitis.

Option B (Brain biopsy) is incorrect. This would be appropriate once an antitoxoplasma antibody level were obtained, or if there were a single, poorly enhancing lesion that suggested central nervous system (CNS) lymphoma.

Option C (Fluconazole) is incorrect. Fluconazole can be used as prophylaxis against cryptococcosis, but routine prophylaxis is not recommended, because of the low incidence of disease.

Option D (Pyrimethamine and sulfadiazine) is incorrect. This is the standard therapy for toxoplasmosis and should be started if antitoxoplasma antibodies are positive in this patient.

High-yield Hit 1
Toxoplasmosis may initially be seen with cervical lymphadenopathy. Although the lymphoglandular form is more common in adults, the disease does occur in children. Multiple lymph nodes are usually involved, and signs of acute inflammation are absent. The infecting agent is Toxoplasma gondii, the definitive host is the cat, and human infection occurs through contact with cat feces or through consumption of contaminated meat or milk. Diagnosis is usually made by biopsy and supported with antitoxoplasma serum titers. Antibiotic therapy is effective.

From Essentials of Surgery by Becker & Stucchi
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