It is a relatively common occurrence for radiologists to be asked to distinguish between cerebral toxoplasmosis and primary CNS lymphoma (PCNSL) in patients with HIV/AIDS. Treatment is clearly different and thus accurate interpretation of CT and MRI is essential.
In many instances appearances are classic and pose little problem, however, in 50-80% of cases the appearances can be very similar requiring careful interpretation 1. Below are helpful distinguishing features.
Primary CNS lymphoma typically demonstrates subependymal spread, whereas toxoplasmosis tends to be scattered through the basal ganglia and at the corticomedullary junction 1.
HIV lymphoma also is far more frequently a solitary lesion, whereas toxoplasmosis is usually multifocal (86%) 2-3.
Following administration of contrast, on both CT and MRI, both entities enhance, however typically lymphoma is solid whereas toxoplasmosis demonstrates ring or nodular enhancement 1-2. It should be noted however that it is in patients with HIV/AIDS that primary CNS lymphoma may demonstrate ring enhancement also.
Haemorrhage does not happen typically in PCNSL before treatment but may be seen occasionally in toxoplasmosis, a finding that can help differentiate them.
Although both entities have increased lactate and lipids, this tends to be less marked in lymphoma. Lymphoma typically demonstrates marked increase in Cho, whereas it is reduced in toxoplasmosis 1-2. Both demonstrate decreased Cr and NAA. However, this pattern is variable.
MRS should be performed with both long and short TE sequences 1.
A decrease in cerebral blood volume (rCBV) centrally within lesions suggests toxoplasmosis, whereas it is increased in lymphoma 1. Unfortunately it is reduced in the perilesional oedema of both lesions.
Thallium 201 Chloride SPECT demonstrates increased uptake in lymphoma whereas it is decreased in toxoplasmosis 2.
Features that favour primary CNS lymphoma include:
- single lesion
- subependymal spread
- solid enhancement
- no haemorrhage before treatment
- Thallium SPECT positive
- MRS: increased choline (Cho)
- MR perfusion: increased rCBV
Features that favour cerebral toxoplasmosis include:
- multiple lesions
- scattered though basal ganglia and corticomedullary junction
- ring or nodular enhancement
- haemorrhage occasionally occurs mostly in periphery of lesion
- Thallium SPECT negative
- MRS: decreased choline (Cho)
- MR perfusion: decreased rCBV
- manifestations of HIV/AIDS
- CNS manifestations
- pulmonary manifestations
- cardiovascular manifestations
- gastrointestinal manifestations
- hepatobiliary manifestations
- genitourinary manifestations
- musculoskeletal manifestations
- AIDS defining illnesses
- HIV associated neoplasms
- immune reconstitution inflammatory syndrome (IRIS)
- AIDS embryopathy
- 1. Gupta RK, Lufkin RB. MR Imaging and Spectroscopy of Central Nervous System Infection. Springer Verlag. (2001) ISBN:0306465515. Read it at Google Books - Find it at Amazon
- 2. Chang L, Cornford ME, Chiang FL et-al. Radiologic-pathologic correlation. Cerebral toxoplasmosis and lymphoma in AIDS. AJNR Am J Neuroradiol. 1996;16 (8): 1653-63. Pubmed citation
- 3. Kornienko VN, Pronin I. Diagnostic Neuroradiology. Springer. (2009) ISBN:3540756523. Read it at Google Books - Find it at Amazon
- 4. Ernst TM, Chang L, Witt MD et-al. Cerebral toxoplasmosis and lymphoma in AIDS: perfusion MR imaging experience in 13 patients. Radiology. 1998;208 (3): 663-9. doi:10.1148/radiology.208.3.9722843 - Pubmed citation
- 5. Trenkwalder P, Trenkwalder C, Feiden W et-al. Toxoplasmosis with early intracerebral hemorrhage in a patient with the acquired immunodeficiency syndrome. Neurology. 1992;42 (2): 436-8. Pubmed citation