Presentation
Headache, expressive dysphasia, altered consciousness. Fevers, chills, rigors. Recent travel from Uganda.
Patient Data
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Innumerable, irregular, peripherally contrast enhancing lesions are seen in the supra and infratentorial brain, of varying sizes. These are mostly distributed in the basal ganglia and at the grey-white matter junction. The largest are located in the parietal lobes, measuring up to 4.5 cm on the right and 2.7 cm on the left. Several of lesions have a mural nodule e.g. in the right basal ganglia, and the left frontal lobe lesion has a target-like pattern of enhancement. No convincing central diffusion restriction. Many are however T2 hypointense centrally, with foci of susceptibility. Extensive surrounding vasogenic edema. No definite leptomeningeal or pachymeningeal thickening/hyperenhancement.
No ventricular enlargement or ependymal enhancement to suggest ventriculitis. No subfalcine, uncal or tonsillar herniation. Paranasal sinuses are unremarkable.
Case Discussion
The patient subsequently underwent a craniotomy and biopsy, which confirmed the presence of toxoplasmosis gondii on microscopy and immunohistochemistry. Patient was also newly diagnosed with HIV, with HIV-related immunosuppression thought to be the predisposing factor for neurotoxplasmosis. MRI features suggestive of neurotoxoplasmosis include:
- peripherally-enhancing lesions of varying sizes distributed in the basal ganglia and grey-white matter junctions
- extensive vasogenic edema surrounding the lesions
- several lesions have a mural nodule e.g. right basal ganglia
- the left frontal lobe lesion has a target-like pattern of enhancement, which can be seen in neurotoxoplasmosis