Presentation
Known case of HIV with a CD4 count of 67. Left-sided weakness for three days with altered sensation.
Patient Data
A large mass in the right basal ganglia, with the described morphology and significant surrounding perilesional edema causing mass effect on the adjacent ventricle, is most likely suggestive of toxoplasmosis, with lymphoma being less likely.
Multiple, irregular peripherally enhancing lesions, few of them appearing conglomerate, in the right frontal-parietal, temporal and occipital lobes and left frontal lobe, predominantly at the Grey-white junction with few of the lesions showing concentric target sign on T2 imaging, with thick wall and diffuse perilesional edema likely suggestive of infective etiology.
Diffuse leptomeningeal enhancement along the right Sylvian fissure and basal cisterns suggests meningitis.
Few acute infarcts in right corona radiata, internal capsule, right cerebral peduncle and bilateral thalami.
Case Discussion
In view of the low CD 4 count and multiple lesions, the above features are likely suggestive of infective etiology likely cerebral toxoplasmosis with meningoencephalitis.
Other likely differential are lymphoma and tuberculomas.
Imaging features of common pathologies in immunocompromised appear atypical, hence giving an exact diagnosis on imaging becomes difficult. Acute cases of toxoplasmosis can show strong restriction diffusion.
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