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Clinical microbiological case: ‘soap bubbles’ in the cerebellum of an HIV-infected patient
CONTINUING MEDICAL EDUCATION Clinical microbiological case: ‘soap bubbles’ in the cerebellum of an HIV-infected patient J. M. Garcı´a-Lechuz1, M. Sa´nchez-Conde1, L. Mun˜oz2 and C. Benito2 Departments of 1Clinical Microbiology and Infectious Diseases and 2Radiology, Hospital General Universitario ‘Gregorio Maran˜o´n’, Madrid, Spain Accepted 15 October 2002
CASE REPORT A 35-year-old intravenous drug user was admitted with a five-day history of cough, fever, pleuritic chest pain, dysmetria and headache. His past medical history revealed pulmonary tuberculosis diagnosed a year before without appropriate adherence to treatment. HIV infection was first detected in 1990. The CD4 count and toxoplasma titers were unknown at this time. Chest radiography showed a right upper lobe infiltrate. Acid-fast stain from sputum (AFB) was negative. A first cranial scan (CT) without contrast was unreliable, because the patient was uncooperative. Lumbar puncture was performed, and the following features were found in the CSF: glucose 49 mg/ dL, proteins 47 mg/dL, white blood cell (WBC) 20/mm3 (mainly lymphocytes), and adenosine deaminase (ADA) 5 U; Gram, AFB and India ink stains were negative. A second contrast-enhanced CT scan (Figure 1) and a subsequent MRI of the brain (Figure 2a,b) showed multiple lesions with nodular, multiloculated, soap bubble-shaped and ring-enhancing patterns; mass effect and marked edema were also observed. Treatment with isoniazid, rifampin, pyrazinamide, pyrimethamine and sulfadiazine was started. Two days later, the patient suffered an episode of hydrocephalus that responded to intensive medical therapy (mannitol and dexamethasone). Serum antitoxoplasma antibodies were negative. CSF and sputum cultures were also negative. Corresponding author and reprint requests: J. M. Garcı´aLechuz Moya, Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario ‘Gregorio Maran˜o´n’, C/Avenida Doctor Esquerdo no. 46, 28007 Madrid. Spain Tel: þ34 915868453 Fax: þ34 915044906 E-mail: [email protected] or [email protected]
Figure 1 Post-contrast-enhanced CT images show multiple focal lesions in the cerebellum, with ring enhancement and mass effect on the 4th ventricle and extensive edema.
ß 2003 Copyright by the European Society of Clinical Microbiology and Infectious Diseases
420 Clinical Microbiology and Infection, Volume 9 Number 5, May 2003
QUESTIONS After viewing the images, what would be your diagnosis? Make your differential diagnosis, selecting from the following choices: 1. Tuberculosis. 2. Toxoplasmosis. 3. Metastatic lymphoma. 4. Cryptococcoma
Figure 2 (a) MR-Philips ACS 0.5 T. T2-weighted MR image: multiple round lesions with a hypointense ring and hyperintense central core. Perilesional edema with important mass effect around nucleus dentatus area (displaced IV ventricle). (b,c) SE (TR 500, Te 20) axial and coronal images. The ring lesions enhanced after gadolinium administration with typical soap bubble shapes.
ß 2003 Copyright by the European Society of Clinical Microbiology and Infectious Diseases, CMI, 9, 419–420
CASE REPORT A 35-year-old intravenous drug user was admitted with a five-day history of cough, fever, pleuritic chest pain, dysmetria and headache. His past medical history revealed pulmonary tuberculosis diagnosed a year before without appropriate adherence to treatment. HIV infection was first detected in 1990. The CD4 count and toxoplasma titers were unknown at this time. Chest radiography showed a right upper lobe infiltrate. Acid-fast stain from sputum (AFB) was negative. A first cranial scan (CT) without contrast was unreliable, because the patient was uncooperative. Lumbar puncture was performed, and the following features were found in the CSF: glucose 49 mg/ dL, proteins 47 mg/dL, white blood cell (WBC) 20/mm3 (mainly lymphocytes), and adenosine deaminase (ADA) 5 U; Gram, AFB and India ink stains were negative. A second contrast-enhanced CT scan (Figure 1) and a subsequent MRI of the brain (Figure 2a,b) showed multiple lesions with nodular, multiloculated, soap bubble-shaped and ring-enhancing patterns; mass effect and marked edema were also observed. Treatment with isoniazid, rifampin, pyrazinamide, pyrimethamine and sulfadiazine was started. Two days later, the patient suffered an episode of hydrocephalus that responded to intensive medical therapy (mannitol and dexamethasone). Serum antitoxoplasma antibodies were negative. CSF and sputum cultures were also negative. Corresponding author and reprint requests: J. M. Garcı´aLechuz Moya, Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario ‘Gregorio Maran˜o´n’, C/Avenida Doctor Esquerdo no. 46, 28007 Madrid. Spain Tel: þ34 915868453 Fax: þ34 915044906 E-mail: [email protected] or [email protected]
Figure 1 Post-contrast-enhanced CT images show multiple focal lesions in the cerebellum, with ring enhancement and mass effect on the 4th ventricle and extensive edema.
ß 2003 Copyright by the European Society of Clinical Microbiology and Infectious Diseases
420 Clinical Microbiology and Infection, Volume 9 Number 5, May 2003
QUESTIONS After viewing the images, what would be your diagnosis? Make your differential diagnosis, selecting from the following choices: 1. Tuberculosis. 2. Toxoplasmosis. 3. Metastatic lymphoma. 4. Cryptococcoma
Figure 2 (a) MR-Philips ACS 0.5 T. T2-weighted MR image: multiple round lesions with a hypointense ring and hyperintense central core. Perilesional edema with important mass effect around nucleus dentatus area (displaced IV ventricle). (b,c) SE (TR 500, Te 20) axial and coronal images. The ring lesions enhanced after gadolinium administration with typical soap bubble shapes.
ß 2003 Copyright by the European Society of Clinical Microbiology and Infectious Diseases, CMI, 9, 419–420