Title : Neurotoxoplasmosis with spinal cord involvement: A rare case
Abstract:
Introduction/Background: Toxoplasmosis of the central nervous system (CNS) ranks third among the most prevalent opportunistic infections defining AIDS in Brazil, with the brain being the most frequently affected site. Toxoplasma gondii myelitis is considered rare, even in immunosuppressed patients; however, it should always be considered as a diagnostic hypothesis, as it is strongly associated with severe outcomes and unfavorable prognosis.
Objective: To report a case of CNS toxoplasmosis with spinal cord involvement in an HIV-positive patient without prior antiretroviral treatment.
Methods: A 49-year-old male patient, white, HIV-positive for 15 years, presented with detectable viral load and CD4 count of 29 cells/mm³. He was admitted with cervical pain radiating to the lateral aspect of both upper and lower limbs, progressive weakness, and paraplegia. Brain MRI revealed hypointense lesions on T1 and T2-weighted images located in the left occipital region and right cerebellar peduncle. Based on clinical and imaging findings compatible with neurotoxoplasmosis, treatment with sulfadiazine, pyrimethamine, and folinic acid was initiated.
Results: During hospitalization, the patient developed fecal and urinary incontinence followed by paraplegia. Spinal MRI showed a grossly nodular, expansive, intra-rachidian, intra- and intramedullary lesion extending from C7 to T1. Neurosurgical intervention was performed, and histopathological examination confirmed the diagnosis of neurotoxoplasmosis. The patient progressed to death one month after starting treatment.
Conclusion/Final Considerations: Neurotoxoplasmosis is a severe opportunistic infection that should be included in the differential diagnosis of HIV-positive patients presenting with neurological symptoms. Literature reviews suggest that, in these patients, the presence of T. gondii infection markers and myelitis symptoms should prompt empirical antiparasitic therapy due to the high lethality rate. Biopsy should be reserved for cases with no clinical improvement after adequate treatment. The rarity of spinal cord involvement highlights the importance of early diagnosis and timely treatment to reduce morbidity and mortality. Broader access to antiretroviral therapy has significantly decreased the incidence of T. gondii infection, which remains a marker of poor prognosis in the natural history of HIV.
