A Sexually Active 23-Year-Old With Seizures and Tongue Pain

Manuel Salinas, MD


October 05, 2021

Toxoplasmosis treatment is often empiric in the appropriate clinical setting, pending confirmatory testing. The standard regimen for treating acute infection is a combination of three drugs given for 6 weeks: pyrimethamine, sulfadiazine, and folinic acid. Cotrimoxazole (trimethoprim-sulfamethoxazole) can be used as an alternative regimen; it is better tolerated with no differences in the clinical outcomes.

In cases of allergy to sulfa drugs, clindamycin, clarithromycin, azithromycin, or atovaquone combined with pyrimethamine and folinic acid are viable alternatives. The treatment of acute infection should last 4-6 weeks and is followed by long-term suppressive therapy at reduced doses. The initiation of highly active antiretroviral therapy (HAART) for HIV is as important as the treatment of acute infection. Suppressive therapy should continue until CD4 counts remain > 200 cells/µL and lesions are no longer detected on MRI.[3,4]

In this patient, the history of sex with men combined with the physical finding of lesions on the tongue, compatible with thrush, led to the suspicion of HIV infection. Because the neurologic state of the patient had declined and there was a possibility of immunodeficiency, a decision was made to treat for bacterial meningitis and to also treat empirically for CNS toxoplasmosis, given the results of the noncontrast CT scan of the head, pending the serologic results. A lumbar puncture was considered but was deferred as a result of concern for neurologic complications stemming from evidence of increased intracranial pressure on the noncontrast CT scan of the head. HAART was also initiated empirically.

With treatment, the patient's mental status improved and, over a period of time, he progressively returned to normal mentation. HIV infection was confirmed by serologic studies (ie, enzyme-linked immunosorbent assay [ELISA] and Western blot), and the patient was noted to have a decreased CD4 count (< 150 cells/µL). A week later, therapy with pyrimethamine, sulfadiazine, and folinic acid was initiated. The patient was eventually discharged with only a mild language disturbance and a discreet motor deficit in his left leg.


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