Calcified cerebral toxoplasmosis associated with recurrent perilesional edema causing neurological manifestations in an HIV-infected individual: case report with a decade-long follow-up

Four cases of people living with HIV/AIDS (PLWHA) with calcified cerebral toxoplasmosis associated with perilesional edema causing a single episode of neurological manifestations have recently been reported. Here, we describe the first detailed description of perilesional edema associated with calcified cerebral toxoplasmosis causing three episodes of neurological manifestations in a PLWHA, including seizures in two of them. These recurrences occurred over approximately a decade. Throughout this period, the patient showed immunological and virological control of the HIV infection, while using antiretroviral therapy regularly. This case broadens the spectrum of an emerging presentation of calcified cerebral toxoplasmosis, mimicking a well-described finding of neurocysticercosis in immunocompetent hosts.

Cerebral toxoplasmosis; Pathologic calcification; Edema; Neuroimaging; HIV

Authorship

Flávia Carolina Soares Bonato

methodology

investigation

data curation

writing–original draft preparation

writing–review and editing

All authors have read and agreed with the published version of the manuscript

Instituto de Infectologia Emílio Ribas, Departamento de Doenças Infecciosas, São Paulo, São Paulo, BrazilInstituto de Infectologia Emílio RibasBrazilSão Paulo, São Paulo, BrazilInstituto de Infectologia Emílio Ribas, Departamento de Doenças Infecciosas, São Paulo, São Paulo, Brazil

http://orcid.org/0009-0006-6905-1887

René Leandro Magalhães Rivero

investigation

writing–review and editing

All authors have read and agreed with the published version of the manuscript

Instituto de Infectologia Emílio Ribas, Divisão de Apoio ao Diagnóstico e Terapêutica, Setor de Radiologia, São Paulo, São Paulo, BrazilInstituto de Infectologia Emílio RibasBrazilSão Paulo, São Paulo, BrazilInstituto de Infectologia Emílio Ribas, Divisão de Apoio ao Diagnóstico e Terapêutica, Setor de Radiologia, São Paulo, São Paulo, Brazil

http://orcid.org/0000-0002-8451-1101

Hector Hugo Garcia

writing–review and editing

All authors have read and agreed with the published version of the manuscript

Universidad Peruana Cayetano Heredia, Centro de Salud Global, Lima, PeruUniversidad Peruana Cayetano HerediaPeruLima, PeruUniversidad Peruana Cayetano Heredia, Centro de Salud Global, Lima, Peru

Instituto de Ciencias Neurológicas, Unidad de Cisticercosis, Lima, PeruInstituto de Ciencias NeurológicasPeruLima, PeruInstituto de Ciencias Neurológicas, Unidad de Cisticercosis, Lima, Peru

http://orcid.org/0000-0002-4633-6269

José Ernesto Vidal

Conceptualization

methodology

investigation

data curation

writing–original draft preparation

supervision

writing–review and editing

All authors have read and agreed with the published version of the manuscript

Instituto de Infectologia Emílio Ribas, Departamento de Neurologia, São Paulo, São Paulo, BrazilInstituto de Infectologia Emílio RibasBrazilSão Paulo, São Paulo, BrazilInstituto de Infectologia Emílio Ribas, Departamento de Neurologia, São Paulo, São Paulo, Brazil

Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Divisão de Moléstias Infecciosas, São Paulo, São Paulo, BrazilUniversidade de São PauloBrazilSão Paulo, São Paulo, BrazilUniversidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Divisão de Moléstias Infecciosas, São Paulo, São Paulo, Brazil

Universidade de São Paulo, Faculdade de Medicina, Instituto de Medicina Tropical de São Paulo (LIM-49), São Paulo, São Paulo, BrazilUniversidade de São PauloBrazilSão Paulo, São Paulo, BrazilUniversidade de São Paulo, Faculdade de Medicina, Instituto de Medicina Tropical de São Paulo (LIM-49), São Paulo, São Paulo, Brazil

http://orcid.org/0000-0001-7830-8716

Correspondence to: José Ernesto Vidal Instituto de Infectologia Emílio Ribas, Departamento de Neurologia, Avenida Dr. Arnaldo, 165, CEP 01249-000, São Paulo, SP, Brazil Tel: + 55 11 3896-1200. E-mail: josevibe@gmail.com

SCIMAGO INSTITUTIONS RANKINGS

Universidad Peruana Cayetano Heredia, Centro de Salud Global, Lima, PeruUniversidad Peruana Cayetano HerediaPeruLima, PeruUniversidad Peruana Cayetano Heredia, Centro de Salud Global, Lima, Peru

Instituto de Ciencias Neurológicas, Unidad de Cisticercosis, Lima, PeruInstituto de Ciencias NeurológicasPeruLima, PeruInstituto de Ciencias Neurológicas, Unidad de Cisticercosis, Lima, Peru

Figures

Figures (3)

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Figure 1
Neuroimaging showing the findings of the initial diagnosis of cerebral toxoplasmosis and the first and third subsequent episodes of perilesional edema and enhancement around a calcification secondary to this opportunistic disease. In the first row: initial MRI (10/2010) with the lesion located in the precentral gyrus. (1) T1-weighted image, before contrast administration and (2) post-gadolinium image showing ring enhancement with an eccentric nodule in this lesion; in (3) and (4), T2 and FLAIR images, respectively, showing associated edema in the surrounding white matter. In (5), T2* image (GRE), with no signs of calcification or hemorrhage in this lesion; In the second row: MRI of the first episode of perilesional edema associated with calcification (11/2015). T1-weighted image showing the previous lesion with a smaller size, (6) before and (7) after gadolinium; in (8) and (9), T2 and FLAIR images, respectively, showing associated edema in the surrounding white matter. In (10), T2* image (GRE), some low signal areas can be seen, which may represent early calcium deposits; In the third row: following MRI (03/2016) showing resolution of the first episode of perilesional edema associated with calcification. T1-weighted images, (11) before and (12) after gadolinium, showing significant regression of the lesion enhancement and T2 (13) and FLAIR (14) images without edema. In (15), T2* image (GRE), better definition of the pronounced low signal areas, suggesting intensification of the calcium deposits in the lesion site; In the fourth row: CT and MRI (12/2021) of the last episode of perilesional edema associated with calcification. (16) CT showing calcification in lesion site with surrounding edema and (17) MRI T1-weighted post-gadolinium image with lesion enhancement, as well as increased perilesional edema in T2 (18) and FLAIR (19) images. In (20), T2* image (GRE), increasing of the pronounced low signal areas, compatible with the calcification showed in the concomitant CT scan (16); In the fifth row: subsequent MRI (04/2022) of the third episode of perilesional edema associated with calcification. T1-weighted images, (21) before and (22) after gadolinium, showing resolution of the inflammatory activity with minimal enhancement and the disappearance of the edema in the T2 (23) and FLAIR (24) images. In (25), T2* image (GRE) showing persistence of pronounced low signal areas, compatible with calcification (16).

Thumbnail

Figure 2
Timeline of the case report. cART: combined antiretroviral therapy.

Thumbnail

Figure 3
Simplified scheme of the evolution of cerebral toxoplasmosis (A) and parenchymal neurocysticercosis (B) lesions with or without antiparasitic therapy.

Figure 1 Neuroimaging showing the findings of the initial diagnosis of cerebral toxoplasmosis and the first and third subsequent episodes of perilesional edema and enhancement around a calcification secondary to this opportunistic disease. In the first row: initial MRI (10/2010) with the lesion located in the precentral gyrus. (1) T1-weighted image, before contrast administration and (2) post-gadolinium image showing ring enhancement with an eccentric nodule in this lesion; in (3) and (4), T2 and FLAIR images, respectively, showing associated edema in the surrounding white matter. In (5), T2* image (GRE), with no signs of calcification or hemorrhage in this lesion; In the second row: MRI of the first episode of perilesional edema associated with calcification (11/2015). T1-weighted image showing the previous lesion with a smaller size, (6) before and (7) after gadolinium; in (8) and (9), T2 and FLAIR images, respectively, showing associated edema in the surrounding white matter. In (10), T2* image (GRE), some low signal areas can be seen, which may represent early calcium deposits; In the third row: following MRI (03/2016) showing resolution of the first episode of perilesional edema associated with calcification. T1-weighted images, (11) before and (12) after gadolinium, showing significant regression of the lesion enhancement and T2 (13) and FLAIR (14) images without edema. In (15), T2* image (GRE), better definition of the pronounced low signal areas, suggesting intensification of the calcium deposits in the lesion site; In the fourth row: CT and MRI (12/2021) of the last episode of perilesional edema associated with calcification. (16) CT showing calcification in lesion site with surrounding edema and (17) MRI T1-weighted post-gadolinium image with lesion enhancement, as well as increased perilesional edema in T2 (18) and FLAIR (19) images. In (20), T2* image (GRE), increasing of the pronounced low signal areas, compatible with the calcification showed in the concomitant CT scan (16); In the fifth row: subsequent MRI (04/2022) of the third episode of perilesional edema associated with calcification. T1-weighted images, (21) before and (22) after gadolinium, showing resolution of the inflammatory activity with minimal enhancement and the disappearance of the edema in the T2 (23) and FLAIR (24) images. In (25), T2* image (GRE) showing persistence of pronounced low signal areas, compatible with calcification (16).

Figure 2 Timeline of the case report. cART: combined antiretroviral therapy.

Figure 3 Simplified scheme of the evolution of cerebral toxoplasmosis (A) and parenchymal neurocysticercosis (B) lesions with or without antiparasitic therapy.

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Calcified cerebral toxoplasmosis associated with recurrent perilesional edema causing neurological manifestations in an HIV-infected individual: case report with a decade-long follow-up

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[1] Correspondence to: José Ernesto Vidal Instituto de Infectologia Emílio Ribas, Departamento de Neurologia, Avenida Dr. Arnaldo, 165, CEP 01249-000, São Paulo, SP, Brazil Tel: + 55 11 3896-1200. E-mail: josevibe@gmail.com