Unusual presentation of more common disease/injury

CASE REPORT

Seizure as an initial presentation of human
immunodeficiency virus: acute toxoplasmosis
mimicking glioblastoma multiforme
Parth Parekh,1 Jody P Boggs,1 Marc Silverberg,2 Paul Marik3
1

Department of Internal
Medicine, Eastern Virginia
Medical School, Norfolk,
Virginia, USA
2
Department of Pathology,
Sentara Norfolk General
Hospital, Norfolk, Virginia, USA
3
Division of Pulmonary and
Critical Care Medicine, Eastern
Virginia Medical School,
Norfolk, Virginia, USA
Correspondence to
Dr Paul Ellis Marik,
marikpe@evms.edu

SUMMARY
We present a case of a 46-year-old man with a history
significant only for hypertension and depression that
presented with a new onset seizure resulting from a
right parietal lobe mass. Further evaluation determined
the parietal mass to be central nervous system
toxoplasmosis, which was the initial presentation of his
underlying HIV/AIDS. This case provided a diagnostic
challenge and demonstrates the importance of a
thorough evaluation as it pertains to a newly diagnosed
brain lesion.

DIFFERENTIAL DIAGNOSIS
BACKGROUND
Seizures are a relatively common initial manifestation of a space-occupying brain lesion. The differential diagnoses of a new onset seizure are vast and
therefore it is essential for the clinician to perform
a thorough evaluation. CT and MRI are often the
initial diagnostic tests used in the setting of a new
onset seizure to evaluate for any space occupying
lesions. If present, the characteristics of the lesion
seen on imaging may be suggestive of a neoplastic
or infectious aetiology, however as this case demonstrates, should not preclude further exploration of
other causes.

CASE PRESENTATION
A 46-year-old man, with a medical history significant only for hypertension and depression, presented to an outside hospital with a witnessed
episode of a new onset seizure. As per family
accounts, he was performing yard work for the
greater portion of the day in extreme heat after

To cite: Parekh P, Boggs JP,
Silverberg M, et al. BMJ
Case Rep Published online:
[please include Day Month
Year] doi:10.1136/bcr-2013200795

which he came home and sat down at the dinner
table of hunger and dehydration when the episode
ensued. The family described the episode as echolalia followed by 3–5 min of generalised tonic–clonic
activity. Once the seizure had subsided, the patient
was unaware of his surroundings and unable to recognise his family members for 20–30 min.
Emergency medical services were called and the
patient arrived to the emergency department (ED)
through ambulance no longer in a postictal state.

Figure 1

▸ Primary
brain
neoplasm
(glioblastoma
multiforme)
▸ Central nervous system (CNS) lymphoma
▸ Bacterial or fungal abscess
▸ CNS toxoplasmosis

TREATMENT
At the outside hospital, an initial CT scan was performed which revealed a white matter low-density
change in the right deep high parietal lobe. At this
point the patient was transferred to a tertiary care
facility for further evaluation and neurosurgical
intervention.
Once transferred to the tertiary care facility the
patient was given intravenous dexamethasone and a
loading dose of phenytoin. MRI was performed to
further characterise the lesion. The results of MRI
confirmed the findings on CT describing the lesion
as a ring-enhancing mass in the deep right parietal
lobe which was most concerning for a primary
brain neoplasm such as glioblastoma multiforme or
less likely lymphoma (figure 1). Neurosurgery then

MRI demonstrating ring-enhancing mass in the right parietal lobe.

Parekh P, et al. BMJ Case Rep 2013. doi:10.1136/bcr-2013-200795

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Unusual presentation of more common disease/injury
the voices of and seen family members not present in addition
to recurrent phantosmia, which the patient described as that of
a dead rodent. His hallucinations initially attributed to steroid
psychosis quickly subsided once his dexamethasone was tapered
to discontinuation. He made a full recovery and is currently
being followed as an outpatient with plans to start HAART once
genotyping results become available.

DISCUSSION

Figure 2 Brain biopsy specimen demonstrating a blood vessel with
coagulative necrosis (large arrow) and nuclear debris/necrosis (thin
arrows). The overall image is without definition or detail due to
extensive necrosis.

performed a biopsy demonstrating significant necrosis, which
can be consistent with glioblastoma multiforme. Interestingly,
however, there was no evidence of malignant cells seen in the
limited viable tissue of the biopsy specimen which raised
concern for the possibility of an infectious aetiology be it bacterial or fungal in origin (figure 2). The patient was then tested for
HIV and was found to be positive on initial antibody screening
with subsequent positive confirmatory western blot. His CD4
count was measured to be 17 and as a result was further evaluated for any opportunistic infections, namely toxoplasmosis as
the culprit. Serum toxoplasma IgG was positive at greater than
900 IU/mL (≥12 IU/mL is positive indicating IgG antibody to
Toxoplasma gondii detected which may indicate current or past
T gondii infection). Subsequently, the patient’s biopsy sample
was sent for toxoplasmosis-specific staining which revealed the
aetiology of his brain lesion (figure 3). The patient was started
on leucovorin, sulfadiazine and pyrimethamine with plans to
start highly active antiretroviral therapy (HAART) as an
outpatient.

OUTCOME AND FOLLOW-UP
The patient improved during the course of hospitalisation. His
hospital course was complicated by several episodes of auditory,
visual and olfactory hallucinations. He claimed to have heard

The advent of HAART has significantly reduced the morbidity
and mortality associated with HIV. As a result, this disease once
thought of as a ‘death sentence’ is now considered to be a
chronic manageable condition. Despite advances in therapy,
however, patients are consistently being diagnosed in the latter
stages of the disease process. Several reports have estimated that
30–40% of persons with HIV have already reached the point of
AIDS (as defined by a CD4 count of <200) at the time of diagnosis.1 Early detection is of utmost importance as studies have
shown a direct correlation with improved prognosis in patients’
initiating HAART at a higher CD4 count.2
The US Preventative Service Task Force (USPSTF) recently
updated its 2005 recommendations on HIV screening guidelines. The updated guidelines recommend clinicians to screen
adolescents and adults from the ages of 15–65 for HIV infection. Patients younger than 15 years should be screened if risk
factors for HIV transmission are present and similarly patients
older than 65 years should be screened if there are on-going risk
factors for HIV transmission. The USPSTF states those who are
active intravenous drug misusers, have unprotected vaginal or
anal intercourse, multiple sexual partners, sexual partners who
are positive for HIV and homosexual males as highly at risk for
acquiring HIV infection.3
Toxoplasmosis, an infection caused by the intracellular protozoan parasite T gondii, is the most common opportunistic infection of the CNS in patients with AIDS. Initially latent, the
parasite reactivates and causes infection when the patients CD4
count falls below 100 cells/mm3, as was the case in our patient.4
Patients with toxoplasmic encephalitis typically present with
headache, as did our patient stating he had been experiencing
worsening nocturnal headaches for 1 month proceeding the
seizure. In one retrospective analysis of 115 patients with toxoplasmosis, 55%, 52% and 47% of patients presented with headache, confusion and fever, respectively.5
The diagnosis of toxoplasmosis is primarily through imaging
and brain biopsy. Serology can be obtained however it is not

Figure 3 Brain biopsy with immunoperoxidase stains (brown is the positive ‘horseradish peroxidase’ reaction) against antigens for Toxoplasma
species. The larger stained objects are cysts and the smaller, slightly oval ones are tachyzoites of Toxoplasma.
2

Parekh P, et al. BMJ Case Rep 2013. doi:10.1136/bcr-2013-200795

Unusual presentation of more common disease/injury
particularly helpful as toxoplasma IgG are positive in the vast
majority of patients and IgM antibodies are typically absent
even in the acute setting.6 MRI and CT imaging tend to show
multiple ring-enhancing brain lesions with predilection towards
the basal ganglia.7 Levy et al performed a prospective study on
50 neurologically symptomatic AIDS patients. Each patient was
evaluated using both modalities; MRI was better than CT for
the detection of intracranial pathology and significantly altered
the diagnosis and treatment in 40% of these patients.8 Thallium
single photon emission CT (SPECT) and positron emission tomography (PET) have been shown as useful adjunctive imaging to
further delineate toxoplasmosis or other infection from CNS
lymphoma as it has increased thallium uptake on SPECT and
greater glucose and methionine metabolism on PET.9

Contributors All authors have contributed to this case report, have reviewed the
final version and approve it for publication.
Competing interests None.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.

REFERENCES
1

2

3
4

Learning points
▸ The characteristics of space occupying lesions seen on CT or
MRI may be suggestive of a neoplastic or infectious
aetiology; however, this should not preclude further
exploration of other causes.
▸ Toxoplasmosis is a protozoan parasite which reactivates and
causes infection when the patients CD4 count falls below
100 cells/mm.
▸ MRI or CT imaging with multiple ring-enhancing brain
lesions with predilection towards the basal ganglia may be
suggestive of toxoplasmosis.
▸ MRI because of its great sensitivity might be the best
neuroimaging modality for the evaluation of neurologically
symptomatic patients with AIDS.
▸ Single photon emission CT or positron emission tomography
may be useful in differentiating toxoplasmosis and other
infection from central nervous system lymphoma.
▸ The treatment of choice for toxoplasmosis is pyrimethamine,
sulfadiazine and leucovorin for a 6-week duration.
Alternative regiments for the treatment of toxoplasmosis
include pyrimethamine plus clindamycin, pyrimethamine plus
azithromycin, pyrimethamine plus atovaquone or
trimethoprim–sulfamethoxazole.
▸ The US Preventative Service Task Force (USPSTF) recently
updated its HIV screening guidelines, recommending that
clinicians should screen all patients from 15 to 65 years of
age for HIV as well as all pregnant women including those
who are present in labour and are untested, and those
whose HIV status is unknown. If risk factors are present,
earlier screening or continued screening is appropriate.
Further studies need to be performed to determine optimum
intervals for HIV screening.

5
6
7

8

9

Klein D, Hurley LB, Merrill D, et al. Review of medical encounters in the 5 years
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Kaplan J, Hanson D, Karon J, et al. Late initiation of antiretroviral therapy (at CD4+
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Porter SB, Sande MA. Toxoplasmosis of the central nervous system in the acquired
immunodeficiency syndrome. N Engl J Med 1992;327:1643–8.
Luft BJ, Brooks RG, Conley FK, et al. Toxoplasmic encephalitis in patients with
acquired immune deficiency syndrome. JAMA 1984;252:913–17.
http://www.uptodate.com/contents/toxoplasmosis-in-hiv-infected-patients?
source=search_result&search=toxoplasmosis&selectedTitle=2~150#H6 (accessed 16
Jun 2013).
Levy RM, Mills CM, Posin JP, et al. The efficacy and clinical impact of brain imaging
in neurologically symptomatic AIDS patients: a prospective CT/MRI study. J Acquir
Immune Defic Syndr 1990;3:461–71.
Skiest DJ, Erdman W, Chang WE, et al. SPECT thallium-201 combined with
Toxoplasma serology for the presumptive diagnosis of focal central nervous system
mass lesions in patients with AIDS. J Infect 2000;40:274–81.

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