Diagnosis and Treatment of Tuberculous Meningoencephalitis and Toxoplasma Encephalitis in Positive HIV Patient: Case Report

Abstract

Background
Tuberculous meningoencephalitis (TBME) and toxoplasma encephalitis (TE) are the most frequent
cerebral opportunistic infections in positive HIV patients in developed countries. This study aims to
determine a presumptive diagnosis of TBME and TE based only on clinical, CD4-count, and radiology
features and to attend suitable early treatment for better patient outcomes.

Case Description
A 40-year-old presented to the emergency unit of dr. Mintohardjo Naval Hospital with decreased
consciousness. History of positive HIV status, pulmonary tuberculosis for six months and antitubercular-treatment (ATT) drop-out. The GCS was E2M5V2, lung crackles, nuchal rigidity, positive
Babinski reflex, and duplex hemiparesis. CD4-count: 4 cells/mm3
. Multiple hypodense lesions, “fingerlike-oedema”, featured on non-contrast head CT-scan. A lumbar puncture was not performed.
Treatment of TBME included an ATT regimen, pyridoxine, cotrimoxazole, anti-oedema, and TE
treatment included clindamycin and pyrimethamine. Based on the clinical and radiological diagnosis
of TBME (nuchal rigidity, history of ATT drop-out, multiple hypodense lesions on CT-scan) and TE
(altered mental status, duplex hemiparesis, CD4-count, “finger-like-oedema” projections on CT-scan),
ATT and TE treatment were given for ten days. There were significant clinical improvements by GCS
E4M6V3, negative nuchal rigidity after being treated early by ATT and TE treatment.

Conclusions
Presumptive Diagnosis of TBME and TE in HIV patients can be determined only based on clinical, CD4-
count, and radiology examination. However, there are significant clinical improvements in giving ATT
along with TE treatment immediately in positive HIV patients.