Disclosures: Andriana Tompary, DO: No financial relationships or conflicts of interest

Case Diagnosis: Neurotoxoplasmosis

Case Description: A 43-year-old male with history of untreated Human Immunodeficiency Virus (HIV) presented to the hospital for new bilateral foot weakness, difficulty ambulating, and urinary retention. He was asymptomatic, though COVID-19 positive on hospital admission screening. His presentation progressed over three days to paraplegia, neurogenic bowel/bladder, and altered sensation to his umbilicus. Magnetic Resonance Imaging (MRI) was delayed several days as a result of his COVID status. MRI brain/spine were significant for a single T2 hyperintensity within the right corona radiata, increased T2 signal within the gray matter from T10 to the conus, and focal enhancement of the spinal cord at T12. Intravenous steroids were held given concern for underlying infection due to the patient’s HIV status. Cerebrospinal fluid (CSF) diagnostics were positive for Toxoplasmosis and Epstein Barr Virus (EBV) on Polymerase Chain Reaction (PCR). His brain lesion noted on MRI was considered too small for stereotactic biopsy to rule out CNS lymphoma. He had an excisional lymph node biopsy on an avid node found on Positron Emission Tomography. Lymph node pathology was negative for malignancy.

Setting: Tertiary care teaching hospitalAssessment/

Results: Treatment for CNS toxoplasmosis with Pyrimethamine, Sulfadiazine, and Leucovorin was initiated on hospital day 5. There was complete resolution and slight improvement on his follow up brain MRI and spine MRI, respectively. It was felt his spinal cord lesions were irreversible. He was discharged to acute inpatient rehabilitation.

Discussion: Brain lesions in neurotoxoplasmosis are usually multiple in number and ring enhancing. As found in this case, solitary and non-enhancing brain lesions are atypical in neurotoxoplasmosis, which can radiographically mimic CNS lymphoma. Additionally, spinal cord lesions from neurotoxoplasmosis are generally rare.

Conclusion: Atypical imaging findings are possible in cases of neurotoxoplasmosis. Empiric treatment should be considered in an HIV positive patient if there are delays in diagnosis to reduce patient morbidity and mortality.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/atypical-imaging-findings-in-neurotoxoplasmosis-a-case-report/