PRESENTASI KASUS:

CEREBRAL TOXOPLASMOSIS
PEMBIMBING:
DR. DR. RINI ANDRIANI, SP.S

Stella Angelina (406172063)

Marsella Epifania (406182028)
Wenny Damayanti (406181044)

ILMU PENYAKIT SARAF

KEPANITERAAN KLINIK
RUMAH SAKIT ROYAL TARUMA
UNIVERSITAS TARUMANAGARA
PERIODE 30 JUNI-4 AGUSTUS 2019
CASE
Identitas Pasien
• Name: Tn. MFR
• Age: 35 th
• Address: Jl. Makaliwe, Grogol, Jakarta Barat
• Entry date: 27 Juni 2019
• Exit date: 7 Juli 2019
Anamnesis: Autoanamnesis
• Chief complaint: dizziness, vomit
• Current medical history: Patient came to Royal Taruma emergency department
with complaints of dizziness since two days ago. The dizziness has been felt
continuously and insidious and aggravated by activity but reduced by rest.
Additional complaints are fever, nausea, vomit, more than 5 times a day and
decreased in appetite. Besides that, patient feels tired and stiff in whole body. No
complaint loss of consciousness, and slurred speech.
• Past medical history: Patient once felt the same complaint two years ago, No
history of hypertension and diabestes
• Family medical history: There is history of hypertension and diabetes
• Habit history: There is no history of smoking, drinking and consumpting narcotic
drugs
Pemeriksaan Fisik
General condition Patient looks tired
Kesadaran Compos Mentis
GCS E4M6V5
Vital signs
Blood pressure 110/80 mmHg
Pulse 78 x/m, regular, adekuat
Respiration rate 20 x/m
Temperature 37.8℃
SpO2 99%
Weight 75 kg
Height 184 cm
BMI 22,15
Head Normocephal, black hair, even distribution

Pupil: round, equal, Ø 2mm/2mm, palpebral edema (-/-), anemic conjunctiva (-/-),
Eyes
icteric sclera (-/-)

Ears Normal shape, otorrhea (-/-)

Nose Septum deviation (-), secrete (-/-)

Mouth Dry lips, dry mucose, dirty tounge: oral candidiasis (+), pharing hperemis

Neck Trachea deviation (-)

 Inspection Simetrical, both sides are even in static and dynamic state

Thorax – Palpation No palpable mass, no crepitation

Pulmo Percussion Sonor on both lungs

Auscultation Vesicullar (+/+), rales (-/-), wheezing (-/-)

Inspection Ictus cordis pulsation not seen

Palpation Ictus cordis pulsation palpable on ICS V MCLS

Cor • Right heart margin : ICS III - V linea parasternalis dextra

Percussion • Left heart margin : ICS V, 1 cm at medial line MCLS
• Upper heart margin : ICS III linea parasternalis sinistra

Auscultation S1 and S2 heart sound in normal range, murmur (-), gallop (-)
 Inspection Flat on inspection, wound (-), mass (-)

Auscultation bowel sounds (+)

Abdomen Muscular defence (-), no pain response, no liver or spleen enlargement

Palpation
palpated

Percussion Tympanic on all abdomen region

Extremities All extremities warm, CRT < 2sec, edema (-/-)

Skin Skin turgor in normal range, cyanosis (-)

Pemeriksaan Neurologi
MENINGEAL SIGN

Cervical stiffness
(-)
Brudzinsky I

Brudzinsky II (-)

Brudzinsky III (-)

Brudzinsky IV (-)

Laseq (-) (-)

Kernig (-) (-)

 CRANIAL NERVE

N. I No examinations were performed

N. II No examinations were performed

Ocular movements In normal range In normal range

Ptosis - -
N. III
Pupil size 2 mm 2 mm
N. IV
Pupil shape Round, equal Round, equal
N. VI
Direct Light Reflex + +

Indirect Light Reflex + +

N. V Open mouth
Moving the jaw +

Biting

Palpebral fissure
Frontal contraction +
N. VII
Grinning
Lagopthalmus -/-
N. VIII No examinations was performed

Swallowing
N. IX
Pharynx Arc +
N. X
Uvula
M. Sternocleidomastoideus
N. XI Normal strength
M. Trapezius

N. XII Tongue Tremor +

 MOTORIK
Kanan Kiri
Kekuatan 4444 4444
4444 4444
Tonus Hipertoni
Trofi Normotrofi
Pemeriksaan Koordinasi
Pemeriksaan Hasil
Finger to nose +
Heel to knee +/+
Dysdiadokokinesia -
 PHYSIOLOGIC REFLEX
Right Left
Biceps + +
Triceps + +
Patella + +
PATHOLOGICAL REFLEX
Hoffman - tromner - -
Babinski - -
Chaddock - -
Schaefer - -
Gordon - -
Oppenheim - -
Klonus paha - -
Klonus kaki - -
 LABORATORIUM 27 Juni 2019 UNIT Nilai Rujukan
Hemoglobin 11,4 g/dl 14.0-18.0
LED 85 mm/jam 2-30
Leucoytes 3,5 103/uL 5.0-10.0
Basophil 0 % 0-1
Eosinophil 1 % 1-3
Segment 71 % 50-70
Lymphosyte 21 % 21-40
Monosite 7 % 2-8
MCV 88 u3 82 – 92
MCH 29 pg 26 – 32
MCHC 33 g/dl 31 – 36
Hematocrit 34.2 Vol % 42.0-52.0
Eritrosit 3,9 106/uL 4.50-5.50
Platelets 237.0 103/uL 150.0-450.0
Ureum 28 mg/dl 15-37
Creatinin 1,15 mg/dl 0.80-1.30
GDS 133 mg/dl 70-180
 LABORATORIUM 27 Juni 2019 UNIT Nilai Rujukan
SGOT 39 u/l 15 – 37
SGPT 46 u/l 12 – 78
Potassium 4,7 mmol/l 3.50 – 5.10
Natrium 133 mmol/l 137 – 145
 Sero-Imunologi Result
Screen Aids
Anti HIV Screening
Methode -1 Reactive
Methode -2 Reactive
Methode -3 Reactive
Conclusion Anti HIV (screening)=
Reactive
 Moleculer Result UNIT Normal Range Information
Diagnositc
CD 4

CD 4 Absolut 9 sel/ul 410– 1590 Limfosit T Helper

decrease

CD 4 % 2 % 31 – 60
 Sero Imunologi Result UNIT Normal range Information
TORCH

Anti Toxoplasma Positive 297 IU/ml 410– 1590 Negative: <4

IgG Equivocal: 4 -<8
Positive: >=8
Anti Toxoplasma Negative 0,13 index 31 – 60 Negative:<0,55
IgM Equivocal:0,55-0,65
Positiv:>=0,65
 Test Result UNIT Method

TB-IGRA Negatif - TB-SPOT

Pemeriksaan Radiologi
• MRI-BRAIN: potongan axial T1W1, T2W1, FLAIR dan sagittal T1W1 serta coronal T2W1 tanpa dan dengan
kontras GdDTPA.
• Tidak tampak gambaran akut infark.
• Tampak gambaran multiple hypodens pada cerebellum terutama bag kiri yg pada post kontras tampak rim
enhancement dan menekan ventrikel IV dan memberikan efek pelebaran ventrikel III dan lateral D et S
• Intracerebral tidak tampak gambaran infark lama/s.o.l/perdarahan
• Axial FLAIR tampak gambaran multiple deep white matter brain ischemic foci di parietal kanan dan kiri
• Tidak tampak periventrikuler hyperintensity of aging
• Diferensiasi white dan gray matters baik, tidak tampak shift dari midline struktur
• Batang otak dala batas noral
• Sinus paranasalis dan mastoid baik, tidak menunjukan sinusitis/mastoiditis
• KESAN:
• Tidak tampak gambaran akut infark
• Tampak gambaran multiple hypodens pada cerebellum terutama bagian kiri yang pada
post kontras tapak rim enhancement dan menekan ventrikel IV dan memberikan efek
pelebaran ventrikel III dan lateral D et S. Hak ini mencurigakan gambaran peradangan
opportunistic.
• Intra cerebral tidak tampak gambaran infark lama/sol/perdarahan
• Axial FLAIR tampak gambaran multiple deep whitw matter brain ischemic foci di parietal
kanan dan kiri
• Batang otak dalam batas normal
• Saran korelasi dengan lab dan klinis
• X foto toraks:
• Cor dalam batas normal
• Hilus dan mediastinum tidak melebar
• Kesuraman pada lobus superior paru kanan dan perhiler kiri
• Tidak tampak gabaran edema
• Tidak tampak gambaran pneumotoraks/efusi
• Sinus dan diafragma dalam batas normal
• Jar tulang dalam batas normal
• KESAN:
• Cor dalam batas normal
• Pulmo suggest gambaran br pneumonia. Saran korelasi dengan lab dan klinis
Diagnosis
• Cerebral Toxoplasmosis
• HIV
Tatalaksana
• Primet 2x25 mg
• Infus:
• Sanprima Forte 1x ½ tab
• Betaserc 3x 24 mg • Ceftriaxon 2x2 gr
• Unalium 3x10 mg • Manitol 500/ 8 jam
• Lexotan 3x 1,5 mg • Atripla 1x1 tab
• Maganol 3x1 TAB
• Omevel 1x4
• Sporacid 1x1
• Mycostatin
THEORY
 Criteria for Starting, Discontinuing, and Restarting
Opportunistic Infection Prophylaxis for Adults with HIV
Criteria for Criteria for Criteria for Criteria for Criteria for Discontinuing Criteria for
Initiating Discontinuing Restarting Initiating Secondary Prophylaxis Restarting
Primary Primary Primary Secondary Secondary
Prophylaxis Prophylaxis Prophylaxis Prophylaxis Prophylaxis
OI
PCP CD4 < 200 or CD4 > 200 CD4 < 200 Prior PCP CD4 > 200 for 3 mos CD4 < 200
oral candidasis for 3 mos

Toxoplasmosis + serum IgG CD4 > 200 CD4 < 100 – Prior CD4 > 200 sustained and CD4 < 200
CD4 < 100 for 3 mos 200 toxoplasmic completed initial therapy and
encephalitis is asymptomatic

MAC CD4 < 50 CD4 > 100 for 3 CD < 50 – 100 Documented CD4 > 100 sustained and CD4 < 100
mos disseminated completed 12 mos of MAC tx
disease and asymptomatic

Cryptococcosis none n/a n/a Documented CD4 > 100 – 200 sustained CD4 < 100 -
disease and completed initial therapy 200
and asymptomatic

Histoplasmosis none n/a n/a Documented No criteria recommended for n/a

disease stopping

CMV none n/a n/a Documented CD4 > 100 – 150 sustained CD4 < 100 -
end-organ and no evidence of active 150
disease disease and regular exams
Background
• Toxoplasmosis is a parasitic disease caused by
the protozoan Toxoplasma gondii.

• The parasite infects most animals, including

humans, but the primary host is the felid (cat)
family

• Toxoplasma may be transmitted via mouth-to-

hand contact from improper handling or
ingestion of raw meat or undercooked meat
containing cyst from cat feces.
Acute toxoplasmosis
• Immunocompetent persons with primary infection are usually
asymptomatic (90%), but latent infection can persist for the rest of
the hosts life.

• The most common signs in acute infection are:

• influenza-like symptoms
• enlarged lymph nodes, especially around the neck in adults, but in
children multiple sites may be more common
Latent toxoplasmosis
• Recent research has also linked toxoplasmosis with attention deficit
hyperactivity disorder, obsessive compulsive disorder, and
schizophrenia.

• Numerous studies found a positive correlation between latent

toxoplasmosis and suicidal behavior in humans.

• “Crazy cat lady syndrome' is a term coined by news organizations to

describe scientific findings that link the parasite Toxoplasma gondii to
several mental disorders and behavioral problems.

• Jaroslav Flegr (biologist) is a proponent of the theory that toxoplasmosis

affects human behavior

Weiss LM, Dubey JP (2009). "Toxoplasmosis: A history of clinical observations".

International Journal for Parasitology 39 (8): 895–901. doi:10.1016/j.ijpara.2009.02.004.
PMC 2704023. PMID 1921790
• Toxoplasma gondii can sometimes cause or contribute to Chronic
Fatigue Syndrome
• is a neurological condition characterized by cognitive dysfunction, mood
disorders, fatigue
 Immunosuppressed persons

• More serious disease can develop

due to Toxoplasma reactivation in
AIDS, especialy when the
lymphocyte CD4 cell count drops
below 100 cells / mm3
• cerebral toxoplasmosis (Fig.1)
Fig. 1. Cerebral toxoplasmosis
• chorioretinitis (Fig.2) Multiple ring enhancing lesions are present throughout both
cerebral hemispheres, with associated marked edema.

• Toxoplasmosis is the most common

parasitic CNS opportunistic infection
in AIDS patients

• The HLA-DQ3 antigen is associated

with susceptibility to toxoplasmic
encephalitis in HIV-infected patients Fig. 2. Toxo chorioretinitis
• Chemotherapy patients can develop eye, heart (myocarditis), lung
or brain involvement when parasites become reactivated.

• In transplant patients, Toxoplasmosis

• may result from reactivation of latent infection or from primary infection
and
• involve febrile myocarditis,encephalitis or pneumonitis.
Interaksi antara Agent, Host,
dan Environment
Evaluation of CNS Mass Lesions in
Patients with AIDS
Radiologic
Toxoplasmosis non specific
Lymphoma extra CNS lesions
PML
Tuberculosis
Fungus Laboratory
Nocardia Serology – Toxo IgG, crypt Ag
Blood culture – AFB, fungus
Bacterial CSF – Crypt Ag, CMV PCR, EBV PCR
Syphilis Urine – Histo Ag

Kaposi Sarcoma
Glioblastoma
Empiric Therapy
Toxoplasmosis - Diagnosis
• Definite diagnosis: Biopsy with demonstration of tachyzoites
• Presumptive diagnosis acceptable when
• CD4 < 200
• Compatible neurologic disease
• No prophylaxis
• Serology: positive toxo IgG
Therapy for Cerebral Toxoplasmosis
• Preferred Regimen
• Sulfadiazine + pyremethamine

• Alternative Regimen
• Clindamycin + pyremethamine

• Less studied regimens

• TMP-SMX
• Atovaquone + sulfadiazine
• Azithromycin + pyremethamine
• Dapsone + pyremethamine