Toxoplasmic Encephalitis in Patients with the Acquired Immunodeficiency Syndrome

In patients with the acquired immunodeficiency syndrome (AIDS), toxoplasmic encephalitis is usually a presumptive diagnosis based on the clinical manifestations, a positive antitoxoplasma-antibody titer, and characteristic neuroradiologic abnormalities. A response to specific therapy helps to confirm the diagnosis, but it is unclear how rapid the response should be. We studied the course of patients treated for acute toxoplasmic encephalitis and evaluated objective clinical criteria for this empirical diagnosis. A quantifiable neurologic assessment was used prospectively to evaluate the clinical outcome of patients with AIDS and toxoplasmic encephalitis who were treated with oral clindamycin (600 mg four times a day) and pyrimethamine (75 mg every day) for six weeks. Thirty-five of 49 patients (71 percent) responded to therapy, and 30 of these (86 percent) had improvement by day 7. Thirty-two of those with a response (91 percent) improved with respect to at least half of their base-line abnormalities by day 14. Improvement in neurologic abnormalities within 7 to 14 days after the start of therapy was strongly associated with the neurologic response at 6 weeks. The four patients in whom treatment failed and the two patients with lymphoma had progressing neurologic abnormalities or new abnormalities during the first 12 days of therapy. Nonlocalizing abnormalities (headache and seizure) improved regardless of the clinical outcome. Oral clindamycin and pyrimethamine are an effective treatment for toxoplasmic encephalitis. Patients who have early neurologic deterioration despite treatment or who do not improve neurologically after 10 to 14 days of appropriate antitoxoplasma therapy should be considered candidates for brain biopsy., Encephalitis caused by Toxoplasma gondii is the most frequent cause of focal central nervous system infection complicating the acquired immunodeficiency syndrome (AIDS)¹. If untreated, toxoplasmic encephalitis is uniformly fatal. In the United States, it develops in 3 to 10 percent of patients with AIDS. In Europe and Africa, where the overall seroprevalence of toxoplasma is higher, it is estimated that toxoplasmic encephalitis will ultimately develop in 25 to 50 percent of patients with AIDS¹. Toxoplasma can infect any cell in the brain. Therefore, the clinical syndrome of toxoplasmic encephalitis is nonspecific and may include both focal and nonfocal…