Spinal Cord Involvement and Brain Hemorrhage as an Atypical Presentation of Toxoplasmosis in a Patient with HIV

Central nervous system (CNS) toxoplasmosis is a well-known opportunistic infection in patients with AIDS. Spinal cord involvement and brain hemorrhage are very infrequent manifestations of CNS toxoplasmosis. In this report, we describe a patient with unknown AIDS presenting with bilateral headaches and new onset of bilateral leg weakness, diagnosed with CNS toxoplasmosis with a CSF polymerase chain reaction (PCR) for T. gondii, associated with spinal cord involvement (a central lesion in the conus medullaris) and multiple brain lesions with hemorrhage. The patient required therapy with pyrimethamine, sulfadiazine, and dexamethasone, with favorable outcomes after 30 days of therapy. Our case re-emphasizes the diagnosis of CNS toxoplasmosis in patients with advance HIV disease and spinal cord involvement. A high index of suspicion is needed, especially in HIV/AIDS patients not receiving HAART, who are seropositive for T. gondii, have a CD4+ count less than 100 cells/mm3, and present with symptoms consistent with spinal disease and even more with suggestive coincident brain lesions.