Journal of the Louisiana State Medical Society
continuing treatment of toxoplasmosis andHIV and increas- ing the dose of steroids as needed to control symptoms. After six weeks of treatment, secondary prophylaxis is instituted and can be safely stopped once the patient re- covers and CD4 has been consistently >200/ul for at least six months on antiretroviral therapy. 4 It usually consists of the same regimen but with lower doses of pyrimethamine, sulfadiazine, and leucovorin. Alternative regimens include clindamycin, pyrimethamine, and leucovorin, or atova- quone with or without pyrimethamine, or atovaquone with sulfadiazine. 4,33,40,41 Primary prophylaxis is indicated for patients with HIV and CD4 counts <100 cells/mm3 who are T. gondii IgG-positive. 4,42 The preferred agent is TMP-SMX. 4 Other options are dapsone plus pyrimethamine or atvaquone. 35 Primary prophylaxis may be discontinued if CD4 count is greater than 200 cells/mm3 for more than three months. 4 REFERENCES 1. Cohen BA. Neurologic manifestations of toxoplasmosis in AIDS. Semin Neurol . 1999;19(2):201–211. 2. Tenter AM, Heckeroth AR, Weiss LM. Toxoplasma gondii: from animals to humans. Int J Parasitol 2000; 30:1217-1258. 3. Jones JL, Kruszon-Moran D, Sanders-Lewis K, Wilson M. Toxoplasma gondii infection in the United States, 1999 2004, decline from the prior decade. Am J TropMed Hyg 2007; 77:405-410. 4. Kaplan JE, Benson C, Holmes KH, et al. Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. MMWR Recomm Rep 2009; 58:1-207. 5. Falusi O, French AL, Seaberg EC, et al. Prevalence and predictors of Toxoplasma seropositivity inwomenwith and at risk for human immunodeficiency virus infection. Clin Infect Dis 2002; 35:1414- 1417. 6. Wallace MR, Rossetti RJ, Olson PE. Cats and toxoplasmosis risk in HIV-infected adults. JAMA 1993; 269:76-77. 7. San-Andrés FJ, Rubio R, Castilla J, et al. Incidence of acquired immunodeficiency syndrome-associated opportunistic diseases and the effect of treatment on a cohort of 1115 patients infected with human immunodeficiency virus, 1989-1997. Clin Infect Dis 2003; 36:1177-1185. 8. Porter SB, SandeMA. Toxoplasmosis of the central nervous system in the acquired immunodeficiency syndrome. N Engl J Med 1992; 327:1643-1648. 9. Cohen O, Wiessman D, Fauci AS. The Immunopathogenesis of HIV Infection. In: Paul WE ed. Fundamental Immunology. Philadelphia: Lippincott-Raven 1999:1455-509. 10. Jones JL, Roberts JM. Toxoplasmosis hospitalizations in the United States, 2008, and trends, 1993-2008. Clin Infect Dis 2012; 54:e58-61. 11. Sacktor N, Lyles RH, Skolasky R, Kleeberger C, Selnes OA, Miller EN, Becker JT, Cohen B, McArthur JC; Multicenter AIDS Cohort Study. HIV-associated neurologic disease incidence changes:: Multicenter AIDS Cohort Study, 1990-1998. Neurology . 2001 Jan 23;56(2):257-260. 12. Belanger F, Derouin F, Grangeot-Keros L, Meyer L. Incidence and risk factors of toxoplasmosis in a cohort of human immunodeficiency virus-infected patients: 1988-1995. HEMOCO and SEROCO Study Groups. Clin Infect Dis 1999; 28:575-581.
13. Rabaud C, May T, Amiel C, et al. Extracerebral toxoplasmosis in patients infected with HIV. A French National Survey. Medicine (Baltimore) 1994; 73:306-314. 14. Remington JS. Toxoplasmosis in the adult. Bull NYAcadMed 1974; 50:211-227. 15. McCabe RE, Brooks RG, Dorfman RF, Remington JS. Clinical spectrum in 107 cases of toxoplasmic lymphadenopathy. Rev Infect Dis 1987; 9:754-774. 16. O’Connell S, Guy EC, Dawson SJ, et al. Chronic active toxoplasmosis in an immunocompetent patient. J Infect 1993; 27:305-310. 17. Luft BJ, Remington JS. Toxoplasmic encephalitis in AIDS. Clin Infect Dis . 1992 Aug;15(2):211-222. 18. Navia BA, Petito CK, Gold JW, Cho ES, Jordan BD, Price RW. Cerebral toxoplasmosis complicating the acquired immune deficiency syndrome: clinical and neuropathological findings in 27 patients. Ann Neurol . 1986 Mar;19(3):224-238. 19. Renold C, Sugar A, Chave JP, Perrin L, Delavelle J, Pizzolato G, Burkhard P, Gabriel V, Hirschel B. Toxoplasma encephalitis in patients with the acquired immunodeficiency syndrome. Medicine (Baltimore). 1992 Jul;71(4):224-239. 20. Gray F, Gherardi R, Wingate E, Wingate J, Fenelon G, Gaston A, Sobel A, Poirier J. Diffuse “encephalitic” cerebral toxoplasmosis in AIDS. Report of four cases. J Neurol . 1989 Jul;236(5):273-277. 21. Luft BJ, Brooks RG, Conley FK, et al. Toxoplasmic encephalitis in patients with acquired immune deficiency syndrome. JAMA 1984; 252:913-317. 22. Levy RM, Mills CM, Posin JP, et al. The efficacy and clinical impact of brain imaging in neurologically symptomatic AIDS patients: a prospective CT/MRI study. J Acquir Immune Defic Syndr 1990; 3:461-471. 23. Ciricillo SF, Rosenblum ML. Use of CT and MR imaging to distinguish intracranial lesions and to define the need for biopsy in AIDS patients. J Neurosurg 1990; 73:720-724. 24. O’Doherty MJ, Barrington SF, Campbell M, et al. PET scanning and the human immunodeficiency virus-positive patient. J Nucl Med 1997; 38:1575-1583. 25. Lorberboym M, Wallach F, Estok L, et al. Thallium-201 retention in focal intracranial lesions for differential diagnosis of primary lymphoma and nonmalignant lesions in AIDS patients. J Nucl Med 1998; 39:1366-1369. 26. Miller RF, Hall-Craggs MA, Costa DC, et al. Magnetic resonance imaging, thallium-201 SPET scanning, and laboratory analyses for discrimination of cerebral lymphoma and toxoplasmosis in AIDS. Sex Transm Infect 1998; 74:258-264. 27. Skiest DJ, Erdman W, Chang WE, et al. SPECT thallium-201 combined with Toxoplasma serology for the presumptive diagnosis of focal central nervous systemmass lesions in patients with AIDS. J Infect 2000; 40:274-281. 28. Cinque P, Scarpellini P, Vago L, et al. Diagnosis of central nervous system complications inHIV-infected patients: cerebrospinal fluid analysis by the polymerase chain reaction. AIDS 1997; 11:1-17. 29. Mesquita RT, Ziegler AP, Hiramoto RM, et al. Real-time quantitative PCR in cerebral toxoplasmosis diagnosis of Brazilian human immunodeficiency virus-infected patients. J MedMicrobiol 2010; 59:641-647. 30. Dannemann B, McCutchan JA, Israelski D, et al. Treatment of toxoplasmic encephalitis in patients withAIDS. A randomized trial comparing pyrimethamine plus clindamycin to pyrimethamine plus sulfadiazine. The California Collaborative Treatment Group. Ann Intern Med 1992; 116:33-34. 31. Nath A, Sinai AP. Cerebral Toxoplasmosis. Curr Treat Options Neurol 2003; 5:3-12.
44 J La State Med Soc VOL 166 January/February 2014
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