Clinical Presentation:

- A 40-year-old Hispanic man was admitted to the hospital after being found unconscious. He had a 2-day history of disorientation that manifested itself as his being unable to recognize family members.

- Upon admission he regained consciousness, becoming alert and oriented, but developed urinary retention and was unable to move or feel his lower extremities.

- Spinal MRI (with and without gadolinium) showed the spinal cord to be abnormally diffuse, with swelling and edema in the cervicothoracic region.

Diagnosis:

- After an extensive work up for lymphoma and CNS infection, he was discovered to have toxoplasmosis and was found to be HIV positive, which was previously undiagnosed.  

Discussion:

- Approximately 10% of patients with AIDS present with some neurological deficit as their initial complaint, and up to 80% will have CNS involvement during the course of their disease.

- Myelitis is a known complication of AIDS and is occasionally the initial complaint.

      The incidence of myelopathy may be as high as 20%, with 50% of the cases reported post-mortem

- Toxoplasmosis is the most common cause of cerebral mass lesions in patients with AIDS

      Occurring in 3–10% of patients in the United States and in up to 50% of AIDS patients in Europe, Latin America, and Africa

Bottom Line:

New neurological deficit in any patient should raise suspicion of HIV infection

Most patients with AIDS that present with evolving myelopathy, characterized by extremity weakness, sensory involvement, spinal cord enlargement, enhancing lesions in brain or spinal cord CT or MRI, have toxoplasmic myelitis

University of Maryland Section of Global Emergency Health

Author: Terrence Mulligan DO, MPH

References

"Spinal cord toxoplasmosis as an unusual presentation of AIDS: case report and review of the literature", Int J Emerg Med (2010) 3:439–442