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Re: Case study regarding HIV/TB/Tuberculoma Brain.

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Re: /message/8589

Greetings! The case study Dr. Anburajan sent is challenging.

In spit of taking all possible correct measures some times you just fail to save

the patient. This patient is rapidly deteriorating but still he and the

relatives do not want invasive investgations. As clinicians, this is not

uncommon for us to face a situation like this. In 90% cases,though, the refusal

is due to financial constrains. So I feel, the patient is as helpless as you

yourself might feel. You were lucky to have initial investigations like viral

load, CT scans ( both done twice). How often a patient can offrd to have such

investigations done? In a set up like mine 90% patients cannot.

I have never come across any patient with Tuberculoma brain co-existing with

Toxoplasma Encephelitis. In the present case, the first time investigations

should have included Toxoplasma IgG which (is a highly sensitive test) as there

were focal neurological presentation. India ink for Cryptococcus infection

should also have been seen.

Secondly, ART could have withheld for first 2 months of ATT. ART is never an

emergency especially with a count is 189. IRIS can always pose a major problem

in such a situations,other than pill burden and overlapping toxicities of ATT

and ART if both are initiated together. Somehow this temptation of starting

early ART should be avoided. All the possible O/Is should be vigorously

investigated and treated and then ART started.

This patients' brain lesion keeps growing with proper ATT and anti-toxo therapy

is really confusing as the investgations say he has both Kochs and Toxoplasma

infection. The SOL now needs further evaluation for malignancy though it will

not explain the dignosis of Tuberculoma and Toxoplasma.

Dr. Divya Mithel,

Jyothis Care center, Kalamboli

E-mail: <d_mithel@...>

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Dear all,

Re: /message/8625

I fully agree with Dr Divya mithel>This patient is going through immune

reconstitution syndrome to TB . I wont generally consider toxoplasma in this

case as first diagnosis since there are more than one clues favouring

tuberculosis. I am bit worried about the falling CD4 if ot is real ( it is

likely that one of the CD4 results are wrong and it is very common to have a

wrong results like that).Is this patient on steroid? If not steroid in adequate

dose may improve the patient by suppressing IRIS.

Dear Dr Anburajan, AIDS INDIA may not the wrte forum for clearing clinical

queries because very rarly doctors in clinical side respond to messages in this


Dr Ajith



Dr Ajithkumar.K

Asst Professor In Dermatology and Veneriology

Medical collge Chest Hospital

MG Kav,Trichur, Kerala ,India

Ph 04872333322 (res)


e-mail: <ajisudha@...>

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Dear Friends,

Re: /message/8625

I am Dr.Suresh Kumar MD., Fellow HIV/AIDS care, Tambaram, Chennai.

First i thank Dr. Anburajan to post the case in this forum. There are

lot of clinicians closely monitoring this forum and respond appropriately.

To the case

1. We have seen lot of cases with similar presentation in Tambaram,

what is our policy is if the patient presented with focal neurological

problem 3 things should done

a)CD4 test

b)Toxoantibody test

c)CT/MRI brain

along with Xray chest, sputum AFB, mantoux.

If the person positive for Toxoantibody and not taken CTZ prophylaxis

and the CD4 less than 100. Start both ATT and toxo traetment if

the CT/MRI suggest mass lesion in brain.

If the person negative for toxo antibody, taken CTZ prophylaxis and

CD4 more than 200 and CT showing single lesion start ATT alone.

The important thing is steroid in this type of cases so ensure steroid

for these type of cases.

The usual worsening is expected in these type of cases. Repeat the CD4

testing in the same lab possibly at the same time. Don't bother about

the CD4 count as long as viral load is under control.

So continue the same line (ATT+ ART+ Antitoxo)add steroid. Closely

follow to ensure good adherence and no need for any invasive

investigations at the moment.

I am happy to answer this type of questions posted in this forum in future as


Dr.D.Suresh Kumar MD., FHIV,

Senior Consultant Physician,

Devaki Hospital LTD,

Mylapore, Chennai 600004.

e-mail: dsk_1973@...

Tel: 09444186807.

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Dr. Anburajan's posting of the case study, regarding HIV/TB/Tuberculoma Brain.

Re: /message/8625

This patient's condition (cerebral mass lesion) worsened despite ATT and ART.

If his adherence has been good, this is consistent with IRIS. The only

inconsistent finding is the falling CD4 cell counts, although the viral load has

come down dramatically. The etiology is very unlikely to be toxoplasmosis as he

has not shown a prompt therapeutic response typical of toxo encephalitis in


I would suggest the following:

1. Continue ATT

2. Add steroids.

3. If no improvement, consult neurosurgeons.

I would also suggest the following line of management for any PLHA with CD4

less than 200 and brain mass lesion:

Start ant-toxo treatment first (unless Toxo IgG is negative or there is

evidence of TB elsewhere). The therapeutic response is so prompt and

predictable, and you will have an answer in less than 2 weeks.

Dr. O.C. Abraham

e-mail: <ocabraham@...>

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