The patient's clinical presentation is consistent with a central nervous system infection with Toxoplasma gondii, likely in the setting of acquired HIV from multiple transfusions.
Toxoplasma gondii is a common central nervous system infection in immunocompromised patients that appears as ring-enhancing lesions on MRI. It often presents with several weeks of constitutional symptoms and headaches in addition to focal findings related to the location of the lesions. It occurs in 3-10% of HIV positive patients in the United States and more than 25% of HIV positive patients in Africa. Standard treatment includes pyrimethamine, sulfadiazine, and folic acid.
Chu and Selwyn discuss complications of HIV infection. They note an increased incidence of cardiovascular disease, malignancy, and renal disease, in addition to neuropsychiatric complications. They also discuss common side effects of HIV medications, such as lipoatrophy (increased central fat distribution with peripheral wasting).
Dai et al. discuss frequencies of different central nervous system infections in patients with HIV in a large hospital in China. They report that cryptococcal meningitis, cerebral toxoplasmosis, and CNS tuberculosis are the most common such infections in their population.
Figure A shows a CT head with the typical, ring-enhancing lesion of T. gondii infection. Illustration A shows a chest radiograph showing P. jiroveci pneumonia, another common opportunistic infection in patients with AIDS. Illustration B is a photo showing oral thrush, which is caused by Candida albicans and is another common opportunistic infection in patients with AIDS.
Answer 1: Neurocysterocercosis is caused by CNS infection with Taenia solium and typically presents with seizures.
Answer 3: PML, which is caused by the JC virus, does not present with ring-enhancing lesions.
Answer 4: Central nervous system lymphoma can cause ring-enhancing lesions, but the ring is typically more subtle, and fewer lesions are present.
Answer 5: Cryptococcus typically causes meningitis or pneumonia, which are not suggested by this presentation.
Chu C, Selwyn PA. Complications of HIV infection: a systems-based approach. Am Fam Physician. 2011 Feb 15;83(4):395-406.
PMID:21322514 (Link to Abstract)
Dai L, Mahajan SD, Guo C1, Zhang T, Wang W, Li T, Jiang T, Wu H, Li N. Spectrum of central nervous system disorders in hospitalized HIV/AIDS patients (2009-2011) at a major HIV/AIDS referral center in Beijing, China. J Neurol Sci. 2014 Apr 30. pii: S0022-510X(14)00267-6.
PMID:24836573 (Link to Abstract)