Treatment

Since TE was the most common cause of focal CNS lesions in AIDS patients before the era
of HAART (highly active antiretroviral therapy), empiric anti-T. gondii therapy used to be the
standard approach. However, the incidence of TE in AIDS patients has significantly
decreased since the introduction of HAART and the widespread use of prophylaxis.
Therefore, this empiric therapeutic approach may miss or delay the appropriate work-up and
management of important diagnosis like CNS lymphoma. Algoritum 31(A) illustrates the
management approach to TE in HIV patient.12 In general, the presence of multiple brain
lesions with CD4 T-cell counts of less than 100/L and positive anti-T. gondii antibodies in an
HIV patient who is not taking anti-T. gondii prophylaxis is highly predictive of TE.
Combination of pyrimethamine/sulfadiazine and folinic acid is considered the standard
regime for the treatment of TE (Box 31.1).8 Unfortunately sulfadiazine is not available in
Hong Kong. Clindamycin can be used instead of sulfadiazine in this regard. Infected patient
should be treated for at least 4-6 weeks after the resolution of all signs and symptoms. It is
important to note that, as a result of the myelotoxicity of sulfonamides and pyrimethamine,
"folinic acid" instead of "folic acid" should be used since the latter will reverse the action of
pyrimethamine. The efficacy of Trimethoprim/sulfamethoxazole (co-trimoxazole) appears
to be comparable to that of pyrimethamine/sulfadiazine in AIDS patients.13 Short course of
corticosteroid can be used in TE patient with significant cerebral oedema and elevated
intracranial pressure.
In one study 51% of patients with TE developed clinical response to anti-T. gondii therapy
within the first 3 days and 91% by day 14.6 Other investigation including brain biopsy should
be considered if there is no improvement by 2 weeks or when there is deterioration by day 3.6
Over 90% of patients have radiological response by 2 weeks of therapy. Monitoring brain
CT/MRI every 4-6 weeks is suggested until there is complete resolution of the lesions.

Prophylaxis
After the acute treatment of TE, maintenance therapy (secondary prophylaxis) should
follow since the current anti-T. gondii therapy cannot eradicate tissue cysts. Normally the
same medications used in the acute phase could be continued at half dose to this effect (Box
31.1).
Primary prophylaxis should be considered in HIV patient with CD4 cell counts less than
100/L. Use of co-trimoxazole for the prophylaxis of Pneumocystis jiroveci pneumonia
(PCP) could also provide protection against toxoplasmosis. Other alternatives include high
dose dapsone alone or dapsone plus pyrimethamine. Both primary or secondary prophylaxis
can be discontinued when the patient's CD4 cell count has returned to over 200/L for at least
6 months.14

Prevention of toxoplasmosis in HIV/AIDS

HIV-infected persons should be tested for baseline IgG antibodies to Toxoplasma to detect
latent infection with T. gondii. All HIV-infected persons should be counseled regarding
exposure to toxoplasmic infection:15

(a) Avoid eating raw or undercooked meat, including undercooked mutton, beef, pork, or
venison
(b) Wash hands after contact with raw meat, after gardening or other contact with soil
(c) Wash fruits and vegetables well before eating them raw
(d) Avoid handling cats' litter and wash hands thoroughly after changing the litter box
(e) Keep cats inside, and do not to adopt or handle stray cats
(f) Feed cats only with canned or dried commercial food or well-cooked table food, not raw
or undercooked meats

Further reading

1. Montoya JG, Kovacs JA, Remington JS. Toxoplasma gondii. In: Mandell GL, Bennett JE,
Dolin R, 6th eds. Principles and Practice of Infectious Diseases. Philadelphia: Churchill
Livingstone, 2005;3170-98.
2. Hunter CA & Reichmann G. Immunology of toxoplasma infection. In Joynson DHM,
Wreghitt TG. Toxoplasmosis: a comprehensive clinical guide. Cambridge: Cambridge
University Press, 2001;43-57.
3. Montoya JG, Liesenfeld O. Toxoplasmosis. Lancet 2004;363:1965-76.
References

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Int J Parasitol 2000;30:1217-58.
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the Chinese population of Hong Kong. Trans R Soc Trop Med Hyg 1980;74:351-4.
3. Grant IH, Gold JW, Rosenblum M, Niedzwiecki D, Armstrong D. Toxoplasma gondii
serology in HIV-infected patients: the development of central nervous system
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Churchill Livingstone, 2005;3170-98.
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11. Parmley SF, Goebel FD, Remington JS. Detection of Toxoplasma gondii in
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persons infected with human immunodeficiency virus. U.S. Public Health Service
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