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Clinical Case Presentation Task

Cerebral Toxoplasmosis with


Immunocompromised

Aprilia
Moderator : dr. Yovita Andhitara, Sp.S,
Msi.Med, FINS
Lumbar puncture
INDICATION

To investigate or exclude meningitis


Bacterial
Viral
Tuberculous
Cryptococcal

To investigate neurological disorders


Multiple Sclerosis
Sarcoidosis
Guillian Barre, Chronic Inflammatory Demyelinating Polyneuropathy

To demonstrate and manage disorders of Intracranial Pressure

To administer therapeutic or diagnostic agents* Spinal anaesthesia


Intrathecal chemotherapy
Intrathecal antibiotics
Intrathecal baclofen
Contrast media in myelography or cisternography
The National Patient Safety Agency recommends formal training for those who undertake intrathecal injection
Lumbar puncture
Indications
Emergency Department lumbar puncture
may be necessary to investigate suspected:
Meningitis
Encephalitis
Subarachnoid haemorrhage (> 12 hrs
after symptoms)
Guillain Barre Syndrome
Multiple Sclerosis

Williams J, Lye D and Umapathi T. Diagnostic lumbar puncture: minimising complications Internal Medicine Journal 2008;38: 587-9
Lumbar puncture
Contraindications
Absolute contraindications for lumbar puncture are
The presence of infected skin over the needle entry site
The presence of unequal pressures between the supratentorial and
infratentorial compartments.

Usually inferred from the following characteristic findings on computed


tomography (CT) of the brain:
Midline shift
Loss of suprachiasmatic and basilar cisterns
Posterior fossa mass
Loss of the superior cerebellar cistern
Loss of the quadrigeminal plate cistern

Relative contraindications for lumbar puncture include the following:


Increased intracranial pressure (ICP)
Coagulopathy
Brain abscess
Lumbar puncture
Contraindications
Lumbar Puncture should not be performed on a patient
demonstrating:
Clinical signs of raised intra cranial pressure
altered level of consciousness
focal neurology
recent seizure
brain stem signs (pupillary changes / irregular respiration)
Focal infection over puncture site
Bleeding tendency:
systemic anticoagulation,
bleeding diathesis,
thrombocytopenia with platelets < 100 x10^9/L

Williams J, Lye D and Umapathi T. Diagnostic lumbar puncture: minimising complications Internal Medicine Journal 2008;38: 587-9
Lumbar puncture
Indications for performing brain CT scanning before lumbar puncture in
patients with suspected meningitis include the following [8] :
Patients who are older than 60 years
Patients who are immunocompromised
Patients with known CNS lesions
Patients who have had a seizure within 1 week of presentation
Patients with an abnormal level of consciousness
Patients with focal findings on neurologic examination
Patients with papilledema seen on physical examination, with clinical
suspicion of an elevated ICP

Cranial CT scanning should be obtained before lumbar puncture in all


patients with suspected SAH in order to diagnose obvious intracranial
bleeding or any significant intracranial mass effect that might be present
in awake and alert SAH patients with a normal neurologic examination.
Table 1. Prophylaxis to Prevent First Episode of
Opportunistic Disease

Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and
Adolescents
(Last updated December 10, 2015; last reviewed December 10, 2015)
Table 2. Treatment of AIDS-Associated Opportunistic
Infections
(Includes Recommendations for Acute Treatment and Secondary Prophylaxis/Chronic
Suppressive/Maintenance Therapy)
Cerebral Toxoplasmosis
imaging
CT
Typically, cerebral toxoplasmosis appears as multiple hypodense regions
predominantly in the basal ganglia and at the corticomedullary junction.
However, they may be seen in the posterior fossa. Size is variable, from less
than 1 cm to more than 3 cm, and there may be associated mass effect.
enhancement: following administration of contrast there is nodular or ring
enhancement which is typically thin and smooth 5
double-dose delayed scan: may show a central filling on delayed scans
calcification: seen in treated cases; may be dot-like or thick and 'chunky'

MRI
T1: may be difficult to identify, but are typically isointense or hypointense
T2
intensity is variable, from hyperintense to isointense
hyperintense: thought to represent necrotising encephalitis
isointense: thought to represent organising abscess 4
lesions are surrounded by perilesional oedema

Kornienko VN, Pronin IN. Diagnostic Neuroradiology. Springer Verlag. (2009) ISBN:3540756523
y RG, Gean AD. Neuroimaging of AIDS. I. Central nervous system toxoplasmosis. Neuroimaging Clin. N. Am. 1997;7 (2): 1
Fig. (a) Non-contrast CT scan showing an extensive hypodense lesion
in the area of the right basal ganglia with mass effect. (b) Contrast
enhancement shows multiple ring enhancing lesions within the
hypodense mass. This was a case of cerebral toxoplasmosis as the
patient recovered completely with drug treatment for this condition

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