Q87) A 42 year old african-american man is admitted to hospital with acute seizures. Seizures were appropriately controlled in the ER and the patient currently, in post-ictal confusion. He is unable to give further history. However, a review of the old records reveal that the patient has history significant of Chronic HIV infection. He also has a history of IV drug use. As per his sister, the patient has been compliant with Highly active anti-retroviral therapy and prophylactic medications for Pneumocystis jiroveci and Mycobacterium Avium Complex for the past one year. His recent CD4 count 1 month ago was 45. On physical examination, he is afebrile with a blood pressure of 120/60. He is confused. Reflexes are intact. Electrolytes and CBC are with in normal limits. Urine drug screen is negative. A non-contrast CT scan did not not reveal any bleed. A CT scan with IV contrast reveals a 4 cm ring – enhancing lesion in left cerberal hemisphere. A subsequent MRI brain confirmed the findings on the CT. There is no mass effect. Next step in approaching this patient ?
A. Stereotactic Brain Biopsy
B. Start emperic Toxoplasma therapy.
C. Obtain Toxoplasma Serology ( IgM and IgG)
D. PCR for Papova Virus JC
E. Emperic therapy for CNS tuberculosis.
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The answer is C. Anyone can explain why the ans is C and not B?
OK
you do that but you should start tx until the results come back.
It doesnt hurt to tx and u can change your treatment if its not toxo.
The patient has a ring-enhancing lesion. In developed countries such as the US, the most common causes include toxoplasma and CNS lymphoma. About 10% of general population has toxoplasma antibody; so a positive serology is not confirmatory. So, empiric treatment with sulfadiazine & pyrimethamine. After 10-14 days, a repeat CT/MRI is done. If the size of the lesion is reduced, then continue initial treatment; otherwise treat for CNS lymphoma.
b
B. Treat x2wks then repeat CT head. If shrinking, continue Tx, if not shrinking, do brain lesion biopsy to r/o lymphoma.