Results: the patient went to our hospital for the onset of left occipito-parietal
headache and blurred vision. Brain CT and MRI were performed which did not show focal lesions or vascular alterations.
Syphilis serology was negative, Toxoplasma gondii serology showed positive
IgG and negative
IgM, serum CMV-
DNA was 31.184 IU/mL. Eye fundus evidenced intraretinal
hemorrhages,
fluorescein angiography and computed optical tomography documented cottony exudates,
retinal hemorrhages and vitreous involvement.
Therapy with
valganciclovir was initiated for suspicion of CMV
retinitis. About a month later, the patient reported blurred vision for which she was re-admitted. Ocular fundus showed a cottony lesion near the macula. Molecular test on vitreous body was positive for Toxoplasma gondii, while on cerebrospinal fluid it was negative; in addition, an MRI of the brain with contrast medium was performed which showed an area of altered hyperintense signal compatible with a diagnosis of Toxoplasma gondii
uveitis and
neurotoxoplasmosis.
Therapy with
pyrimethamine and
clindamycin (
allergy for
sulfonamide reported by the patient) was started.
Allergy counseling was performed with the execution of
allergy tests (patch test) with negative result; therefore the administration of
clindamycin was replaced with
sulfadiazine. A month following the start of anti-toxoplasma
therapy, there was a clinical and radiological improvement.
Conclusions: despite progressive developments in the management of PLWH, in this case two different kind of
opportunistic infection are found in a late-presenter patient. In particular, two aspects can be highlighted. The first one is that, in the setting of an highly impaired immune system, clinical presentation can be deceptive and more than one
opportunistic infection can be observed together in the same patient. The second aspect is that after starting antiretroviral
therapy, a rapid improvement of viro-immunologic parameters has been documented, probably leading to an
immune reconstitution inflammatory syndrome (IRIS).