toxoplasmosis occurs in advanced stages of human immunodeficiency virus ( hiv ) infection and is the most common opportunistic infection of the central nervous system in patients with the acquired immunodeficiency syndrome ( aids ) , especially in those patients with a cd4 + count < 200 cells / mm .
the most common clinical presentation of cerebral toxoplasmosis in patients with hiv infection is headache , focal neurological deficits and seizures .
we present two cases with stroke - like presentation of cerebral toxoplasmosis from our centre .
a 30-year - old right - handed nigerian woman was admitted to the university of calabar teaching hospital , nigeria , with a 1-week history of inability to move the left upper and lower limbs of acute onset . there was a history of headache , but no seizures , vomiting or loss of consciousness .
she was not known to be hypertensive or diabetic , and she does not drink alcohol nor does she smoke .
the patient was diagnosed to be hiv positive about 2 years prior to this admission and commenced on antiretroviral drugs ( arv ) but defaulted on therapy for about 1 year prior to the current presentation .
her latest cd4 + count was not known . on neurologic examination , she showed left upper motor neuron facial nerve palsy and increased tone and brisk reflexes in both left upper and lower limbs .
power was grade 0/5 and grade 1/5 in the left upper and lower limbs , respectively , on the medical research council scale , with a positive babinski sign on the left .
a brain ct scan revealed a rounded ring - enhancing hypodense lesion in the parafalcine region of the right parietal cortex ( fig .
a complete blood count revealed low haemoglobin ( 8 g / dl ) , esr 80 mm in the first hour , and cd4 + count 18 cells / mm .
iu / l and toxoplasma igg was 202.0 iu / l , both markedly raised .
a diagnosis of stroke - like syndrome due to cerebral toxoplasmosis in the background of hiv infection was made and the patient was commenced on pyrimethamine ( 200 mg at start , then 50 mg daily ) , clindamycin ( 600 mg every 6 h ) , folic acid ( 10 mg daily ) , septrin ( 960 mg b.i.d . ) , amoxicillin / clavulanic acid ( 625 mg t.d.s . ) , and haematinics .
two weeks after treatment , the patient resumed arv therapy with truvada and lopinavir / ritonavir .
power gradually improved to 4/5 in both limbs , and she started ambulating and was discharged to follow - up as an outpatient .
a 35-year - old female was referred to the university of calabar teaching hospital , nigeria , with a 2-day history of left - sided weakness affecting her leg and arm and focal seizures involving her left upper limb .
she had a history of hiv infection , diagnosed 4 years prior to the current presentation and treated with arv drugs .
her last cd4 + count ( 6 months before ) was 28 cells / mm . on neurologic examination ,
there was left hemiparesis ( grade 3:5 on the medical research council scale for both left upper and lower limbs ) with increased tone and brisk reflexes and upgoing plantar reflexes ( babinski sign ) .
an urgent brain ct showed a rounded marginally enhancing hyperdense lesion with perilesional oedema in the right thalamus ( fig .
there was obliteration of the posterior horn of the ipsilateral lateral ventricle by the aforementioned mass . a similar but ill - defined lesion with more extensive perilesional oedema
blood tests showed haemoglobin 10 g / dl , esr 106 mm in the first hour , cd4 + count 24 cells / mm and toxoplasma igg antibody 300 iu / l .
based on these findings , a diagnosis of cerebral toxoplasmosis presenting with a stroke - like syndrome , on the background of hiv treatment failure , was made .
the patient was discharged home to continue follow - up at the medical outpatient department .
 toxoplasmosis is the most common opportunistic infection of the central nervous system in patients with acquired immunodeficiency syndrome ( aids ) . 
 clinical presentation of cerebral toxoplasmosis in these patients includes headache , focal neurological deficits and seizures . 
 prompt diagnosis and appropriate therapy results in rapid clinical and radiological improvement as well as good outcome for patients . in this article 
 , we report two cases with stroke - like presentation of cerebral toxoplasmosis in the setting of hiv infection . 