A 33-year-old Hispanic male with unremarkable past medical history presented to another hospital with headaches for 1.5 weeks associated with blurring of vision. He denied any recent illnesses or other symptoms prior to the onset of headaches. Magnetic resonance imaging (MRI) of the brain revealed a 2.7-cm ring-enhancing intracranial lesion in the right temporal lobe with mass effect. He was subsequently transferred to our facility for neurosurgical intervention. After right craniotomy with mass resection and biopsy, the patient became febrile. On initial workup, he was screened and diagnosed with AIDS; CD4 count was less than 20 cells/microL (1%) and RNA-PCR (polymerase chain reaction) 191 000 copies/mL. ART, azithromycin 1200 mg PO (per os) once weekly for Mycobacterium avium complex prophylaxis, and trimethoprim/sulfamethoxazole 400 mg intravenous Q12H (every 12 hours) for treatment of presumed CNS toxoplasmosis were started. Further investigation revealed that the patient was made aware of HIV diagnosis 2 years prior but remained in denial.
Comprehensive screening in this immunocompromised host revealed elevated immunoglobulin (Ig) G for toxoplasma, positive serum Cytomegalovirus IgG, positive serum herpes simplex virus-1 IgG and herpes simplex virus-2 IgG, and reactive hepatitis A antibody. Coccidioides serology was nonreactive for IgM and IgG with complement fixation (CF) titer <1/2. Lumbar puncture showed cell count 48 cells/microL, RBC 7 cells/microL, neutrophils 0%, lymphocytes 97%, glucose 55 mg/dL, protein 42 mg/dL, and opening pressure 210 mm H2O. All cerebrospinal fluid (CSF) studies, including Coccidioides serology, aerobic and fungal cultures, cryptococcal antigen screen, and acid-fast Bacillus (AFB) smear/culture, were negative except for positive CSF toxoplasma IgG with DNA-PCR for Toxoplasma gondii 286 copies/mL. HIV-1 subtype B was identified with no predicted genotypic resistance to reverse transcriptase inhibitors, protease inhibitors, or integrase inhibitors. Screening for HLA-B5701 was negative. Single-tablet regimen of abacavir/dolutegravir/lamivudine was selected as the preferred regimen for ART.
The hospital course was complicated as the patient remained persistently febrile with temperatures up to 39.4 C. Blood cultures were negative without leukocytosis or bandemia. Empiric therapy for brain abscess with ceftriaxone, vancomycin, and metronidazole was initiated. MRI of the brain on postoperative day 4 showed a reduction in the size of the ring-enhancing lesion with no mass effect and appearance consistent with toxoplasmosis. Immunostains from the biopsy specimens showed bradyzoites and tachyzoites consistent with toxoplasmosis and confirmed the presumed diagnosis. Periodic acid-Schiff and Gomori methenamine silver stains were negative for fungal organisms and AFB stain was negative for acid-fast bacilli. No evidence of malignancy was identified. Antibiotics for possible brain abscess were discontinued. The patient was discharged after clinical symptoms improved and fever resolved. Discharge medications included trimethoprim/sulfamethoxazole, azithromycin, and abacavir/dolutegravir/lamivudine.
Approximately 2 weeks later, the patient represented to the emergency department with fevers, generalized weakness, and 1-day history of cough productive of white sputum. The temperature was 39.6 C and chest X-ray (CXR) showed a new area of left upper lobe (LUL) opacification with diffuse reticulonodular prominence of the interstitium. Computed tomography scan of brain without contrast showed postsurgical changes in the right temporal lobe with no mass effect or intracerebral hemorrhage. Broad-spectrum antibiotics with vancomycin and piperacillin/tazobactam plus fluconazole were started and the patient was placed on airborne precautions until tuberculosis could be ruled out. Repeat MRI showed no irregular enhancing lesions, and Coccidioides serology was again negative.
The patient's condition continued to deteriorate. Repeat CXR showed diffuse infiltrates with air bronchograms, ground glass opacities, and consolidation much worse relative to the prior examination. Computed tomography scan of chest revealed extensive reticulonodular interstitial infiltrates with focal consolidation in the LUL. Bronchoscopy was arranged but the patient required intubation due to worsening hypoxemia. After 3 sputum AFB smears were negative, bronchoalveolar lavage was performed and histopathology from the LUL showed spherules containing endospores on potassium hydroxide wet mount (Figure 1) and gram stain (Figure 2). Multiple blood cultures grew Coccidioides immitis (Figure 3). Antifungal treatment was changed to liposomal amphotericin B; however, the patient developed severe acute respiratory distress syndrome (ARDS) with fraction of inspired oxygen requirement of 60%. Electrocardiogram revealed tachycardia up to 140 beats per minute with wide QRS complexes. The patient went into cardiac arrest and subsequently expired.