A 26-year-old man with a history of long standing smoked hashish, inhaled ketamine and lysergic acid diethylamide use was admitted to the emergency department with 5-days of uncontrolled, large amplitude movements of left hemibody and fronto-temporal headache and photophobia in the last 12 days. On arrival, Glasgow coma scale was 8, he was afebrile; arterial pressure of 84/55 mmHg, with a normal capillary blood glucose level. Chest auscultation revealed rhonchi bilaterally. The patient had whitish lesions on the oral mucosa and on neurological examination he avoided eye contact, he had isocoric and symmetric pupils, without abnormal eye movement; fundoscopy revealed no papilledema, the speech was disorganized and he had ballistic movements of left hemibody, more severe in the upper limb.
Serum analysis showed hemoglobin 9.2 g/dL, normal white blood cell count, C-reactive protein and renal function, Lactic acid dehydrogenase was 798 U/L. The electroencephalogram was not conclusive due to the lack of conditions to perform a correct test.
The HIV serology and confirmatory test were positive and other serologic exams showed: HBV immune, HCV negative, Toxoplasma IgG positive, EBV IgG positive, IgM negative, CMV and HSV 1/2 IgG/IgM negative and negative tests for syphilis. The first cranial CT (computed tomography) revealed a: slight hypodensity at lower left cerebellar hemisphere, with small dots among it - calcifications/petechial hemorrhages. Based on these results, anti-toxoplasmosis therapy (pyrimethamine 75 mg/day plus clindamycin 600 mg every 6 h and folinic acid 25 mg/day) and high doses of antiepileptics and neuroleptics were initiated. Twelve hours later he was transferred to the intensive care unit.
Successive brain MRI showed: lesions at lower left and right cerebellar hemisphere with adjacent parenchymal changes, one of them thalamus-mesencephalic with extension to the internal capsule, another one frontobasal, suggesting toxoplasmosis [Fig. 1, Fig. 2].
A lumbar puncture was performed and cerebrospinal fluid (CSF) analysis showed: 5000 WBCs/muL (3150 neutrophils/muL, 1100 lymphocytes/muL), protein 232 mg/dL, Glucose 28 mg/dL, ADA 12.0 IU, HIV-RNA 1188 copies/mL; India ink test was negative; Cryptococcus antigen, V.D.R.L/FTA-abs, CSF culture and polymerase chain reaction (PCR) for Toxoplasma, HSV, CMV, VZV, JC virus, EBV, Enterovirus and Mycobacterium tuberculosis were all negative.
Serum HIV viral load was 1337147 copies/mL, cd4 40/mm3 and ART: tenofovir/emtricitabine 245/200 mg plus raltegravir 400 mg was initiated.
Despite anti-toxoplasmosis, ART, antimicrobials and anti-epileptics, in the 24th day of hospitalization involuntary movements remained and a stereotaxic cerebellar biopsy was performed [Fig. 3]. The histologic result raised the hypothesis of Whipple's disease; however the upper endoscopy didn't show erythema and duodenum biopsy did not reveal PAS material. After one month of admission, another CSF was performed and the PCR for Tropheryma whipplei was negative and positive for M. tuberculosis with an undetermined Quantiferon test. Culture of bronchial aspirates didn't isolate M. tuberculosis, but anti-tuberculosis treatment with isoniazid 300 mg/day, rifampin 600 mg/day, pyrazinamide 1500 mg/day and ethambutol 1200 mg/day was started. The patient kept uncontrolled and refractory movements despite medical treatment, therefore stereotactic right pallidotomies were performed in the day 46 and 69 of hospitalization.
During almost 12 weeks at intensive care unit, anti-epileptics were titrated, sedation reduced, while ballistic movements were progressively disappearing. The patient was referred for immunodeficiency consultation after 5 months of hospitalization and has been under anti retroviral therapy, after 12 months of anti-tuberculosis and almost one year of neurotoxoplasmosis maintenance treatment. In the last control he had cd4 count of 436/mm3 and undetectable viral load with a decrease in the left globus pallidus lesion and a right globus pallidus scar [Fig. 4], with no more choreiform movements, just a thin tremor on left hand.