The patient was a 23-year-old man who was living in a village in his private small livestock farm and was an owner of a cat. His past medical history was unremarkable. He presented to the Clinic of Infectious diseases of the University hospital, Stara Zagora with a 3-week history of asthenia, fever - up to 39 C, cough and loose stools, lethargy, confusion, slurred speech and unsteady gait. On admission he complained of a progressively worsening headache, photophobia and dizziness.
Signs of meningoradicular irritation - severe neck stiffness, positive Brudzinski's neck sign and positive Kernig's sign.
VI, central VII and XII cranial nerve lesions on the right side
Right hemiparesis
Static and locomotor ataxia
Brisk tendon reflexes and clonus on the left foot
Dysarthria
The patient was admitted in a generally bad condition, toxic appearing but conscious with a fever -39,6  C, dry pharyngeal and oral mucoses, whitish coated tongue. There was no skin rash. Cardiovascular and pulmonary exams were unremarkable - heart rate 78 bpm, blood pressure- 110/70 mm Hg, respiratory rate - 22/min and oxygen saturation - 94% on room air. There were enlarged liver -3-3, 5-4 cm and spleen - 1-1,5 cm. The neurological examination revealed:
Laboratory investigations showed anemia, mild leukocytosis with left shift. Renal and liver function tests were unremarkable. There were no hemostatic disorders. There were high levels of C-reactive protein (CRP). CSF changes were consistent with those of viral meningoencephalitis. Table 1.
Based on clinical presentation and laboratory findings a provisional diagnosis of serous meningoencephalitis was considered.
Treatment with Ceftriaxone, Amikacin, Mannitol, Dexamethasone, fluids, and multivitamins was started. The patient was treated symptomatically as well. Despite the negative results of pulmonary X-ray and screening tests for tuberculosis (Mantoux test and QuantiFERON -TB Gold test), tuberculostatic drugs were included in the therapy.
On the first hospital week the patient continued to spike fevers - up to 38  C (despite of antipyretics). On the 10-th day his condition deteriorated. He had severe headache, bradypsichia, bradylalia, sensory-motor aphasia and III cranial nerve lesion on the right side were demonstrated. On the third hospital week he was clinically improved. The temperature was subfebrile, symptoms of meningoradicular irritation and VI and VII cranial nerve were reduced. Right hemiparesis regressed to monoparesis on the lower limb. On the 21-st hospital day a new febrile peak up to 39,8  C was registered. The patient appeared anxious and irritable and experienced communication difficulties.
During his hospital stay, the patient underwent several brain imaging tests (CT and MRI) - on the day of admission and thereafter. Figs. 1, 2A, 2B and 3 show some of the most pronounced pathological lesions. Brain CT and MRI images arose a high index of suspicion of a parasitic infection, especially of Toxoplasma infection. A combination of Clindamycin and TMP/SMX was included in the therapy.
Toxoplasma CSF serological tests both IgM and IgG were requested for the patient at the Nacional Reference Laboratory for diagnosis of Parasitic diseases, Sofia. Both tests were positive and this confirmed the diagnosis.
To assess the patient's immune status, 4 classes of immunoglobulins (A, G, M, E) and complement factors (C3, C4) as well as the CD panel parameters were tested. All of them were in the lower reference range. Due to evidence for slight immunological suppression (Table 2) the patient underwent 3 HIV tests with ELISA and 1 with Western blot following nationally validated testing algorithm.
The recommended by Ministry of Health in Republic of Bulgaria laboratory HIV testing algorithm follows these steps: The ELISA test is done first. If the ELISA is positive, a Western blot test is performed. If the ELISA and Western blot test are positive, the viral load must be determined. If ELISA is negative, the Western blot test is performed only in high-risk persons. The testing algorithm is validated by the National Reference Laboratory for HIV/ AIDS in Sofia.
On the day of admission - ELISA negative result.
On the 10-th day, when the diagnosis of cerebral toxoplasmosis was confirmed and high index of suspicion for HIV infection arose - ELISA negative, Western blot test negative, too.
On the 41-st hospital day - ELISA negative result.
The our patient HIV testing was as follows:
The patient's wife underwent 2 ELISA HIV tests, too. They were all negative.
The patient and his family requested for discharge. He left the clinic with a slight improvement after a 45 hospital stay regardless of a possible risk. The discontinuation of the treatment against medical advice resulted in a lethal outcome.