1472: TRAPPED BY TOXOPLASMA: VENTRICULAR COMPROMISE IN A PREVIOUSLY UNDIAGNOSED HIV PATIENT

Introduction: Cerebral toxoplasmosis is a common opportunistic infection in patients with advanced HIV, particularly those with CD4 counts below 100 cells/uL. It usually presents with subacute neurologic symptoms and responds well to medical management alone. In rare cases, it presents aggressively with life threatening complications requiring neurosurgical intervention. We report a rare case of fulminant toxoplasma cerebritis as the initial presentation of HIV with significant structural complications necessitating urgent neurosurgical intervention. Description: A 33-year-old woman with no medical history presented with two weeks of confusion, lethargy, and vomiting as reported by family. She was somnolent with a Glasgow Coma Scale of 9, right arm weakness and a positive right Babinski reflex. Head CT revealed a large left thalamic mass with 11mm midline shift. Initial management included glucocorticoids, antiepileptic prophylaxis, and hypertonic saline. CT chest, abdomen and pelvis showed no acute pathology. Due to concern for trapped ventricle from mass effect, an extra-ventricular drain (EVD) was placed. Subsequent MRI brain showed a 3.8 x 2.1 x 3.0 cm multiloculated enhancing left basal ganglion mass with extensive adjacent edema, mass effect, 7.5mm midline shift and two foci of T2 FLAIR hyperintensity in the right thalamus. Stereotactic brain biopsy revealed tachyzoites and bradyzoites consistent with toxoplasmosis. HIV serology was positive, with a CD4 count of 24 cells/uL and viral load of 1.4 million copies/mL. Treatment with sulfadiazine, pyrimethamine and leucovorin was initiated. The patient’s neurological status improved and the EVD was removed. Antiretroviral therapy is planned two weeks after anti-toxoplasmosis therapy initiation. Discussion: This case illustrates a rare presentation of fulminant cerebral toxoplasmosis with structural brain complications at initial HIV diagnosis. Early imaging, aggressive critical care management, and timely multidisciplinary coordination were essential to this patient’s stabilization and recovery. This case highlights the need for a high index of suspicion for toxoplasmosis in patients with unexplained neurologic decline, even before HIV is confirmed, and supports a multidisciplinary approach to optimize outcomes in severe opportunistic infections.