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A 33 year old African man presented with a history of fever, confusion, and headache. An magnetic resonance imaging (MRI) scan revealed hydrocephalus, marked enhancement within the ventricular walls, and extensive confluent T2-weighted/fluid attenuated inversion recovery (FLAIR), high signal around the 3rd and lateral ventricles, as well as within the splenium of the corpus callosum. Bilateral extra-ventricular drains were inserted. Cerebrospinal fluid (CSF) examination revealed: 28/mm3 lymphocytes, protein 2557 mg/l, glucose 1.8 mmol/l (serum 6.3 mmol/l), no organisms, and polymerase chain reaction (PCR) negative for tuberculosis (TB), cytomegalovirus (CMV), herpes simplex virus (HSV), and JC virus, but positive for Epstein-Barr virus (EBV). An human immunodeficiency virus (HIV)-1 enzyme-linked immunosorbent assay (ELISA) was positive with a CD4 count of 158/mm3. Serum CMV IgG and Toxoplasma IgG were positive consistent with previous exposure.
Treatment was commenced with anti-tuberculous medication, Aciclovir, and Ganciclovir. Despite this, he deteriorated and died a few days later. Post-mortem examination revealed extensive necrotising toxoplasmosis along the ventricular walls.
The radiological differential diagnosis of ventriculitis in HIV infection is usually that of TB, CMV, or lymphoma.1 In the context of HIV disease, lesions in the corpus callosum are most often seen in lymphoma and rarely in toxoplasmosis.2 Positive EBV PCR is also thought to be both highly sensitive and specific for primary central nervous system (CNS) lymphoma.3 Cerebral toxoplasmosis in the immunocompromised characteristically presents with mass lesions and although hydrocephalus is a common manifestation in congenital toxoplasmosis, it is rarely seen in adults.4 Our case stresses the importance that in HIV disease, neuroradiological and laboratory investigations can be grossly misleading, and that a trial of empirical anti-toxoplasmosis treatment should be considered for any CNS lesion in a deteriorating patient.