HIV WITH SEIZURE ACTIVITY

31yrs/M newly diagnosed with HIV presented to casusalty in with tonic clonic activity,The patient reported several syncopal events only a months prior to admission. Chief Complaints Headache, vomitting Vitals GCS -12/15,Bp -160/90,PR -92,RR -22,Spo2-98°F,Temp -100°F Lab Report CD4 counts -402,TLC -12000,CRP -22,B.urea -48,S.creatinine -1.8,Elevated liver enzymes,Na -132,K -2.2.

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CT scan head shows RING ENHANCING LESIONS right frontal lobe and left occipital lobe with significant perilesional oedema. Diagnosis is HIV with cerebral Toxoplasmosis with uraemia with severe hypokalemia , mild hyponatremia and early septicaemia. Patient needs an ICU care 1.Inj Eptoin × 8 hourly 2.inj Dexamethasone 4 mg × B.D to reduce perilesional cerebral oedema 3.IV fluids to correct dehydration if any and maintenance fluid 4 Hypokalemia treatment with ECG monitoring- inj KCL in drip and regulat × 4 hour monitoring of s.potassium levels 5.Parenteral antibiotics- Preferably 3rd generation cephalosporins which are reno - safe 6.Once patient is stable - definitive treatment for Toxoplasmosis- either co -trimoxazole or a combination of pyrimethamine , sulfadiazine and folinic acid to be started and continued for 6 weeks . 7.CD 4 count is raised - definitive treatment for HIV with HAART needs to be started 8.Once seizures are stable - oral tab levetiracetam 500 mg B.D or 1 gm O.D to be started . In some case - a second AED "s may have to be added
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MRI shows manifestations of central nervous system disorders in patients infected with human immunodeficiency virus (HIV). Seizures are more common in advanced stages of the disease, although they may occur early in the course of illness. In the majority of patients, seizures are of the generalised type. Status epilepticus is also frequent. Associated metabolic abnormalities increase the risk for status epilepticus. Cerebral mass lesions, cryptococcal meningitis, and HIV-encephalopathy are common causes of seizures Intracranial mass lesions account for nearly half the neurological disorders in AIDS patients. The nature of these mass lesions can be broadly divided into three distinct groups: opportunistic infections, neoplasms, and cerebrovascular diseases. Seizures are dominant manifestations of most of these disorders
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Multiple ring enhancing lesions Rt frontal and left parietal with perilesional edema in the back ground history of HIV with high CD4 count. The DD include Toxoplasmosis , Lymphoma ,TB abscess. Suggest Toxoplasma IgG . Location is not in favour of lymphoma ,usually periventricular . Common site for Toxoplasma is multiple ring enhancing lesions in frontal,parietal,corticomedullary junction,centrum semiovale,basal ganglia with mass effect. TB can affect anywhere in the brain.Other blood abnormalities due to the underlying disease.CSF PCR for M Tubercolosis also
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The syncopal events which you describe may be those are aura of seizure only. Imaging suggestive of ring enhancement lesion in both hemisphere with mass effect and edema. 1st differential would be tubercular due to highly endemic 2nd In view of HIV positivity other opportunistic infections like toxoplasmosis can present as same radiological features Get an MRI, fundus examination, start AEDs as per weight, get an CSF and do complete workup. Including malignant cytology. Get blood and csf toxoplasma antibody titer
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Cerebral lesion with intellectual mass/ cerebral edema developed encephalopathy with meningitis/ that's why Pt. Developed partial seizures due to HIV INFECTION, GIVE HAART THERAPY WITH MANNITOL TDS, FOR PARTIAL SEIZURES GIVES Inj. 6 amp. epsilon conc. with 100 me NS then follow up TDS 1amp. Epsilon in 100 ml NS. start tab. Valporate DS BD , maintain Electrolyte balance. Consultant HIV specialist ND Neurophysian Treat symptomatically & supportive therapy
Thanx@Dr. Mansukh Shah Sir Ji
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immunodeficiency leads to easy cerebral infections..multiple abscesses...tap one, send for all stains and all culture including atypical.. treat if organism is picked up...otherwise broad spectrum coverage..sos anti fungals anti protozoals..add anti epileptics.. short course of steroids only if patient drowsy, sos mannitol as I described earlier
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Granuloma annulare is known in HIV pt hyponatremia hypolaelemia serum creatinine & blood urea raised cd4 very low Leucocytosis gcs bad admit under neurosurgeon corebiopsy HP
Thank you doctor
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Congratulations! Your case has been selected as Case of the day and you have been awarded 5 points for sharing the case. Keep posting your interesting cases, Happy Curofying!
Thank you doctor
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Cystic lesions in rt frontal and lt occipital lobes in a case of hiv pt Leucocytosis Hypokalamia and elevated liver enzymes Sr creatinine is raised Likely toxoplasmosis
Thanx dr Rajendra Rai
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Multiple ring enhancing lesions,could be toxoplasmosis, lymphoma.
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