A 33-year-old HIV-positive man (CD4 count 40 cells/μL) presents with subacute headache and left hemiparesis. Contrast MRI shows multiple ring-enhancing lesions in the basal ganglia and corticomedullary junction with marked surrounding oedema. Toxoplasma IgG is positive. What is the most appropriate initial management?

• A Isoniazid, rifampicin, pyrazinamide and ethambutol empirically
• B Immediate stereotactic brain biopsy
• C Liposomal amphotericin B followed by flucytosine
• D Pyrimethamine plus sulfadiazine plus leucovorin ✓

Explanation

Multiple ring-enhancing basal ganglia lesions with positive Toxoplasma serology in a patient with CD4 under 100 are treated empirically as cerebral toxoplasmosis with pyrimethamine, sulfadiazine and folinic acid; biopsy is reserved for non-response after 1 to 2 weeks. Amphotericin with flucytosine is cryptococcal therapy, and anti-tuberculous therapy suits solitary lesions with pulmonary findings. Leucovorin prevents pyrimethamine-induced myelosuppression.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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