A 35-year-old HIV-positive man (CD4 count 75 cells/μL) presents with focal seizures and right hemiparesis. MRI shows multiple ring-enhancing lesions in the basal ganglia and at the gray-white junction. Toxoplasma IgG is positive. What is the most appropriate initial management?
- A Start high-dose dexamethasone for cerebral edema
- B Perform brain biopsy immediately to confirm the diagnosis
- C Start pyrimethamine plus sulfadiazine plus leucovorin and observe clinical response over 2 weeks ✓
- D Initiate antiretroviral therapy alone and defer anti-toxoplasma therapy
Correct answer: C. Start pyrimethamine plus sulfadiazine plus leucovorin and observe clinical response over 2 weeks
Explanation
In an HIV patient with CD4 <100 cells/μL, multiple ring-enhancing lesions at the gray-white junction and basal ganglia, and positive Toxoplasma IgG, empiric anti-toxoplasma therapy is indicated. Clinical and radiographic improvement within 10-14 days confirms the diagnosis. Brain biopsy is reserved for non-responders. ART should be started within 2 weeks of OI treatment. Steroids are used only if mass effect is significant.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.