A 29-year-old HIV-positive woman (CD4 count 65 cells/μL, not on ART) presents with 2 weeks of headache and left hemiparesis. MRI shows multiple ring-enhancing lesions in both basal ganglia with surrounding oedema. Serum Toxoplasma IgG is positive. The most appropriate initial treatment is:

• A Liposomal amphotericin B followed by fluconazole
• B Pyrimethamine plus sulfadiazine plus leucovorin ✓
• C Ceftriaxone plus vancomycin
• D Isoniazid, rifampicin, pyrazinamide and ethambutol alone

Explanation

Multiple ring-enhancing lesions in the basal ganglia in a patient with CD4 under 100 cells/μL and positive Toxoplasma serology is cerebral toxoplasmosis until proven otherwise. Standard induction therapy is pyrimethamine plus sulfadiazine with leucovorin to prevent haematological toxicity. Amphotericin followed by fluconazole treats cryptococcal meningitis, which typically shows single or few lesions or meningeal enhancement rather than multiple basal ganglia rings. Empirical anti-TB therapy is not first line here.

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

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.