A 34-year-old HIV-positive woman presents with a single generalised seizure and left hemiparesis of 5 days duration. CD4 count is 70 cells/μL. MRI brain shows two ring-enhancing lesions in the right basal ganglia with surrounding oedema. Toxoplasma serology is positive. What is the most appropriate initial treatment?

• A Amphotericin B followed by fluconazole
• B Acyclovir intravenously
• C Pyrimethamine plus sulfadiazine plus leucovorin ✓
• D Isoniazid, rifampicin, pyrazinamide and ethambutol

Explanation

Multiple ring-enhancing basal ganglia lesions in a patient with CD4 below 100 cells/μL are classical for cerebral toxoplasmosis, and positive serology supports the diagnosis. First-line therapy is pyrimethamine plus sulfadiazine with leucovorin to prevent haematological toxicity. Acyclovir treats HSV encephalitis, amphotericin treats cryptococcal disease, and empiric anti-tubercular therapy is considered only when the presentation or response makes toxoplasmosis unlikely.

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

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.