A 29-year-old man with HIV (CD4 count 40 cells/μL, not on ART) presents with 10 days of headache, left hemiparesis, and two generalised seizures. MRI brain shows multiple ring-enhancing lesions in the basal ganglia and corticomedullary junction with surrounding oedema. Toxoplasma serology is positive. What is the most appropriate initial therapy?

• A Ganciclovir induction followed by valganciclovir maintenance
• B Liposomal amphotericin B followed by fluconazole
• C Whole-brain radiotherapy plus dexamethasone
• D Pyrimethamine plus sulfadiazine plus leucovorin ✓

Explanation

Multiple ring-enhancing lesions in the basal ganglia of a patient with CD4 below 100 cells/μL are classical for cerebral toxoplasmosis, and standard induction therapy is pyrimethamine plus sulfadiazine with leucovorin to prevent haematological toxicity. Amphotericin targets cryptococcal disease, ganciclovir targets CMV, and radiotherapy is for CNS lymphoma. If no clinical and radiological response occurs after 2 weeks, stereotactic biopsy is pursued to exclude lymphoma.

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

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.