A 36-year-old HIV-positive patient (CD4 52 cells/μL, not on ART) presents with right-sided focal neurological deficit. MRI brain shows multiple ring-enhancing lesions in the basal ganglia. Toxoplasma IgG is positive. What is the BEST initial management?
- A Immediate brain biopsy to confirm diagnosis
- B Empiric pyrimethamine + sulfadiazine + folinic acid for 2 weeks; reassess clinically and radiologically ✓
- C Start ART immediately before any treatment
- D Amphotericin B for cryptococcal encephalitis coverage
Correct answer: B. Empiric pyrimethamine + sulfadiazine + folinic acid for 2 weeks; reassess clinically and radiologically
Explanation
In an HIV patient with CD4 <100 and ring-enhancing lesions with positive Toxoplasma serology, empiric anti-toxoplasma therapy (pyrimethamine + sulfadiazine + folinic acid to prevent haematological toxicity) is initiated without biopsy, as clinical/radiological improvement within 10-14 days confirms the diagnosis with high specificity. Brain biopsy is reserved for cases with negative Toxoplasma serology, atypical lesions, or failure to improve on treatment. ART is started after 2-3 weeks of stable anti-toxoplasma therapy to avoid IRIS.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.