A 32-year-old man with HIV infection and a CD4 count of 60 cells/mm3 presents with headache, low-grade fever, and left hemiparesis. MRI shows multiple ring-enhancing lesions in both cerebral hemispheres with surrounding edema. Anti-Toxoplasma IgG antibody is positive. After induction therapy, the appropriate maintenance regimen includes which combination?

• A Pyrimethamine plus sulfadiazine ✓
• B Pyrimethamine plus clindamycin
• C Trimethoprim-sulfamethoxazole alone at prophylactic dose
• D Amphotericin B plus flucytosine

Explanation

Cerebral toxoplasmosis in advanced HIV disease is treated with pyrimethamine plus sulfadiazine along with folinic acid, continued as maintenance until immune recovery on antiretroviral therapy. Clindamycin plus pyrimethamine is an alternative when sulfa drugs are not tolerated but carries higher relapse rates. Trimethoprim-sulfamethoxazole is given as primary prophylaxis when CD4 falls below 200 cells/mm3, not as definitive maintenance therapy, which makes option C the tempting but incorrect choice.

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

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Written and medically reviewed by the StethoPrep medical team.