Space Occupying Lesion

Case Report
SPACE OCCUPYING
LESION
( Cerebral Toxoplasmosis with HIV/AIDS)
by :
T. Widya Wira Utami, S.Ked
Supervisor :
dr. Eny Lestari, Sp.S
DEPARTMENT OF NEUROLOGY
MEDICAL SCHOOL RIAU UNIVERSITY
ARIFIN ACHMAD RIAU PROVINCE GENERAL HOSPITAL
PEKANBARU
2018
Patient’s Identity
Name Mr. R
Age 34 years old
Gender Male
Address Salo, Kampar
Religion Moslem
Marital Status Married
Occupation Farmer
Date of
December, 31th 2017
Admission
Medical
9749xx
Record SPACE OCCUPYING LESION
(Susp. Cerebral Toxoplasmosis with
HIV/AIDS)
Anamnesis
Alloanamnesis with patient’s parent (December, 31th 2017)
Chief complaint
 Loss of conciousness since 1 day

before admitted to the hospital.
SPACE OCCUPYING LESION

HIV/AIDS)
Present Illness
History
1 day
before admitted to
the hospital patient
was loss of
9 days conciousness since
before admitted to the one day and felt
hospital Patien feel tired, restless, loss the
after that patient oing to appetite,feelt
accupuncture and numbness on his limb
bekam tomorow patient started from on his
felt weakness in his right hand and vomit in the
side of bod emergency room.
suddenly.Patient treated
in National Stroke Center
Patient was denial of
Bukit Tinggi. Patient headache, fever,
diagnosed with stroke seizure and loss of
infark, after feel better sensory. No complain
patient got vitamin B1 in of urinate and
home SPACE OCCUPYING LESION
defecate(Susp. Cerebral Toxoplasmosis with
HIV/AIDS)
Family Illness
Past Illness History
History
 History of Infarct Stroke • No family
(+)
 History of progressively
complain that
headache since 1 years same complaint
before admitted (+) • A history of brain
History of HIV (+)

tumours (-)
History of brain and spine

trauma (-)
• A history of HIV
 History of last fever (-)
AIDS (-) patient’s
 History of brain tumour (-) wife
HIV/AIDS)
Custom History
 History of eating the undercooked foods and

the raw vegetables : not detected
 History of having a pet : nothing
 History of tattooing: nothing
 History of free sexual behaviour: denial
 History of drug use: not detected
 History of blood product transfusional: not
detected

HIV/AIDS)
 Patient Mr. S, 34 years of age, entered to
RSUD Arifin Achmad patient complained
of loss of consciousness. Patient also got
the restless. Patient also loss the appetite,
RESUME
vomit and numbness. Patient also feel

weakness of his right side of the body. This
complained has feel 9 days before
admitted to hospital. One years before
admited often felt the headache. History
of infarct stroke (+) and HIV AIDS (+)

HIV/AIDS)
Physical Examination
January, 3 2017)
Generalized Physical
Neurological status
Condition examination
• Blood Presure: 120/70

• Neck: • Consciousness
mm/Hg no lymph node :
• Heart Rate : 75 bpm enlargement Composmentis
• Respiratory rate : 24 • Thorax: GCS : 15 (E4V5M6)
x/mnt normal limit • Noble Function :
• Temperature: 37,3°C
• Abdomen: normal
• Weight : 48 kg
• Height : 152 cm normal limit • Neck Rigidity :
• BMI : 20,86 Negative
kg/m (normoweight )
2
• Cranial nerves :

HIV/AIDS)
N. I (Olfactory)
Right Left Interpretation
Sense of Smell Normal Normal Normal limit
N. II (Optic)
Eyesight
Field of view
Normal Normal Normal limit
The introduction of
color
N. III (Oculomotor)
Ptosis
Pupil
Form
Size
Eye movement Normal Normal Normal
Pupillary reflex
Direct SPACE OCCUPYING LESION
Indirect (Susp. Cerebral Toxoplasmosis with
HIV/AIDS)
N. IV (Trochlear)
Eye movement Normal Normal Normal limit
N. V (Trigeminal)
Motor
Sensibility Normal Normal Normal limit
Corneal reflex
N. VI (Abducens)
Eye movement
Strabismus Normal Normal Normal
Deviation SPACE OCCUPYING LESION
HIV/AIDS)
N. VII (Facial)
Tic
Motoric
-Angle of mouth
-Close eye
-Forehead
-Eyebrows Normal Normal
-Fleksure Normal
nasolabial
-Wince
-Cheek balloning
Flavouring
Chvostek Sign
N. VIII (Acoustic)
Hearing
Rhine test
Normal Normal Normal
Weber test
Swabach test

HIV/AIDS)
N. IX (Glossopharyngeal)
Pharyngeal
Arch Normal Normal Normal limit
Sense of Taste
Gag Reflex
N. X (Vagus)
Pharyngeal
Arch Normal Normal Normal
Dysphonia
N. XI (Accessory)
Motor
-See Normal Normal Normal
-Shrug
Trophy
N. XII (Hypoglossal)
Motor
Trophy Normal Normal Normal
Tremor SPACE OCCUPYING LESION
Dysarthria (Susp. Cerebral Toxoplasmosis with
HIV/AIDS)
Motor System
Upper Extremity
Strength
Distal 4 5
Proximal 4 5
Tone NormaL Normal
Trophy Eutrophy Eutrophy
Involuntary (-) (-)
movements (-) (-)
Clonus Hemiparese
Lower Extremity dekstra
Strength
Distal 4 5
Proximal 4 5
Tone Normal Normal
Eutrophy Eutrophy
Trophy (-) (-)
Involuntary (-) (-)
movements
Clonus
Body
Trophy Eutrophy Eutrophy
Involuntary - -
Normal LESION
SPACE OCCUPYING
movements Normal Normal(Susp. Cerebral Toxoplasmosis with
Abdominal Reflex HIV/AIDS)
Sensory System

Touch
Pain Normal Normal Normal
Temperature
Proprioceptive

HIV/AIDS)
Reflexes

Physiologic
Biceps
Triceps Normal Normal
Normal
patella
Achilles
Pathologic
Babinsky
Chaddock
Normal Normal Normal
Hoffman Tromer
Openheim
Schaefer

HIV/AIDS)
Function Coordination

Point finger to nose test
Nose-finger-nose test
Point finger-point finger
tesst
Normal
Disdiadokinesia
Normal Normal
Heel to knee test
Rebound test
Gait
Tandem
Romberg

HIV/AIDS)
Autonomy System Others Examination
Urinate : Normal Laseque : Negative
Defecation : Normal Kernig : Negative
Patrick : Negative
Kontrapatrick : Negative
Brudzinski : Negative
Valsava test : Negative

HIV/AIDS)
Resume of Examination
General status
Awareness CM, GCS : 15 (E4V5M6)
Blood Pressure 120/70 mmHg
Heart Rate 79 beat / minute, regular
Respiratory Rate 22 time / minute
Temperatue 37,3°C
Other examination
Cognitive function Normal
Meningeal sign Normal
Crania nerves Normal

Motoric Hemiparese dekstra
Sensoric Normal
Coordination Normal
Autonom system Normal
Reflex Physiologic Normal

Reflex Pathologic Normal
HIV/AIDS)
Working Diagnosis
Clinical diagnosis
Space Occupying Lesion
Topical diagnosis
• Intracranial
Etiological diagnosis
• Cerebral Toxoplasmosis
Differential diagnosis
• Brain Tumor
HIV/AIDS)
Suggestion Examination
Laboratory Study
• Blood routine, blood chemistry, electrolites
Imaging Study
• Chest X-Ray, Head CT with and without
contrast
VCT Consultation
IgM and IgG Antitoxoplasmosis

HIV/AIDS)
Management
Non pharmacologic Pharmacologic

therapy therapy
Give O2 3 lpm Dexamethason 3 x 5 mg I.V
IVFD Ringer Lactat 20 dpm Ranitidine 2 x 50 mg I.V
Ketolorac inj 2 x1 gr I.V

HIV/AIDS)
Laboratory Study
(December, 31th 2017)
Blood Routine Blood Chemistry Electrolit
• Hb : 13,4 g/dl • Glucose : 120 • Na+ : 134 mmol/L

• Ht : 39,6 % mg/dL • K+ : 3,8 mmol/L
• WBC : 7350 /uL • Ureum : 31 mg/dl • Cl- : 93 mmol/L
• PLT : 269.000/uL • Creatinin: 0,6
mg/dl
• AST : 18 u/l
• ALT : 53

HIV/AIDS)
HIV Rapid Test and Serology
Toxoplasma
 SD Bioline HIV ½ reagent : reactive

 Intace reagent : reactive
 Oncoprobe reagent : reactive
 Ig G Anti Toxoplasma : Negative

 Ig M Anti Toxoplasma : Positif

HIV/AIDS)
Head CT without Contrast
 Interpretation:
SOL on ganglia
basalis sinistrath
perifocal
oedema

HIV/AIDS)
Final Diagnose
SOL ec. toxoplasmosis

cerebral with HIV/AIDS.

HIV/AIDS)
FOLLOW UP
HIV/AIDS)
January, 3rd 2018
S : Headache (+), appetite A : SOL+ Toxoplasmosis with HIV AIDS
improve (+), limp (+), confusion (+),
insomnia (+) P :
IVFD RL 20 dpm
O :Consiousness: sopor; GCS: 15 Dexametason inj 2 x 5 mg
(E4V5M6)
BP: 130/80 mmHg, HR : 88 x/minute, Ranitidin inj 2x1 amp
R : 21 x/minute, T : 36,7°C
Kognitive Function : Normal
Meningeal sign : Normal
Cranial nerves : Normal
Physiological reflexes: (+/+)
Pathological reflexes: (-/-)
Coordination examination: Normal
Motoric examination: tone (+)
3 5
5 5

HIV/AIDS)
January, 4th 2018
S : Headache (+), appetite not A : SOL+ Toxoplasmosis with HIV AIDS
improve (+), limp (+), confusion (+),
insomnia (+) P :
IVFD RL 20 dpm
O :Consiousness: sopor; GCS: 15 Dexametason inj 2 x 5 mg
(E4V5M6)
BP: 130/80 mmHg, HR : 88 x/minute, Ranitidin inj 2x1 amp
R : 21 x/minute, T : 36,7°C
Kognitive Function : Normal
Meningeal sign : Normal
Cranial nerves : Normal
Physiological reflexes: (+/+)
Pathological reflexes: (-/-)
Coordination examination: Normal
Motoric examination: tone (+)

HIV/AIDS)
DISCUSSION
HIV/AIDS)
Space occupying lesion (SOL)
 SOL is a extended lesion in brains including tumor,

hematoma and abscesses.
 The position of the lesion in the brain space urges
can have a dramatic influence on the signs and
symptoms
 Signs and symptoms allows doctors to localize the
lesion will depend on the occurrence of a disorder
in the brain as well as the degree of tissue damage
caused by nerve lesion

HIV/AIDS)
 A lumbar pungsi should not be
performed on patients suspected
intracranial tumors
 At this time the CT-scan and MRI is
used to enforce a diagnose

HIV/AIDS)
Loss of consciousness
 Loss of consciousness is a very common clinical

disorder. This can be transient lasting seconds or
minutes as occurs in syncope and seizures or more
prolonged as occurs in coma
 The causes of coma are generally classified as
intracranial or extracranial
 A focal brain lesion occurring below the tentorium
interfering with the reticular activating system can
result in coma
 Diffuse lesions which affect the function of the brain
as a whole including the reticular activating system
can result in coma

HIV/AIDS)
HUMAN IMMUNODEFICIENCY VIRUS (HIV)
HIV-infection and particularly its late

stage of severe immunodeficiency
(AIDS) render the nervous system
susceptible to an array of neurological
disorders.
At least 40% of HIV-infected patients develop
neurological symptoms during the course of their
illness.
Central nervous system (CNS) is infected during the
primary infection itself and the CNS becomes a
watershed for HIV infection thereafter.

HIV/AIDS)
In acute primary infection patients may experience a
syndrome of headache, photophobia and
occasionally frank encephalitis.
The syndrome usually resolves within 2 to 4 weeks;
however, in some patients, signs and symptoms persist
chronically.
Cryptococcal meningitis, toxoplasma encephalitis,
progressive multifocal encephalopathy and CMV
encephalitis occur in AIDS patients with CD4 count
<200/ cubic mm.

HIV/AIDS)
CNS involvement may be diffuse, as is typical of HIV
encephalopathy, or associated with more discrete
solitary or multifocal lesions.
A diagnostic approach thus minimizes both empiricism

and the need for brain biopsy.

HIV/AIDS)
CEREBRAL TOXOPLASMOSIS
Definition
A zoonotic disease caused by the obligate intracellular parasite

called Toxoplasma gondii.
Etiology
Caused by Toxoplasma gondii .
Epidemiology
 United states 15% to 29,2%

 United states HIV-infected with toxoplasmic encephalitis 10%
to 20%
HIV/AIDS)
Pathogenesis
Cat feses containing oocytes
Eaten accidentally by humans
Takizoit (rapidly replicates) penetration into nucleated cells

and formed vacuoles dead cells, takizoit spread to other cells
immune response (CD4 + T cells, IL-12, IFN-γ, TNF-α) →

bradizoit (slow replicates)
Tissue cysts in the brain, heart and muscles (chronic phase)
In immunocompromised patients, the cyst turned into takizoid

and infect the tissues
HIV/AIDS)
Clinical
Presentations
 Altered mental status (62%)

Headaches (59%)
Fever (14%)
 Focal neurologic deficit
Confusion
Drowsiness
Seizures
Hemiparesis
Hemianopsia
Aphasia
Ataxia
Cranial nerve palsies
Motor weakness and speech disorders

HIV/AIDS)
Diagnosis Studies
Cerebrospinal Fluid
Serology Imaging Studies
Analysis
•IgG titer peaks •Contrast-enhanced •Rarely useful in the diagnosis
between 1 and 2 MRI or CT of cerebral toxoplasmosis
months after primary •Multiple lesions located •CSF findings may include
infection and typically in the region of the elevated protein, variable
remains detectable for cerebral cortex, glucose levels, and mildly
the rest of the patient’s corticomedullary elevated white blood cell
life. junction, or basal counts with a mononuclear
•Patients with elevated ganglia, although a predominance
IgG (in patients with single lesion may
known levels of IgG sometimes be present
before) in the presence •CT scan with contrast
of clinical will demonstrate the
manifestations may typical ring-enhancing
indicate reactivation sign
•IgM antitoxoplasma
antibody usually
disappears within
weeks to months after
the primary infection
but may remain
elevated for more than
1 year.
•Positive and rising IgM SPACE OCCUPYING LESION
levels can be (Susp. Cerebral Toxoplasmosis with
interpreted as acute HIV/AIDS)
Differential Diagnosis
•Acute toxoplasmosis
•Primary central nervous system lymphoma
•Primary brain tumors (rarely glioblastoma)
•Brain metastasis
•Demyelinating diseases (eg, multiple sclerosis,
vasculitis)
•Infections (eg, brain abscess, tuberculoma)
•Multifocal infarcts
•Inherited lesions (eg, hemangioblastoma
associated with von Hippel-Lindau disease)
•Arteriovenous malformation

HIV/AIDS)
Treatment
Preferred Therapy Alternative Regimens

and Duration
Pyrimethamine (200-mg oral Pyrimethamine (200-mg oral loading dose, followed by
loading dose, followed by 50– 50–75 mg/day orally) and clindamycin (600 mg
75 mg/day orally), intravenously [IV] or orally 4 times daily)
sulfadiazine (1000–1500 mg
TMP (5 mg/kg) and SMX (25 mg/kg) IV or orally twice daily
4 times daily), and leucovorin
Atovaquone* (1500 mg orally twice daily) plus
(10–20 mg/day) for up to 6
pyrimethamine (50–75 mg/day) and leucovorin (10–20
weeks
mg/day)
Atovaquone* (1500 mg orally twice daily) plus

sulfadiazine (1000–1500 mg 4 times daily)
Atovaquone* (1500 mg orally twice daily)

Pyrimethamine (50–75 mg/day) and leucovorin (10–20
mg/day) plus azithromycin (900–1200 mg/day orally)
For severely ill (Susp. Cerebral
patients who Toxoplasmosis with
cannot tolerate oral
HIV/AIDS)
Prophylaxis

HIV/AIDS)
BASIC DIAGNOSIS
HIV/AIDS)
Basic Clinical Diagnosis
 A loss of
conciousness
 Headache
SOL
 Vomit
 Hemiparese
 Thumbness
Based
on the
location
HIV/AIDS)
Basic Topic Diagnosis
 A loss of conciousness
 Headache
Intracrania
 Hemiparese
l process
 Thumbness
 Vomit

HIV/AIDS)
Basic Etiologic Diagnosis
• From anamnesis there are obtained loss of

consciousness, restless, thumbness and hemiparese with
history of hiv aids is suitable the etiologic from the
diagnose in this patient is cerebral toxoplasma.
• Ig M anti toksoplasma are negatif but Ig G is positif, the
view of CT Scan we can see there are SOL in ganglia
basalis

HIV/AIDS)
Basic Differntial Diagnosis
 From the anamnesis, patient’s headche occur

slowly and feels increasingly worse.
 The brain tumour make a same symptomps with this
patient, because cerebral toxoplasma and brain
tumour make increase of intracranial pressure.
 Patient is not fever, so brain abscess may be no
suitable with this patient.

HIV/AIDS)
Basic of Supportive Examination
• Laboratory
knowing risk factors whether infection exists, and
knowing the general condition of the patient.
• Thoracic x-rays
see the existence of a specific process, the primary
infection in the lung.
• Head CT-scan
see a cross-section of the brain as whole which related
to patient’s complained.
• VCT Consultation
knowing HIV status in this patient and if positive HIV, it
could be treated as soon as
• IgM and IgG Antitoxoplasmosis
detects IgM and IgG antibodies against ToxoplasmaSPACE OCCUPYING LESION
gondii. (Susp. Cerebral Toxoplasmosis with
HIV/AIDS)
Basic of Management
Non pharmacologic
Pharmacologic therapy:
therapy:
 Head up 30o : to prevent • Dexamethason 3 x 5 mg I.V :
aspiration to reduce brain edema.
• Ranitidine 2 x 50 mg I.V : to
 Give O2 3 lpm : to keep preventing side effect of
brain oxygenation dexamethasone.
 IVFD NaCl 0,9% 20 dpm: to • Citikolin 2 x 500 mg I.V : as
neuroprotector agent.
maintain the state of
• Phenitoin 3 x 100 mg I.V
euvolemic
(initiated) : as anticonvulsant.
 Using nasogastric tube : to • Pirymethamine tab 1 x 8 tab
prevent aspiration (25 mg) P.O and
Clindamycin 3 x 150 mg P.O :
as treatment regimens for
acute toxoplasmosis in adult
HIV patients.
HIV/AIDS)
THANK YOU 

HIV/AIDS)

Space Occupying Lesion

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Case Report

 Loss of conciousness since 1 day

SPACE OCCUPYING LESION

 History of eating the undercooked foods and

SPACE OCCUPYING LESION

vomit and numbness. Patient also feel

SPACE OCCUPYING LESION

• Blood Presure: 120/70

SPACE OCCUPYING LESION

Sense of Smell Normal Normal Normal limit

Eye movement Normal Normal Normal limit

SPACE OCCUPYING LESION

Right Left Interpretation

SPACE OCCUPYING LESION

Right Left Interpretation

SPACE OCCUPYING LESION

Right Left Interpretation

SPACE OCCUPYING LESION

Urinate : Normal Laseque : Negative

Defecation : Normal Kernig : Negative

Valsava test : Negative

Meningeal sign Normal

Crania nerves Normal

Autonom system Normal

Reflex Physiologic Normal

IgM and IgG Antitoxoplasmosis

SPACE OCCUPYING LESION

Non pharmacologic Pharmacologic

Give O2 3 lpm Dexamethason 3 x 5 mg I.V

IVFD Ringer Lactat 20 dpm Ranitidine 2 x 50 mg I.V

Ketolorac inj 2 x1 gr I.V

SPACE OCCUPYING LESION

Blood Routine Blood Chemistry Electrolit

• Hb : 13,4 g/dl • Glucose : 120 • Na+ : 134 mmol/L

SPACE OCCUPYING LESION

 SD Bioline HIV ½ reagent : reactive

 Ig G Anti Toxoplasma : Negative

SPACE OCCUPYING LESION

SPACE OCCUPYING LESION

SOL ec. toxoplasmosis

SPACE OCCUPYING LESION

SPACE OCCUPYING LESION

SPACE OCCUPYING LESION

 SOL is a extended lesion in brains including tumor,

SPACE OCCUPYING LESION

SPACE OCCUPYING LESION

 Loss of consciousness is a very common clinical

SPACE OCCUPYING LESION

HIV-infection and particularly its late

SPACE OCCUPYING LESION

SPACE OCCUPYING LESION

A diagnostic approach thus minimizes both empiricism

SPACE OCCUPYING LESION

A zoonotic disease caused by the obligate intracellular parasite

Caused by Toxoplasma gondii .

 United states 15% to 29,2%

Cat feses containing oocytes

Eaten accidentally by humans

Takizoit (rapidly replicates) penetration into nucleated cells

immune response (CD4 + T cells, IL-12, IFN-γ, TNF-α) →

Tissue cysts in the brain, heart and muscles (chronic phase)

In immunocompromised patients, the cyst turned into takizoid

 Altered mental status (62%)