Toxoplasmic encephalitis unmasked during treatment for miliary tuberculosis in a patient with human immunodeficiency virus infection: a case report and literature review

Yuta Kubono; Akira Kawashima; Takato Nakamoto; Fumiya Kawahara; Ryo Kuwata; Eri Inoue; Naokatsu Ando; Haruka Uemura; Daisuke Mizushima; Takahiro Aoki; Kisaburo Nagamune; Katsuji Teruya; Hiroyuki Gatanaga

doi:10.1186/s41182-025-00852-z

Toxoplasmic encephalitis unmasked during treatment for miliary tuberculosis in a patient with human immunodeficiency virus infection: a case report and literature review

Trop Med Health. 2025 Dec 1;53(1):178. doi: 10.1186/s41182-025-00852-z.

Authors

Yuta Kubono^{1

2}, Akira Kawashima^{3

4

5}, Takato Nakamoto^{1

6}, Fumiya Kawahara⁷, Ryo Kuwata¹, Eri Inoue¹, Naokatsu Ando¹, Haruka Uemura¹, Daisuke Mizushima^{1

6}, Takahiro Aoki¹, Kisaburo Nagamune⁷, Katsuji Teruya¹, Hiroyuki Gatanaga^{1

6}

Affiliations

¹ AIDS Clinical Center, National Center for Global Health and Medicine, Japan Institute for Health Security, 1-21-1 Toyama, Shinjuku ku, Tokyo, 162-8655, Japan.
² Disease Control and Prevention Center, National Center for Global Health and Medicine, Japan Institute for Health Security, 1-21-1 Toyama, Shinjuku ku, Tokyo, 162-8655, Japan.
³ AIDS Clinical Center, National Center for Global Health and Medicine, Japan Institute for Health Security, 1-21-1 Toyama, Shinjuku ku, Tokyo, 162-8655, Japan. kawashima.a@jihs.go.jp.
⁴ Department of Parasitology, National Institute of Infectious Diseases, Japan Institute for Health Security, 1-23-1 Toyama, Shinjuku ku, Tokyo, 162-8640, Japan. kawashima.a@jihs.go.jp.
⁵ Joint Research Center for Human Retrovirus Infection, Kumamoto University, 2-2-1 Honjo, Chuo-ku, Kumamoto City, Kumamoto, 860-0811, Japan. kawashima.a@jihs.go.jp.
⁶ Joint Research Center for Human Retrovirus Infection, Kumamoto University, 2-2-1 Honjo, Chuo-ku, Kumamoto City, Kumamoto, 860-0811, Japan.
⁷ Department of Parasitology, National Institute of Infectious Diseases, Japan Institute for Health Security, 1-23-1 Toyama, Shinjuku ku, Tokyo, 162-8640, Japan.

Abstract

Background: Toxoplasmic encephalitis (TE) and tuberculoma are the leading causes of ring-enhancing brain lesions in patients with human immunodeficiency virus (HIV) infection. Because imaging findings of the two conditions overlap and cerebrospinal fluid (CSF) tests lack sensitivity, timely diagnosis is critical. Herein, we report the rare case of a patient with HIV infection and miliary tuberculosis who developed intracranial mass lesions after antiretroviral therapy (ART) initiation with high-dose prednisolone administration.

Case presentation: A 53-year-old Nepalese man who had been living in Japan was diagnosed with HIV infection (CD4 count, 146 cells/µL) and miliary tuberculosis. Four-drug rifabutin-based therapy was initiated. However, trimethoprim-sulfamethoxazole (TMP-SMX) prophylaxis was discontinued because of a rash and replaced with monthly pentamidine. ART (dolutegravir/lamivudine) was initiated 3 weeks later. Prednisolone (60 mg/day) was administered for refractory tuberculous ascites, and the dose was tapered over 6 weeks. Eight weeks after ART, the patient developed a headache, and laboratory tests revealed a CD4 count of 384 cells/µL. Magnetic resonance imaging (MRI) revealed right frontal ring-enhancing lesions. CSF was acellular; polymerase chain reaction yielded negative results for several pathogens including Mycobacterium tuberculosis and positive results for Toxoplasma gondii. After a 5-day graded TMP-SMX desensitization, the patient received full-dose therapy for 6 weeks, followed by secondary prophylaxis. The patient's headache resolved, and repeat MRI after 2 weeks revealed marked regression of the lesions. No radiological relapse was observed 3 months after treatment completion.

Conclusions: TE can emerge during immune recovery at CD4 counts > 100 cells/µL when corticosteroid administration coincides with early ART. In patients receiving tuberculosis treatment who develop new brain lesions soon after ART, T. gondii polymerase chain reaction and prompt antiparasitic therapy should be pursued. Rifabutin permits concomitant use of dolutegravir, and TMP-SMX desensitization allows effective treatment and prophylaxis.

Keywords: Toxoplasma gondii; Case report; Human immunodeficiency virus; Opportunistic infection; Polymerase chain reaction; Toxoplasmic encephalitis.

Abstract

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