A 49-year-old Peruvian man who had lived in Spain for 10 years and last travelled to his country in 1995, with no history of interest except sexual assault in 1996, with severe tearing of the anal canal that caused rectorrhagia requiring transfusion of two red blood cell concentrates; no toxic habits or risk practices for HIV infection. Consultation for symptoms of 4-5 stools per day, liquid, without pathological products, of about 6 months of evolution, with added fever of up to 39ºC in the last two months. Weight loss of 2-3 kg during this time; mild abdominal pain; holocranial headache. The rest of the anamnesis by apparatus was unremarkable.
On physical examination, fever of 38.5°C well tolerated, with normal cardio-pulmonary auscultation, abdomen discreetly and diffusely painful on palpation, with no signs of peritoneal irritation, rectal examination with preserved sphincter and no alterations, and strictly normal neurological examination.
Laboratory data: erythrocyte sedimentation rate (ESR) 35; haemogram, blood biochemistry, basic coagulation study, thyroid hormones and routine urine tests were normal. Anti Hbc and anti HBe positive; HCV, RPR, Rose Bengal, Ac. Leishmania, cryptococcus ag. and Mantoux negative. Antigenemia for CMV 70 cells; Toxoplasma positive; HIV positive (ELISA and Western Blot). CD4 96; Viral load 153,690 copies. Blood cultures (X3) negative (2 batches); fresh parasites negative for cryptosporidium and microsporidia; enteropathogens and Clostridium difficile toxin negative; duodenal juice and biopsy of 2nd duodenal portion without pathogens; CMV is isolated in colon biopsy culture, the rest of the study at that level being negative; CMV is isolated in urine cell culture.
Fundus examination showed no evidence of CMV retinitis. Imaging tests: Chest X-ray, abdominal ultrasound, oesophago-gastroscopy, colonoscopy and gastrointestinal transit without notable alterations. Cranial CT scan showed an intra-axial mass, with predominantly annular enhancement after IV contrast, centred in the region of the anterior arm of the internal capsule and left basal ganglia, with significant associated vasogenic oedema (differential diagnosis toxoplasmosis/lymphoma).
Treatment was started with Ganciclovir IV for treatment of CMV infection, as well as Sulfadiazine and Pyrimethamine OV, plus IV corticosteroid for the brain mass, with disappearance of fever and normalisation of diarrhoea 48 hours after starting treatment. Fourteen days after starting treatment, the patient was still asymptomatic; the cranial CT scan was repeated, showing a considerable decrease in the size of the lesion, which supports the diagnosis of cerebral toxoplasmosis.
