A 60-year-old male patient with a history of transient relapse in Ovalle, Coquimbo Region, for work reasons for approximately 20 years, in addition to peripheral facial paralysis one year earlier.
She presented with a two-month weight loss of 8 kg, repeated vomiting, and a subsequent disturbance in balance and verdict.
Upon admission, the patient was suffering from mental illness, conscious and oriented, with no other findings on the general examination.
The neurological examination showed no aphasia, with a positive test of minimal paresis, left dysmetria and dysdiadochokinesia.
Laboratory tests showed normal blood count, C-reactive protein, renal function, hepatic profile, coagulation and complete urine, except for an albuminemia of 3.4 g/dl. Computed tomography (CT) scan of the brain showed a vasogenic lobe edema with an irregular contrast
Magnetic resonance imaging (MRI) of the brain confirmed the presence of at least three hypointense lesions with marginal impregnation with contrast medium and significant perilesional edema of frontal location, with characteristics of granulomas in the left frontal lobe 2.6 cm.
Segmental physical examination revealed oropharyngeal candidiasis and villous leukoplakia and suspected cerebral toxoplasmosis therapy was initiated with cotrimoxazole at doses 8-10 mg/kg/day fluconazole (prim-16 mg/day).
IgG positive serology for HIV and ELISA of T. cruzi were reactive, both confirmed later in the national reference laboratory (ELISA and IFI positive for Chagas disease) and confirmed to be positive.
Serology for syphilis, hepatitis B and C were negative, without detecting anomalies in the eye fundus.
The CSF analysis showed no alterations in its values and the study for syphilis, bacteria and tuberculosis was negative.
No molecular study was performed in this first lumbar puncture.
Subsequently, the CD4 lymphocyte count was 73 cells/mm3 and the HIV viral load was 54,438 copies/ml (log 4,74).
CT scan of the chest, abdomen and pelvis showed no lymphadenopathy, visceromegaly or residual lesions of tuberculosis.
1.
The patient was admitted with food refusal, low mood and emotional lability.
A severe depressive/adaptive disorder was diagnosed, which was treated with midazolam and olanzapine.
After 10 days of treatment with co-trimoxazole and 26 hospitalization antiretroviral therapy (HAART) was initiated for abacavir, lamivudine and raltegravir, which tolerated adequately and with negative HLA*B5701 prior study.
The use of protease inhibitors is discouraged due to possible interactions with psychoactive drugs and efavirenz through concurrent depression.
During the first days of HAART initiation, the patient presented diplopia, nystagmus and right eye strabismus, associated with marked aggressiveness.
A new brain MRI was controlled after 15 days of cotrimoxazole (+31 days of hospitalization), which showed a significant decrease in frontal lesions and edema, but with cerebellar edema in the perioral MRI.
A histological study of the lesions was performed to rule out primary CNS lymphoma and other differential diagnoses.
However, due to the fact that these radiological lesions did not worsen, the neurosurgical team decided to perform an open biopsy.
During the fourth week of treatment with cotrimoxazole and the third week of HAART, Klebsiella pneumoniae started fever up to 38°C, drowsiness to the deep murmur, paresis of the left hemibody, of the left palatine tract and intense dysarthria.
A new control of brain MRI, after one month of treatment with cotrimoxazole, confirmed the progression of brain lesions, especially of the left posterior fossa with greater edema of the right frontal lesion and appearance of new supra- and infratentorial herniation effect.
A probable CNS involvement due to Chagas' disease or an inflammatory syndrome of reconstitution with mechanical ventilation SIRI was proposed. Five patients were treated with corticoids in the ICU on the same day for airway protection (Glasgow-S scale).
Nifurtimox 8 mg/kg/day was initiated empirically (120 mg administered every 6 hours by NGT), associated with i.v. meropenem for the management of urinary infection.
The etiological study was extended with an undetectable viral load for cytomegalovirus in blood and negative hemocultive for mycobacteria.
A second lumbar puncture was performed with current culture, Chinese dye and dye in new negative CSF, but a proteinorrhachia of 55 mg/dL appeared.
Placement of CSF with trypanostes stain, PCR with Xpert MTB/RIF for Mycobacterium tuberculosis and PCR for herpes simplex-1 and 2, varicella zoster, Epstein negative JC.
In addition, PCR for T. gondii in peripheral blood and CSF was also negative targeting the multicopy B1 gene 9.
However, PCR for T. cruzi in blood revealed 1,400 copies/mL, and 35,000 copies/mL in CSF, confirming an encephalitis.
The targets for T. cruzi detection were for the minicirrhosis detection (minicircumvention detection target audience)10 (ADNk10) DNA minicirculation, although antiretroviral treatment-naïve patient (HAART) log10) viral load > 1 week) was discontinued in a.
The patient presented vasoactive bladder with extreme severity, continuous need for MV and amines, without greater neurological response to established therapies.
After two months of hospitalization he died due to intracranial hypertension syndrome and multiple organ failure.
