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case_images: Post-gadolinium T1 contrast enhanced axial slices from MRI brain performed 2 days following the initial clinical presentation. Multiple ring-enhancing lesions are seen within the right frontal (a), left basal ganglia and corticomedullary junction within the right parietal lobe (b). Effacement of anterior horn of the left lateral ventricle is noted (a).
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case_images: Magnetic resonance imaging (MRI) of the brain was also undertaken at this time, which demonstrated multiple ring-enhancing lesions (Figure 1).
case_images: Axial slices from portal venous phase contrast enhanced CT thorax, abdomen and pelvis performed at initial presentation, which demonstrates mediastinal (a) and hilar (b) lymph node enlargement. These nodes were later not found to be FDG-avid on FDG-PET-CT.
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case_images: Mediastinal and hilar lymph node enlargement identified on CT imaging of the chest, abdomen and pelvis was felt to be in keeping with persistent generalised lymphadenopathy (PGL) because of advanced HIV as there was no palpable cervical, axillary or inguinal lymphadenopathy (Figure 2).
case_images: Axial (a, b) and coronal (c, d) slices from T1 post-contrast enhanced MR brain 2 weeks following the initial imaging. No significant treatment response following 2 weeks of toxoplasmosis treatment with sulfadiazine/pyramethamine/folinic acid and adjunctive high-dose dexamethasone with persistent ring-enhancing lesions identified. There was marked peri-lesional vasogenic oedema and two new lesions were seen. A few of these lesions, for example, the lesion within the head of the left caudate nucleus demonstrated restricted diffusion on diffusion weighted imaging (not demonstrated), in keeping with increased cellularity. This finding is atypical of toxoplasmosis and thus raised the suspicion for alternative diagnoses over toxoplasma.
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case_images: Following 2 weeks of toxoplasmosis treatment, there was no improvement in the appearances of the intra-cranial lesions on repeat MR brain imaging, with two new lesions being identified (Figure 3).
case_images: Post-gadolinium contrast enhanced T1 axial slices from MR brain performed 2 months following the initial clinical presentation. The patient had been commenced on MATRix chemotherapy. Multiple peripherally enhancing parenchymal (b) and sub-ependymal lesions (a) are demonstrated with a significant improvement in the size of all lesions since the last examination. New high signal on T1 imaging (not demonstrated) may represent post-treatment interval haemorrhage.
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case_images: There has also been a marked improvement in cognitive function and gait following four cycles of MATRix chemotherapy (Figure 4).
case_images: Post-gadolinium contrast enhanced T1 axial slices from MR brain following four cycles of MATRix chemotherapy, which shows marked interval improvement in both the size of the ring-enhancing lesions (a) and the degree of peri-lesional oedema (b), in keeping with positive disease response.
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case_images: Repeat MRI imaging 6 months following initial presentation also demonstrates a reduction in volume of the supra and infra-tentorial parenchymal and sub-ependymal lesions, with improvement in the degree of peri-lesional vasogenic oedema, in keeping with a positive disease response (Figure 5).