Toxoplasma gondii Encephalitis
Toxoplasma gondii Encephalitis
Primary Prophylaxis
Start: if CD4 count < 200 cells/μL, or CD4 percentage < 14%, oral thrush, or relevant concomitant immunosuppression, see Primary prophylaxis of OIs
Stop: if CD4 count > 100 cells/μL and HIV-VL undetectable over 3 months
Drug / Dose | Comments | |
---|---|---|
Preferred prophylaxis | TMP-SMX 400/80 mg qd po or 800/160 mg qd po or 800/160 mg x 3/week po |
All regimens are also effective against PcP |
Alternative prophylaxis | atovaquone suspension 1500 mg qd po (with food) |
|
dapsone 200 mg/week po + pyrimethamine 75 mg/week po + folinic acid 25-30 mg/week po |
Check for G6PD-deficiency | |
atovaquone suspension 1500 mg qd po (with food) + pyrimethamine 75 mg/week po + folinic acid 25-30 mg/week po |
Treatment
Treat 6 weeks, then secondary prophylaxis until CD4 count > 200 cells/μL and HIV-VL undetectable over 6 months
Diagnosis:
- Definitive diagnosis: clinical symptoms, typical radiology of the cerebrum AND cytological / histological detection of organism in tissue
- Presumptive diagnosis: clinical symptoms, typical radiology AND response to empirical treatment. This is the standard in most clinical settings
Drug / Dose | Comments | |
---|---|---|
Preferred therapy |
pyrimethamine + sulfadiazine + folinic acid |
Monitor for myelotoxicity of pyrimethamine, mostly neutropenia Sulfadiazine is associated with crystalluria and may lead to renal failure and urolithiasis. Good hydration is essential. Check renal function and urine sediment for microhematuria and crystalluria |
Alternative therapy |
pyrimethamine + clindamycin + folinic acid |
Monitor for myelotoxicity of pyrimethamine, mostly neutropenia Additional PcP prophylaxis is necessary |
OR TMP-SMX 5 mg TMP/kg bid iv/po, 25 mg SMX/kg bid iv/po |
Preferred intravenous regimen if oral route not possible | |
OR pyrimethamine + atovaquone + folinic acid |
Monitor for myelotoxicity of pyrimethamine, mostly neutropenia | |
OR sulfadiazine + atovaquone |
Sulfadiazine is associated with crystalluria and may lead to renal failure and urolithiasis. Good hydration is essential. Check renal function and urine sediment for microhematuria and crystalluria |
|
OR pyrimethamine + azitromycin + folinic acid |
Monitor for myelotoxicity of pyrimethamine, mostly neutropenia |
Secondary Prophylaxis, Maintenance Therapy
Stop: if CD4 count > 200 cells/μL and HIV-VL undetectable over 6 months
Regimens listed are alternatives
Drug / Dose | Comments |
---|---|
sulfadiazine 2000-3000 mg bid - qid po + pyrimethamine 25-50 mg qd po + folinic acid 10-15 mg qd po |
|
OR clindamycin 600 mg tid po + pyrimethamine 25-50 mg qd po + folinic acid 10-15 mg qd po |
Additional PCP prophylaxis is necessary |
OR atovaquone suspension 750-1500 mg bid po (with food) + pyrimethamine 25-50 mg qd po + folinic acid 10-15 mg qd po |
|
OR atovaquone suspension 750-1500 mg bid po (with food) |
|
OR TMP-SMX 800/160 mg bid po |