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Previous Volume 329:995-1000 September 30, 1993 Number 14 Next

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ABSTRACT

Background In patients with the acquired immunodeficiency syndrome (AIDS), toxoplasmic encephalitis is usually a presumptive diagnosis based on the clinical manifestations, a positive antitoxoplasma-antibody titer, and characteristic neuroradiologic abnormalities. A response to specific therapy helps to confirm the diagnosis, but it is unclear how rapid the response should be. We studied the course of patients treated for acute toxoplasmic encephalitis and evaluated objective clinical criteria for this empirical diagnosis.

Methods A quantifiable neurologic assessment was used prospectively to evaluate the clinical outcome of patients with AIDS and toxoplasmic encephalitis who were treated with oral clindamycin (600 mg four times a day) and pyrimethamine (75 mg every day) for six weeks.

Results Thirty-five of 49 patients (71 percent) responded to therapy, and 30 of these (86 percent) had improvement by day 7. Thirty-two of those with a response (91 percent) improved with respect to at least half of their base-line abnormalities by day 14. Improvement in neurologic abnormalities within 7 to 14 days after the start of therapy was strongly associated with the neurologic response at 6 weeks. The four patients in whom treatment failed and the two patients with lymphoma had progressing neurologic abnormalities or new abnormalities during the first 12 days of therapy. Nonlocalizing abnormalities (headache and seizure) improved regardless of the clinical outcome.

Conclusions Oral clindamycin and pyrimethamine are an effective treatment for toxoplasmic encephalitis. Patients who have early neurologic deterioration despite treatment or who do not improve neurologically after 10 to 14 days of appropriate antitoxoplasma therapy should be considered candidates for brain biopsy.

Source Information

From the State University of New York at Stony Brook (B.J.L., E.M.B., J.F.); the Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda, Md. (R.H.); Harvard School of Public Health, Boston (A.H.K., D.D.B.); Groupe Hospitalier Bichat-Claude Bernard, Paris (C.L., J.-L.V.); Los Angeles County-University of Southern California Medical Center, Los Angeles (D.A.); University of Miami, Miami (R.U.); Mount Sinai Medical Center, New York (J.J.); Hopital Pellegrin, Bordeaux, France (P.M.); and the Palo Alto Medical Foundation, Palo Alto, Calif. (J.S.R.) The contributing members of the Agence Nationale de Recherches sur le SIDA (ANRS) of the Institut National de la Sante et de la Recherche Medicale, the AIDS Clinical Trials Group (ACTG) of the National Institute of Allergy and Infectious Diseases, and the independent investigators are listed in the Appendix.

Address reprint requests to Dr. Luft at the Division of Infectious Diseases, State University of New York at Stony Brook, Stony Brook, NY 11794.

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