19-§2-Asymmetrical neurological signs +/- Headache
means that muscle strength, deep tendon reflexes, Babinski reflex, sensation,
pupils (...) is different for each side of the body. (E.g.: paraplegia
is "symmetrical" but hemiplegia is "asymmetrical")
TOXOPLASMOSIS? Common!!! (Normally asymmetrical BUT 20% of patients
are symmetrical! That means possible confusion with crypto, HIV Dementia...
See "19-§1-Symmetrical neuro")
- Diagnosis: Basically, toxo
is like one (or several) tumor(s) in the brain -- the symptoms depend
on the position of the tumors. Paresis/paralysis; alertness
can be reduced ("slow brain"); the pronunciation of words
can be strange; aphasia can be the only sign; +/- confusion; +/-
headache; +/-convulsions; +/-fever...
- Similar diseases: easy confusion with cerebral TB (common,
but will also have TB signs) or Lymphoma (less common) or PML, stroke
etc. (less common-see below).
- A "Toxo test" is the first thing to do (for a
minimum of 5 days!!!): pyrimethamine 25mg 1tab 2x/day (first day 1tab
4x/day) + sulfadiazine 500mg 2-3tabs
4x/day. If patient is allergic to sulfa give pyrimethamine 25mg 1tab 2x/day + one of the following drugs: clindamycin 150mg 3-4tabs 4x/day or doxycycline 100mg 1tab 2x/day (only if clinda
is not available because it is still not well established that doxy+pyri
is active enough...).
- If neuro signs improve (stop all pain killers on fifth day to
observe the level of pain compared to pre-treatment levels) we should
continue the treatment for at least 6 weeks (or forever if possible).
- Consider that only "pyrimethadine+sulfa" acts very quickly.
For allergic patients, 5 days are not enough for a "toxo test".
- Consider that toxo is an acute disease that will kill your patient
before TB... If the patient is unable to take toxo+TB treatment
(can be more than 20 pills!), consider stopping TB treatment during
the cure of acute toxo symptoms with the stronger toxo treatment
(pyrimethadine+sulfa). When toxo is under control, give TB
treatment + "light" toxo treatment (doxy+pyrimethadine)...
Common!!! (But 80% of cerebral
TB is symmetrical!) See "19-§1-Symmetrical Neuro"
- Diagnosis: "chronic";
characteristic TB signs of cycles of fever, loss of weight, skin
color... sometimes confusion, +/-convulsions, often patients have
a stiff neck...
- See "31-Tuberculosis"
PML (PROGRESSIVE MULTIFOCAL LEUKOENCEPHALOPATHY)?
- Diagnosis: Multiple "anatomically disconnect"
focal signs... Ataxia, hemiparesis, visual field defects,
aphasia, sensory defects... Dementia and other problems with
cognition are possible as well...Majority of patients will die within
3 to 6 months... but some "resist" more than one year
(some patients start disease with CD4>500!!!)
- No treatment in a poor hospice
- Diagnosis: CNS is involved in approximately one-third of
all patients with lymphoma. Lymphoma is a cancer. Basically,
the neuro symptoms depend on the position of the tumor(s) in brain
(like toxo). Usually we only dare to make this diagnosis when
we observe that TOXO and TB treatments are not effective...
In addition, lymphoma may involve the gastrointestinal tract, bone
marrow, liver, and lung. Any site in the gastrointestinal
tract may be involved, and patients may complain of difficulty swallowing
or abdominal pain.
- No treatment is available/affordable in a poor hospice.
- Think about stroke/hematoma if, in contrast to the other causes
of focal neurological deficits, the symptoms are of sudden onset.
(Paralysis occurs within a few minutes or few hours). HIV
infection increases the risk of stroke and increases the risk of
accidents (falling, slipping, etc) that may cause cerebral hematomas
(accidents are more likely because of weakness, hemostatic problems,
etc.). Among the infectious that may be associated with stroke
are vasculitis due to cerebral varicella zoster or neurosyphilis
and septic embolism in association with fungal infection... and
injectable drugs (dermato (pxx 265...)
or lungs symptoms can be associated).
- Can also be Neuro Syphilis, HIV dementia
- If no recent history of a toxo test or toxo treatment, nocardiosis
is possible (but rare). Treat with Bactrim