Toxoplasmosis differential diagnosis: Difference between revisions

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{{Toxoplasmosis}}
[[Image:Home_logo1.png|right|250px|link=https://www.wikidoc.org/index.php/Toxoplasmosis]]
{{CMG}} ; {{AE}} {{ADG}}
{{CMG}} ; {{AE}} {{ADG}}
==Overview==
==Overview==
Toxoplasmosis manifests as a painless [[lymphadenopathy]] in an [[immunocompetent]] individual.  In patients with [[HIV AIDS|AIDS]] and other [[immunocompromised]] conditions, it mainly involves [[brain]] and presents with [[fever]] and focal neurological symptoms. The major differential diagnosis of focal CNS lesions in patients with [[AIDS]] is CNS [[lymphoma]], which manifests as multiple enhancing lesions in 40% of cases. Other differentials in the diagnosis of [[toxoplasmosis]] include [[brain abscess]], [[Cytomegalovirus infection|cytomegalovirus]], [[herpes simplex]], [[histoplasmosis]], [[infectious mononucleosis]], [[listeria monocytogenes infection]] (Listeriosis), [[lymphoblastic lymphoma]], metastatic cancer with unknown primary site.<ref name="pmid27383150">{{cite journal |vauthors=Ellis R, Letendre SL |title=Update and New Directions in Therapeutics for Neurological Complications of HIV Infections |journal=Neurotherapeutics |volume=13 |issue=3 |pages=471–6 |year=2016 |pmid=27383150 |doi=10.1007/s13311-016-0454-2 |url=}}</ref><ref name="pmid23221843">{{cite journal |vauthors=Kranick SM, Nath A |title=Neurologic complications of HIV-1 infection and its treatment in the era of antiretroviral therapy |journal=Continuum (Minneap Minn) |volume=18 |issue=6 Infectious Disease |pages=1319–37 |year=2012 |pmid=23221843 |pmc=3760534 |doi=10.1212/01.CON.0000423849.24900.ec |url=}}</ref><ref name="pmid26171483">{{cite journal |vauthors=Evzelman MA, Snimschikova IA, Koroleva LY, Kamchatnov PR |title=[Neurological disorders associated with HIV-infection] |language=Russian |journal=Zh Nevrol Psikhiatr Im S S Korsakova |volume=115 |issue=3 |pages=89–93 |year=2015 |pmid=26171483 |doi= |url=}}</ref>
==Differential Diagnosis==
==Differential Diagnosis==
[[Toxoplasmosis]] manifests as a painless [[lymphadenopathy]] in an [[immunocompetent]] individual. In patients with [[HIV AIDS|AIDS]] and other [[immunocompromised]] conditions, it mainly involves [[brain]] and presents with [[fever]] and focal neurological symptoms. The major differential diagnosis of focal CNS lesions in patients with [[AIDS]] is CNS [[lymphoma]], which manifests as multiple enhancing lesions in 40% of cases. Other differentials in the diagnosis of toxoplasmosis include [[brain abscess]], [[Cytomegalovirus infection|cytomegalovirus]], [[herpes simplex]], [[histoplasmosis]], [[infectious mononucleosis]], [[listeria monocytogenes infection]] (Listeriosis), [[lymphoblastic lymphoma]], metastatic cancer with unknown primary site.<ref name="pmid27383150">{{cite journal |vauthors=Ellis R, Letendre SL |title=Update and New Directions in Therapeutics for Neurological Complications of HIV Infections |journal=Neurotherapeutics |volume=13 |issue=3 |pages=471–6 |year=2016 |pmid=27383150 |doi=10.1007/s13311-016-0454-2 |url=}}</ref><ref name="pmid23221843">{{cite journal |vauthors=Kranick SM, Nath A |title=Neurologic complications of HIV-1 infection and its treatment in the era of antiretroviral therapy |journal=Continuum (Minneap Minn) |volume=18 |issue=6 Infectious Disease |pages=1319–37 |year=2012 |pmid=23221843 |pmc=3760534 |doi=10.1212/01.CON.0000423849.24900.ec |url=}}</ref><ref name="pmid26171483">{{cite journal |vauthors=Evzelman MA, Snimschikova IA, Koroleva LY, Kamchatnov PR |title=[Neurological disorders associated with HIV-infection] |language=Russian |journal=Zh Nevrol Psikhiatr Im S S Korsakova |volume=115 |issue=3 |pages=89–93 |year=2015 |pmid=26171483 |doi= |url=}}</ref>
{| class="wikitable"
{| class="wikitable"
!Disease
!Disease
!Differentiating signs and symptoms
!Differentiating signs and symptoms
!Differentiating tests
!Differentiating tests
!
|-
|-
|CNS lymphoma
|[[Lymphoma|CNS lymphoma]]
|
|
|
* [[Immunocompetent]] individual
* Focal symptoms indicative of a mass lesion
* [[Seizure]]
|
|
*Single solitary ring enhacning lesion on CT or MRI
|-
|-
|Metastatic brain tumor
|Disseminated tuberculosis
|
|
|
* Prior history of residence in an endemic area.
* Chronic [[cough]], [[weight loss]], [[hemoptysis]]
|
|
* [[PCR]] of [[CSF]] for [[tuberculosis]]
* Mycobacterial culture of CSF
* Brain biopsy for [[acid-fast bacilli]] staining
* Culture and acid stain positive for [[acid-fast bacilli]]
* CXR shows cavitations.
|-
|-
|Mycobacterial CNS
|[[Aspergillosis]]
|
|
|
* Pulmonary lesions in addition to CNS lesions.
* Symptoms may include [[cough]], [[chest pain]], and [[hemoptysis]].
|
|
*CSF fungal culture, galactomannan.
|-
|-
|Aspergillosis
|[[Cryptococcosis]]
|
|
|
*Symptoms include [[cough]], [[chest pain]], and [[hemoptysis]]
|
|
*[[Cryptococcal antigen]] from [[CSF]] and serum
*CSF fungal culture
|-
|-
|Cryptococcosis
|[[Chagas disease]]
|
|
|
*History of residence in Central and South America
*Acute infection is rarely symptomatic,
*[[Encephalitis]] or focal brain lesions
*[[Myocarditis]]
*Chronic infections in [[immunocompromised]] patients develops into [[encephalitis]] with necrotic brain lesions causing mass effect.
|
|
*Trypanosoma cruzi in blood, tissue or CSF, PCR of tissue or body fluids, serologic tests.
|-
|-
|Chaga's disease
|[[Cytomegalovirus infection|CMV infection]]
|
|
|
*Most common CNS opportunistic infection in AIDS patients
*Presents with [[encephalitis]], [[retinitis]], progressive [[myelitis]] or [[polyradiculitis]].
*In disseminated disease, it involves both [[liver]] and [[renal organs]].
|
|
*Brain CT/MRI/biopsy: location of lesions are usually near the [[brain stem]] or [[periventricular]] areas.
*[[PCR]] of CSF with detectable virus is diagnostic.
*Brain biopsy with + staining for [[CMV]] or evidence of owl's eyes is also diagnostic, but it is rarely performed, because of the location of brain lesions.
|-
|-
|CMV infection
|[[HSV|HSV infection]]
|
|
|
*[[Seizures]], [[headache]], [[confusion]] and/or [[urinary retention]] can be seen in disseminated disease, which usually affects only [[immunocompromised]] or acute infections
*In pregnant women it may be associated with concurrent genital/oral lesions; can be spread to the neonate during acute infection in the mother, or via viral shedding in the birth canal.
*Neonatal HSV can range from localized skin infections to encephalitis, pneumonitis, and disseminated disease.
|
|
*Brain CT/MRI/biopsy: location of lesions is usually the medial [[temporal lobe]] or the orbital surface of the [[frontal lobe]].
*[[PCR]] of [[CSF]] with detectable virus is diagnostic.
|-
|-
|HSV infection
|Varicella Zoster infection
|
|
|
*Multifocal involvement has subacute course, usually only in immunosuppressed, with headache, fever, focal deficits, and seizures.
*Unifocal involvement is more typically seen in immunocompetent hosts, occurring after contralateral cranial nerve herpes zoster, with mental status changes, TIAs, and stroke.
*Disseminated [[varicella zoster virus]] can occur in adults during primary infection, presenting with [[pneumonitis]] and/or [[hepatitis]].
*Disease is a [[vasculopathy]], with [[hemorrhage]] and [[stroke]].
|
|
*[[PCR]] of [[CSF]] with detectable virus is diagnostic.
|-
|-
|VZ infection
|[[Brain abscess]]
|
|
|
*Associated with [[sinusitis]] (abutting the sinuses) or with [[bacteremia]].
*Signs and symptoms includes [[fever]] and necrotizing brain lesions with mass effect
|
|
*CSF culture or culture of brain abscess.
|-
|-
|Bacterial abscess
|[[Progressive multifocal leukoencephalopathy]]
|
|
|
|-
|Progressive multifocal leukoencephalopathy
|
|
|
|-
|Cat Scratch Disease 
|
|
|
*Symptoms are often more insidious in onset and progress over months. Symptoms include progressive weakness, poor coordination, with gradual slowing of mental function. Only seen in the immunosuppressed. Rarely associated with fever or other systemic symptoms.
|
|
*PCR of CSF for JC virus.
*Biopsy reveals white matter lesions and not well-circumscribed lesions.
|}
|}


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Latest revision as of 00:27, 30 July 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2]

Overview

Toxoplasmosis manifests as a painless lymphadenopathy in an immunocompetent individual. In patients with AIDS and other immunocompromised conditions, it mainly involves brain and presents with fever and focal neurological symptoms. The major differential diagnosis of focal CNS lesions in patients with AIDS is CNS lymphoma, which manifests as multiple enhancing lesions in 40% of cases. Other differentials in the diagnosis of toxoplasmosis include brain abscess, cytomegalovirus, herpes simplex, histoplasmosis, infectious mononucleosis, listeria monocytogenes infection (Listeriosis), lymphoblastic lymphoma, metastatic cancer with unknown primary site.[1][2][3]

Differential Diagnosis

Toxoplasmosis manifests as a painless lymphadenopathy in an immunocompetent individual. In patients with AIDS and other immunocompromised conditions, it mainly involves brain and presents with fever and focal neurological symptoms. The major differential diagnosis of focal CNS lesions in patients with AIDS is CNS lymphoma, which manifests as multiple enhancing lesions in 40% of cases. Other differentials in the diagnosis of toxoplasmosis include brain abscess, cytomegalovirus, herpes simplex, histoplasmosis, infectious mononucleosis, listeria monocytogenes infection (Listeriosis), lymphoblastic lymphoma, metastatic cancer with unknown primary site.[1][2][3]

Disease Differentiating signs and symptoms Differentiating tests
CNS lymphoma
  • Single solitary ring enhacning lesion on CT or MRI
Disseminated tuberculosis
Aspergillosis
  • CSF fungal culture, galactomannan.
Cryptococcosis
Chagas disease
  • History of residence in Central and South America
  • Acute infection is rarely symptomatic,
  • Encephalitis or focal brain lesions
  • Myocarditis
  • Chronic infections in immunocompromised patients develops into encephalitis with necrotic brain lesions causing mass effect.
  • Trypanosoma cruzi in blood, tissue or CSF, PCR of tissue or body fluids, serologic tests.
CMV infection
  • Brain CT/MRI/biopsy: location of lesions are usually near the brain stem or periventricular areas.
  • PCR of CSF with detectable virus is diagnostic.
  • Brain biopsy with + staining for CMV or evidence of owl's eyes is also diagnostic, but it is rarely performed, because of the location of brain lesions.
HSV infection
  • Seizures, headache, confusion and/or urinary retention can be seen in disseminated disease, which usually affects only immunocompromised or acute infections
  • In pregnant women it may be associated with concurrent genital/oral lesions; can be spread to the neonate during acute infection in the mother, or via viral shedding in the birth canal.
  • Neonatal HSV can range from localized skin infections to encephalitis, pneumonitis, and disseminated disease.
  • Brain CT/MRI/biopsy: location of lesions is usually the medial temporal lobe or the orbital surface of the frontal lobe.
  • PCR of CSF with detectable virus is diagnostic.
Varicella Zoster infection
  • Multifocal involvement has subacute course, usually only in immunosuppressed, with headache, fever, focal deficits, and seizures.
  • Unifocal involvement is more typically seen in immunocompetent hosts, occurring after contralateral cranial nerve herpes zoster, with mental status changes, TIAs, and stroke.
  • Disseminated varicella zoster virus can occur in adults during primary infection, presenting with pneumonitis and/or hepatitis.
  • Disease is a vasculopathy, with hemorrhage and stroke.
  • PCR of CSF with detectable virus is diagnostic.
Brain abscess
  • Associated with sinusitis (abutting the sinuses) or with bacteremia.
  • Signs and symptoms includes fever and necrotizing brain lesions with mass effect
  • CSF culture or culture of brain abscess.
Progressive multifocal leukoencephalopathy
  • Symptoms are often more insidious in onset and progress over months. Symptoms include progressive weakness, poor coordination, with gradual slowing of mental function. Only seen in the immunosuppressed. Rarely associated with fever or other systemic symptoms.
  • PCR of CSF for JC virus.
  • Biopsy reveals white matter lesions and not well-circumscribed lesions.

References

  1. ↑ 1.0 1.1 Ellis R, Letendre SL (2016). "Update and New Directions in Therapeutics for Neurological Complications of HIV Infections". Neurotherapeutics. 13 (3): 471–6. doi:10.1007/s13311-016-0454-2. PMID 27383150.
  2. ↑ 2.0 2.1 Kranick SM, Nath A (2012). "Neurologic complications of HIV-1 infection and its treatment in the era of antiretroviral therapy". Continuum (Minneap Minn). 18 (6 Infectious Disease): 1319–37. doi:10.1212/01.CON.0000423849.24900.ec. PMC 3760534. PMID 23221843.
  3. ↑ 3.0 3.1 Evzelman MA, Snimschikova IA, Koroleva LY, Kamchatnov PR (2015). "[Neurological disorders associated with HIV-infection]". Zh Nevrol Psikhiatr Im S S Korsakova (in Russian). 115 (3): 89–93. PMID 26171483.


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