CEREBRAL TOXOPLASMOSIS

Hana Handwiratna
2011730034
Pembimbing : dr. Susanto, Sp. S

PENDAHULUAN
Infeksi dengan Human Immunodeficiency Virus/Acquired Immunodeficiency
Syndrome (HIV/AIDS) merupakan masalah kesehatan di semua negara di
dunia, pada kedua gender, semua umur, budaya, dan tingkat sosioekonomi.
Penyakit neurologi pada pasien HIV/AIDS sangat luas, dan frekuensi komplikasi
neorologi meningkat selama perjalanan penyakit.
Toxoplasmosis adalah penyebab utama morbiditas dan mortalitas pada
pasien yang terinfeksi HIV, terutama di negara berkembang

TOXOPLASMOSIS
Toksoplasmosis merupakan penyakit yang disebabkan oleh parasit obligat
intraseluler jenis protozoa (Toxoplasma gondii) yang menginfeksi manusia
melalui oral ataupun transplasenta .

TACHYZOITES

TISSUE CYST

OOCYST

Oocysts with 4 sporozites

Sexual reproduction
merozoites

Asexual reproduction
Tachyzoites in intestinal ephitelial cells
Cats definitive host

Ingestion of tissue cysts with raw meat

Human intermediate hosts
Warm bloods animals
Tachyzoites in macrophages
Tissue cysts with bradyzoits in organs
Asexual reproduction

Tissue cysts with bradyzoits in organs

Asexual reproduction
Tachyzoites in macrophages

CEREBRAL TOXOPLASMOSIS
Cerebral toxoplasmosis merupakan penyakit infeksi
oportunistik yang biasa terjadi pada pasien dengan acquired
immunodeficiency syndrome (AIDS).
Disebabkan oleh parasit jenis protozoa obligat intraseluler yaitu
Toxoplasma gondii.
Cerebral toxoplasmosis didapatkan terutama pada pasien
dengan jumlah CD4+ <200 cells/L.

INSIDENSI
CT PADA HIV/AIDS

USA-UK
16-40%

Perancis
75-90%

Spanyol
60%

<20% negara
ASIA

Brazil
50-80%

RSCM 2004-2007
125 kasus dari 300
didiagnosis CT

PATOFISIOLOGI
Oro-fekal

Oosit-takizoit

Reflikasi cepat

Nukleated cell

Aktivasi CD4+

Takizoit dalam darah

Sel mati-tersebar ke
seluruh tubuh

Fakuol

CD154

Denritic sel &

makrofag

IL-12

Anti toxoplasmik

T cell- IFN
Makrofag dan non
fagosit

TANDA DAN GEJALA

Pemeriksaan fisik biasanya didapatkan :
Kesadaran : kebingungan (kontak tidak adekuat)
Somnolen
Koma
Perubahan status
62%
Demam
41%
SOmental
: hemianopsia,
parese N.
Cranial
Gangguan berbicara
Headaches 59%
Defisit
neurologis fokal
Motorik : hemiparesis,
ataxia
FL : perubahan mental status yang mendalam
Toxoplasmic mata : nyeri pada mata dan penurunan visus
Paru-paru :sesak nafas, demam, batuk non produktif

DIAGNOSA
Serologi : IgG antitoxsoplasma, IgM antitoxoplasma
Imaging : CT lesi hipodens, CT contrast ring-enhanching
T1 Weighted MRI : hipointens, T2 Weighted MRI : Hiperintens
Gadolinium-enhanched MRI : ring-enhanching with edema
Cerebrospinal Fluid : peningkatan protein, glukosa,
leukositosis dominan mononuklear
Pathologic evaluation : ditemukan takizoit atau kista pada
daerah inflamasi

DIFFERENTIAL DIAGNOSIS FOR RING-ENHANCHING

LESIONS IN HIV-INFECTED PATIENS

Acute toxoplasmosis

Primary central nervous system lymphoma

Primary brain tumors (glioblastoma)

Brain metastasis

Demyelinating disease (multiple sklerosis, vasculitis)

Infections (brain abcess, tuberculoma)

Multifocal infarcts

Inherited lesions (hemangioblastoma)

Arteriovenous malformation

TREATMENT
Preferred Theraphy and Duration

Alternative Regimens

Pyrimethamine (200 mg oral

loading dose, followed by 50-75
mg/day orraly), sulfadiazine (10001500 mg 4 kali perhari) dan
leucovorin (10-20 mg/hari) sampai
6 minggu

Pyrimethamine (200 mg oral loading dose, followed by 50-75

mg/hari oral) dan clindamycin (600 mg IV/ 4 kali sehari oral)
TMP (5mg/kgbb) dan SMX (25 mg/kgbb) IV / 2 kali sehari
Atovaquone (1500 mg oral 2 kali/hari) dan Pyrimethamine (5075 mg/hari) dan leucovorin (10-20 mg/hari)
Atovaquone (1500 mg oral 2 kali/hari) dan sulfadiazine (10001500 mg 4 kali/hari)
Atovaquone 1500 mg oral 2 kali/hari
Pirimetamine (50-75 mg/hari) leucovorin (10-20 mg/hari) dan
azytromicin (900-1200 mg/hari oral)
TMP (10mg/kgbb/hari) dan SMX (50mg/kg/hari. IV

Adapted from Benson CA, Kaplan JE, Masur H, et al. Treating opportunistic infection among HIV-infected adults and adolescents:
recomendetions from CDC, the Nationaal Institutes of Health, and the HIV Medicine Association/Infections Diseases Society of America.
Available at http://aidsinfo.nih.gov/contentfiles/TreatmentofOIAA.pdf.
TMP = trimethoprim, SMX = sulfametroxazole

PRIMARY AND SECONDARY PHARMACOLOGIC

PREVENTION
Primary : untuk pasien dengan CD4+ <100 cells/mm3 atau CD4+
<200 cells/mm3 dengan infeksi oportunistik / keganasan : TMP
SMX (160 mg TMP/ 800 mg SMX) tablet/hari
Secondary : tidak mendapatkan maintenance risiko relaps 50-80%.
Sulfadiazine (500-1000 mg oral 4 kali/hari), pyrimetamine 25-50
mg/hari oral, leucovorin (10-25 mg/hari oral)

NON PHARMACOLOGIC
Pasien harus di edukasi untuk cuci tangan
daging mentah, mencuci sayur dan buah,
langsung dengan feses kucing terutama,
kucing, terutama pasien dengan HIV jangan
dengan kucing.

setelah memegang
mengindari kontak
membersihkan box
berkontak langsung

PROGNOSIS
Malam : jika pasien tidak di diagnosis secara cepat dan
penanganan tidak tepat

DAFTAR PUSTAKA

Crescencio R, Perez V, Antonieta M, et al. 2013. Epidemiology and Trend of Neurological Disease Associated to HIV/AIDS. Experience of Mexican
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Chioccola P, Lucia V, Vidal, et al. 2009. Toxoplasma Gondii Infection and Cerebral Toxoplasmosis in HIV-Infected Patient . Future Microbiology 4.10
(Dec 2009): 1363-79

Jones JL, Hanson DL, Dworkin MS, et al. Toxoplasma gondii infection in the United States: Seroprepalence and Risk Factors . Am J Epidemiol
2001; 154:357-65

Antinori A, Larussa D, Cingolani A, et al.2004. Prevalence, Associated Factors, and Prognostic Determinants of AIDS-related Toxoplasmic
Enchepalitis in The Era of Advanced Highly Active Antiretroviral Theraphy. Clin Infect Dis 39: 1681-1691. doi: 10.1086/424877

Porter SB, Sande MA. Toxoplasmosis of The Central Nervous System in The Acquired Immunodeficiency Syndrome . N Engl J Med 1992;327: 16438

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Sacktor N, Lyles RH, Skolasky R, et al. Multicenter AIDS Cohort Study, HIV Associated Neurologic Disease Incidence Changes Multicenter AIDS
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Levy RM, Bredesen DE. Central Nervous System Dysfunction in Acquired Immunodeficiency Syndrome .

Porter, Steven B, Sande, Merle, et al. Toxoplasmosis of the Central Nervous System in the Acquired Immunodeficiency Syndrome. The New
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Sensini A. Toxoplasma gondii Infection in Pregnancy: Opportunities and pitfalls of serological diagnosis . Clin Microbiol Infect 2006; 12:504-12

Montoya JG. Laboratory diagnosis of Toxoplasma gondii Infection and Toxoplasmosis . J Infect Dis 2002;185 Suppl 1:S73-S82

Miguel J, Champalimaud JL, Borges A, et al. Cerebral Toxoplasmosis in AIDS Patient, CT and MRI Images and Differential Diagnostic Problem

Post MJ. Sheldon JJ, Hensley GT, et al. Central Nervous System Disease in AIDS: prospective correlation using CT, MRI, and Patologic Studies .
Radiology 1986; 158:141-8

Amogne, W., Teshager, G & Zeneb, G. 2006. CNS Toxoplasmosis in Adult Ethiophians. Ethiophians Medical Journal , Vol. 44, No. 2, pp.113-120.
ISSN 0014-1755

http://www.med.unc.edu/neurology/divisions/neuroAIDS/conferences-1/venice/IMRAN%20%20Cerebral%20Toxoplasmosis%20Jakarta%20for%20Ven
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Levy RM, Bredesen DE, Rosenblum ML. Neurological manifestation of the AIDS: experience at UCSF and review of literature . J neurosurg 62-47595

THANK YOU