Successful Treatment of Cerebral

Toxoplasmosis with Clindamycin: A Case Report

Deepak Madi1, Basavaprabhu Achappa1, Satish Rao1,
John T. Ramapuram1, Soundarya Mahalingam2
1

Department of Internal Medicine, Kasturba Medical College, Mangalore, India

2Department of Pediatrics, Kasturba Medical College, Mangalore, India

KNEDRICK KEVIN C. MACALMA

DOCTOR OF MEDICINE II

OBJECTIVES
O To correlate the Natural History of

Toxoplasmosis
to
an
actual
medical case
O To
be
able
to
apply
the
importance of understanding the
disease process, its occurrence
and the disease progression
O To be able to discuss briefly the
mechanism
of
action
of
Clindamycin in the treatment of
Toxoplasmosis

OUTLINE
O ABSTRACT
O INTRODUCTION
O THE CASE
History
Diagnostics
Laboratory Findings
Treatment
O DISCUSSION
Toxoplasmosis
Immunology
Clindamycin as a treatment for

Toxoplasmosis

ABSTRACT

A 30-year-old male known case of retroviral disease

presented to Kasturba Medical College, India, with
complaints of fever, headache and vomiting. Computed
tomography scan of his brain showed irregular ring
enhancing lesion in the right basal ganglia. Toxoplasma
serology revealed raised IgG antibody levels. Based on the
CT features and serology, diagnosis of cerebral
toxoplasmosis was made. He was treated with clindamycin
alone as he had history of sulfonamide allergy. The patient
was symptomatically better after 48 hours. After 21 days,
repeat CT of brain was done which was normal. The
patient showed good clinical improvement within 48 hours
and the lesion resolved completely within 3 weeks. The
authors
recommend
using
clindamycin
without
pyrimethamine in resource poor settings and in patients
who do not tolerate sulfa drugs.

Introduction
O Toxoplasmosis is a zoonotic disease caused by the
O

O
O

obligate intracellular protozoa Toxoplasma gondii

Toxoplasmosis is one of the most common causes
of focal brain lesions in patients with acquired
immune deficiency syndrome
Primary routes of oral transmission: Consumption
of raw or undercooked meat containing viable
cysts, water contaminated with oocysts from cat
feces, and unwashed vegetables
Definitive hosts: Felid family
Intermediate hosts: Humans, birds, rodents, sheep
and cattle

THE CASE

The Case
A 30-year-old male presented to
Kasturba Medical College, India,
with complaints of fever, headache
and vomiting of 7 days duration.
He was diagnosed with retroviral
disease one month back and was
on antiretroviral drugs (stavudine,
lamivudine, nevirapine).

Upon more thorough investigation,

the
patient
indicated
that
approximately one month ago he
ate raw kibbe, a dish that consists
of spiced uncooked beef or lamb
with grains.
On examination, he was febrile
and drowsy. There was no focal
neurological deficit.

Laboratory investigations showed:

ANALYTE

RESULTS

NORMAL
VALUES

Hb

8.8 g/dL

13.5 17.5 g/dL

Total WBC

2.2109/L

4-11109/L

ANC

0.8109/L

2.07.0109/L

Platelet count

353109/L

150-400109/L

ESR

28 mm/1st hour

<15 mm/hr

CD4+ count

38 cells/l

400-1600
cells/l

HIV-1 Test

Reactive

Toxoplasma IgG
antibody

326 IU/mL

Laboratory investigations showed:

Peripheral smear : dimorphic anemia
with leukopenia
Normal Serum electrolytes
Normal blood sugar
Normal renal and liver function tests
Normal Chest X-ray and ultrasound of
the abdomen
DIAGNOSIS: CEREBRAL TOXOPLASMOSIS

Figure 1: Computed tomography scan of the brain showed an

irregular ring enhancing lesion in the right basal ganglia with
surrounding marked white matter edema and mass effect

Treatment
O IV mannitol
O Clindamycin (600 mg 3x daily)
O Anticonvulsants
O Antiretroviral drugs were continued

O After 21 days, repeat CT of brain was

done which was normal. The patient

was discharged from hospital in an
ambulatory state. He was advised to
continue antiretroviral drugs and
anticonvulsants.
Trimethoprimsulfamethoxazole
was
started
(prophylactic dose) after following a
sulfa desensitization protocol. He has
been asymptomatic for the past 9
months.

Figure 2: CT scan after 21 days of treatment.

DISCUSSION

Toxoplasmosis
O Zoonotic

disease caused by the

obligate
intracellular
protozoa
Toxoplasma gondii
O Infection in humans usually occurs
via the oral or transplacental route.
O Primary routes of oral transmission:
Consumption of raw or undercooked
meat containing viable cysts, water
contaminated with oocysts from cat
feces, and unwashed vegetables

O Definitive hosts: Felid family

O Intermediate hosts: Humans, birds,

rodents, sheep and cattle

O Infected cats spread disease when
oocytes pass in their feces.

immunocompromised

OOCYST
S

TACHYZOITES Rapid replication

Penetrate nucleated cells
and form vacuoles
Spread throughout the
body
Infect other tissue
Cause inflammatory
response

BRADYZOITES replicate more slowly

CYSTS

retained in the:
Brain
Heart
skeletal muscle

OOCYSTS TACHYZOITES
CYSTS

BADYZOITES

CD4+ T
CELLS
CD 154
DENDRITIC CELLS

MACROPHAGES
IL-12
IFN-

MACROPHAGES
OTHER NONPHAGOCYTIC CELLS

ANTITOXOPLASMIC RESPONSE

OOCYSTS TACHYZOITES
CYSTS

BADYZOITES

ED
R
I
A
IMP CD4+ T
CELLS

CD 154
DENDRITIC CELLS

MACROPHAGES
IL-12
IFN-

MACROPHAGES
OTHER NONPHAGOCYTIC CELLS

ANTITOXOPLASMIC RESPONSE

CLINDAMYCIN FOR
TOXOPLASMOSIS?
A coincidence? A new wonder
drug?

Effect of Clindamycin in Toxoplasmosis

MICHAEL G. DAVIDSON, MICHAEL R. LAPPIN, JIM R. ROTTMAN, MARY B. TOMPKINS, ROBERT V. ENGLISH, ANDREW T.
BRUCE, AND JUDITH JAYAWICKRAMA1

O Antiprotozoal drug that Inhibits

protein synthesis and replication

O Further study is to be done