LATE-ONSET CEREBRAL TOXOPLASMOSIS IN A POST-RENAL TRANSPLANT PATIENT: A CASE REPORT

Introduction:

Cerebral toxoplasmosis, a rare but often fatal condition in immunocompromised individuals such as solid organ transplant recipients, is caused by the parasite Toxoplasma gondii. This parasite is commonly found in cat feces and can be spread through contaminated food or organ transplants. Typically, cerebral toxoplasmosis presents with neurological symptoms within the first three months post-transplant; however, cases occurring beyond five years are uncommon. In such delayed cases, diagnosis and treatment can be challenging, often leading to poor outcomes.

Methods:

A 38-year-old Male, post-renal allograft recipient (2015), with chronic graft dysfunction (baseline creatinine: 1.8 mg/dL), presented with a 10-day history of dull headache and a 2-day history of fever, vomiting, and double vision. His symptoms were insidious and progressively worsened. Examination revealed left abducens nerve palsy. The patient was diagnosed with chronic kidney disease and hypertension in 2015. He underwent a live-related renal transplant from his father (ABO compatible) and received 225 mg of anti-thymocyte globulin (body weight: 80 kg). He was maintained on Tacrolimus, Mycophenolate sodium, and Prednisolone. Blood investigations were within normal limits. An MRI brain without contrast revealed a space-occupying lesion in the left frontal lobe. Neurosurgery was consulted and recommended an MRI brain with contrast, which revealed a rim-enhancing lesion and perilesional edema. The patient was initially treated with intravenous dexamethasone, anti-epileptics, antibiotics, antifungals, and IV fluids. Immunosuppression was minimized. The neurosurgery team performed a left frontal craniotomy and subtotal frontal lobectomy. The sample sent for histopathology examination revealed a necrotizing brain lesion with vasculitis secondary to parasitic infection, confirming Toxoplasma infection. The patient required mechanical ventilation.The patient was then treated with Sulfadoxine and Pyrimethamine as per protocol. He developed ventilator-associated pneumonia (Klebsiella pneumoniae). He eventually improved, was extubated, and stabilized with high-flow nasal cannula and face mask oxygen. A follow-up CT scan showed resolution of the mass lesion, and he was discharged with ongoing treatments and advised follow-up.

Results:

Although the patient was improving of Toxoplasmosis, he developed sepsis and multi-organ failure from a lower respiratory tract infection, leading to his readmission at his native place. Despite treatment according to sepsis guidelines, he ultimately succumbed to sepsis on June 19, 2024.

Conclusions:

This case underscores the fact that cerebral toxoplasmosis should be considered among primary diagnoses even if the patient presents late after a solid organ transplant. Effective outcomes rely on early consideration, prompt diagnosis, and aggressive treatment, supported by a multidisciplinary approach and tailored immunosuppressive and sepsis management strategies.

I have no potential conflict of interest to disclose.

I did not use generative AI and AI-assisted technologies in the writing process.