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Key Features

  • AIDS patients may present with primary cerebral lymphoma, cerebral toxoplasmosis, or cryptococcal meningitis

  • Progressive multifocal leukoencephalopathy (PML) or cytomegalovirus meningoencephalitis can occasionally have similar clinical presentations and overlapping MRI findings

Clinical Findings

  • Disturbances in cognition or consciousness

  • Focal motor, sensory, or other neurologic deficits

  • Aphasia

  • Seizures

  • Cranial neuropathies

Diagnosis

  • Neither CT nor MRI findings distinguish primary cerebral lymphoma from toxoplasmosis

  • Serologic tests for toxoplasmosis are unreliable in AIDS patients; therefore, response to empiric treatment helps in diagnosis

  • Although the finding of Epstein-Barr virus DNA in the spinal fluid by polymerase chain reaction suggests lymphoma, it is not specific enough to initiate treatment

  • If lesion does not improve after empiric therapy, cerebral biopsy is necessary

  • CT scans are usually normal in cryptococcal meningitis

Treatment

  • Primary cerebral lymphoma is treated with corticosteroids, high-dose methotrexate, and antiretroviral therapy

  • Rituximab may be used in some patients

  • Whole-brain irradiation may not be necessary

  • For neurologically stable patients with possible toxoplasmosis

    • Pyrimethamine and sulfadiazine are recommended for 3 weeks (Table 31–3)

    • If lesion improves, the regimen is continued indefinitely

Table 31–3.Treatment of AIDS-related opportunistic infections and malignancies.1

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