("Asymmetrical" means that muscle strength, deep tendon reflexes, Babinski reflex, sensation, pupils (...) is different for each side of the body.  (E.g.: paraplegia is "symmetrical" but hemiplegia is "asymmetrical")  (nxx001) (nxx003) (nxx005) (nxx006)

TOXOPLASMOSIS? 

• Diagnosis: Basically, toxo is like one (or several) tumor(s) in the brain -- the symptoms depend on the position of the tumors.  Paresis/paralysis; alertness can be reduced ("slow brain"); the pronunciation of words can be strange; aphasia can be the only sign; +/- confusion; +/- headache; +/-convulsions; +/-fever...
• Similar diseases: easy confusion with cerebral TB (common, but will also have TB signs) or Lymphoma (less common) or PML, stroke etc. (less common-see below).
• A "Toxo test" is the first thing to do (for a minimum of 5 days!!!): pyrimethamine 25mg 1tab 2x/day (first day 1tab 4x/day) + sulfadiazine 500mg 2-3tabs 4x/day.  If patient is allergic to sulfa give pyrimethamine 25mg 1tab 2x/day + one of the following drugs: clindamycin 150mg 3-4tabs 4x/day or doxycycline 100mg 1tab 2x/day (only if clinda is not available because it is still not well established that doxy+pyri is active enough...).
• If neuro signs improve (stop all pain killers on fifth day to observe the level of pain compared to pre-treatment levels) we should continue the treatment for at least 6 weeks (or forever if possible).
• Consider that only "pyrimethadine+sulfa" acts very quickly.  For allergic patients, 5 days are not enough for a "toxo test".
• Consider that toxo is an acute disease that will kill your patient before TB... If the patient is unable to take toxo+TB treatment (can be more than 20 pills!), consider stopping TB treatment during the cure of acute toxo symptoms with the stronger toxo treatment (pyrimethadine+sulfa).  When toxo is under control, give TB treatment + "light" toxo treatment (doxy+pyrimethadine)...

CEREBRAL TB?

Common!!! (But 80% of cerebral TB is symmetrical!)  See "19-§1-Symmetrical Neuro"

• Diagnosis: "chronic"; characteristic TB signs of cycles of fever, loss of weight, skin color... sometimes confusion, +/-convulsions, often patients have a stiff neck...
• See "31-Tuberculosis"

PML (PROGRESSIVE MULTIFOCAL LEUKOENCEPHALOPATHY)?

Not common...

• Diagnosis: Multiple "anatomically disconnect" focal signs...  Ataxia, hemiparesis, visual field defects, aphasia, sensory defects...  Dementia and other problems with cognition are possible as well...Majority of patients will die within 3 to 6 months... but some "resist" more than one year (some patients start disease with CD4>500!!!)
• No treatment in a poor hospice

 

LYMPHOMA?

Not common...

• Diagnosis: CNS is involved in approximately one-third of all patients with lymphoma.  Lymphoma is a cancer.  Basically, the neuro symptoms depend on the position of the tumor(s) in brain (like toxo).  Usually we only dare to make this diagnosis when we observe that TOXO and TB treatments are not effective...  In addition, lymphoma may involve the gastrointestinal tract, bone marrow, liver, and lung.  Any site in the gastrointestinal tract may be involved, and patients may complain of difficulty swallowing or abdominal pain.
• No treatment is available/affordable in a poor hospice.

STROKE/HEMATOMA?

• Think about stroke/hematoma if, in contrast to the other causes of focal neurological deficits, the symptoms are of sudden onset.  (Paralysis occurs within a few minutes or few hours).  HIV infection increases the risk of stroke and increases the risk of accidents (falling, slipping, etc) that may cause cerebral hematomas (accidents are more likely because of weakness, hemostatic problems, etc.).  Among the infectious that may be associated with stroke are vasculitis due to cerebral varicella zoster or neurosyphilis and septic embolism in association with fungal infection... and injectable drugs (dermato (pxx 265...) or lungs symptoms can be associated).

• Can also be Neuro Syphilis, HIV dementia …
• If no recent history of a toxo test or toxo treatment, nocardiosis is possible (but rare).  Treat with Bactrim 2tabs 3x/day.