An Unusual cause of headache

I really enjoy working in the private setting.  There is the opportunity to directly impact my patient’s outcomes without going through intermediaries, fellows, trainees and residents.  What I like about Pacific Health Medical Centre is that it is such a well known and respected centre, staffed by so many high quality professionals.  If there is a complex problem requiring a multi disciplinary approach, I can access some of the best doctors and dental surgeons in the country just within the same building, with a phone call.  If I utilise high quality professionals to help patients and make sure that happens, then everybody wins.   

We have just discharged a patient from Mt Elizabeth today.  This 50 year old gentleman flew in from Solo in Indonesia to seek treatment for severe headache.  He had a left homonymous hemianopia and mild papilloedema but no other fundal lesions.  The brain scans showed multiple enhancing brain lesions, some hemorrhagic and encased in a calcified covering.  The largest lesion was in the right parietal region of the brain.  Radiologists wisely pointed out that this could be due to a parasite infesting the brain.

There are many parasites that can infest human brains but in recent times, food hygiene and public sanitation have all but eliminated such diseases from our society, except in immune compromised individuals.  Even so, contact with cats, ingestion of uncooked meets should always be carefully looked for in the history.  The commonest cause for a weakened immune system in this day and age is HIV infection.  In patients with HIV infection, the cause of a toxoplasma infestation is most often due to a reactivation of an infection which happened long ago.  There appears a threshold at which such reactivation occurs and that is when CD4 counts drop below 200cells/micro liter.  CD4 is a protein found on the cell surface of certain cells in the blood.(the T lymphocyte).  The HIV virus needs to bind to this protein in order to enter the T-cell.  As more T cells are infected, less T cells will manifest CD4 on their cell membranes.  The lower the CD4 counts drop, the weaker the immune system.  

However if all investigations prove to be negative, the patient will have to be subjected to a brain biopsy.  We know that lymphoma of the brain can present with multiple lesions.  This was something which the patient and I were reluctant to do.

What was the outlook for this patient if this turned out to be a cerebral lymphoma?  Not too good I am afraid.  With aggressive treatment, 70% of HIV patients with cerebral lymphoma were dead by 2 years.  

What was the outlook for this patient if this turned out to be HIV with toxoplasmosis?  Its actually quite good, much better than cerebral lymphoma.  He would have to take anti-Toxoplasma medications for the rest of his life for Toxoplasmosis in immunodeficient patients often relapses if treatment is stopped. Immune reconstitution significantly reduce the risk of recurrent infection.  HIV treatment with HAART (highly active antiretroviral therapy) will reconstitute the immune system. Nowadays the outlook is not hopeless.  

My patient's blood tests showed a high toxoplasma antibody titers and a positive HIV test. Breaking the news to the patient was not easy.  I softened the blow by gathering them in a private quiet room, speaking to them in a calm monotone and expressing a lot of hope in the treatment that will ensue.   The wife, I am surprised to say, took it calmly.  She remained supportive of the patient throughout this crisis.  Naturally, she had to be counseled and tested as well.   

As for me, what appeared at first instance to be a patient with a headache, turned out to be something very very different.  You could say, far in the periphery of pain management. Which leads me to again to express my appreciation for being in a center where each member of the team is so readily accessible.