Headache – Is it different if the patient has HIV?

A case of a 34yow from the Dominican Republic with a hx of HIV (not on ART) and G6PD who presented with 3 months of frontal/top of the head 10/10 throbbing headaches that kept her awake at night, woke her up in the morning and lasted through the day. Also with 3 months of rhinorrhea & nasal congestion and a 20lb weight loss. Moved to the US 3 months prior.

Differential diagnosis of headache as it pertains to a patient with HIV and how it changes based on CD4 count/percentage: > 500 think of the “normal things”, < 200 think of OI, HIV-related cancers

Differential of brain lesions in HIV positive patients – changes based on whether there is mass effect

• Mass effect: toxomplasmosis (90% of patients who aren’t on ppx and have positive serum antibodies), lymphoma, abscess, TB, cysticercosis
• No mass effect: PML, CMV

Diagnose toxoplasmosis, neurocysticercosis

• Toxo: start with serum antibodies (IgM, IgG); PCR on CSF – generally solid mass(es)
• Cysticercosis: serum antibodies; PCR on CSF – generally cystic mass(es)

When must you obtain imaging prior to LP? Based on initial paper in NEJM 2001

• immunocompromised: cancer, HIV
• neurologic findings including altered mental status, papilledema or other signs of increased ICP
• recent seizure
• history of CNS disease

When can you empirically treat CNS toxoplasmosis? If a patient with HIV and appropriate CD4 count with imaging findings consistent with toxo and positive serum antibodies presents you can empirically treat for toxoplasmosis while investigating other possible etiologies (i.e. lymphoma, etc.)

• Preferred regimen: pyrimethamine, sulfadiazine, leucovorin
• Steroids only if there is midline shift, increased ICP or clinical decline within 48 hours of treatment
• No role for seizure prophylaxis

Note that this patient’s lesion was found to be in the basal ganglia which can be seen with parasites (i.e. toxo, cysticercosis) and is a very rare location for lymphomas.