Neurologic outcomes and adjunctive steroids in HIV patients with severe cerebral toxoplasmosis.
OBJECTIVE
Cerebral toxoplasmosis remains a common neurologic complication in patients with AIDS. In this study, we aimed to characterize the prognosis of patients with HIV infection with severe forms of cerebral toxoplasmosis and to investigate the effects of adjunctive steroids on outcomes.


METHODS
We carried out a retrospective cohort study (2000-2011) on consecutive patients with cerebral toxoplasmosis admitted to the medical intensive care unit (ICU) of 5 hospitals. Functional prognosis was graded at 3 months using the modified Rankin Scale (mRS).


RESULTS
We studied 100 patients with a CD4 cell count of 25 (8-62) cells/μL and a Glasgow Coma Scale (GCS) score of 11 (6-14). At follow-up, 51 patients had an mRS score of 0-2 (functional independence), 30 had an mRS score of 3-5 (severe disability), and 19 had an mRS score of 6 (death). Compared with other specific treatments, the use of pyrimethamine-sulfadiazine was associated with improved survival (p = 0.03). Two factors present at ICU admission were independently associated with a poor outcome (mRS score >2) at 3 months: a CD4 cell count <25 cells/μL (odds ratio [OR] 2.7, 95% confidence interval [CI] 1.1-6.7) and a GCS score ≤8 (OR 3.1, 95% CI 1.2-7.7). In patients treated with pyrimethamine-sulfadiazine, the use of adjunctive steroids to treat cerebral edema associated with focal lesions appeared safe but was not associated with better neurologic outcomes.


CONCLUSIONS
Severe forms of cerebral toxoplasmosis in patients with HIV infection are characterized by a good prognosis in approximately 50% of cases. Profound immunodepression and impaired consciousness represent major determinants of outcome. In our study, the benefit of adjunctive steroids to treat cerebral edema could not be demonstrated.
Service de Réanimation Médicale et des Maladies Infectieuses, Université Paris Diderot, Sorbonne Paris Cité, Assistance Publique–Hôpitaux de Paris, Hôpital Bichat–Claude-Bernard, Paris, France. romain.sonneville@bch.aphp.fr
Romain
R
Sonneville
Matthieu
M
Schmidt
Jonathan
J
Messika
Ali
A
Ait Hssain
Daniel
D
da Silva
Isabelle F
IF
Klein
Lila
L
Bouadma
Michel
M
Wolff
Bruno
B
Mourvillier
D000328:Adult; D000981:Antiprotozoal Agents / Q000008:administration & dosage*; D015897:Comorbidity; D018450:Disease Progression; D004359:Drug Therapy, Combination; D005260:Female; D015600:Glasgow Coma Scale; D015658:HIV Infections / Q000188:drug therapy* / Q000453:epidemiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D012189:Retrospective Studies; D012720:Severity of Illness Index; D013256:Steroids / Q000009:adverse effects / Q000627:therapeutic use*; D013411:Sulfadiazine / Q000008:administration & dosage; D016781:Toxoplasmosis, Cerebral / Q000188:drug therapy* / Q000453:epidemiology / Q000401:mortality; D016896:Treatment Outcome
D000981:Antiprotozoal Agents; D013256:Steroids; D013411:Sulfadiazine