LETTER
Distinguishing Central Nervous System Lymphoma from Toxoplasma Encephalitis
Christina Marra, MD
1 May 1994 | Volume 120 Issue 9 | Pages 812-813
TO THE EDITOR:
In their review of primary central nervous system lymphoma, Fine and Mayer [1] recommend an empiric treatment trial for toxoplasmosis in all patients with the acquired immunodeficiency syndrome (AIDS) and a computed tomographic (CT) scan of the cranium suggestive of toxoplasmosis or lymphoma. An alternative approach would be to reserve a toxoplasmosis treatment trial for patients with the highest likelihood of toxoplasmosis, such as those with detectable serum anti-Toxoplasma IgG, those with multiple mass lesions on cranial magnetic resonance imaging (MRI), or those receiving Pneumocystis prophylaxis with agents other than trimethoprim-sulfamethoxazole.
The likelihood of Toxoplasma encephalitis is low in human immunodeficiency virus (HIV)-infected patients with nondetectable serum anti-Toxoplasma IgG [2]. In addition, a single lesion viewed by cranial MRI is more likely to be caused by primary central nervous system lymphoma than to toxoplasmosis [3]. The presence of Epstein-Barr virus DNA in cerebrospinal fluid has been shown to be a sensitive and specific way to distinguish primary central nervous system lymphoma from Toxoplasma encephalitis [4]. Preliminary data also suggest that thallium single-photon emission computed tomography (SPECT) may also be able to make this distinction accurately [5].
Rather than undergoing a low-yield treatment trial, patients who are unlikely to have Toxoplasma encephalitis and in whom primary central nervous system lymphoma is suspected could be further evaluated with such tests as cerebrospinal fluid studies for Epstein-Barr virus DNA, thallium SPECT, or brain biopsy.
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Author and Article Information
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University of Washington School of Medicine; Seattle, WA 98104-2499
1. Fine HA, Mayer RJ. Primary central nervous system lymphoma. Ann Intern Med. 1993; 119:1093-104.
2. Luft BJ, Brooks RG, Conley FK, McCabe RE, Remington JS. Toxoplasmic encephalitis in patients with acquired immune deficiency syndrome. JAMA. 1984; 252:913-7.
3. Ciricillo SF, Rosenblum ML. Imaging of solitary lesions in AIDS (Letter). J Neurosurg. 1991; 74:1029.
4. Cinque P, Brytting M, Vago L, Castagna A, Parravicini C, Zanchetta N, et al. Epstein-Barr virus DNA in cerebrospinal fluid from patients with AIDS-related primary lymphoma of the central nervous system. Lancet. 1993; 342:398-401.
5. Ruiz A, Ganz WI, Donnovan Post MJ. Use of thallium-201 brain SPECT to differentiate cerebral lymphoma from Toxoplasma encephalitis in AIDS patients. 31st Annual Meeting of the American Society of Neuroradiology, 16 to 20 May 1993, Vancouver, British Columbia, Canada.
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