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Alternate Hemibody Hyperkinetic and Hypokinetic Movement Disorders Due to Strategic Lesions in Cerebral Toxoplasmosis

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1 Credit CME

Cerebral toxoplasmosis is a frequent opportunistic infection in patients with HIV. Due to Toxoplasma Gondii’s predilection for basal ganglia structures, movement disorders are a well-recognized complication of cerebral toxoplasmosis.1 We report a case of a 59-year-old female with a background of HIV presenting with complex involuntary movements with markedly different phenomenology on the right and left side of her body. She was diagnosed with cerebral toxoplasmosis 18 months prior, after the onset of the movement disorder and completed antimicrobial treatment with marginal improvement in symptoms. On examination, there was cogwheel rigidity in her right upper limb with accompanying rest tremor and bradykinesia. In contrast, there were prominent hyperkinetic movements of the left side of her body with dystonic posturing of the left upper and lower limb and choreiform movements. Arm swing was reduced on the right (with rest tremor) with dystonic posturing on the left and some subtle patterned movements of left foot while walking (Video). Magnetic resonance imaging of the brain was performed with contrast and it demonstrated multiple ring-enhancing lesions in the right thalamus, left lentiform nucleus, right frontal lobe, and right posterior-temporal lobe (Figure 1). Cerebrospinal fluid (CSF) test result was normal and HIV-1 and -2 were not detected in CSF. HIV viral load was undetectable and CD4 count was 174. Toxoplasma DNA was not detected in serum or CSF. A computerized tomography brain scan was compared with imaging 18 months prior and all lesions were more calcified and felt to be compatible with chronic toxoplasmosis (Figure 2). The left lentiform lesion was felt to be causative for the right-sided hemiparkinsonism, while the right thalamic lesion was felt to be the culprit of the left-sided hemidystonia. A brief trial of risperidone (0.5 mg daily) was not tolerated due to flattened mood and orobuccal dyskinesia and the patient did not wish to pursue further treatment.

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Article Information

Corresponding Author: Eoghan Donlon, MB, BCh BAO, MRCPI, Dublin Neurological institute, Mater Misericordiae University Hospital, 57 Eccles St, Phibsboro, Dublin D07 W7XF, Ireland (eoghandonlon@mater.ie).

Published Online: August 14, 2023. doi:10.1001/jamaneurol.2023.2709

Conflict of Interest Disclosures: None reported.

References
1.
Nath  A , Hobson  DE , Russell  A .  Movement disorders with cerebral toxoplasmosis and AIDS.   Mov Disord. 1993;8(1):107-112. doi:10.1002/mds.870080119PubMedGoogle ScholarCrossref
2.
Tse  W , Cersosimo  MG , Gracies  JM , Morgello  S , Olanow  CW , Koller  W .  Movement disorders and AIDS: a review.   Parkinsonism Relat Disord. 2004;10(6):323-334. doi:10.1016/j.parkreldis.2004.03.001PubMedGoogle ScholarCrossref
3.
Malaquias  MJ , Magrinelli  F , Quattrone  A ,  et al.  Presynaptic hemiparkinsonism following cerebral toxoplasmosis: case report and literature review.   Mov Disord Clin Pract. 2022;10(2):285-299. doi:10.1002/mdc3.13631PubMedGoogle ScholarCrossref
4.
Noël  S , Guillaume  MP , Telerman-Toppet  N , Cogan  E .  Movement disorders due to cerebral Toxoplasma gondii infection in patients with the acquired immunodeficiency syndrome (AIDS).   Acta Neurol Belg. 1992;92(3):148-156.PubMedGoogle Scholar
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Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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