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The article focuses on the integration of robot-assisted gait training into conventional rehabilitation for a patient with chronic neurological and functional impairments. Topics include the patient's medical history with toxoplasmic encephalitis, the implementation and outcomes of hybrid assistive limb therapy, and the potential benefits and limitations of robotic rehabilitation in enhancing neuroplasticity and functional recovery.

Toxoplasma gondii is an Apicomplexan parasite that is estimated to infect at least one-third of the global human population. T. gondii infection may be transmitted horizontally or vertically. The main risk factors for transmission to humans are related to diet, especially the consumption of undercooked meat, along with soil contact. In immunocompetent persons, the acute infection may go undetected as it typically produces minor, non-specific symptoms that are self-limited. After infection is established, recurrent retinochoroiditis is the most common clinical disease. In contrast, severe systemic or cerebral toxoplasmosis may be life-threatening for immunocompromised individuals. Furthermore, congenital toxoplasmosis acquired in utero may have devastating consequences if not recognized and promptly treated. A growing body of research has identified associations between latent T. gondii infection, and personality traits and risk-taking behaviors. Other studies have documented associations between latent infection and psychiatric conditions that include schizophrenia and bipolar affective disorder. With no current treatment regimens being curative of T. gondii infection, effective prevention measures at both the public health and individual levels are vitally important. [ABSTRACT FROM AUTHOR]

Infection by T. gondii is a significant cause of morbidity and mortality among people infected with HIV. The disease presents cerebral or encephalic involvement, especially among severely immunosuppressed patients. We present the case of HIV-infected pregnant women who presented with focal neurological manifestations during the second trimester of gestation. A single intracerebral lesion was found on brain imaging, and a brain biopsy and PCR identified toxoplasmosis. She improved clinically and radiographically after receiving proper treatment. The main contribution of our case is implementing a molecular test to define the diagnosis instead of a therapeutic challenge that may not make the diagnosis. [ABSTRACT FROM AUTHOR]

Humans are infected by Toxoplasma gondii worldwide and its consequences may seriously affect an immune deprived population such as HIV and transplanted patients or pregnant women and foetuses. A deep knowledge of toxoplasmosis seroprevalence in Spain is needed in order to better shape health policies and educational programs. We present the results of the first systematic review and meta-analysis on the human prevalence for this disease in Spain. Databases (PubMed, Web of Science, SCOPUS and Teseo) were searched for relevant studies that were published between January 1993 and December 2023 and all population-based cross-sectional and longitudinal studies reporting the human seroprevalence in Spain were revised. Within the population analysed, our targeted groups were immunocompetent population, pregnant women and immunocompromised patients. Among 572 studies and 35 doctoral theses retrieved, 15 studies and three doctoral theses were included in the meta-analysis. A random effects model was used for the meta-analyses due to the high heterogeneity found between studies (I2: 99.97), since it is a statistically conservative model, in addition to allowing better external validity. The global pooled seroprevalence was 32.3% (95% CI 28.7–36.2%). Most of the studies carried out were in pregnant women and the meta-analysis reported that the pooled seroprevalence of toxoplasmosis in pregnant women in Spain was 24.4% (24,737/85,703, 95% CI 21.2–28.0%), based on the random effects model. It is recommended to continue monitoring the seroprevalence status of T. gondii in order to obtain essential guidelines for the prevention and control of the infection in the population. [ABSTRACT FROM AUTHOR]

Toxoplasmosis of the brain is a pressing issue in the practice of neurologists and neurosurgeons. Most patients with cerebral toxoplasmosis are persons with AIDS. However, toxoplasmic encephalitis can develop in patients with any immunodeficiency conditions that lead to reactivation of toxoplasmosis infection in the central nervous system. Although cerebral toxoplasmosis is not a neurosurgical pathology, patients sometimes require neurosurgical interventions: diagnostic biopsy and lesion removal. Moreover, literature shows cases of removal of brain lesions initially mistaken for a brain tumor, which, as a rule, occurs when the patient’s HIV status is unknown and the severity of their condition does not allow for a comprehensive additional examination.This article reviews Russian and foreign publications on neurosurgical interventions in patients with cerebral toxoplasmosis.

Abstract Cerebral toxoplasmosis is a common opportunistic infectious disease in immunocompromised patients that usually involves the central nervous system. The clinical features and neuroimaging findings of cerebral toxoplasmosis are often similar to brain abscess and tuberculoma. We report a case of hepatitis C with cerebral toxoplasmosis, with the aim of enhancing understanding of the imaging manifestations of cerebral toxoplasmosis and thereby improving the differential diagnosis of brain space‐occupying lesions.

Cerebral toxoplasmosis is one of the most common opportunistic infections in HIV-infected patients. Neurological disorders in this group of patients require a differential diagnosis with demyelinating diseases, toxic damage to the nervous system, acute cerebrovascular accident and brain tumors. Cerebral toxoplasmosis can be accompanied by damage to internal organs and be combined with other secondary diseases in HIV-infected patients who are not aware of the presence of HIV-infection or hide this fact. Therefore, it becomes important to inform doctors of all specialties about features of clinical manifestations and the course of this pathology, which will allow early diagnosis and timely prescribing of effective therapy for the disease.

Background: Little is known about the etiology, clinical presentation, management, and outcome of central nervous system (CNS) infections in Indonesia, a country with a high burden of infectious diseases and a rising prevalence of HIV. Methods: We included adult patients with suspected CNS infections at two referral hospitals in a prospective cohort between April 2019 and December 2021. Clinical, laboratory, and radiological assessments were standardized. We recorded initial and final diagnoses, treatments, and outcomes during 6 months of follow-up. Results: Of 1051 patients screened, 793 were diagnosed with a CNS infection. Patients (median age 33 years, 62% male, 38% HIV-infected) presented a median of 14 days (IQR 7–30) after symptom onset, often with altered consciousness (63%), motor deficits (73%), and seizures (21%). Among HIV-uninfected patients, CNS tuberculosis (TB) was most common (60%), while viral (8%) and bacterial (4%) disease were uncommon. Among HIV-infected patients, cerebral toxoplasmosis (41%) was most common, followed by CNS TB (19%), neurosyphilis (15%), and cryptococcal meningitis (10%). A microbiologically confirmed diagnosis was achieved in 25% of cases, and initial diagnoses were revised in 46% of cases. In-hospital mortality was 30%, and at six months, 45% of patients had died, and 12% suffered from severe disability. Six-month mortality was associated with older age, HIV, and severe clinical, radiological and CSF markers at presentation. Conclusion: CNS infections in Indonesia are characterized by late presentation, severe disease, frequent HIV coinfection, low microbiological confirmation and high mortality. These findings highlight the need for earlier disease recognition, faster and more accurate diagnosis, and optimized treatment, coupled with wider efforts to improve the uptake of HIV services. [ABSTRACT FROM AUTHOR]

Children with severe β-thalassemia major (β-TM) are at high risk of developing toxoplasmosis after allogeneic hematopoietic stem cell transplantation (allo-HSCT). The aim of this study was to identify the neuroimaging findings of cerebral toxoplasmosis in pediatric patient with β-TM for early diagnosis and treatment of cerebral toxoplasmosis. We performed a retrospective assessment of clinical and neuroimaging data of children with severe β-TM who had cerebral toxoplasmosis after allo-HSCT. Additionally, we reviewed and summarized the literature on cerebral toxoplasmosis in patients with other underlying conditions. This case series identified three children who had severe β-TM and had subsequent cerebral toxoplasmosis after allo-HSCT. In addition, we identified 23 patients from literature who had toxoplasmosis and had underlying conditions other than β-TM. We found that the most common clinical symptom among the patients from our series and the patients from literature was fever upon presentation. We identified the typical neuroimaging findings including brain lesions with ring enhancement and eccentric/central nuclear target-like enhancement, which should facilitate early diagnosis and treatment of cerebral toxoplasmosis.

Toxoplasma gondii is an Apicomplexan parasite that is estimated to infect at least one-third of the global human population. T. gondii infection may be transmitted horizontally or vertically. The main risk factors for transmission to humans are related to diet, especially the consumption of undercooked meat, along with soil contact. In immunocompetent persons, the acute infection may go undetected as it typically produces minor, non-specific symptoms that are self-limited. After infection is established, recurrent retinochoroiditis is the most common clinical disease. In contrast, severe systemic or cerebral toxoplasmosis may be life-threatening for immunocompromised individuals. Furthermore, congenital toxoplasmosis acquired in utero may have devastating consequences if not recognized and promptly treated. A growing body of research has identified associations between latent T. gondii infection, and personality traits and risk-taking behaviors. Other studies have documented associations between latent infection and psychiatric conditions that include schizophrenia and bipolar affective disorder. With no current treatment regimens being curative of T. gondii infection, effective prevention measures at both the public health and individual levels are vitally important.

Progressive multifocal leukoencephalopathy (PML) is an opportunistic infection of the central nervous system (CNS) caused by the reactivation of John Cunningham polyomavirus (JCV). Most often, this disease is observed in patients with severe immune suppression, such as those with AIDS. Cerebral toxoplasmosis results from the reactivation of a latent infection with Toxoplasma gondii, an intracellular parasite. This parasitosis is relatively rare in the United States, while in some regions of Europe the seropositive population is over 90%. Similarly, to PML, cerebral toxoplasmosis develops in stages of advanced immune deficiency. Both of these opportunistic infections of the central nervous system can cause severe neurological symptoms, and their simultaneous presentation can represent a diagnostic and therapeutic problem. We present a case of a 59-year-old patient with a newly diagnosed HIV infection with manifestations of epilepsy and progressive cognitive impairment. The patient was diagnosed initially with cerebral toxoplasmosis and subsequently with progressive multifocal leukoencephalopathy.

Objectives: This study analyzes the occurrence of epileptic seizures in HIV-infected patients with cerebral toxoplasmosis compared to those with multiple cerebral disorders, including cerebral toxoplasmosis. Methods: We conducted a retrospective, observational study with 94 HIV-infected patients at Constanta Clinical Infectious Disease Hospital from 2003-2023. Patients were divided into two groups: 34 with cerebral toxoplasmosis and 60 with multiple cerebral disorders, including toxoplasmosis. Data were analyzed using IBM SPSS Statistics 25, and 3-hour EEGs were recorded for five patients to observe cerebral electrical activity. Results: Generalized onset seizures occurred in 12.77% of patients. Of these, 18.33% were from the multiple disorders group (T+AC), and 2.94% were from the cerebral toxoplasmosis group. The risk of developing generalized seizures was significantly higher in the T+AC group (OR = 7.408). Conclusions: Maintaining a good immune status in HIV-infected patients can prevent multiple cerebral disorders and associated epileptic seizures, reducing the risk of severe complications. Antiepileptic drugs with minimal interaction with HIV medications are recommended, and EEG is useful for diagnosis and treatment monitoring. [ABSTRACT FROM AUTHOR]

Objectives: Cerebral toxoplasmosis is an opportunistic infection often seen in people living with HIV/AIDS. This research aims to determine how risk factors and associated diseases modify the evolution and prognosis of HIV-infected patients with cerebral toxoplasmosis. Methods: We conducted a case-control, observational, retrospective study. The research enrolled 94 patients with HIV-related cerebral toxoplasmosis at the Infectious Diseases Clinic, split into two sample groups. The first sample group included 51 patients who were initially discovered with cerebral toxoplasmosis and only afterward tested and confirmed HIV-positive. The second sample group of 43 patients were diagnosed as HIV-positive from the beginning and subsequently developed cerebral toxoplasmosis due to non-adherence to treatment. Results: The first sample group, discovered first with cerebral toxoplasmosis and only later diagnosed as HIV-positive, had a higher probability of death, mainly due to an advanced state of HIV disease. Therapy adherence in both sample groups played a key role in immune restoration status and long-term survival. Conclusions: Comparative analysis of the sample groups highlights the importance of early diagnosis of cerebral disease at the first neurological symptoms and signs. Early initiation of antiparasitic and antiretroviral therapy has proven to be decisive for favorable evolution and prognosis. [ABSTRACT FROM AUTHOR]

Four cases of people living with HIV/AIDS (PLWHA) with calcified cerebral toxoplasmosis associated with perilesional edema causing a single episode of neurological manifestations have recently been reported. Here, we describe the first detailed description of perilesional edema associated with calcified cerebral toxoplasmosis causing three episodes of neurological manifestations in a PLWHA, including seizures in two of them. These recurrences occurred over approximately a decade. Throughout this period, the patient showed immunological and virological control of the HIV infection, while using antiretroviral therapy regularly. This case broadens the spectrum of an emerging presentation of calcified cerebral toxoplasmosis, mimicking a well-described finding of neurocysticercosis in immunocompetent hosts. [ABSTRACT FROM AUTHOR]

Cerebral abscesses are uncommon space occupying lesions; they are associated with high morbidity and mortality, though are potentially treatable. Patients often present with nonspecific symptoms and may have few clinical signs. Routine clinical imaging may not give a definite diagnosis, as the findings can be indistinguishable from those of other intracranial mass lesions. We review the role of advanced MR techniques to characterise brain abscesses and discuss the role of imaging in monitoring their response to the treatment. [ABSTRACT FROM AUTHOR]

Background: Hemichorea and hemiballismus are rare movement disorders caused by central nervous system toxoplasmosis. Objective: To describe the case of a male patient with treatmentnaïve HIV who initiated with right hemichorea and hemiballismus. Case report: We present a 29-year-old male with a history of untreated HIV. He presented to the emergency room with rightsided hemichorea and hemiballismus. The neurological examination was unremarkable, except for the presence of abnormal movements characterized by non-rhythmic, large-amplitude, violent and occasionally choreiform movements in the right side of his body. Brain MRI revealed a ringenhancing lesion in the left basal nuclei, raising suspicion of CNS toxoplasmosis. Further serologic tests confirmed the diagnosis. Treatment was initiated with trimethoprim-sulfamethoxazole, pyrimethamine/clindamycin and antiretrovirals. Haloperidol, aripiprazole, and clonazepam were administered to alleviate abnormal movements. Subsequent MRI scans showed radiological improvement, and the patient was discharged. Conclusion: Hemichorea-hemiballismus is a neurological manifestation unfrequently related to CNS toxoplasmosis. Prompt initiation of antiretroviral therapy and antimicrobial treatment is crucial to improve patient outcomes. [ABSTRACT FROM AUTHOR]

Cerebral toxoplasmosis is an opportunistic infection that, by itself, is difficult to differentiate from cerebral neoplasms by conventional neuroimaging. It rarely occurs concurrently in patients with a primary brain tumor but when it does, it makes diagnosis and management more difficult. This is a case of a 28-year-old female, diagnosed with a right frontal pleomorphic xanthoastrocytoma with several recurrences, treated with surgery, radiation, and chemotherapy. Three years from diagnosis, the patient was readmitted for generalized body weakness, fever, and a decrease in sensorium. A repeat cranial magnetic resonance imaging showed multiple enhancing lesions in both cerebral hemispheres and in the posterior fossa. Serum toxoplasma IgM and IgG antibody titers were elevated. Single-photon emission computerized tomography (SPECT) with thallium-201 did not show increased tracer uptake in these lesions, favoring toxoplasmosis over tumor recurrence. The patient was treated with trimethoprim-sulfamethoxazole with significant improvement. This is a rare account of cerebral toxoplasmosis arising in the setting of astrocytoma. This is also the first case report to demonstrate the value of thallium-201 SPECT in differentiating central nervous system infection from tumor recurrence, which is pivotal in management. More studies exploring the use of thallium-201 SPECT in distinguishing central nervous system infections from glioma and other malignant tumors should be undertaken to maximize this imaging modality in neuro-oncology practice.

Purpose Toxoplasma gondii is a parasite that is widely distributed around the globe and can cause brain inflammation, particularly in immunosuppressed patients such as those diagnosed with human immunodeficiency virus (HIV). This paper reviews the efficacy of azithromycin and pyrimethamine combination therapy for cerebral toxoplasmosis in patients with HIV. Methods The scope of the studies included in this review was limited from 1992 to 2022, with studies primarily being randomized, controlled clinical trials available on online scientific journal databases. The authors screened eligible records for review, removing those that did not fit the inclusion and exclusion criteria. The risk of bias of the extracted data was analyzed through the Cochrane risk-of-bias tool for randomized trials. Results A broad search of major online databases such as PubMed, Medline, Google Scholar, and Cochrane using keywords, limit fields, and Boolean operators yielded 3,130 articles. After thoroughly screening the search results, two studies were included in this review. Results from the studies included in the review demonstrate that the combination therapy of azithromycin and pyrimethamine is favorable for cerebral toxoplasmosis. However, the net response is less effective than the standard treatment regimen (pyrimethamine and sulfadiazine). Conclusion The combination therapy of azithromycin and pyrimethamine is less effective than the standard treatment regimen for maintenance therapy for cerebral toxoplasmosis; thus, administering these medications for this indication must be met with caution.

Background Concomitant neurological diseases in people living with HIV/AIDS (PLWHA) is a challenging subject that has been insufficiently evaluated by prospective clinical studies. The goal of the present study was to identify the clinical characteristics and outcomes of PLWHA with cerebral toxoplasmosis and neurological co-infections. Methods We conducted a prospective observational cohort study at a tertiary teaching center in São Paulo, Brazil, from January to July 2017. Hospitalized PLWHA aged ≥ 18 years with cerebral toxoplasmosis were consecutively enrolled. A standardized neurological examination was performed at admission and weekly until discharge or death. Diagnosis and treatment followed institutional routines; neuroradiology, molecular diagnosis, neurosurgery, and the intensive care unit (ICU) were available. The main outcomes were neurological coinfections and in-hospital death. Results We included 44 (4.3%) cases among 1,032 hospitalized patients. The median age was 44 (interquartile range [IQR]: 35–50) years, and 50% (n = 22) of the patients were male. The median CD4+ T lymphocyte count was of 50 (IQR: 15–94) cells/mm3. Multiple lesions on computed tomography were present in 59% of the cases. Neurological coinfections were diagnosed in 20% (n = 9) of the cases, and cytomegalovirus was the most common etiology (encephalitis: n = 3; polyradiculopathy: n = 2). Longer hospital stays (30 versus 62 days; p = 0.021) and a higher rate of ICU admissions (14% versus 44%; p = 0.045) were observed among PLWHA with neurological coinfections in comparison to those without them. The rate of in-hospital mortality was of 13.6% (n = 6) (coinfection group: 33%; no coinfection group: 8.6%; p = 0.054). Conclusion Neurological c-infections were common among PLWHA with cerebral toxoplasmosis, and cytomegalovirus was the main copathogen. The group of PLWHA with neurological co-infections underwent longer hospital stays and more frequent intensive care unit admissions. Additionally, this group of patients tended to have higher in-hospital mortality rate.

Objective: We aimed to determine the frequency, type, and mortality rate of central nervous system infections (CNSI) in patients infected with the human immune deficiency virus (HIV). Methods: A total of 353 HIV/AIDS cases hospitalized in our clinic between January 2014 and March 2020 were retrospectively analyzed. Patients diagnosed with CNSI were included in the study. Epidemiological data, diagnoses, clinical, and laboratory information, and clinical progress data of the cases were collected from patient files and recorded. Variables were analyzed. Results: Thirty-four (9.6%) of 353 inpatients diagnosed with HIV/AIDS were followed with CNSI diagnosis. 88.2% of the cases were male, and the median age was 43.5 [interquartile range (IQR)= 26-62) ]. Toxoplasma encephalitis (n=7, 20.6% ), neurosyphilis (n=7, 20.6%), tuberculous meningitis (n=4, 11.8%), cryptococcal meningitis (n=4, 11.8%), HIV encephalopathy (n =3, 8.8%), progressive multifocal leukoencephalopathy (PML) (n=3, 8.8%), and bacterial meningitis (n=2, 5.9%), and 1 case of herpes simplex virus (HSV) encephalitis, varicella zoster virus (VZV) encephalitis, chronic encephalitis, cytomegalovirus (CMV) meningoencephalitis were seen. The median CD4+ T lymphocyte count of the cases was 44.5 /uL (IQR=5-627), HIV RNA level was 215 000 copies/mL (IQR=20-617 000) in patients under antiretroviral therapy (ART), 227 500 (IQR=32 000-4 500 000) copies/ml in patients not receiving ART. CD4+ T lymphocyte count of 25 (73.4%) patients was <200/uL. Twenty-one patients (61.8% ) were simultaneously diagnosed with HIV/AIDS and CNSI, and 14 were in the AIDS stage. The mortality rate was 32.4 % (n=11), and all fatal cases had CD4+ T lymphocyte counts below 200/uL. Conclusion: Central nervous system infections continue to cause severe mortality and morbidity in HIV-infected individuals. We observed that the frequency and mortality rate of CNSI is higher in patients who do not know their HIV status, late-presenters, and those who are not under treatment and/or do not adhere to treatment. Facilitating access to diagnostic tests, rapid treatment initiation, and counseling on treatment compliance is essential to prevent CNSI and, thus, reduce mortality. [ABSTRACT FROM AUTHOR]

Abstract Background Cerebral infection with the protozoan Toxoplasma gondii (T. gondii) is responsible for inflammation of the central nervous system (CNS) contributing to subtle neuronal alterations. Albeit essential for brain parasite control, continuous microglia activation and recruitment of peripheral immune cells entail distinct neuronal impairment upon infection-induced neuroinflammation. PACAP is an endogenous neuropeptide known to inhibit inflammation and promote neuronal survival. Since PACAP is actively transported into the CNS, we aimed to assess the impact of PACAP on the T. gondii-induced neuroinflammation and subsequent effects on neuronal homeostasis. Methods Exogenous PACAP was administered intraperitoneally in the chronic stage of T. gondii infection, and brains were isolated for histopathological analysis and determination of pathogen levels. Immune cells from the brain, blood, and spleen were analyzed by flow cytometry, and the further production of inflammatory mediators was investigated by intracellular protein staining as well as expression levels by RT-qPCR. Neuronal and synaptic alterations were assessed on the transcriptional and protein level, focusing on neurotrophins, neurotrophin-receptors and signature synaptic markers. Results Here, we reveal that PACAP administration reduced the inflammatory foci and the number of apoptotic cells in the brain parenchyma and restrained the activation of microglia and recruitment of monocytes. The neuropeptide reduced the expression of inflammatory mediators such as IFN-γ, IL-6, iNOS, and IL-1β. Moreover, PACAP diminished IFN-γ production by recruited CD4+ T cells in the CNS. Importantly, PACAP promoted neuronal health via increased expression of the neurotrophin BDNF and reduction of p75NTR, a receptor related to neuronal cell death. In addition, PACAP administration was associated with increased expression of transporters involved in glutamatergic and GABAergic signaling that are particularly affected during cerebral toxoplasmosis. Conclusions Together, our findings unravel the beneficial effects of exogenous PACAP treatment upon infection-induced neuroinflammation, highlighting the potential implication of neuropeptides to promote neuronal survival and minimize synaptic prejudice.

We report a case of an apparently healthy, immunocompetent individual who presented with headache and symptoms suggestive of raised intracranial pressure. Neurological imaging revealed marked edema in the basal ganglia. His history was remarkable for sustained contact with domestic felines. He was started on trimethoprim-sulphamethoxazole based on history, strongly positive serology, and radiological findings. He showed a marked response to treatment. The characteristic radiological findings, serology, and dramatic response to treatment confirmed the diagnosis in this case. A tissue diagnosis was not required in our case. This case highlights that immunocompetent individuals can develop neurological manifestations. Though cerebral toxoplasmosis is classically associated with multiple lesions, our case highlights that presentation as a solitary space-occupying lesion is also possible. Further research is needed to ascertain if prolonged exposure or extensive exposure is associated with severe manifestations.

A case of a 30 years-old male patient, diagnosed with cerebral toxoplasmosis, confirmed HIV, with positive COVID-19. Once he came to the emergency department with a chief complaint of left upper and lower limbs weakness progressing for two days. The patient appeared malnourished and was afebrile and assessed to be well hydrated. He was alert but drowsy and had speech difficulty. A focused neurologic examination was performed and revealed a loss of nasolabial fold indicating facial nerve palsy. Neck stiffness was present and there was reduced motoric power in the left upper and lower limb of 2/5, with positive Babinski sign and Chaddock sign. According to brain CT, showed vasogenic cerebral edema and midline shift. Further laboratory exams showed positive IgG antibodies for Toxoplasma, with a titer exceeding 300 IU/ml, positive serum HIV, with CD4 cell count below 200cell/mm³. Complete blood count study highlighted low haemoglobin and elevated white cell count. He tested positive for COVID-19 by nasopharyngeal swab RT-PCR. Chest CT were done and revealed features of viral pneumonia with ground glass opacity appearance. In summary, we present a patient with cerebral involvement of toxoplasmosis possibly facilitated by pre-existing immunodeficiency as an opportunistic infections of HIV, and with COVID-19 complicated as acute infections. This case report reinforces a potential role for other comorbidities, rather than HIV infection as regards SARS-CoV-2 infection outcomes. For better assessment we need to do MRI. [ABSTRACT FROM AUTHOR]

Abstract Background The present case contributes to the limited literature on central nervous system involvement of blastic plasmacytoid dendritic cell neoplasm (BPDCN). Case presentation A 63-year-old male presented to the department of neurology with a three-day history of rapidly progressing headache, fatigue, and confusion. Physical examination revealed multiple bruise-like skin lesions. Initial laboratory workup raised suspicion of acute leukemia, and a brain computer tomography identified several hyperdense processes. A bone marrow biopsy gave the diagnosis BPDCN, a rare and aggressive hematologic malignancy derived from plasmacytoid dendritic cells with a poor prognosis. Lumbar puncture showed not only signs of BPDCN, but also cerebral toxoplasmosis, thus providing a differential diagnosis. Despite intensive systemic and intrathecal chemotherapy, the patient died 25 days later due to multi-organ failure. Discussion The exact incidence of BPDCN is unknown and perhaps underestimated but may account for 0.5 – 1% of all hematological malignancies. The median age at onset is 60 to 70 years, and most patients are men. Cutaneous lesions are the most frequent clinical manifestation at diagnosis. Other symptoms present at time of diagnosis or during disease progression include lymphadenopathy, splenomegaly and cytopenia caused by bone marrow involvement. Although the majority of BPDCN patients have no symptoms or signs of central nervous system involvement, plasmacytoid dendritic cells have been detected in the cerebrospinal fluid in more than 50%. Conclusions This case highlights the importance of considering hematological malignancies as a differential diagnosis in patients developing acute neurological symptoms and raises suspicion of a possible association between toxoplasmosis and hematological malignancies.

Most people with toxoplasmosis infection are asymptomatic. Cerebral toxoplasmosis in HIV patient represents poor prognostic determinant, but treatable if early treatment is initiated. A case of delayed diagnosis of cerebraltoxoplasmosis is presented.A 27-year-old man presented with one-sided facial numbness and treated as Bell’s Palsy. Later he developed slurred speech. Contrast enhanced CT brain showed left frontal temporal hypodense lesion, leptomeningeal enhancement and perilesional oedema. Steroid was started. Four days later, he presented with decreased responsiveness. Retroviral was detected and diagnosis changed to opportunistic brain infection. He died after 3 days. Toxoplasmosis IgG antibodies turned out positive.In diagnosing cerebral toxoplasmosis, clinical presentation and examination are as important as laboratory testing and radiological imaging.

Background: Cerebral toxoplasmosis (CTx) is a central nervous system opportunistic infection with variable neurological manifestations. Although tropism of Toxoplasma gondii for the basal ganglia is well known, movement disorders (MDs) represent only a small percentage of CTx‐related neurological complications. CTx‐associated MDs are usually hyperkinetic, whereas parkinsonism associated with evidence of presynaptic dopaminergic deficit has never been described. Case: We report a human immunodeficiency virus–positive patient who developed a complex MD featuring unilateral tremor combined with parkinsonism and dystonia following an acute episode of disseminated CTx. Her dopamine transporter scan (DaTscan) documented contralateral presynaptic dopaminergic deficit. Levodopa initiation improved both tremor and parkinsonism after ineffective trials of several other medications over the years. Literature Review: A total of 64 patients presenting with CTx‐related MDs have been described. The most common MD was chorea (44%), followed by ataxia (20%), parkinsonism (16%), tremor (14%), dystonia (14%), myoclonus (3%), and akathisia (2%). DaTscan was performed only in 1 case, of Holmes tremor, that demonstrated reduced presynaptic dopaminergic uptake. Positive response to dopaminergic treatment was reported in 3 cases of Holmes tremor and 2 cases of parkinsonism. Conclusions: Presynaptic dopaminergic deficit may occur in CTx‐related tremor combined with parkinsonism. Its identification should prompt initiation of levodopa, thus avoiding unnecessary trials of other drugs. [ABSTRACT FROM AUTHOR]

Background Toxoplasmic encephalitis (TE) is an opportunistic infection of people with human immunodeficiency virus (HIV) or other causes of immunosuppression. Guideline-recommended treatments for TE are pyrimethamine and sulfadiazine (P-S) or pyrimethamine and clindamycin (P-C); however, a substantial price increase has limited access to pyrimethamine. Consequently, some centers have transitioned to trimethoprim-sulfamethoxazole (TMP-SMX), an inexpensive alternative treatment. We aimed to review the evidence on the efficacy and safety of pyrimethamine-containing therapies vs TMP-SMX. Methods We searched for and included randomized controlled trials (RCTs) and observational studies of TE treatments, regardless of HIV status. Data for each therapy were pooled by meta-analysis to assess the proportions of patients who experienced clinical and radiologic responses to treatment, all-cause mortality, and discontinuation due to toxicity. Sensitivity analyses limited to RCTs directly compared therapies. Results We identified 6 RCTs/dose-escalation studies and 26 single-arm/observational studies. Identified studies included only persons with HIV, and most predated modern antiretroviral treatment. Pooled proportions of clinical and radiologic response and mortality were not significantly different between TMP-SMX and pyrimethamine-containing regimens (P >.05). Treatment discontinuation due to toxicity was significantly lower in TMP-SMX (7.3%; 95% confidence interval [CI], 4.7–11.4; I2 = 0.0%) vs P-S (30.5%; 95% CI, 27.1–34.2; I2 = 0.0%; P <.01) or P-C (13.7%; 95% CI, 9.8–18.8; I2 = 32.0%; P =.031). These results were consistent in analyses restricted to RCT data. Conclusions TMP-SMX appears to be as effective and safer than pyrimethamine-containing regimens for TE. These findings support modern RCTs comparing TMP-SMX to pyrimethamine-based therapies and a revisiting of the guidelines. [ABSTRACT FROM AUTHOR]

Cerebral toxoplasmosis is a parasitic disease resulting, in most cases, from a reactivation of a latent cyst with Toxoplasma gondii. The disease mainly affects immunosuppressed individuals, such as HIV (human immunodeficiency virus)-infected patients. Diagnosis is based on specialized antibody testing, clinical symptoms, neuroimaging methods, and histological examination. The gold standard for diagnosis is a brain biopsy, but more often the response to treatment seen in clinical symptoms and neuroimaging studies is sufficient. The imaging features support the diagnosis of cerebral toxoplasmosis and help assess the effectiveness of treatment. [ABSTRACT FROM AUTHOR]

To analyze the factors associated with limitations for walking at hospital discharge in people living with HIV/AIDS diagnosed with cerebral toxoplasmosis. Cross-sectional and quantitative research, carried out from the analysis of 88 medical records of hospitalized patients with cerebral toxoplasmosis and HIV in the years of 2018 and 2019. Information regarding sociodemographic, clinical data and reports of mobility difficulties at the time of hospital discharge were collect. Statistics were performed using inferential analysis. Most of the participants were men, divorced, employed, living in Fortaleza-Ceará and with their own home, with a mean age between 37.63 ± 9.32 years. The factors that were statistically associated with limitations for walking at hospital discharge were length of stay, physiotherapy care, and use of mechanical ventilation. In this study, the factors associated with limitation for walking at hospital discharge were the prolonged hospitalization time, physiotherapy care and the use of mechanical ventilation. [ABSTRACT FROM AUTHOR]

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Background: Cerebral toxoplasmosis is a relatively rare disorder that usually affects immunocompromised patients. The most common scenario occurs among human immunodeficiency virus (HIV)-positive patients. In those patients, toxoplasmosis is the most frequent cause of expansive brain lesion and continues to cause elevated morbidity and mortality. In typical cases of toxoplasmosis, both computed tomography and magnetic resonance imaging reveal single/multiple nodular or ring-enhancing lesions with surrounding edema. Nevertheless, cases of cerebral toxoplasmosis with atypical radiological features have been reported. Diagnosis can be obtained by finding organisms in the cerebrospinal fluid or in stereotactic biopsy samples of the brain lesion. If untreated, cerebral toxoplasmosis is uniformly fatal, so prompt diagnosis is mandatory. A prompt diagnosis is necessary, as untreated cerebral toxoplasmosis is uniformly fatal. Case Description: We discuss imaging and clinical findings of a patient - not aware of being HIV-positive - with a solitary atypical brain localization of toxoplasmosis mimicking a brain tumor. Conclusion: Although relatively uncommon, neurosurgeons should be aware of the potential occurrence of cerebral toxoplasmosis. High index of suspicion is needed for timely diagnosis and prompt initiation of therapy. [ABSTRACT FROM AUTHOR]

Cerebral toxoplasmosis is an opportunistic infection that, by itself, is difficult to differentiate from cerebral neoplasms by conventional neuroimaging. It rarely occurs concurrently in patients with a primary brain tumor but when it does, it makes diagnosis and management more difficult. This is a case of a 28-year-old female, diagnosed with a right frontal pleomorphic xanthoastrocytoma with several recurrences, treated with surgery, radiation, and chemotherapy. Three years from diagnosis, the patient was readmitted for generalized body weakness, fever, and a decrease in sensorium. A repeat cranial magnetic resonance imaging showed multiple enhancing lesions in both cerebral hemispheres and in the posterior fossa. Serum toxoplasma IgM and IgG antibody titers were elevated. Single-photon emission computerized tomography (SPECT) with thallium-201 did not show increased tracer uptake in these lesions, favoring toxoplasmosis over tumor recurrence. The patient was treated with trimethoprim-sulfamethoxazole with significant improvement. This is a rare account of cerebral toxoplasmosis arising in the setting of astrocytoma. This is also the first case report to demonstrate the value of thallium-201 SPECT in differentiating central nervous system infection from tumor recurrence, which is pivotal in management. More studies exploring the use of thallium-201 SPECT in distinguishing central nervous system infections from glioma and other malignant tumors should be undertaken to maximize this imaging modality in neuro-oncology practice. [ABSTRACT FROM AUTHOR]

Intracranial lesions can present a diagnostic challenge in patients without previously known immunosuppression. When focal neurological signs and seizures occur in a patient with no established medical history, an expansive brain lesion may be initially interpreted as a neoplasm, influencing early clinical decisions regarding the extent of supportive measures. However, opportunistic infections, such as cerebral toxoplasmosis, should remain on the differential diagnosis - particularly after consideration of the patient's background and potential epidemiological risks. We present the case of a middle-aged woman of African origin who presented with new-onset seizures and a prolonged history of anorexia and weight loss. Initial neuroimaging suggested a primary or metastatic brain tumor, raising concerns regarding the patient's prognosis and the appropriateness of aggressive support in the emergency setting. The patient received corticosteroids and anticonvulsants in the emergency department (ED), with a subsequent need to start noninvasive ventilation. Further laboratory workup revealed the inaugural human immunodeficiency virus (HIV) and Toxoplasma gondii infection rather than a neoplastic process. Following targeted antimicrobial therapy and initiation of antiretroviral treatment (ART), she demonstrated remarkable neurological and functional recovery. This case underscores the importance of maintaining a broad differential diagnosis in the ED, performing a thorough background evaluation of patients, and sustaining supportive management until a definitive diagnosis is established., Competing Interests: Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2025, Alves et al.)

Abstract Background Central nervous system (CNS) infections are serious and debilitating diseases with significant mortality, and high prevalence in the context of human immunodeficiency virus (HIV) pandemic in Africa. However, their diagnosis remains challenging due to outdated technical platform. We aimed to determine the frequency of CNS infection and to describe the epidemiological, clinical and outcome of this at the Douala General Hospital (DGH), Cameroon. To carry out this study, we collected the medical records of patients hospitalized for CNS infections in the internal medicine department of DGH from January 2015 to December 2019. Results Among 8430 files reviewed, 336 cases of CNS infection were identified giving a frequency of CNS infection of 3.99% among which 204 files were included in the study (54.4% were male). HIV infection was found in 147 patients (72.1%) with 38.1% (n = 56) of them on regular follow-up. The most common clinical signs were fever (84.8%), headache (68.6%), meningeal syndrome (38.7%), and seizures (36.3%). Cerebral toxoplasmosis (24.5%), cryptococcal meningitis (21.1%), and acute bacterial meningitis (8.3%) were leading aetiologies. Of the 143 CSF samples, 70.6% (n = 101) were sterile. The in-hospital mortality rate was 23.5% with CNS infection of unknown cause (22.1%) be independently associated to this [OR = 2.24; 95% CI 1.04–4.80, p = 0.039]. Conclusion Clinical presentations of CNS infections are same with classical data. HIV-related opportunistic infections are the main aetiologies. About one over four patients with CNS died. Two thirds of CSF are sterile using basic laboratory assessment giving a need to identify simple tests to increase sensibility and specificity of diagnostic tools in our setting.

Resumen: Mycobacterium tuberculosis genera infecciones que llegan a tener una alta prevalencia en pacientes inmunodeprimidos y con menor frecuencia en pacientes inmunocompetentes. Lesiona comúnmente al pulmón; sin embargo, también infecta otros órganos como el sistema nervioso central. Los abscesos tuberculosos son una forma de presentación de esta infección, siendo el método diagnóstico la punción-aspiración o biopsia quirúrgica. Según la evolución clínica, la resolución de los abscesos tuberculosos será quirúrgico o farmacológico. Se presenta el caso de una paciente joven de 14 años de edad, con antecedentes de tuberculosis (TB) pulmonar hace seis meses, quien concomitantemente recibía terapia inmunosupresora para lupus eritematoso sistémico (LES). La paciente debuta con cuadro clínico de fiebre y paresia braquio-crural izquierda; tras estudios imagenológicos y microbiológicos se diagnostica un absceso cerebral tuberculoso que se trató de manera farmacológica y con cirugía descompresiva, evolucionando satisfactoriamente. Summary: Mycobacterium tuberculosis is responsible for infections primarily encountered in immunosuppressed patients. It mainly targets the lungs; however, other organs can be involved, such as the central nervous system. A tuberculous brain abscess is a rare form of this infection, requiring a surgical brain biopsy or puncture aspiration to get a definitive diagnosis. The treatment of tuberculous abscesses, either surgical or pharmacological, depends on its clinical evolution. We present the case of a 14-year-old female teen who debuted with fever and left brachio-crural paresis. The patient was receiving treatment for systemic lupus erythematosus at the moment of admission and had a six month clinical history of pulmonary tuberculosis. Imaging and microbiological results confirmed the presence of a tuberculous brain abscesses that required surgical and anti-tuberculosis treatment. Post-operative clinical evolution was satisfactory.

Background: We aimed to investigate whether susceptibility-weighted imaging (SWI) and contrast-enhanced 3D-T1WI can differentiate Acquired Immune Deficiency Syndrome-Related Primary Central Nervous System Lymphoma (AR-PCNSL) from cerebral toxoplasmosis. Methods: This was a prospective cohort study. 20 AIDS patients were divided into AR-PCNSL group (13 cases) and cerebral toxoplasmosis group (7 cases) based on pathology results. We analyzed the appearance of lesions on SWI and enhanced 3D T1WI and ROC curves in the diagnosis of AR-PCNSL and cerebral toxoplasmosis. Results: Cerebral toxoplasmosis was more likely to show annular enhancement (p = 0.002) and complete smooth ring enhancement (p = 0.002). It was also more likely to present a complete, smooth low signal intensity rim (LSIR) (p = 0.002) and an incomplete, smooth LSIR (p = 0.019) on SWI. AR-PCNSL was more likely to present an incomplete, irregular LSIR (p

Central nervous system (CNS) toxoplasmosis is an opportunistic infection caused by the intracellular protozoan parasite Toxoplasma gondii. This organism typically causes disease in immunocompromised patients with human immunodeficiency virus (HIV). We reported a case of a 52-year-old woman with neurology symptoms and Magnetic resonance imaging (MRI) brain shows both eccentric and concentric target signs, which are typical signs in a patient with cerebral toxoplasmosis but rarely displayed in the same lesion. The MRI played a crucial role in diagnosing the patient and distinguishing CNS diseases commonly found in HIV patients. Our objective is to discuss the imaging findings that aided in the patient's diagnosis.

Background: Cerebral infection with the protozoan Toxoplasma gondii (T. gondii) is responsible for inflammation of the central nervous system (CNS) contributing to subtle neuronal alterations. Albeit essential for brain parasite control, continuous microglia activation and recruitment of peripheral immune cells entail distinct neuronal impairment upon infection-induced neuroinflammation. PACAP is an endogenous neuropeptide known to inhibit inflammation and promote neuronal survival. Since PACAP is actively transported into the CNS, we aimed to assess the impact of PACAP on the T. gondii-induced neuroinflammation and subsequent effects on neuronal homeostasis.Methods: Exogenous PACAP was administered intraperitoneally in the chronic stage of T. gondii infection, and brains were isolated for histopathological analysis and determination of pathogen levels. Immune cells from the brain, blood, and spleen were analyzed by flow cytometry, and the further production of inflammatory mediators was investigated by intracellular protein staining as well as expression levels by RT-qPCR. Neuronal and synaptic alterations were assessed on the transcriptional and protein level, focusing on neurotrophins, neurotrophin-receptors and signature synaptic markers.Results: Here, we reveal that PACAP administration reduced the inflammatory foci and the number of apoptotic cells in the brain parenchyma and restrained the activation of microglia and recruitment of monocytes. The neuropeptide reduced the expression of inflammatory mediators such as IFN-γ, IL-6, iNOS, and IL-1β. Moreover, PACAP diminished IFN-γ production by recruited CD4+ T cells in the CNS. Importantly, PACAP promoted neuronal health via increased expression of the neurotrophin BDNF and reduction of p75NTR, a receptor related to neuronal cell death. In addition, PACAP administration was associated with increased expression of transporters involved in glutamatergic and GABAergic signaling that are particularly affected during cerebral toxoplasmosis.Conclusions: Together, our findings unravel the beneficial effects of exogenous PACAP treatment upon infection-induced neuroinflammation, highlighting the potential implication of neuropeptides to promote neuronal survival and minimize synaptic prejudice. [ABSTRACT FROM AUTHOR]

Introduction: The acquired immunodeficiency syndrome is the final stage of a chronic, communicable and progressive disease of viral cause. The neurotoxoplasmosis is the most frequent opportunist infection in immunodepressed patients. Objective: To characterize patients with secondary neurotoxoplasmosis to human immunodeficiency virus/aids according to epidemiological, clinical and imaging variables. Methods: An observational, descriptive and cross-sectional study of 18 patients with AIDS was carried out, who received clinical and microbiological diagnosis of neurotoxoplasmosis, characterized according to findings in the magnetic resonance by images before and after the treatment, from January, 2017 to December, 2019. Results: In the investigation there was a prevalence of the male sex, the ages of 34 or less years (66.7 %) and the clinical signs of fever (100.0 %) and headache (88.9 %). Themost common localization of the lesions was in the cortico-subcortical juntion (66.1 %). The hypointense images in T1 and fluid attenuated inversion recovery and hyperintense images in T2 were the most frequent; the multiple lesions (66.7 %) of small size (50.0 %) and irregular contours (88.9 %) were notable. Before the treatment the enhance of anular type had more frequency (72.2 %) and grade 2 vasogenic edema (50.0 %); after this, 55.6 % of those affected persons presented calcifications and 72.2 % intralesional hemorrhages. It was evidenced that 77.8 % had improvement respect the cerebral edema. Conclusions: The magnetic resonance by images allowed to characterize the patients with human immunodeficiency virus/aids and cerebral toxoplasmosis, as well as to evaluate the therapeutic response through the modifications in the imaging findings. Key words: acquired immunodeficiency syndrome; cerebral toxoplasmosis; opportunist infections; magnetic resonance. [ABSTRACT FROM AUTHOR]

Toxoplasmosis is defined as a cosmopolitan protozoan disease caused by an obligate intracellular coccidia, Toxoplasma gondii. The advent of HIV infection has made cerebral toxoplasmosis one of the most widespread neurological opportunistic infections. Method: We conducted a descriptive crosssectional study with retrospective review of files of cerebral toxoplasmosis on HIV infected patients who had been hospitalized in the infectious diseases department of Point G University Hospital between January 1st, 2014 and September 30th, 2019. Results: During the study period, the frequency of cerebral toxoplasmosis was 10.1% and in 46.4% of the patients, the diagnosis led to the discovery of HIV co-infection. The clinical features were characterized by fever, headaches, and motor deficit at 86.6%, 84.5% and 69.1% respectively. Roundel image on computed tomography was most represented and was found in 24.4% of patients. Anti-toxoplasma treatment based on trimethoprim /sulfamethoxazole (TMP/SMX) associated with folinic acid was initiated in 78 patients out of 90, but 19 patients had a contraindication or adverse effects to this combination and were treated with clindamycin. HAART was initiated in 31 patients out of 45 (68.9%) newly diagnosed. The overall prognosis was limited with a mortality rate of 42%. Conclusion: The prevalence of cerebral toxoplasmosis was high in our study, 10.1%. To reduce this prevalence, chemoprophylaxis should be initiated in all HIV-infected patients with a CD4 count below 200 cells/mm³. [ABSTRACT FROM AUTHOR]

Background: Patients with acquired immunodeficiency syndrome (AIDS) tend to suffer from several central nervous system (CNS) infections due to hypoimmunity. However, CNS aspergillosis (CNSAG) is extremely rare and difficult to diagnose. Thus, it is easily misdiagnosed. Case presentation: We reported a 47-year-old male AIDS patient with ghosting vision and anhidrosis on the left head and face. He was accordingly diagnosed with Toxoplasma gondii encephalitis (TE) at other hospitals, for which he received regular anti-Toxoplasma gondii and anti-human immunodeficiency virus (anti-HIV) treatment. Then, the patient was transferred to our hospital due to a lack of any improvement with the prescribed treatment. The patient's neurological examination revealed no abnormalities at admission, only a slight change in the cerebrospinal fluid. His cranial magnetic resonance imaging (MRI) revealed multiple abnormal signals in the brain parenchyma, and his blood was positive for Toxoplasma gondii IgG antibody. The initial diagnosis at our hospital was also TE. Considering the poor efficacy of anti-TE treatment, cerebrospinal fluid metagenomics next-generation sequencing (mNGS) was performed, but no pathogenic bacteria were detected. However, Aspergillus fumigatus was detected in the cerebrospinal fluid via targeted next-generation sequencing (tNGS) and bronchoalveolar alveolar lavage fluid via mNGS. The diagnosis was accordingly revised to CNSAG combined with his other clinical manifestations. After administering voriconazole antifungal therapy, the patient's symptoms were relieved, with improved absorption of the intracranial lesions. Conclusions: The present case experience indicates the need for clinicians to strengthen their understanding of CNSAG. Moreover, for patients with diagnostic difficulties, early mNGS and tNGS (using biological samples with only a few pathogens) are helpful for early diagnosis and treatment, potentially allowing patients to achieve favorable outcomes. [ABSTRACT FROM AUTHOR]

Introduction. Cerebral toxoplasmosis is one of the diseases of the central nervous system that can occur in people with AIDS. Cerebral toxoplasmosis occupies third place among fatal diseases that can occur in people with AIDS. Prevalence of toxoplasmosis is about 25-30% of the world’s human population, and in Asia it is as high as 40%. Risk factors for developing cerebral toxoplasmosis is needed to be sought to find out risk factors that triggers and acts as protective factors for toxoplasmosis cerebral in HIV-positive patients. Methods. Two reviewers searched PubMed and Medline to identify cohort, case-control and cross-sectional studies. Two independent reviewers searched the databases, identified studies and extracted data. Inclusion and exclusion criteria were applied for the data screening. Results. Four studies were included. Two prospective cohort studies, one multicenter cohort study and one case control study. Age was not found to have a role as a risk factor. Gender was shown to have significant in one study (Male vs female OR 0.47 95% CI 0.25-0.88, p = 0.02). CD4 100.000 was associated with 5.10 times higher to develop cerebral toxoplasma. Prophylaxis therapy using cotrimoxazole can reduce the risk of cerebral toxoplasmosis. Conclusion. Age, female sex, low CD4 cell count, and high HIV viral load increase the risk of cerebral toxoplasmosis, whereas ART therapy and prophylaxis with cotrimoxazole can reduce the risk.

HIV-infection is number one cause of mortality among all the infectious diseases in the Russian Federation. In cases of atypical clinical course early diagnosis is an issue, especially in primary health clinics, as clinical manifestation often carries polymorphic features. Thus, the late prescription of antiretroviral therapy, combined with opportunistic infections therapy often contributes to exacerbation of the patient’s condition, to severe complications and disability. This article discusses examples of such clinical cases.