EFFICACY AND TOLERANCE OF COTRIMOXAZOLE AS A FIRST LINE TREATMENT OF TOXOPLASMA ENCEPHALITIS IN MART

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EFFICACY AND TOLERANCE OF COTRIMOXAZOLE AS A
FIRST LINE TREATMENT OF TOXOPLASMA ENCEPHALITIS
IN MARTINIQUE S. Abel1, A. Foltzer1, Ph.
Cabre2, D. Smadja2, B. Liautaud1, A. Cabié1
(1) Service de Maladies Infectieuses et
Tropicales (2) Service de Neurologie CHU de
Fort-de-France, Martinique
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MAIN CENTRAL NEUROLOGICAL DISEASES IN HIV
INFECTED PATIENTS
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TOXOPLASMA ENCEPHALITIS IN AIDS PATIENTS

• Major cause of morbidity and mortality
• Often revealing HIV infection
• Uneasy Diagnosis
• Clinical
• TDM or MRI where available
• Probability based treatment
• Sulfadiazine pyriméthamine acide folinique
• Bad tolerance
• Not always available
• No IV form available
• Costly
• Need for Alternative choice of treatment

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TREATMENT OF TOXOPLASMOSIS WITH COTRIMOXAZOLE
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Efficacy and tolerance of Cotrimoxazole as a
first line treatment of Toxoplasma Encephalitis
in Martinique

• Patients and methods
• Open label prospective study, from August 1993 to
  December 2002
• Inclusion criteria
• HIV seropositive status
• Neurological disorders compatible with the
  diagnosis of toxoplasma encephalitis
• Brain Scan imaging judged typical of TE by the
  radiologist, or
• Abnormal brain scan imaging not typical of TE but
  with no other identified cause of laboratory
  workup
• CD4 lt 200 /mm3
• Exclusion criteria
• Cotrimoxazole prophylaxis with good compliance
• History of cotrimoxazole intolerance
• Toxoplasma negative serology

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TOXOPLASMA ENCEPHALITIS AND COTRIMOXAZOLE IN
MARTINIQUE

• Patients and methods
• Induction therapy
• TMP (10 mg/kg) SMZ (50 mg/kg) /day
• Intravenous or oral route
• During 6 to 8 weeks
• Until resolution of radiological lesions
• Follow-up
• Clinical and biological
• CT or RMI at day 15, and between 4 to 8 weeks
• Maintenance therapy
• TMP (160mg) SMZ (800 mg) x 1 /day (1
  double-strength tablet)

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TOXOPLASMA ENCEPHALITIS AND COTRIMOXAZOLE IN
MARTINIQUE

• Results
• 61 patients (36 men and 25 women), 39.1 years

MSM 15
IV drug use 8
Hetero. 77
HIV transmission group
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TOXOPLASMA ENCEPHALITIS AND COTRIMOXAZOLE IN
MARTINIQUE

• HIV infection at time of toxoplasma encephalitis
  (TE) diagnosis

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TOXOPLASMA ENCEPHALITIS AND COTRIMOXAZOLE IN
MARTINIQUE Clinical and radiographic features at
presentation
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TOXOPLASMA ENCEPHALITIS AND COTRIMOXAZOLE IN
MARTINIQUE Efficacy

• In an intent-to-treat analysis

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TOXOPLASMA ENCEPHALITIS AND COTRIMOXAZOLE IN
MARTINIQUE Tolerance
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TOXOPLASMA ENCEPHALITIS AND COTRIMOXAZOLE IN
MARTINIQUE Relapses

• 17 of 50 patients (34)
• Median time of relapse 22 weeks
• Always in patients with poor observance of
  maintenance therapy
• Treatment of relapses
• Cotrimoxazole 75
• Efficacy 87.5

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TOXOPLASMA ENCEPHALITIS AND COTRIMOXAZOLE IN
MARTINIQUE Survival after TE
Since 1997
Probability of survival,
Logrank p 0.1
Before 1997
12 months Survival 0.71
Months from TE diagnosis
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TOXOPLASMA ENCEPHALITIS AND COTRIMOXAZOLE IN
MARTINIQUE Follow-up at 31/10/2003
Lost of follow-up 15
Patients dead 47 TE 2/29
Patients alive 38
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TOXOPLASMA ENCEPHALITIS AND COTRIMOXAZOLE IN
MARTINIQUE Follow-up at 31/10/2003
Patients dead 47 TE 2/29
Lost of follow-up 15
Patients alive 38
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EFFICACY AND TOLERANCE OF TREATMENTS OF
TOXOPLASMOSIS ENCEPHALITIS
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Randomized trial of trimethoprim-sulfamethoxazole
versus pyrimethamine-sulfadiazine for therapy of
toxoplasmic encephalitis in patients with
AIDSTorre et al, AAC 1998.
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STRONG POINTS OF COTRIMOXAZOLE IN TOXOPLASMA
ENCEPHALITIS
1- MMWR June 2002
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TOXOPLASMA ENCEPHALITIS AND COTRIMOXAZOLEConclusi
on

• Prophylaxis
• Bacterial infections
• Pneumocystosis
• Toxoplasmosis

• Induction phase
• Isosporiasis
• Pneumocystosis
• Nocardiosis
• Toxoplasmosis ?

Using CTX, which offers the great flexibility of
either oral or IV administration, as a first line
medication in the management of opportunistic
infections in HIV positive patients in the
Caribbean and particularly in resource poor
settings is a simplified cost-effective strategy
and could be part of the algorithms designed for
the management of HIV positive patients.
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