Ventriculitis and hydrocephalus with hypoglycorrhachia in congenital toxoplasma infection.

Sir,

Congenital central nervous system toxoplasmosis can present in varied different forms. One of its rarest presentations is isolated hydrocephalus and ventriculitis with no parenchymal lesion.

A 4-month-old child was brought to the hospital with a complaint of enlarging head size, fever, and poor feeding for 3 weeks. Examination revealed enlarged head circumference and bulging anterior fontanelle. Ultrasonography showed increased echogenicity of ventricles while gadolinium-magnetic resonance (MR) revealed hydrocephalus with no focal parenchymal lesions. The debris within the ventricle was evident on MR imaging as focal hypointense lesion within the ventricle on T2-weighted image [Figure 1]. Cerebrospinal fluid (CSF) analysis showed sugar 12 mg/dl, counts 450/mm3, and proteins 60 mg/dl. CSF was positive for polymerase chain reaction for toxoplasma while immunoglobulin G (IgG) and IgM were both negative. With a working diagnosis of congenital toxoplasmosis, the child was started on sulfadiazine and pyrimethamine therapy. The child improved clinically, started tolerating feeds and cells in CSF decreased, but sugars persistently remained below 20 mg/dl. Since the CSF picture was normal other than sugar value, we proceeded ahead with endoscopic third ventriculostomy for persistent hydrocephalus, 3 weeks later.

Figure 1

(a) T2-weighted image showing hydrocephalus with hypointensity of mural nodule in right lateral ventricle. (b) T1-weighted contrast image showing contrast enhancement of mural nodule

Congenital toxoplasmosis results from the transplacental passage of the toxoplasma gondi parasite from the mother to the fetus. Though the majority of babies are asymptomatic, some may present with anemia, jaundice, hepatosplenomegaly, seizures, hydrocephalus, chorioretinitis, and sensori-neural deafness. Radiology shows ring enhancing lesions at corticomedullary junction, white matter of basal ganglia (75–88%), thalamus or as diffuse cerebritis.[12] Ventriculitis and consecutive obstructive hydrocephalus may occur due to compression of CSF outflow pathway by ring enhancing lesions or ventriculitis.[13] Postcontrast periventricular enhancement on MR imaging is consistent with ventriculitis.[24] Though antitoxoplasma therapy alone may suffice and spontaneous resolution of hydrocephalus may be seen, the enlarging head circumference in our patient made CSF diversion compulsory.[4] We emphasize on early suspicion of toxoplasmosis in newborns with hydrocephalus and to proceed with CSF diversion for hydrocephalus despite persistent hypoglycorrhachia.

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Conflicts of interest

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