Late diagnosis, CD4 count 30, CNS toxo. Lymphoma?

Question

I was diagnosed positive at 15 May 2018 with CD4 count only 30 and VL 180.000/ml. I was headache and dizziness, imparied vision, oral candidiasis, night sweats and persistent cough. I don't remember much when I landed in hospital. MRI scan showed multifocal lesion, biggest of them was 25mm diameter, other lesions were below 3mm. My Toxo IGg was 2800, IGm neg, CMV Igg 380 and IGm neg. My LDH was 160 and b2 microglobulin 1.6. My doctor prescribe me empirically anti toxo regimen as below. I started Sulfadiazine 2x3g, Daraprim 75mg, Calcium Folinate 15mg, Dexamethasone i.v., Mannitol i.v. and after HLA screening, 30th May I started Triumeq. At end of May my MRI scan showed only a litte improvement and greater clinical improvement. 20th June I was dismissed hospital with Triumeq, 2x1.5g Sulfadizine, Daraprim 50mg and 15mg Calcium Folinate. 9th July I was CD4 130 22%, 8th August I was UD VL (37 copies/ml) and MRI scan showed only a litte improvement. 15th August I was CD4 count 110 11% and MRI scan showed 5mm regression of lesion (diameter below 20mm). 24th August I did MR Spectroscopy, what ruled out tumor character of lesion. Description of MR Spectroscopy was done by MD professor of radiology. My condition is gradually improve, my vision is now normal, the cough, night sweats, headche and dizziness has passed. 10th October my CD4 count drop to 94 and 9%. My doctor worry about my CD4 level and suggest to carry brain biopsy to confirm toxo diagnosis. I afraid of biopsy because it is risky. My doctor left me a decision what to do. I would like to avoid biopsy because I fell well, much better than in May. I think about perform SPECT/PET scan or MRI with perfussion to confirm toxo diagnosis. My doctor say only biopsy can get sure diagnosis and certainly ruled out lymphoma. What should I do? Perform above tests or agree biopsy? What could decrase CD4 count, maybe Daraprim? CNS lymphoma can decrease CD4 level itself? I would be very thankful for any suggestion. Sorry for any grammal mistakes - English isn't my native language.

Answer

Thank you for providing the information regarding your complex medical history. Your doctors appear to be doing a good job. It is difficult for me to determine exactly what is going on without reviewing all the medical records. Given the positive toxoplasmosis blood test, scan results, and your response to HIV and toxoplasmosis treatment, toxoplasmosis seems the most likely diagnosis. I think if lymphoma were present, symptoms would have progressed, not gotten better. I might wait a bit more and see whether there is any progression on a new scan or not before deciding what the next step is.