WBR1502

Author	PageAuthor::William J Gibson
Exam Type	ExamType::USMLE Step 2 CK
Main Category	MainCategory::Internal medicine
Sub Category	SubCategory::Neurology
Prompt	[[Prompt::A 43 year old man presents with three weeks of severe dysphagia to solids resulting in a 25 pound weight loss. He has oral candidiasis and is admitted for inpatient workup. EGD reveals esophageal stricture. The patient reports that since the onset of his dysphagia, he has stopped taking his anti-retroviral regimen due to difficulty swallowing. On day 4 of his admission, he reports headaches and his mental status begins deteriorating. An MRI with contrast is performed (shown below). File:WBR1502 What is the most appropriate therapy to address the cause of this patient's neurological symptoms?]]
Answer A	AnswerA::Methotrexate
Answer A Explanation	AnswerAExp::Methotrexate is the preferred first line therapy for primary CNS lymphoma. The presence of multiple enhancing lesions in this patient's MRI make the diagnosis of primary CNS lymphoma less likely than Toxoplasmosis.
Answer B	AnswerB::Dexamethasone
Answer B Explanation	[[AnswerBExp::Dexamethasone is a corticosteroid used to decrease inflammation that may be associated with increased inctracranial pressure. While this patient may have some increased intracranial pressure from his toxoplasma infection, dexamethasone would not be the definitive therapy.]]
Answer C	AnswerC::Trimethoprim-Sulfamethoxazole
Answer C Explanation	AnswerCExp::Trimethoprim-Sulfamethoxazole (TMP-SMX) is often used as a second agent in regimens against Toxoplasmosis. TMP-SMX is synergistic in combination with Pyrimethamine. However, TMP-SMX is not recommended as a monotherapy against Toxoplasmosis.
Answer D	AnswerD::Pyrimethamine
Answer D Explanation	AnswerDExp::Pyrimethamine is the drug of choice in treating Toxoplasmosis.
Answer E	AnswerE::Azithromycin
Answer E Explanation	AnswerEExp::The efficacy of azithromycin in treating Toxoplasmosis is unclear.
Right Answer	RightAnswer::D
Explanation	[[Explanation:: Educational Objective: Multiple ring enhancing lesions in the brain of an HIV infected patient is highly concerning for cerebral Toxoplasmosis. Pyrimethamine is the preferred therapy. References: ]]
Approved	Approved::No
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