Teaching neuroimages: conus medullaris involvement in cerebrospinal toxoplasmosis.

A 41-year-old woman originally from West Africa presented with a 3-week history of generalized weakness. Clinical examination demonstrated quadriparesis, urinary incontinence, and reduced level of consciousness. The imaging of the neuraxis revealed multiple bilateral cerebral lesions, including basal ganglia and midbrain. Spinal cord imaging showed lesions in the conus medullaris (figure). The HIV test was reactive, with a CD4 count of 10 cells/mL (normal range 700–1,200/mL). CSF PCR forToxoplasma gondiiwas positive. CSF cryptococcal antigen, fungal and mycobacterial cultures, Epstein-Barr virus PCR, andMycobacterium tuberculosis PCR were negative. Conus medullaris involvement is an uncommon manifestation of toxoplasmosis in advanced HIV.