Title : When standard treatment fails: A case report on clindamycin and azithromycin for toxoplasma encephalitis in HIV
Abstract:
Background: Toxoplasma encephalitis represents a prevalent late-stage complication of severe immunodeficiency in patients living with HIV. Within resource-constrained settings in the Philippines, Trimethoprim-Sulfamethoxazole is the sole available therapeutic intervention for this condition.
Case Proper: We present a case of a 29-year-old male with advanced HIV who initially received Trimethoprim-Sulfamethoxazole for toxoplasma encephalitis After three months, he developed hypersensitivity reactions, including periorbital swelling and pruritic wheals, which led to discontinuation of Trimethoprim-Sulfamethoxazole after failed desensitization. Despite a temporary improvement in CD4 count, he returned with new-onset diplopia. Cranial imaging showed multiple ring-enhancing lesions indicative of toxoplasma encephalitis recurrence. Consequently, a combination of Clindamycin and high dose Azithromycin was initiated as secondary prophylaxis, alongside antiretroviral therapy comprising Tenofovir, Lamivudine, and Dolutegravir. Within two weeks, his diplopia improved significantly, and he was discharged without recurrence of neurological symptoms during follow-up.
Discussion: The only available treatment for toxoplasma encephalitis in the Philippines is Trimethoprim-Sulfamethoxazole, with no immediate access to alternative regimens such as Pyrimethamine. Similar cases have been reported in Iran and Japan where the use of Trimethoprim-Sulfamethoxazole resulted in adverse reactions such as thrombocytopenia and acute liver toxicity, while alternative regimens led to renal failure. In these case reports, a combination of Clindamycin and Azithromycin was started with no observed adverse effects. Clindamycin and macrolide Azithromycin are known to exhibit in vitro activity against Toxoplasma gondii, though this regimen is not widely used in the Philippines due to its limited evidence, and concerns about prolonged use, including the risks of arrhythmia and gastrointestinal symptoms. The patient in our case tolerated the treatment for nine months without experiencing any adverse effects.
Conclusion: In individuals presenting with advanced HIV disease complicated by toxoplasma encephalitis and for whom Trimethoprim-Sulfamethoxazole is not tolerated, the combination of Clindamycin and Azithromycin offers. a promising alternative. Although clinical improvement is promptly discernible, full resolution of lesions on imaging may take over a year. This is the first documentation of the usefulness of Clindamycin and Azithromycin drug combination in successfully treating Toxoplasma Encephalitis in the Philippines.
