THERAPEUTIC MANAGEMENT OF NEUROTOXOPLASMOSIS: FIRST-LINE PROTOCOLS

Abstract

Neurotoxoplasmosis is a serious opportunistic disease of the central nervous system (CNS), caused by the reactivation of cysts of the intracellular protozoan Toxoplasma gondii. It is the main cause of intracranial expansive lesions in immunosuppressed individuals, particularly in people living with HIV/AIDS with advanced immunodeficiency, as well as in transplant recipients and patients using modern immunomodulatory therapies. This study aimed to synthesize contemporary evidence on the diagnosis and first-line protocols for the management of neurotoxoplasmosis, with emphasis on practical approaches and current controversies. Clinical management requires the integration of epidemiological suspicion, neuroimaging, and early therapeutic response. The diagnosis is mostly presumptive, supported by a combination of compatible clinical presentation and typical neuroimaging findings, such as ring enhancement and multifocal lesions. Magnetic Resonance Imaging (MRI) is the method of choice, although Computed Tomography (CT) is widely used in emergency scenarios or with limited resources. Confirmatory tests, such as the detection of T. gondii DNA by PCR in cerebrospinal fluid, have high specificity but variable sensitivity, reinforcing that a negative result does not exclude the diagnosis. First-line treatment remains centered on the combined therapy of pyrimethamine and sulfadiazine with folinic acid rescue, the "standard" regimen. However, trimethoprim-sulfamethoxazole (SMX-TMP) has grown as an effective and preferred alternative in certain contemporary protocols, standing out for its accessibility, lower cost, and better adherence profile. Despite advances, current therapies control the infection but are not effective in eliminating latent tissue cysts. Atypical cases and differential diagnosis with primary CNS lymphoma justify dynamic reassessment and, occasionally, biopsy. It is concluded that therapeutic success depends on early recognition, appropriate regimen selection, management of complications, and surveillance in new at-risk populations related to immunotherapies.