Toxoplasmosis vs lymphoma
Updates to Article Attributes
It is common for radiologists to be asked to distinguish between Toxoplasmosis and cerebral toxoplasmosisprimary CNS lymphoma (PCNSL) inlymphoma are frequently differential diagnoses in patients with HIV/AIDS. Treatment and as treatment is clearlysubstantially different and thus accurate interpretation of CT and MRIdistinguishing the two is essentialimportant.
In many instances, the imaging appearance is classic and differentiation is not problematic; however, in 50-80% of cases, the appearances can be very similar 1. Below are helpful distinguishing features.
For a general discussion on each diagnosis, please refer to the individual articles: cerebral toxoplasmosis and primary CNS lymphoma.
Radiographic features
Distribution
Primary CNS lymphoma typically demonstrates subependymal spread, whereas toxoplasmosis tends to be scattered through the basal ganglia and at the corticomedullary junction 1.
HIV lymphoma also is far more frequently a solitary lesion, whereas toxoplasmosis is usually multifocal (86%) 2,3.
Enhancement
On CT and MRI, both entities enhance following administration of contrast. Lymphoma may solidly enhance, whereas toxoplasmosis usually demonstrates ring or nodular enhancement 1,2.
However, in the setting of HIV/AIDS, primary CNS lymphoma may also demonstrate ringperipheral enhancement. Thus, the pattern of enhancement may not be helpful.
Haemorrhage
Haemorrhage does not happen typicallyis uncommon in PCNSL beforelymphoma, especially prior to treatment, but may be seen occasionally in toxoplasmosis.
MR spectroscopy
- both entities demonstrate increased lactate and lipids, although this tends to be less marked in lymphoma
- lymphoma typically demonstrates marked increase in
Chocholine, whereas it is reduced in toxoplasmosis 1,2 - both lesions demonstrate decreased
Crcreatine and NAA; however, this finding is variable
Ideally, MRSMR spectroscopy (MRS) should should be performed with both long and short TE sequences 1.
MRI perfusion
A decrease in cerebral blood volume (rCBV) centrally within lesions suggests toxoplasmosis, whereas it is increased in lymphoma 1. However, rCBV is reduced in the perilesional oedema of both lesions.
SPECT
Thallium 201 Chloridechloride SPECT demonstrates increased uptake in lymphomaSPECT, because thallium serves as a potassium analogue and is avidly taken up by hypermetabolic tumortumour cells 6. By contrast, thallium activity is decreased in toxoplasmosis because there is no cellular correlate 2.
Practical points
Features that favour primary CNS lymphoma include:
- single lesion
- subependymal spread
- solid enhancement
- no haemorrhage before treatment
- Thallium SPECT positive
- MRS: increased choline
(Cho) - MR perfusion: increased rCBV
Features that favour cerebral toxoplasmosis include:
- multiple lesions
- scattered
thoughthroughout the basal ganglia and corticomedullary junction - ring or nodular enhancement
- haemorrhage occasionally occurs mostly in the periphery of the lesion
- Thallium SPECT negative
- MRS: decreased choline (Cho)
- MR perfusion: decreased rCBV
-<p>It is common for radiologists to be asked to <strong>distinguish between <a href="/articles/neurotoxoplasmosis">cerebral toxoplasmosis</a> and <a href="/articles/primary-cns-lymphoma">primary CNS lymphoma</a></strong> (PCNSL) in patients with HIV/AIDS. Treatment is clearly different and thus accurate interpretation of CT and MRI is essential.</p><p>In many instances, the imaging appearance is classic and differentiation is not problematic; however, in 50-80% of cases the appearances can be very similar <sup>1</sup>. Below are helpful distinguishing features.</p><h4>Radiographic features</h4><h5>Distribution</h5><p>Primary CNS lymphoma typically demonstrates subependymal spread, whereas toxoplasmosis tends to be scattered through the <a href="/articles/basal-ganglia">basal ganglia</a> and at the corticomedullary junction <sup>1</sup>. </p><p>HIV lymphoma also is far more frequently a solitary lesion, whereas toxoplasmosis is usually multifocal (86%) <sup>2,3</sup>.</p><h5>Enhancement</h5><p>On CT and MRI, both entities enhance following administration of contrast. Lymphoma may solidly enhance, whereas toxoplasmosis usually demonstrates <a href="/articles/cerebral-ring-enhancing-lesions">ring</a> or nodular enhancement <sup>1,2</sup>.</p><p>However, in the setting of HIV/AIDS, primary CNS lymphoma may also demonstrate ring enhancement. Thus, the pattern of enhancement may not be helpful.</p><h5>Haemorrhage</h5><p>Haemorrhage does not happen typically in PCNSL before treatment, but may be seen occasionally in toxoplasmosis.</p><h5>MR spectroscopy</h5><ul>- +<p><strong>Toxoplasmosis and lymphoma</strong> are frequently differential diagnoses in patients with HIV/AIDS and as treatment is substantially different distinguishing the two is important. </p><p>In many instances, the imaging appearance is classic and differentiation is not problematic; however, in 50-80% of cases, the appearances can be very similar <sup>1</sup>. Below are helpful distinguishing features.</p><p>For a general discussion on each diagnosis, please refer to the individual articles: <a title="Cerebral toxoplasmosis" href="/articles/neurotoxoplasmosis">cerebral toxoplasmosis</a> and <a title="Primary CNS lymphoma" href="/articles/primary-cns-lymphoma">primary CNS lymphoma</a>.</p><h4>Radiographic features</h4><h5>Distribution</h5><p>Primary CNS lymphoma typically demonstrates subependymal spread, whereas toxoplasmosis tends to be scattered through the <a href="/articles/basal-ganglia">basal ganglia</a> and at the corticomedullary junction <sup>1</sup>. </p><p>HIV lymphoma also is far more frequently a solitary lesion, whereas toxoplasmosis is usually multifocal (86%) <sup>2,3</sup>.</p><h5>Enhancement</h5><p>On CT and MRI, both entities enhance following administration of contrast. Lymphoma may solidly enhance, whereas toxoplasmosis usually demonstrates <a href="/articles/cerebral-ring-enhancing-lesions">ring</a> or nodular enhancement <sup>1,2</sup>.</p><p>However, in the setting of HIV/AIDS, primary CNS lymphoma may also demonstrate peripheral enhancement. Thus, the pattern of enhancement may not be helpful.</p><h5>Haemorrhage</h5><p>Haemorrhage is uncommon in lymphoma, especially prior to treatment, but may be seen occasionally in toxoplasmosis.</p><h5>MR spectroscopy</h5><ul>
-<li>lymphoma typically demonstrates marked increase in Cho, whereas it is reduced in toxoplasmosis <sup>1,2</sup>- +<li>lymphoma typically demonstrates marked increase in choline, whereas it is reduced in toxoplasmosis <sup>1,2</sup>
-<li>both lesions demonstrate decreased Cr and NAA; however, this finding is variable</li>-</ul><p><a href="/articles/mr-spectroscopy-1">MRS</a> should be performed with both long and short TE sequences <sup>1</sup>.</p><h5>MRI perfusion</h5><p>A decrease in cerebral blood volume (rCBV) centrally within lesions suggests toxoplasmosis, whereas it is increased in lymphoma <sup>1</sup>. However, rCBV is reduced in the perilesional oedema of both lesions.</p><h5>SPECT</h5><p><a href="/articles/thallium-201-chloride-1">Thallium 201 Chloride</a><a href="/articles/thallium-spect"> </a>SPECT demonstrates increased uptake in lymphoma, because thallium serves as a potassium analogue and is avidly taken up by hypermetabolic tumor cells <sup>6</sup>. By contrast, thallium activity is decreased in toxoplasmosis because there is no cellular correlate <sup>2</sup>.</p><h4>Practical points</h4><p>Features that favour <a href="/articles/primary-cns-lymphoma">primary CNS lymphoma</a> include:</p><ul>- +<li>both lesions demonstrate decreased creatine and NAA; however, this finding is variable</li>
- +</ul><p>Ideally, <a href="/articles/mr-spectroscopy-1">MR spectroscopy (MRS)</a> should be performed with both long and short TE sequences <sup>1</sup>.</p><h5>MRI perfusion</h5><p>A decrease in <a title="relative cerebral blood volume (rCBV)" href="/articles/cerebral-blood-volume-cbv">cerebral blood volume (rCBV)</a> centrally within lesions suggests toxoplasmosis, whereas it is increased in lymphoma <sup>1</sup>. However, rCBV is reduced in the perilesional oedema of both lesions.</p><h5>SPECT</h5><p><a href="/articles/thallium-201-chloride-1">Thallium 201 chloride</a> SPECT demonstrates increased uptake in lymphoma because thallium serves as a potassium analogue and is avidly taken up by hypermetabolic tumour cells <sup>6</sup>. By contrast, thallium activity is decreased in toxoplasmosis because there is no cellular correlate <sup>2</sup>.</p><h4>Practical points</h4><p>Features that favour <a href="/articles/primary-cns-lymphoma">primary CNS lymphoma</a> include:</p><ul>
-<li>MRS: increased choline (Cho)</li>- +<li>MRS: increased choline</li>
-<li>scattered though basal ganglia and corticomedullary junction</li>- +<li>scattered throughout the basal ganglia and corticomedullary junction</li>
-<li>haemorrhage occasionally occurs mostly in periphery of lesion</li>- +<li>haemorrhage occasionally occurs mostly in the periphery of the lesion</li>