Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Bhanu K Bhakhri

"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
Its wide based indexing and open access publications attracts many authors as well as readers
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Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018

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"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."

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Ex-Member, Governing Body, National Neonatology Forum, New Delhi
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Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018

Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

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Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
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Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Important Notice

Case report
Year : 2012 | Month : August | Volume : 6 | Issue : 6 | Page : 1083 - 1085

Cerebral Toxoplasmosis Mimicking Intracranial Tuberculoma

Deepak Madi , Basavaprabhu Achappa, Satish Rao, Prabha Adhikari, Soundarya Mahalingam

1. Assistant Professor, Department of General Medicine, KMC, Mangalore, India. 2. Associate Professor, Department of General Medicine, KMC, Mangalore, India. 3. Associate Professor, Department of General Medicine, KMC, Mangalore, India. 4. Professor, Department of General Medicine, KMC, Mangalore 5. Associate Professor, Department of Paediatrics, KMC, Mangalore, India.

Correspondence Address :
Dr. Basavaprabhu Achappa Associate Professor, Department of General Medicine, KMC Hospital, Attavar, Mangalore, Karnataka, - 575001 (India). (Affiliated to Manipal University) Phone: 9980170480 E-mail:;


Cerebral toxoplasmosis, HIV/AIDS, Tuberculoma

How to cite this article :

Deepak Madi , Basavaprabhu Achappa, Satish Rao, Prabha Adhikari, Soundarya Mahalingam. CEREBRAL TOXOPLASMOSIS MIMICKING INTRACRANIAL TUBERCULOMA . Journal of Clinical and Diagnostic Research [serial online] 2012 August [cited: 2018 Oct 21 ]; 6:1083-1085. Available from

Patients with HIV infection who present with a changed mental status or an abnormal neurologic examination are frequently found to have intracranial parenchymal lesions (1). Toxoplasmosis, cryptococcosis, tuberculosis, primary CNS lymphoma and progressive multifocal leukoencephalopathy are the more frequent opportunistic diseases that involve the central nervous system in HIV-infected patients. Their diagnosis may be difficult, because the findings of lumbar puncture, Computed Tomography (CT), and magnetic resonance imaging are relatively non-specific. Toxoplasmosis is one of the most common causes of the focal brain lesions in patients with the acquired immune deficiency syndrome, particularly in the developing countries. In this case report, we have discussed the differential diagnosis of cerebral toxoplasmosis in an immunocompromised patient.

Case Report

A 21-year-old female, a known case of a retroviral disease who was on treatment (Stavudine, Lamivudine, Efavirenz), presented to our institute with complaints of fever, headache and vomiting of 3 days duration. She was diagnosed to have a retroviral disease 7 years back. She had suffered from pulmonary tuberculosis 4 years ago. Her initial CD4+ count was 241/μl (7 years ago). She was advised second line ART 4 months back in view of the immunological failure (CD4+ count was159/μl). On examination, it was observed that there was no focal neurological deficit.

Her lab investigations showed Hb-12.3 g/dl, total white blood cell count- 6300 cells/, DC– N-77 L-13 E-03 M-7, platelet count-2,06,000 cells/ and ESR-93mm/1st hour. Her serum levels of electrolytes, blood sugar, renal and liver function tests were normal. The HIV test for HIV-1 was reactive. Her chest X-ray and ultrasound abdomen were normal.

The computed tomography scan of her brain showed a 3×2 cm ring enhancing lesion in the left basal ganglia, with extensive surrounding oedema, which caused effacement of the lateral and the 3rd ventricles, with midline shift (Table/Fig 1). CSF analysis was not done. Toxoplasma serology revealed raised IgG antibody levels of 279 IU/ml.

She was treated with mannitol, trimethoprim/sulfamethoxazole, pyrimethamine/sulfadoxine and anti-convulsants. Anti-retroviral drugs were continued. Her symptoms such as headache improved gradually within 4 days after her admission to the hospital. She developed pyrimethamine induced thrombocytopaenia after 10 days of treatment (platelet count-8,000 cells/ So, she was treated with clindamycin 600mg thrice daily for 2 weeks and the other drugs were stopped. After 21 days, a repeat CT of the brain was done, which showed significant resolution of the lesions (Table/Fig 2). She was advised to continue with the antiretroviral drugs (Second line antiretroviral therapy) and trimethoprim/sulfamethoxazole(prophylaxis).


Toxoplasmosis is an infection which is caused by the obligate intra-cellular parasite, Toxoplasma gondii. Cats are the definitive hosts. The human infection occurs via the oral or the transplacental route. Toxoplasmosis is generally a late complication of the HIV infection and it usually occurs in patients with CD4+ T cell counts below 200/μl. The major clinical features of cerebral toxoplasmosis are headache (55%), fever (41%–47%), confusion (52%), hemiparesis (39%–49%) and seizures (29%) (2).

The classic typical CT and MRI findings in patients with toxoplasmosis are ≥2 ring-enhancing lesions with surrounding oedema. The lesions can be solitary in 27%-43% of the patients (3). Our patient had a solitary lesion in the basal ganglia. MRI is more sensitive than CT for detecting the brain lesions which are caused due to toxoplasmosis. One study showed that MRI detected abnormalities in 40% of the patients whose abnormalities were not detected on CT (4). An MR imaging feature which is considered as pathognomonic of toxoplasmosis is the ‘eccentric target sign’ – it is demonstrable on the post-contrast CT or the MRI scans. It is however found in less than 30% of the cases. Other conditions that can cause ring enhancing lesions in patients with AIDS include tuberculosis, CNS lymphoma, gliomas and other primary CNS neoplasms, metastases, and abscesses.

Tuberculomas may be solitary or multiples. There is a direct relationship between the degree of immunosuppression and the presence of the multiple brain tuberculomas. Tuberculomas may be seen as hypo- or hyper dense, round or multilobar lesions on CT, and they may show homogeneity or ring enhancement (5).The target sign has been described as characteristic of tuberculomas, which consists of a ring enhancing lesion with an additional central area of enhancement or calcification. Unfortunately, the “target sign” is an infrequent finding (6). The imaging findings of intracranial tuberculomas are nonspecific, and they have to be differentiated from other causes of the space-occupying lesions such as high grade gliomas, abscesses, toxoplasmosis, cysticercosis, metastases, and lymphomas.

Cerebral toxoplasmosis lesions are generally multiple, tuberculous brain abscesses are usually single, whereas in primary CNS lymphoma, solitary and multiple lesions may occur at approximately the same frequency (7). The lesions which measure more than 4 cm are more likely to be lymphomas, when they are compared with cerebral toxoplasmosis (8). However, it is often difficult to distinguish between these two conditions clinically and radiographically. Thallium-201 SPECT has been used to differentiate the CNS lymphomas from the infectious causes of the brain lesions (most commonly, toxoplasmic encephalitis). In patients with AIDS, the 201 Thallium brain single photon emission computed tomography (SPECT) does not accumulate in the non-neoplastic lesions like haematomas and in infectious processes like toxoplasmosis (9).

Empirical antitoxoplasma treatment is recommended in HIV-positive patients with ring-enhancing lesions, with surrounding oedema and with a positive toxoplasma serology. The definitive diagnosis of toxoplasmosis requires a demonstration of tachyzoites in a biopsy specimen ofthe brain. A brain biopsy should only be considered in patients with a negative toxoplasma serology and in those who do not respond to the antitoxoplasma treatment. Once cerebral toxoplasmosis is suspected, the treatment should be started empirically pending the confirmation of the diagnosis (10).

At our centre, we used trimethoprim/sulfamethoxazole and pyrimethamine/sulfadoxine to treat AIDS-associated cerebral toxoplasmosis, as sulfadiazine was not available in our state. Trimethoprim/sulfamethoxazole (11) is an alternative treatment for toxoplasmic encephalitis because it is inexpensive and because it is as effective as pyrimethamine-sulfadiazine. After 21 days, a repeat CT of the brain was done, which was normal. The response to the drug therapy is typically rapid, with noticeable regression of the lesions, which is apparent on the imaging studies within 10 days to 2 weeks (12).


Cerebral tuberculoma is always considered in the differential diagnosis of solitary and large focal brain lesions in HIV-infected patients, particularly in tuberculosis endemic areas. The differential diagnosis is broad for cerebral toxoplasmosis. This case report will help physicians in making a proper differential diagnosis and in starting the appropriate treatment in HIV patients with intracerebral mass lesions without wasting time, thereby decreasing the morbidity and the mortality.


Jellinger KA, Setinek U, Drlicek M, Bohm G, Steurer A, Lintner F. Neuropathology and general autopsy findings in AIDS during the last 15 years. Acta Neuropathol 2000; 100: 213-20.
Porter S, Sande M. Toxoplasmosis of the central nervous system in the acquired immunodeficiency syndrome. N Engl J Med 1992; 327:1643–8.
Luft B, Hafner R, Korzun A,Leport C, Antoniskis D, Bosler EM, et al. Toxoplasmic encephalitis in patients with the acquired immunodeficiency syndrome. N Engl J Med1993; 329:995–1000.
Levy RM, Mills CM, Posin JP, Moore SG, Rosenblum ML, Bredesen DE. The efficacy and the clinical impact of brain imaging in neurologically symptomatic AIDS patients: a prospective CT/MRI study. J Acquir Immune Defic Syndr. 1990;3:461-71.
De Castro CC, de Barros NG, Campos ZM, Cerri GG. CT scans of cranial tuberculosis. Radiol Clin North Am 1995; 33:753-69.
Whiteman ML. Neuroimaging of the central nervous system tuberculosis in HIV-infected patients. Neuroimaging Clin N Am 1997;7: 199-213.
Skiest DJ. Focal neurological disease in patients with the acquired immunodeficiency syndrome. Clin Infect Dis. 2002;34:103-15.
Offiah CE, Turnbull IW. The imaging appearances of the intracranial CNS infections in adult HIV and AIDS patients. Clin Radiol. 2006;61:393-40.
Black KL, Hawkins RA, Kim KT, Becker DP, Lerner C, Marciano D. Use of 201Tl SPECT to quantitate the malignancy grade of gliomas. J Neurosurg 1989;71:342-6.
Wulf MWH, Van Crevel R, Portier R, TerMeulen CG, Melchers WJ, van der Ven A, et al. Toxoplasmosis after renal transplantation: impli- cations of a missed diagnosis. J Clin Microbiol. 2005;43:3544-7.
Patil HV, Patil VC, Rajmane V, Raje V. Successful treatment of cerebral toxoplasmosis with cotrimoxazole. Indian J Sex Transm Dis 2011;32:44-6.
Luft BJ, Remington JS. AIDS commentary. Toxoplasmic encephalitis. J Infect Dis 1987; 157:1-6.

DOI and Others

ID: JCDR/2012/3927:2340

Date of Submission: Jan 01, 2012
Date of Peer Review: Mar 22, 2012
Date of Acceptance: Mar 29, 2012
Date of Publishing: Aug 10, 2012


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