<![CDATA[Human immunodeficiency virus (HIV) infection impairs cell-mediated immunity, increasing the risk of tuberculous meningitis (TBM) and cerebral toxoplasmosis. Both conditions may present with overlapping clinical and radiological manifestations, creating diagnostic and therapeutic challenges. A 45-year-old woman presented with a chronic headache, fever, and a history of right-sided hemiparesis and hypoesthesia. Magnetic resonance imaging (MRI) performed on August 18, 2026, revealed multiple ring-enhancing lesions with extensive perilesional edema, while repeat MRI on September 4, 2026, demonstrated eccentric target signs, extensive edema, and restricted diffusion. Cerebrospinal fluid (CSF) analysis revealed mononuclear pleocytosis, elevated protein levels, and decreased glucose levels. HIV antibody testing and anti-Toxoplasma gondii immunoglobulin G (IgG) serology were positive. The patient received antituberculosis therapy, trimethoprim-sulfamethoxazole (co-trimoxazole), dexamethasone, and antiretroviral therapy (ART). The CSF findings were consistent with chronic meningitis and raised suspicion for TBM, while serial MRI findings and positive serology supported the diagnosis of cerebral toxoplasmosis. A negative CSF Xpert MTB/RIF result did not exclude TBM. Management required concurrent treatment of both conditions, with careful consideration of drug interactions, adverse effects, and the risk of immune reconstitution inflammatory syndrome (IRIS). Suspected coinfection with TBM and cerebral toxoplasmosis in patients with HIV requires the integration of clinical findings, CSF analysis, serological testing, and MRI findings to guide diagnosis and treatment. In this case, treatment was associated with clinical improvement, including resolution of neurological deficits by the time of hospital discharge.]]>
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