the introduction of highly active antiretroviral therapy ( haart ) and antibiotic prophylaxis against pulmonary opportunistic infections have resulted in considerable reduction of morbidity and mortality of this kind of patients . some of hiv - infected patients have pulmonary opportunistic infections in the haart era associated with different causes including patients who are unaware of their hiv serostatus and do not initiate haart , late stage of hiv infection , cd4 count less than 100 cells/l , haart non - adherence or failure to respond , injection drug use and failure to provide prophylaxis against opportunistic pathogens . pulmonary toxoplasmosis is the second location of extracerebral toxoplasmosis after the ocular form , with 40% of mortality without early diagnosis and specific treatment . pulmonary toxoplasmosis accounts for 4% of all cases of pneumonia in hiv - infected patients in the pre - haart era and is not considered commonly during the haart era . we described two cases of toxoplasma gondii pneumonia in hiv patients in the haart era . a 41-year - old hiv - positive man was admitted to our hospital because of fever and cough since 5 days . his medical history revealed intravenous drugs addiction , chronic renal failure and hepatitis c infection . he was started on haart based on abacavir , lamivudine and efavirenz during the last year . on examination his temperature was 37c , pulse rate of 100 beats per minute and 20 breaths per minute . relevant laboratory findings showed an hemoglobin level of 7 g / dl , total white cell count of 3,700 cells / mm and a normal platelet count . renal dysfunction was evidenced by serum urea of 47 mg / dl and creatinine of 1.8 mg / dl . the cd4 t - cell count was 35 cells/l and the plasma viral load was 203,906 copies / ml . serologic testing revealed the presence of t. gondii igg antibodies with a positive titer of 1:1024 and igm negative by indirect immunofluorescence . chest radiograph showing bilateral interstitial infiltrates fever and cough continued 7 days after admission to the hospital . on the eighth day a bronchoalveolar lavage ( bal ) cytological and microbiological examinations of the bal were negative for bacteria , fungi , pneumocystis jirovecii and mycobacterium tuberculosis . giemsa - stained smears of the bal were negative for tachyzoite forms of t. gondii . an aliquote of the bal fluid was assayed for t. gondii using the pcr technique for amplification of a fragment corresponding to the b1 gene . computed tomography ( ct ) scan of the brain showed marked cerebral atrophy without evidence of focal lesions . he showed a marked improvement in clinical , radiological , and laboratory findings after the seventh day of therapy for t. gondii . he was discharged from the hospital after 15 days of admission in a good clinical condition . he was intravenous drug user and had been diagnosed as hiv seropositive 10 years before . he was discharged from the hospital with improvement in clinical and radiological finding after treatment . the patient was not adhering to treatment with haart and secondary prophylaxis for t. gondii infection . on admission , he was febrile ( 38c ) , pulse rate of 100 beats per minute and 18 breaths per minute . laboratory results showed a white blood cell count of 8,600 cell / mm , an hemoglobin level of 12 g / dl and a normal platelet count . ct scan of the chest showed pleural effusion in the right lung [ figure 2b ] . serologic testing revealed the presence of t. gondii igg antibodies with a positive titer of 1:1024 and igm negative by indirect immunofluorescence . empiric treatment was initiated with ampicilin plus sulbactam . on the fifth day fever and cough continued . cytological and microbiological examinations were negative for bacteria , fungi , p. jirovecii and m. tuberculosis . giemsa - stained smears of the bal were negative for tachyzoite forms of t. gondii . a bal fluid sample was assayed for t. gondii using the pcr technique for amplification of a fragment corresponding to the b1 gene . ct studies of the brain showed a left temporoparietal periventricular lesion with mass effect on the middle - line structures [ figure 3 ] . ( a ) chest radiograph showing pleural effusion in right pulmonary lobe ( b ) computerized tomography showing pleural effusion in right pulmonary lobe computerized tomographic studies of the brain showing evidence of a focal lesion treatment for t. gondii infection was initiated with sulfadiazine plus pyrimethamine and folinic acid . in the following days he was discharged from the hospital after 30 days in a good clinical and neurological condition . a 41-year - old hiv - positive man was admitted to our hospital because of fever and cough since 5 days . his medical history revealed intravenous drugs addiction , chronic renal failure and hepatitis c infection . he was started on haart based on abacavir , lamivudine and efavirenz during the last year . on examination his temperature was 37c , pulse rate of 100 beats per minute and 20 breaths per minute . relevant laboratory findings showed an hemoglobin level of 7 g / dl , total white cell count of 3,700 cells / mm and a normal platelet count . renal dysfunction was evidenced by serum urea of 47 mg / dl and creatinine of 1.8 mg / dl . the cd4 t - cell count was 35 cells/l and the plasma viral load was 203,906 copies / ml . serologic testing revealed the presence of t. gondii igg antibodies with a positive titer of 1:1024 and igm negative by indirect immunofluorescence . chest radiograph showing bilateral interstitial infiltrates fever and cough continued 7 days after admission to the hospital . on the eighth day a bronchoalveolar lavage ( bal ) cytological and microbiological examinations of the bal were negative for bacteria , fungi , pneumocystis jirovecii and mycobacterium tuberculosis . giemsa - stained smears of the bal were negative for tachyzoite forms of t. gondii . an aliquote of the bal fluid was assayed for t. gondii using the pcr technique for amplification of a fragment corresponding to the b1 gene . computed tomography ( ct ) scan of the brain showed marked cerebral atrophy without evidence of focal lesions . he showed a marked improvement in clinical , radiological , and laboratory findings after the seventh day of therapy for t. gondii . he was discharged from the hospital after 15 days of admission in a good clinical condition . he was intravenous drug user and had been diagnosed as hiv seropositive 10 years before . he was discharged from the hospital with improvement in clinical and radiological finding after treatment . the patient was not adhering to treatment with haart and secondary prophylaxis for t. gondii infection . on admission , he was febrile ( 38c ) , pulse rate of 100 beats per minute and 18 breaths per minute . laboratory results showed a white blood cell count of 8,600 cell / mm , an hemoglobin level of 12 g / dl and a normal platelet count . ct scan of the chest showed pleural effusion in the right lung [ figure 2b ] . serologic testing revealed the presence of t. gondii igg antibodies with a positive titer of 1:1024 and igm negative by indirect immunofluorescence . empiric treatment was initiated with ampicilin plus sulbactam . on the fifth day fever and cough continued . cytological and microbiological examinations were negative for bacteria , fungi , p. jirovecii and m. tuberculosis . giemsa - stained smears of the bal were negative for tachyzoite forms of t. gondii . a bal fluid sample was assayed for t. gondii using the pcr technique for amplification of a fragment corresponding to the b1 gene . ct studies of the brain showed a left temporoparietal periventricular lesion with mass effect on the middle - line structures [ figure 3 ] . ( a ) chest radiograph showing pleural effusion in right pulmonary lobe ( b ) computerized tomography showing pleural effusion in right pulmonary lobe computerized tomographic studies of the brain showing evidence of a focal lesion treatment for t. gondii infection was initiated with sulfadiazine plus pyrimethamine and folinic acid . in the following days he was discharged from the hospital after 30 days in a good clinical and neurological condition . spectrum of hiv - related pulmonary complications that can be seen in the haart era include p. jirovecii pneumonia , bacterial pneumonia and interstitial pneumonitis with unknown etiology but not pulmonary toxoplasmosis . clinical manifestations include febrile illness associated with unspecific respiratory symptoms such as cough and dyspnea . here , we described two hiv - infected patients with poor adherence to haart and antibiotic prophylaxis , with fever and cough but not with dyspnea or adult respiratory distress syndrome ( ards ) . kovari and colleagues published two cases in 2010 with unknown hiv status and pulmonary toxoplasmosis in switzerland , one patients with ards and the second with productive cough . other findings include nodular solitary lesions and pneumothorax . in the first case that we described , chest radiograph showed bilateral interstitial infiltrates and , in the second , the swiss cases chest radiographs showed bilateral diffuse interstitial infiltrates , one of them associated with p. jirovecii . pulmonary toxoplasmosis occurred in patients with advanced immunodeficiency with cd4 t - cell count less than 100 cells/l . serological data for the patients showed a rise in igg levels but were negative for igm during the acute episode of pulmonary toxoplasmosis . diagnosis of pulmonary toxoplasmosis is based on the identification of tachyzoites or dna of t. gondii in samples of bal , biopsy specimens or necropsy . bal samples should be processed by several methods such as giemsa staining , tissue culture , intraperitoneal inoculation of mice , immunoperoxidase assay and detection of parasite dna by molecular techniques . giemsa - stained smears of bal fluids from the two patients were negative for tachyzoite forms of t. gondii . visualization of tachyzoites in bal fluid by giemsa is difficult because of their small size or their small number . t. gondii dna is detected in bal specimens with the use of primers targeting the b1 gene . the b1 gene is highly specific for t. gondii and can detect as few as 10 organisms . diagnosis of pulmonary toxoplasmosis was established in the two cases with the use of primers targeting the b1 gene in bal and blood samples . antiparasitic therapy based on sulfadiazine and pyrimethamine was associated with a marked improvement in clinical , radiological , and laboratory findings in our cases . in conclusion , pulmonary toxoplasmosis should be included in the differential diagnosis of hiv positive patients with late stage of hiv infection , cd4 t cell counts less than 100 cells/l , a poor adherence or failure to haart and with fever , cough and pulmonary radiological infiltrates .
toxoplasmosis is a severe opportunistic infection in patients infected with the human immunodeficiency virus ( hiv ) . 
 the lung is a major site of infection after the central nervous system . in this report we described two cases of pneumonia due to toxoplasma gondii infection in hiv patients with antiretroviral therapy . 
 clinical and radiological abnormalities are not specific . pulmonary toxoplasmosis should be considered in hiv - infected patients with late stage of hiv , cd4 count less than 100 cells/l and a poor adherence to haart .