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Case 2: Prophylaxis for Toxoplasma Encephalitis

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D The patient should receive prophylaxis for Toxoplasma encephalitis. Dapsone alone does not provide sufficient protection against reactivation of Toxoplasma; she should take pyrimethamine in addition to dapsone.

This answer is correct. Trimethoprim-sulfamethoxazole is the simplest and most effective prophylaxis for both Pneumocystis pneumonia and Toxoplasma encephalitis, but this patient's severe skin rash caused by trimethoprim-sulfamethoxazole necessitates her using an alternative regimen. Dapsone alone is not effective as prophylaxis against Toxoplasma encephalitis—it must be combined with pyrimethamine and this regimen is the preferred alternative to trimethoprim-sulfamethoxazole for prophylaxis against Toxoplasma encephalitis. When pyrimethamine is used, leucovorin is added to prevent leukopenia. Although not a concern in this patient, pyrimethamine is contraindicated during pregnancy.

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